Editorial Comment: HIV Testing in Prisons and Jails-Providing the Carrot With the Stick

Treatment of HIV infection reduces the risk of transmission and can significantly improve patients’ quality of life. For these reasons, the CDC has recommended routine screening for HIV in all health care settings.¹ HIV testing access in correctional facilities is the weakest link in the fight against HIV infection in the United States; increasing access to testing would improve the identification of HIV-positive inmates as they pass through prisons and jails, providing an opportunity to integrate them into the public health infrastructure of HIV care. However, numerous logistical and cost-related barriers to such testing must be addressed when determining how and when it should be conducted.

 As noted by Beckwith and colleagues,² care providers in prisons and jails are often unable to deliver test results to inmates because of the difficulty associated with tracking patients who are transferred to other correctional facilities or whose medical records are misplaced. Since providing test results and posttest counseling is a time-consuming process, care providers may choose to notify patients only when results are positive. These factors might lead to continued or increased risk behavior by inmates, who might assume that “no news is good news.”

The problem of test result delivery is further exacerbated in jails, where the average stay is very brief. The authors suggest that rapid HIV tests may improve test result delivery. However, there are two additional obstacles to routine testing that should be considered in jail settings. First, testing is complicated by the sheer number of inmates and high rate of turnover, which could cause logistical problems for correctional care providers. Additional staff would be needed to assist with counseling and testing inmates since jails in some metropolitan areas may detain several hundred people in a single night. The limited amount of time and the circumstances of each jail stay also complicate the process of obtaining informed consent. In addition, at the time of arrest, many persons are under the influence of alcohol or drugs, which is problematic for the concept of “informed” consent. Careful screening would be required during the pre-test counseling and consent process to ensure inmates’ ability to understand the procedure and give proper consent.
Another important barrier to testing is the lack of access to appropriate HIV care. Many correctional facilities do not provide access to HIV specialists. Just as testing persons in resource-poor countries without providing access to HIV care providers and medication can lead to stigmatization and despair, screening for HIV infection in jail and prison settings without providing access to appropriate HIV-related services may have a negative impact on the patient (stigmatization, isolation) and the community to which they return after incarceration (continued HIV risk behavior).

Funding for HIV testing is a significant financial impediment in prison and jail settings. Although, in terms of public health, access to routine HIV testing may reduce spread of the virus in the correctional environment and the community, the cost of treating HIV infection in the correctional setting and the costs of increased testing and staff are not covered by government-funded disease-specific programs. If local health departments were able to cover the cost of providing HIV tests (and trained counselors) in jails and prisons, the cost of testing in these settings would shift somewhat to the public sector, lowering the financial barrier to routine testing in correctional settings.

One model for this approach already exists: many states provide sexually transmitted disease (STD) counselors and free STD testing in their jails and prisons. Reducing the impact of HIV testing on the correctional health budget would be a step in the right direction. Improving access to appropriate HIV care is a second important step, which should go hand-in-hand with improving access to testing in correctional settings.

Anne S. De Groot, MD
Executive Editor, Infectious Diseases in Corrections Report, & Associate Professor of Medicine (Adjunct)
The Warren Alpert School of Medicine of Brown University
Providence, RI

Elizabeth Closson, BA
Managing Editor, Infectious Diseases in Corrections Report
Christine Devore
Intern, Infectious Diseases in Corrections Report

No potential conflict of interest relevant to this commentary was reported by the authors.

References:

References

1.

Branson BM, Handsfield HH, Lampe MA, et al; Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.

MMWR

. 2006;55(RR14):1-17.

2.

Beckwith CG, Cohen J, Shannon C, et al. HIV testing experiences among male and female inmates in Rhode Island.

AIDS Reader

. 2007;17:459-464.