Description
Core Elements, Key Characteristics, and Procedures
Resource requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Description

Routine HIV Testing of Inmates in Correctional Facilities is a service in which HIV counseling and testing are routinely offered to all inmates as part of the standard medical intake evaluation.

Background
At the end of 2002, approximately 2 million persons were incarcerated in the United States.¹ And each year, many persons entering correctional facilities have a history of high-risk sexual behaviors, substance abuse, or both. As a result, high rates of HIV and other sexually transmitted diseases have been documented among persons entering the correctional system.² However, less than half of the prison systems, including 3 of the larger prison systems—California, New York, Florida— and few jails routinely provide HIV testing at time of entry.³ Therefore, many persons who may be infected are not routinely offered HIV testing. Each year, approximately 7.5 million inmates are released back into their communities.

CDC is revising its HIV counseling and testing guidelines. Separate guidelines are being developed for HIV testing in health care settings and HIV counseling, testing, and referral in non-healthcare settings. The guidance provided in this document may change, depending on the results of the guideline revision process; however, until that time, the recommendations in this document should be adhered to.

Specifically, Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings will be published later in 2006. They will replace CDC’s 1993 Recommendations for HIV Testing Services for Inpatients and Outpatients in Acute-Care Hospital Settings; and they will update aspects of CDC’s 2001 Revised Guidelines for HIV Counseling, Testing, and Referral that apply to health care settings and the 2001 Revised Recommendations for HIV Screening of Pregnant Women. In addition, the process for updating recommendations for HIV testing in non-healthcare settings is under way, with publication expected in 2007.

Goals
Routine HIV Testing of Inmates in Correctional Facilities will identify HIV infection among those who are unaware of their HIV status or those who have had a previous negative test result and can confirm the HIV status of inmates who report that they are HIV infected. Prevention and care services can then be provided to those who need them, both while they are in the correctional system and after their release.

How It Works
Routine HIV testing can be either standard enzyme immunoassay and Western blot testing or rapid HIV testing with appropriate confirmatory testing. For persons incarcerated for fewer than 30 days, routinely providing rapid HIV counseling, testing, and referral services can greatly increase the proportion tested and notified of their test results before release. These persons can then access partner counseling and referral services, prevention, and care services while in the correctional system and after release.

To address the HIV prevention needs of inmates, CBOs must collaborate with the state or local health department, state and local justice and correctional departments, and officials for the individual correctional facility. If rapid testing will be implemented in the correctional setting, please see Rapid HIV Testing in Nonclinical Settings in this document for further guidance. Health departments or agencies approved to provide partner counseling and referral services should initiate this service for contacts of HIV-infected persons.

Research Findings
The RESPECT 2 study showed that HIV counseling, testing, and referral that used a rapid HIV screening test was as effective as conventional HIV counseling, testing, and referral.⁴

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Core Elements, Key characteristics, and Procedures

Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. Core elements are essential and cannot be ignored, added to, or changed.

Routine Testing of Inmates in Correctional Facilities has the following 8 core elements: 

• Adhere closely to all rules and regulations of the correctional facility to ensure the safety of CBO employees, inmates, and facility staff.
• Routinely offer HIV counseling and testing to all inmates who are provided a medical evaluation at intake.
• Provide all counseling, testing, and referral services consistent with CDC’s Revised Guidelines for HIV Counseling, Testing, and Referral.
• When using the rapid HIV test, follow all standards and procedures related to its use, including guidelines for providing preliminary results and obtaining specimens for confirmatory testing.
• Notify all tested inmates of their HIV test result (whether positive or negative) confidentially and in person.
• Refer HIV-infected persons to partner counseling and referral services, medical care and treatment, and prevention services in the correctional facility, in the community, or both.
• Refer HIV-negative persons at high risk to prevention services in the facility, in the community, or both.
• Provide referral and linkage to care, treatment, and prevention services in the community for HIV-infected persons or HIV-negative persons at high risk being released from the correctional facility.

Key Characteristics
Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population.

Routine HIV Testing of Inmates in Correctional Facilities has the following key characteristics:

• Develop an information sheet with all relevant information about HIV prevention counseling, testing, and referral services; distribute it to all inmates in the orientation package, display posters that convey the information in the facility, or both.
• Establish a system to document consent for testing, record test results, and track specimens sent for confirmatory testing.
• Test inmates before, during, or shortly after the intake medical evaluation.
• Collaborate with the correctional facility to devise a strategy for reporting positive HIV test results to the state health department.
• Identify key contacts within the CBO and at the correctional facility to provide accountability and continuity in the collaboration.

Procedures
Procedures are detailed descriptions of some of the above-listed elements and characteristics.

Procedures for Routine Testing of Inmates in Correctional Facilities are as follows:

Assessing
CBOs should initiate discussions with officials at correctional facilities that do not routinely offer HIV testing to inmates during the intake medical evaluation to determine their willingness to implement routine testing as a standard component of the medical intake evaluation. Additionally, CBOs, in collaboration with the medical staff at the facility, should assess whether rapid HIV testing should be offered by facilities implementing routine testing.

Collaborating
CBOs must collaborate with the state or local health department, state and local justice and correctional departments, and officials for the individual correctional facility (including correctional officers and medical staff) to develop policies and procedures that promote successful training for staff of CBOs and correctional facilities and that promote routine HIV screening and prevention services in correctional facilities.

CBOs should consider working with facility officials to promote the importance of routine testing. They should also address policies related to confidentiality and data security, documenting test results and providing inmates confidential notification of their HIV test results. Informed consent for the HIV test should be obtained in a manner consistent with state laws and facility requirements.

Relationships between the CBO, the correctional facility, health departments (state, local, or both), and other service providers inside and outside the facility should be formally documented. CBOs should document relationships and delineate the roles and responsibilities of each partner in a memorandum of understanding. The CBO and correctional facility officials should designate key contacts to provide accountability and continuity in the collaboration and referral process.

Providing Information
If the facility does not already have an information sheet that has been approved by the health department or Department of Corrections, the CBO should collaborate with medical personnel at the jail or prison to design one. This sheet can be given to all inmates prior to their intake medical evaluation. It should

• describe the risk factors for transmitting or acquiring HIV
• describe features of the HIV antibody test and possible results
• describe services for HIV prevention, support, and care available inside and outside the facility
• advise the inmate that HIV prevention counseling, testing, and referral is provided as a routine part of the intake medical evaluation

Testing
Prisons typically detain inmates for 1 year or longer, and jails typically detain inmates for less than 1 year. Therefore, the CBO should provide either conventional HIV testing with an enzyme immunoassay test followed by a Western blot test, or rapid HIV testing with Western blot confirmatory testing for preliminary positive diagnoses in prison inmates and rapid HIV testing with Western blot confirmatory testing for preliminary positive diagnoses in jails. Regardless of which strategy is used, testing must follow CDC’s Revised Guidelines for HIV Counseling, Testing, and Referral; anyone providing this service should be trained in HIV prevention counseling, testing, and referral. In addition, if the rapid test is used, the CBO representative should have completed training in proper use of the test.

Referring
The CBO should work with correctional officials to identify HIV-related services within the facility and in the community. They should work together to refer all persons with a positive test result and HIV-negative persons at high risk for infection to appropriate care, treatment, or prevention services, as appropriate. The services to which the inmate is referred will be determined by his or her needs and duration of incarceration. When possible, the initial care appointment should occur while the inmate is in the correctional facility, and a plan should be made for continuation of care after release. Inmates with positive test results should be offered and encouraged to participate in partner counseling and referral services, either by referral to the local or state health department or by the CBO, if appropriate. Other services, including discharge planning, should be available either from the correctional facility, the CBO, or by referral and should be initiated before release from the facility.

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Resource Requirements

People
Routine Testing of Inmates in Correctional Facilities needs paid or volunteer staff members who are trained in HIV counseling, testing, and referral. If rapid HIV testing will be used, involved staff members must be trained in the delivery of rapid HIV testing. All polices, quality assurance requirements, and local and state requirements related to rapid HIV testing must be followed. The number of staff needed depends on the number of tests to be done and the type of test used (rapid or conventional). Each counselor may do 1 to 3 tests per hour. Explaining positive test results will take more time. CBOs should staff their programs according to the projected need for testing at the correctional facility. This information can be obtained by reviewing the facility’s medical procedures and intake process.

Space
Routine HIV Testing of Inmates in Correctional Facilities can be done anywhere in the correctional facility that confidentiality of clients can be assured (e.g., private area or room) and where a specimen can be collected according to minimal standards as outlined by the Occupational Safety and Health Administration. Additionally, for rapid testing, the setting must have a flat surface, acceptable lighting, and ability to maintain temperature in the range recommended by the test manufacturer for performing the test.

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Recruitment

CBOs implementing Routine Testing of Inmates in Correctional Facilities should encourage medical providers at the facility to promote HIV testing during the intake medical evaluation. Posters displayed in the facility and information sheets distributed during the intake process can facilitate discussions about HIV risk and testing and can serve as a reminder for the care provider to discuss HIV risk with inmates and to refer them for counseling, testing, and referral services.

Due to the very short detention period for many inmates in jail settings many inmates may be released before an intake medical is provided. To reach this population, a mechanism should be developed so that these inmates can request and be provided with an HIV test prior to release

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Policies and Standards

Before a CBO attempts to implement Routine Testing of Inmates in Correctional Facilities, the following policies and procedures should be in place to protect inmates, the correctional facility and staff, the CBO, and the test provider:

Confidentiality
A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which an inmate is referred, signed informed consent from the inmate or his or her legal guardian must be obtained. If the referral is within the correctional facility, rules regarding communication between departments must be followed.

Cultural Competence
CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to these different cultures. In addition, they should offer materials and services in the preferred language of inmates, if possible, or make translation available, if appropriate. CBOs should facilitate community and inmate involvement in designing and implementing prevention services to ensure that important cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.

Data Security
To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements and state and federal statutes.

Facility Regulations
Regulations of correctional facilities are designed for the protection of inmates, staff, and visitors to the facility. It is essential that CBOs who wish to partner with a jail or prison understand and follow all rules of the facility.

Informed Consent
CBOs must have a consent form that is consistent with the state’s HIV testing requirements. In some states informed consent can be given in either oral or written form. Inmate participation must always be voluntary, and documentation of this informed consent must be maintained in the inmate’s medical record. Regulations vary by state; therefore, CBOs should be familiar with and adhere to informed consent requirements in their state.

Legal and Ethical Policies
Routine testing of inmates in correctional facilities requires specialized training and deals with private inmate medical information. CBOs must follow their state laws and prison policies regarding who may implement counseling, testing, and referral and rapid testing procedures and regarding disclosure of an inmate’s HIV status (whether positive or negative) to sex partners, correctional officers, and other third parties. Additionally, some state laws prohibit the disclosure of preliminary positive HIV test results. CBOs must also know and adhere to all Clinical Laboratory Improvement Amendments regulations for testing, documentation, and use of logs relating to test implementation. CBOs must inform inmates about state laws regarding the reporting of child abuse, sexual abuse of minors, elder abuse, or imminent danger or harm to a specific person.

Referrals
CBOs must be prepared to refer inmates as needed. Providers of HIV testing must know about and have linkage relationships with referral sources for care and prevention interventions and counseling, such as partner counseling and referral services, and health department and CBO prevention programs for persons living with HIV and for inmates who need additional assistance in decreasing risk behavior.

Safety
Counseling, testing, and referral and rapid testing services that are provided in correctional facilities may pose potentially unsafe situations (e.g., the risk of transmitting bloodborne pathogens or risk to personal safety). CBOs should collaborate with corrections officials to develop and maintain written detailed guidelines for ensuring personal safety and security in correctional facilities; for ensuring minimal safety standards regarding specimen collection as outlined by the Occupational Safety and Health Administration; and for safeguarding the security of the data collected, inmate confidentiality, and the chain of custody for testing supplies and specimens collected from inmates.

Volunteers
If the CBO uses volunteers to assist with or conduct counseling, testing, and referral services, then the CBO should know and disclose how their liability insurance and worker’s compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

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Quality Assurance

The following quality assurance activities should be in place when implementing Routine Testing of Inmates in Correctional Facilities:

Counselors
Training
A training program should be in place for all new employees, existing employees, and volunteers who will be providing counseling, testing, and referral services. This program should ensure that all counseling, testing, and referral providers receive

• adequate training
• annual training updates
• continuing education
• adequate supervision to implement counseling, testing, and referral services and the rapid HIV test, if appropriate

The program should also ensure that providers of counseling, testing, and referral are skilled and competent in the provision of services (by using observed practice of counseling, testing, and referral sessions with feedback to counselors and of rapid HIV test procedures, if needed).

Protocol Review
A review mechanism should be in place to ensure that all testing protocols are followed as written. Quality assurance activities can include observation of sessions as well as role-playing demonstration of skills. The review should focus on ensuring that the protocol is delivered with consistency and responsiveness to expressed client needs and should help counselors develop skills for delivering the intervention.

Record Review
Selected medical record reviews should focus on assuring that consent was obtained or documented for all clients and all process and outcome measures are completed as required.

Inmates
Inmates’ satisfaction with the services and their comfort should be assessed periodically. Process monitoring systems should be used to track the number of referrals made, the number completed, and response to the service. Satisfaction with services may differ according to whether obtained while inside the correctional facility or after discharge. Both should be assessed, whenever possible.

Setting
Supervisors should periodically review the testing facility to ensure that a private and confidential setting is available for testing and that the waiting time for a test at this setting does not create a barrier to testing. Feedback should be solicited from correctional officers to ensure that test providers are adhering to the rules and regulations of the facility. Barriers to providing testing may be space available to conduct testing, availability of corrections officers to escort inmates, and the number of inmates being processed.

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Monitoring and Evaluation

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures.  Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting.  PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements.  Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

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Key Articles and Resources

Beck A, Karberg J, Harrison P. Prison and jail inmates at midyear 2001. In: Bureau of Justice Statistics Bulletin. Washington DC: US Department of Justice, Office of Justice Programs; 2002;1–16.

CDC. CDC model performance evaluation program for rapid HIV testing.

CDC. Draft CDC Technical Assistance Guidelines for CBO HIV Prevention Program Performance Indicators. Atlanta, GA: US Department of Health and Human Services, CDC; November 2003.

CDC. Rapid HIV testing.

CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50 RR-19: 1–58.

Desai AA, Latta TE, Spaulding A, Rich JD, Flanigan TP. The importance of routine HIV testing in the incarcerated population: the Rhode Island experience. AIDS Education and Prevention. 2002;14(Supplement B):45–52.

Hammet TM. Public health/corrections collaborations: prevention and treatment of HIV/AIDS, STDs, and TB. Washington, DC: US Department of Justice, Office of Justice Programs; 1998.

Maruschak L. HIV in prisons and jails, 1999. In: Bureau of Justice Statistics Bulletin. Washington, DC: US Department of Justice, Office of Justice Programs; 2001:1–11.

National Alliance of State and Territorial AIDS Directors. Implementing rapid HIV testing: a primer for state health departments; 2003.

National Commission on Correctional Health Care (NCCHS). NCCHS Web site.

OraSure Technologies, Inc. OraQuick Rapid HIV-1 Antibody Test.

Petersilia J. When Prisoners Return to The Community: Political, Economic, and Social Consequences. Sentencing & Corrections. Issues for the 21st Century. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice. 2000; No. 9.

Polonsky S, Kerr S, Harris B, Gaiter J, Fichtner RR, Kennedy MG. HIV prevention in prisons and jails: obstacles and opportunities. Public Health Reports. 1994;109(5):615–625.

Rich JD, Holmes L, Salas C, et al. Successful linkage of medical care and community services for HIV-positive offenders being released from prison. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2001;78(2):279–289.

Spaulding A, Stephenson B, Macalino G, Ruby W, Clarke JG, Flanigan TP. Human immunodeficiency virus in correctional facilities: a review. Clinical Infectious Diseases. 2002; 35:305–312.

US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement amendments.

US Department of Health and Human Services, HIV/AIDS Bureau. AIDS Education Training Centers.

US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care.

US Department of Justice, Office of Justice Programs. Bureau of Justice Statistics Web site.

US Department of Labor. Occupational Safety and Health Administration Web site.

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References

1. Harrison P, Beck A. Prisoners in 2001. In: Bureau of Justice Statistics Bulletin. Washington, DC: US Department of Justice, Office of Justice Programs; 2002;1–16.
2. Hammett TM, Harmon P, Rhodes W. The burden of infectious disease among inmates of and releases from US correctional facilities, 1997. American Journal of Public Health. 2002; 92(11):1789–1794.
3. Hammett TM, Harmon P, Maruschak LM. 1996–1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Washington, DC: US Department of Justice, National Institute of Justice; July 1999.
4. Metcalf CA, Cross H, Dillon BA, et al. Randomized controlled trial of HIV counseling with rapid and standard HIV tests (RESPECT-2). Presented at: XIV International AIDS Conference, July 7–12, 2002; Barcelona, Spain.

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Universal HIV Testing of Pregnant Women