June 25, 2010
The prevalence of human immunodeficiency virus (HIV) infection among incarcerated persons in the United States (1.5%) is approximately four times greater than the prevalence among persons in community settings (0.4%).1 In 2006, CDC recommended HIV testing in correctional facilities and elsewhere as part of routine medical evaluation.2 However, jail-based testing can be difficult logistically because of rapid turnover among detainees. In 2009, the Rhode Island Department of Corrections (RIDOC) reviewed its HIV testing program to assess HIV case identification, characterize HIV risk factors, and estimate the proportion of detainees who might not have been tested if testing had been delayed. RIDOC reviewed records of HIV testing of jail detainees during 2000-2007. During this period, 102,229 HIV tests were administered (representing an estimated 40,000-60,000 unique jail detainees), and HIV infection was newly diagnosed in 169 detainees, including 80 (48%) with unknown HIV risk factors. HIV testing was completed within 24 hours of jail admission. If HIV testing had been delayed for 7 days, 72 detainees (43%) would have been released before they could be tested, resulting in a delay in their HIV diagnosis and care, and continued risk for HIV transmission. To maximize case identification, all detainees should be offered voluntary HIV testing early in their incarceration as part of the first clinical evaluation, regardless of reported risk factors.
RIDOC is a unified state correctional system with six facilities for males and two for females. All pretrial detainees and all sentenced offenders (regardless of sentence length or crime) first pass through a centralized state jail that processes approximately 17,000 detainees each year. At any given time, the total inmate population in the RIDOC system is approximately 3,000-3,500, including 1,100 housed in the jail. Since 1991, the jail routinely has offered HIV testing to every person admitted as part of the initial medical evaluation conducted within 24 hours of admission. The RIDOC testing program uses a conventional laboratory-based HIV enzyme immunoassay (EIA) with Western blot confirmatory testing on blood specimens. HIV testing is voluntary (opt-out), and informed consent is obtained to conduct HIV counseling and testing. HIV test results are available in 7-14 days, and persons with a confirmed HIV-positive result who remain incarcerated are notified by the RIDOC HIV clinical nurse. All persons with confirmed HIV infection receive prevention counseling at RIDOC, referral to specialized HIV care within the correctional facility, and linkage to community care upon release. All HIV test results are reported to the Rhode Island Department of Health (RIDOH), and persons with positive test results who are released before notification are contacted in the community by a RIDOH outreach worker who provides results, prevention counseling, and referral to HIV care.
To determine the number and characteristics of persons with newly identified HIV infection and estimate the proportion of detainees who might not have been tested if testing had been delayed, RIDOC examined jail incarceration and HIV testing data from 2000-2007. A newly identified case of HIV infection was defined in a person with a positive confirmed HIV test at RIDOC who had no record of a previous positive HIV test result according to RIDOH HIV surveillance data. Data from 2000-2007 were selected because reporting of positive HIV test results to RIDOH using unique identifiers began in 2000.
During 2000-2007, the RIDOC jail had 140,739 admissions and conducted 102,229 (73%) HIV tests (Table 1). Because some detainees had multiple arrests and multiple HIV tests, the total number of HIV tests performed represents an estimated 40,000-60,000 unique persons (an exact number was not available). Of the 102,229 tests, a total of 169 detainees had a newly identified HIV infection that had not been reported previously to RIDOH. Of the 169, a total of 72 (43%) were released within 7 days after incarceration, including 49 who were released within 48 hours (Table 1); 97 (57%) detainees were incarcerated for >7 days. From 2000 to 2007, a statistically significant decreasing trend (from 33 to 13) was observed in the number of newly identified HIV infections at RIDOC, using linear regression (p = 0.001).
Of the 168 detainees with newly identified HIV infection for whom data were available, 151 (90%) were men, and 133 (79%) were aged 30-49 years (Table 2). By race/ethnicity, 62 (37%) were Hispanic, 58 (35%) were non-Hispanic black, and 46 (27%) were non-Hispanic white. Eighty (48%) did not specify an HIV risk factor; 44 (26%) were injection-drug users (IDUs), and 27 (16%) were men who have sex with men (MSM).
Reported by CG Beckwith, MD, JD Rich, MD, TP Flanigan, MD, Alpert Medical School of Brown Univ, Providence; M Poshkus, MD, N Aucoin, AM Bandieri, P Threats, Rhode Island Dept of Corrections, Cranston; S Chowdhury, MBBS, MPH, P Loberti, MPH, L Minuto, MEd, Rhode Island Dept of Health. R MacGowan, MPH, A Margolis, MPH, C Courtenay-Quirk, PhD, W Chow, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.
Persons unaware of their HIV infection are approximately three times more likely to transmit HIV than persons who are aware of their infection.3 Jail facilities provide an important setting to offer HIV testing to persons who might not otherwise receive testing.4 The jailed population has a higher prevalence of HIV infection than the general population, and rapid HIV testing in jails is feasible and acceptable.5 In this report, 73% of persons admitted to the jail (including those with multiple admissions) were tested for HIV infection during a medical evaluation within 24 hours of admission. Routine jail-based testing can produce a substantial number of new HIV diagnoses. The 169 newly identified HIV infections at the RIDOC jail during 2000-2007 represented 15% of all new HIV diagnoses in Rhode Island over the same period (RIDOH, unpublished data, 2009).
The results show a decline in the number of new HIV diagnoses made annually at RIDOC from 2000 to 2007, despite an increase in overall HIV prevalence in Rhode Island during this period.6 This decline might indicate fewer new HIV infections among IDUs, who are at increased risk for incarceration.6
The findings support the RIDOC policy of routine HIV testing of detainees within 24 hours of admission to jail. If HIV testing at the RIDOC jail had been conducted >48 hours after admission, 29% of detainees who tested positive for HIV infection would have been released before they could be tested. If HIV testing had been conducted ≥7 days after admission, 43% of detainees with new HIV diagnoses would not have been tested.
Certain challenges are associated with HIV testing immediately upon jail admission. Detainees might be intoxicated or under the influence of drugs and psychologically unable to provide consent for HIV testing when initially detained. Two recent studies that evaluated routine, opt-out, rapid HIV testing conducted in Connecticut jails supported testing within 24 hours of jail admission, compared with testing immediately upon incarceration or testing 1 week later. Testing within 24 hours of admission improved the ability of detainees to provide consent for testing and also minimized the impact of persons being released from the jail before they could be tested.7,8 HIV testing can be especially challenging in large facilities with many detainees processed daily. HIV testing programs require staff support, financial resources, and institutional support from the correctional system administration and officers. Logistical challenges need to be considered when developing a jail-based HIV testing program, yet balanced against the individual and public health benefits of maximizing case identification.
Among detainees with newly diagnosed HIV infection at RIDOC, administrative records did not indicate an HIV risk factor for 48%. This group included persons who had heterosexual sex with persons they thought were not at increased risk for HIV, persons who said they had no HIV risk factors, and persons for whom a risk factor was not recorded. Similarly, in a study involving North Carolina prisoners, 44% of HIV-infected prisoners did not report conventional HIV risk factors.9 Because high proportions of incarcerated persons with newly identified HIV infection do not disclose HIV risk factors, targeting HIV testing to those who report risk factors (e.g., MSM or IDU) likely will miss a sizeable proportion of HIV-infected detainees.
The brief incarceration period for many detainees at RIDOC illustrates the challenges associated with delivering conventional laboratory-based HIV test results to detainees. Although RIDOC detainees routinely are tested within 24 hours, those released from jail within 7-10 days typically do not receive their test results until after their release. RIDOC and RIDOH work collaboratively to locate these persons in the community to deliver confirmed results and offer referral to treatment. The use of preliminary point-of-care rapid HIV tests (with results available in 20 minutes) might be an effective strategy to increase delivery of confirmed results before detainees are released. If a detainee has a preliminary positive rapid test result, a protocol that includes confirmatory testing, delivery of confirmatory results, and linkage to care for those with confirmed infection can be set into motion before release from jail. Optimally, this protocol should operate under the guidance of jail-based HIV care providers, in collaboration with community-based providers and public health departments, to maintain continuity of services after release from jail.
The findings in this report are subject to at least two limitations. First, because this report was based solely on a retrospective review of administrative and surveillance data, information regarding actual receipt of HIV test results within RIDOC or in the community, linkage to HIV care, and HIV counseling could not be analyzed. Second, the newly identified cases described in the analysis do not account for jail detainees who might have tested HIV positive in another state previously, before being tested for HIV for the first time in Rhode Island.
These data, together with published guidance from CDC,10 can be used to assist in the development and implementation of comprehensive HIV services for jail detainees. Expansion of HIV testing within jails has the potential to increase diagnoses of HIV infection, thereby preventing new cases of HIV infection within the United States, especially among persons who might be difficult to reach through traditional community-based services.
What is already known on this topic?
CDC recommendations emphasize that human immodeficiency virus (HIV) testing in correctional facilities can increase diagnoses of HIV infection and help reduce HIV transmission in the United States.
What is added by this report?
A review of 2000-2007 HIV testing records by the Rhode Island Department of Corrections revealed that routine jail testing within 24 hours of admission resulted in newly identified HIV infections in 169 detainees; at least 72 would not have been tested before their release if the testing had been delayed for 7 days.
What are the implications for public health practice?
To maximize case identification in this difficult-to-reach population, all jail detainees should be offered voluntary HIV testing early in their incarceration as part of the first clinical evaluation, regardless of reported risk factors.