Challenges and potential solutions when implementing routine HIV screening in correctional facilities.

Challenges may arise in prisons and jails for administrators and health-care providers who would like to implement routine HIV screening for inmates. The challenges may arise from perceptions held by inmates, costs associated with testing, and policies that may discourage acceptance of testing by inmates.

A. Challenges that could increase inmate refusal for routine testing

Challenge: Breaches in confidentiality and privacy of medical information can arise from intentional or unintentional events and may result in distrust of medical staff by the inmates.

Solution: Ensure that all medical, correctional, and outside agency personnel comply with standard medical practices in maintaining inmates’ protected health information. (See Section 2 for more information.) Incorporate HIV testing into routine medical services to prevent inmates from being identified as seeking HIV testing. Conduct testing as part of routine medical screening process and disclose results privately. Unless required by policy or statute, an inmate’s HIV status should not be disclosed to correctional security or administrative staff.

Challenge: Correctional policies that deny

HIV-infected inmates access to work assignments or educational or training programs may result in disparate treatment for HIV-infected inmates. These policies are not supported by the medical literature, are contrary to state and federal laws that govern access to employment for persons infected with HIV, and may disqualify an inmate from work release programs. These policies may result in an inmate not obtaining credit toward early release.

Solution: Review and revise correctional policies related to restrictions on access to programs and services that may discourage inmates from accepting voluntary HIV testing.

Challenge: Housing HIV-infected inmates in one or few correctional facilities that provide medical care for HIV-infected inmates (medical centers of excellence) may improve access to specialized care. However, this may compromise their confidentiality, and it may restrict their access to educational, program, and housing opportunities available to other inmates.

Solution: Develop policies that allow clinically stable inmates to be transferred to prisons that offer programs not available in the “medical center,” provide condensed programs in the “medical centers,” and use telemedicine for remote locations to allow HIV-infected inmates more housing options.

Challenge: Conjugal visits may be permitted in the correctional system for inmates who are married or who are in a committed relationship. However, policies may exist that do not allow conjugal visits for inmates infected with HIV.

Solution: Revise the policy to allow conjugal visits for inmates infected with HIV who have accepted Partner Services or other means of partner notification. Prior to an approved conjugal visit, provide condoms and HIV prevention counseling to both partners.

Challenge: Inmates who are infected with HIV may be subjected to harsher punishments if they are found guilty of the willful exchange of bodily fluids.

Solution: Review policies related to willful exchange of bodily fluids. Ensure that policies are in accordance with state statutes.

Challenge: The correctional setting may be viewed as coercive, and, therefore, inmates may not truly perceive opt-out HIV testing in a correctional environment as voluntary.

Solution: Assure inmates that they have the right to refuse any voluntary screening tests even though they are encouraged to take them. Consider using community-based organizations as part of HIV prevention services, for example, by providing prevention counseling to inmates who have been screened for HIV.

B. Challenges associated with increased number of tests conducted.

Challenge: The time necessary to obtain and process even the fastest rapid HIV test sample might create logistical barriers.

Solution: Collect the specimen for HIV testing at the beginning of the encounter and then conduct other screening assessments while the test is processing or return the inmate to the waiting area while the test is being processed. Each facility should develop a protocol for incorporating HIV testing into their routine comprehensive medical evaluation procedures.

Challenge: Due to the high prevalence of HIV infection among inmates, prevention counseling should be available to inmates. However, prevention counseling should not be a barrier to providing routine HIV screening in medical settings.

Solution: Provide brochures or videos with HIV education material to all inmates upon entry. Provide prevention counseling to all HIV-infected inmates and to HIV-negative inmates upon request. Determine if your state mandates the provision of prevention counseling to all inmates being screened for HIV. The clinician conducting HIV screening need not provide the prevention counseling. Prevention counseling can be provided by personnel from an outside agency or by other medical staff.

Challenge: Laboratory costs will increase due to processing more HIV EIA test results. Medical costs may increase if HIV rapid test kits are used to screen for HIV.

Solution: Negotiate cost-saving contracts with companies by obtaining a pricing advantage for large volume use. Collaborate with state or local health departments to cover cost of rapid test kits.

Challenge: Routine HIV testing may increase the workload of health-care providers if testing must be explained, additional specimens (blood or oral fluid) are required, inmates are transported additional times to the medical unit, and all test results are provided in person by a clinician.

Solution: To minimize the provider’s increased workload, the following strategies could be implemented:

• Provide educational materials explaining HIV/AIDS and HIV testing to all inmates upon intake;
• Collect blood or oral fluid when obtaining other lab specimens during routine medical intake evaluation;
• Provide positive HIV test results to inmates only in person;
• Provide written notification of negative HIV test results along with other lab test results in language that does not specify type of tests conducted, i.e., all results are normal;
• Educate inmates on HIV risk reduction in classes or use of videos in groups; and
• To avoid duplication of services, obtain medical records from other correctional facilities for inmates who are transferred.

Challenge: Although not all inmates with HIV will require or accept treatment for HIV infection, treatment costs may increase if routine HIV testing identifies more HIV cases among inmates.

Solution: Negotiate contracts to pay lower drug prices based on volume consumption. Many inmates with HIV who are identified in jails will be released before treatment can begin and should be referred to services in the community.

Challenge: The inmate is unable to provide informed consent due to factors such as inebriation or unstable mental illness.

Solution: Delay the offer of voluntary opt-out screening tests for inmates under the influence of substances (e.g., drugs or alcohol) or who are acutely mentally ill until they are capable of making informed decisions about their health-care.

Go to Section VII