Money Well Spent: Opt-Out Testing in Prisons Can Catch STD Cases and Save Taxpayers Money in the Long Run
How much do you think it would cost the health department of a major American city to reduce the amount of gonorrhea, Chlamydia, syphilis and possibly even HIV by 20%? More importantly, if you had to devise the simplest and most cost-effective way to do this, how would you do it?
Millions have been spent on print ads in magazines and newspapers, TV spots, billboards, and Internet messages. Additional monies have been spent for peer and provider education. Schools teach sexual health. Public health agencies spend millions more performing services such as partner tracking and notification. Despite all these efforts, sexually transmitted infections continue to plague our communities.
Perhaps another approach might be to seek out a subpopulation that has a higher than average prevalence of infections. Better yet would be if that population could be gathered into one location to streamline testing, diagnosis, treatment, and linkage to care. In most major metropolitan areas, such places exist: jails and prisons.
STI Testing Lessons
In Chicago, this very scenario played out in reverse. In April 2002 - March 2003 the Cook County Jail performed "universal voluntary screening" for gonorrhea and Chlamydia. More than 85% of men and women entering the facility participated in testing, leading to large numbers of diagnoses and treatment.1 An estimated one in five cases of gonorrhea in the entire county was diagnosed and in most cases treated during incarceration at the jail.
Testing was switched to symptoms-based screening only in March 2003. In the following year, the number of cases of gonorrhea and Chlamydia that were diagnosed in the jail declined by nearly 80%! While this is not exactly comparing apples to apples, it demonstrates the power and dramatic impact opt-out testing can have on the community. All those undiagnosed and untreated patients are potential vectors of disease transmission in the community at large.
In 2007, all intake screening was discontinued, and the number of cases of gonorrhea diagnosed in the County reached its lowest point in more than seven years. This doesn't mean there was any less gonorrhea in Cook County. It just means that the largest single-site testing and treatment facility in the county had ceased to have an impact. All those previously diagnosed and treated cases were going untreated and ultimately returned to the community to be spread to new partners.
By 2008, the number of new cases diagnosed in Cook County had increased by nearly 10% in a single year. This was without having resumed large scale testing at the Cook County Jail. These were all cases diagnosed at the community-level clinics and other health care settings. It was clear that the jail served a massively important role in the cycle of transmission of sexually transmitted diseases. By focusing initiatives on correctional facilities, communities have that cost-effective magical constellation of high disease burden, captive audience, screening, treatment, and linkage to care.
Might jails and prisons be able to have a similar impact on HIV?
HIV Testing Behind Bars
HIV testing is generally considered to be cost-effective, but the biggest "bang for your buck" occurs when screening is applied to populations where the presence of disease is predicted to be higher than average. Correctional settings represent an ideal example of a population that may receive the biggest direct benefit from opt-out HIV testing. The U.S. prevalence of HIV is estimated to be between 0.3 to 0.5%, but in jails and prisons the rate is three to five times higher (as many as 2.5 people out of 100). The reason for the higher rate is because many people who are incarcerated have a higher prevalence of HIV risk factors (e.g., injection drug users, sex workers, the mentally ill, and "risk-takers"). Further, jails and prisons tend to represent a similar economic strata as those who do not routinely have access to health care in their communities (the un- or underinsured) and therefore are less likely to have been offered testing prior to incarceration.
It is estimated that as many as 25% of all Americans who are infected with HIV are currently unaware of their diagnosis. This means there may be more than 250,000 citizens who are not in care and therefore not on medications. An estimated 20% of all HIV-positive people will pass through a correctional facility at some point. Their health may be in jeopardy, but in a broader view, public health is also directly affected. HIV-positive patients not diagnosed and not on treatment are more infectious and may not be taking additional precautions to safeguard their partners (condoms, strategic positioning, serosorting, altering sexual practices, abstinence, etc.). The financial impact of delayed access to HIV treatment is also substantially greater. Presenting with advanced HIV leads to longer and more frequent hospitalizations, more medication expenses, more utilization of HIV primary care resources, and so on.
In 2006 the CDC issued a recommendation that HIV testing should be considered a routine part of an effort to diagnose and ultimately treat the "missing 25%." This included testing anyone ages 13-64 in all health care settings, increased frequency of screening for those at higher risk for HIV, eliminating separate written consent, eliminating the requirement for prevention counseling, including HIV testing in all prenatal panels, and utilizing opt-out testing wherever possible.
CDC Cuts Take More Than $1 Million From HIV Prevention and Education Programs in Massachusetts County Jails
This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
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