Two new studies in the Journal of Acquired Immune Deficiency Syndromes call attention to the challenges associated with encouraging inmates in United States jails to undergo HIV testing and receive appropriate health care.
One study, conducted by the New York City Department of Health and Mental Hygiene, estimated that almost 30% of HIV-positive jail entrants are not aware of their serostatus.
The other, a pilot study, looked at the feasibility of using rapid HIV testing in conjunction with individualised risk reduction counselling at a Rhode Island jail.
In the United States, a country with a high rate of incarceration, there are two major categories of correctional facility: jails, which hold individuals on remand prior to sentencing, as well as people convicted of misdemeanours punisihable by less than a year in jail, and prisons, which hold people convicted of more serious crimes for longer periods.
Jails have a much higher turnover of inmates as a result, and are an important venue for HIV prevention because of the opportunities for encountering large numbers of individuals engaged in high-risk behaviours such as injecting drug use.
Incarcerated populations in many countries have disproportionately high HIV prevalence rates, and efforts to address their HIV-related needs are often hampered by complex social factors.
The New York researchers determined the proportion of HIV-positive people in a cohort of 6411 jail entrants by analysing blood samples drawn for syphilis testing. They found an overall HIV prevalence rate of 5.2%, which is lower than the rate found in the last such study in 1998, but still much higher than prevalence estimates for the city’s general population.
The cohort was comprised of 4669 men and 1742 women. HIV prevalence among men was 4.7%, and among women, 9.8%.
The proportion of HIV-positive people believed to not know their status was determined by matching HIV test results for the blood samples to self-reports of HIV status and to names in New York City’s HIV surveillance registry. (After the matching process was completed, all identifying information was dropped from study records, making it impossible to use the blood samples to learn the names of HIV-positive inmates.)
The HIV surveillance registry did not list 157 of the 389 inmates (40.5%) whose blood samples were found to be HIV-positive. In other words, either those people had been diagnosed with HIV in the past but their names were not submitted to the registry, or else they had not been diagnosed with HIV.
Fifty-three of the 157 acknowledged being HIV-positive during the voluntary health screening that is part of the prison intake process. The other 104 said that they were HIV-negative; this group represents 28.1% of the 389 undiagnosed HIV-positive people who were identified via the syphilis testing samples.
The paper’s authors note that while voluntary rapid HIV testing is offered during the initial health screening, this practice may not result in many more diagnoses of HIV infection. Thirty-two of the 104 people with undiagnosed HIV accepted the offer of testing, and twelve of them tested HIV-positive; this represents only 11.5% of undiagnosed cases.
Among study participants who were not in the HIV surveillance registry and did not report being HIV-positive, women and self-identified men who have sex with men were more likely to have undiagnosed HIV infection (adjusted odds ratio [AOR] 1.7, 95% confidence interval [CI], 1.0-3.0; and AOR 5.2, 95% CI, 1.7-15.9, respectively). Younger people were less likely to have undiagnosed HIV infection (age 16-29 versus age 40-49, AOR 0.55, 95% CI, 0.32-0.92).
Interestingly, those predictors identify less than one-third of people with undiagnosed HIV infection. The finding leads the authors to conclude that greater emphasis should be placed on increasing overall acceptance of HIV testing than on prioritising specific populations.
The authors also suggest that the use of a separate written consent form for HIV testing, a practice imposed by state law, hinders the implementation of a more streamlined opt-out HIV testing model recommended by the US Centers for Disease Control and Prevention. In spite of the introduction of rapid HIV testing in New York City jails in 2004, they note, two-thirds of incoming inmates in 2006 declined to be tested during health screenings.
The Rhode Island research team reported on a pilot study that compared two different HIV testing protocols offered to men at the state’s central jail facility.
One hundred and thirty-two study participants were assigned to the standard protocol of routine opt-out HIV testing, with a seven-to-ten-day waiting period for test results. An equal number of study participants were offered rapid HIV testing in conjunction with an individualised risk reduction counselling session.
Researchers then conducted follow-up behavioural assessments of inmates released within six months of study enrolment. (People were not eligible for follow-up if they were still in jail or had been sentenced to prison.) In the standard arm of the study, 58 former inmates underwent assessments, and in the rapid testing arm, 50 did so. A total of 75 study participants could not be assessed because they were lost to follow-up.
When researchers compared levels of HIV risk behaviour between the two groups of former inmates, they did not observe any statistically significant differences. In other words, the rapid HIV testing protocol with its individualised counselling sessions was not found to have a greater impact on HIV risk behaviour.
However, since this was a pilot study, the researchers did not enrol a large enough cohort to draw conclusions about how the protocols compared with each other. They point to their success at implementing the new protocol and to the relatively high rate of participation in follow-up assessments as evidence of the feasibility of conducting larger-scale studies of this nature.
Beckwith CG et al. HIV risk behavior before and after HIV counseling and testing in jail: a pilot study. J Acquir Immune Defic Syndr (advance online publication, January 2010) doi: 10.1097/QAI.0b013e3181c997b1.
Begier EM et al. Undiagnosed HIV infection among New York City jail entrants, 2006: results of a blinded serosurvey. J Acquir Immune Defic Syndr (advance online publication, January 2010) doi: 10.1097/QAI.0b013e3181c98fa8.