One state found that one-third of all the people who tested positive for HIV between 1989-1999 were tested at the state prison. Counseling and testing services are an important opportunity for drug users in the criminal justice system to find out whether they are infected and learn how to reduce their risks.

Counseling and Testing Services Are a Vital Prevention and Treatment Strategy

HIV counseling and testing (C&T) includes HIV antibody testing and individual, client-centered risk reduction counseling. It provides a way for people to learn whether they have HIV infection and get further help.

Drug users in prisons and jails need to know whether they are infected with HIV.

A comprehensive approach to preventing HIV must include the opportunity for inmates to discover whether they are infected. Whatever the results of testing, inmates need to learn how to reduce their risk of getting or transmitting the infection.

Identifying and informing inmates who are HIV positive is also important because new HIV treatment regimens are available in most correctional facilities. Earlier treatment can delay HIV disease progression and significantly reduce viral load. It offers longer survival with improved quality of life. HIV counseling and testing of pregnant inmates is vital because AZT and other anti-HIV medications in pregnant women infected with HIV can reduce the chance of transmission from mother to baby.

HIV testing and counseling provide a valuable opportunity for intervention.

HIV C&T in prisons and jails takes place in several different contexts -- during and following the initial intake medical screening, during or following education and prevention sessions, and at health care visits. It provides a unique opportunity for staff to work with people whose sexual and drug use behaviors place them at high risk.

By counseling non-infected inmates on how to avoid becoming infected, and by identifying infected inmates and helping them learn how to avoid transmitting the infection, C&T programs can prevent future cases of HIV. It is estimated that lifetime treatment costs for HIV range from $165,000 to $267,000, so investing in C&T programs can have a big payoff.

Many incoming inmates also have physical and mental health problems and little or no previous exposure to health care services. HIV testing can be an entry point to a broader array of needed health care services.

Prisons and Jails Have Various C&T Policies

The 50 states, the District of Columbia, and the Federal Bureau of Prisons (BOP) follow a wide range of HIV testing policies. As of 1999 (the most recent data):

• BOP and all 50 states test inmates if they have HIV-related symptoms or if the inmate requests a test;

• 39 states test inmates after they've been in a fight that causes bleeding;

• 16 states test inmates who belong to specific high-risk groups, such as injection drug users (IDUs), polydrug users, those with multiple sex partners, commercial sex workers, those with previous or current sexually transmitted diseases (STDs), and those with hepatitis;

• 19 states test all entering inmates;

• the BOP and 3 states test all inmates upon release; and

• the BOP and 6 states also randomly test inmates for HIV.

The counseling element of C&T usually involves two sessions -- one before and one after the test. These sessions are designed to:

• provide information about the test;

• help a person assess his or her risk of becoming infected or passing it on and make a risk reduction plan;

• help people understand their responsibilities (if their results are positive) for ensuring that sex and syringe-sharing partners are informed of their possible exposure;

• review options for notifying partners; and

• offer referrals to other services such as substance abuse treatment or mental health.

Maintaining the Confidentiality of C&T Results Can Be Difficult in Prison and Jail

Ensuring the confidentiality of HIV test results is a crucial aspect of providing effective C&T services. This is because fear of disclosure may cause a person to decline testing. Confidentiality in the correctional setting can be difficult because privacy is harder to maintain. For example, inmates may be identified as probably HIV-infected if they are seen being escorted by guards to the medical clinic on a regular basis. These breaches of confidentiality may have severe consequences. The question of who has the right to know test results besides the inmate also is more complicated in correctional settings.

Correctional systems have varied policies about disclosing test results:

• Because the information is needed to guide health care, all state and federal prisons and most city/county jails disclose results to the inmate and his or her health care provider.

• About 90 percent of prisons and 70 percent of jails disclose results to the public health department; this information is included in state and national HIV/AIDS reporting.

• Smaller percentages disclose results to persons the inmate has physically or sexually assaulted (47% prison; 24% jail) or to spouses/sexual partners (31% prison; 15% jail), or syringe-sharing partners (27% prison; 10% jail). This is because it may be difficult to find the partners or there may be concern that the information could be used against the inmate or his or her family.

• About 30 percent disclose results to parole agencies; this information may be helpful because a parole officer can mandate services or help to link the inmate with services.

• Only about 10 percent of prisons and jails disclose results to correctional officers. Because HIV is transmitted primarily through sex and drug injection, it is generally thought that correctional officers do not need to know an inmate's HIV status. All staff should be trained in universal precautions, the use of which make it unnecessary to know an individual's HIV status.

Innovative Programs and Strategies Are Addressing the Problem

Across the country, agencies, organizations, and providers are working to establish and maintain innovative C&T programs for drug users who are involved with criminal justice. Here are a few examples:

Forensic AIDS Project, San Francisco Department of Public Health
Staff of this project offer HIV/AIDS education sessions at all San Francisco jails. Topics covered include information on HIV/AIDS, STDs, and tuberculosis; HIV testing; early intervention; and general health and nutrition. The project also offers multiple-session, individual counseling on HIV risk behaviors and risk reduction. Post-test counseling is provided to all tested inmates after they have received their test results. HIV-positive inmates are referred to the project's Early Intervention Team for in-jail services. For more information, contact: Forensic AIDS Project, 798 Brannan Street, San Francisco CA 94103, 415/863-8237.

Community AIDS Resources and Education (C.A.R.E.) Program
C.A.R.E., located in Austin, Texas, provides confidential and anonymous HIV counseling and testing at two Travis County correctional facilities. This serves as the entry point for inmates to receive a range of additional in-jail services from C.A.R.E. These services include HIV and STD prevention education and early intervention for inmates with HIV infection. Inmates who test positive for HIV while in jail are linked with a C.A.R.E. community outreach worker. This person works with the correctional facility medical staff to make sure that the inmate receives necessary care before and after release. For more information, contact C.A.R.E., Austin, Texas, 512/473-2273 ext 108.

To Learn More About This Topic

Read the overview fact sheet in this series on drug users and the criminal justice system -- "Drug Users, HIV, and the Criminal Justice System." It provides basic background information, links to the other fact sheets in this series, and links to other useful information (both print and Internet).

Check out these sources of information:

Desai A.A., Latta E.T., Spaulding A., Flanigan T.P. The role of the state correctional facility in the diagnosis of HIV in Rhode Island. 2001 National HIV Prevention Conference, Atlanta, Georgia, August 12-15, 2001. Abstract No. 416.

Hammett T.M. Public health/corrections collaborations: prevention and treatment of HIV/AIDS, STDs, and TB. Research in Brief. Washington (DC): U.S. Department of Justice, Office of Justice Programs, National Institute of Justice; July 1998. NCJ 169590. www.ncjrs.org/pdffiles/169590.pdf

Hammett T.M., Harmon P., Maruschak L.M. 1996-1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Issues and Practices in Criminal Justice. Washington (DC): U.S. Department of Justice, National Institute of Justice; July, 1999. NCJ 176344. www.ncjrs.org/pdffiles1/176344.pdf

Maruschak L.M. HIV in Prisons and Jails, 1999. Washington (DC): USDOJ, NIJ/BJS; July 2001. NCJ 187456. www.ojp.usdoj.gov/bjs/abstract/hivpj99.htm

Rich J.D., Dickinson B.P., Macalino G., Flanigan T.P., Towe C.W., Spaulding A., Vlahov D. Prevalence and incidence of HIV among incarcerated and reincarcerated women in Rhode Island. Journal of Acquired Immune Deficiency Syndromes 1999;22(2):161-166.

Sabin K.M., Frey R.L., Horsley R., Greby S.M. Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing, and referral system, 1922-1998. Journal of Urban Health 2001;78(2):241-255.

Varghese B., Peterman T.A. Cost-effectiveness of HIV counseling and testing in U.S. prisons. Journal of Urban Health 2001;78(2):304-312.