Routine, jail-based HIV testing of inmates can successfully identify a substantial proportion of people unknowingly infected with HIV and could play a critical role in preventing the spread of the disease, according to a new report in this week's U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.
The analysis, conducted by researchers with The Miriam Hospital, The Warren Alpert Medical School of Brown University, Rhode Island Department of Corrections (RIDOC), Rhode Island Department of Health (RIDOH) and the CDC, supports previous CDC recommendations calling for HIV testing in jails and prisons as part of a routine medical evaluation.
During a eight-year period, 73 percent of all RIDOC inmates were provided HIV testing during a medical evaluation within 24 hours of incarceration. Nearly 170 new HIV diagnoses, representing more than 15 percent of all newly-diagnosed people with HIV in Rhode Island during the same time period, were identified through this RIDOC testing program.
According to lead author Curt G. Beckwith, MD, an infectious disease specialist with The Miriam Hospital, this testing rate is both noteworthy and encouraging, given that individuals who are unaware of their HIV infection are more than three times more likely to transmit the virus compared to those who are aware of their infection. In addition, HIV rates among prisoners are more than four times higher than in the general population.
"Jails and correctional facilities provide a golden opportunity to offer HIV testing to a population that is hard-to-reach and at increased risk of infection," says Beckwith. "Expansion of HIV testing within jails has the potential to increase HIV diagnoses and make more people aware of their HIV status, which could help reduce the spread of the disease in the United States."
HIV testing has been routinely offered to every person entering the RIDOC since 1991 as part an initial medical evaluation conducted within 24 hours of confinement. Test results are available within a week or two. Anyone who receives an HIV-positive result while incarcerated is notified by an HIV clinical nurse and receives prevention counseling and referrals to HIV care both in the prison setting and in the community. Individuals with a positive diagnosis who are released before they can be notified are contacted by a RIDOH outreach worker who also provides care referrals and prevention counseling.
Following a detailed review of RIDOC records and RIDOH surveillance data, researchers determined that if HIV testing had been conducted after the first 48 hours of incarceration, approximately 29 percent of detainees with new HIV diagnoses would not have been tested. What's even more troubling: if all testing had occurred beyond seven days of incarceration, 43 percent of HIV-positive inmates who had been released within that timeframe would not have been tested, resulting in a delay in their diagnosis and the opportunity for them to unknowingly spread the disease.
In addition, nearly half of the newly-diagnosed HIV-positive inmates did not disclose HIV risk behaviors, such as injection drug use or high risk sexual behaviors. Beckwith, who is also an assistant professor of medicine at Alpert Medical School and a physician with University Medicine, says this finding could be an issue for jurisdictions that rely on HIV testing based on known risk behaviors, since it appears they may miss a sizeable number of HIV-positive detainees.
"These results support policies for HIV testing upon jail intake and routinely providing voluntary, opt-out HIV testing to all detainees, regardless of reported risk factors, in order to maximize our ability to diagnose as many new cases as possible," he adds.
From 2000 through 2007, the RIDOC jail processed 140,739 criminal offenses and conducted 102,229 HIV tests. Due to multiple arrests of some detainees during this timeframe, the total number of HIV tests performed represents approximately 40,000 to 60,000 unique individuals. That's because some detainees may have been tested multiple times depending upon arrest frequency and the time between incarcerations.
The majority of newly-diagnosed detainees were male (90 percent) and more than three-quarters were between the ages of 30 and 49. Blacks and Hispanics represented 72 percent of all cases.
Study co-authors included Josiah D. Rich, MD, and Timothy P. Flanigan, MD, from The Miriam Hospital, Alpert Medical School and University Medicine; Michael M. Poshkus, MD, Ann-Marie Bandieri, Nicole Aucoin and Patricia Threats, RN, from the RIDOC; Sutopa Chowdhury, MBBS, MPH, Paul Loberti, MPH and Lucille Minuto, RN, BSN, Med, from the RIDOH; and Robin MacGowan, MPH, Andrew Margolis, MPH, Cari Courtenay-Quick, PhD, and Walter Chow from the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.
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