April 2003

Current Knowledge

In the United States, approximately 2 million people are currently incarcerated.¹ An additional 4 million individuals are on parole or probation.² Men represent the overwhelming majority of the incarcerated population (92%); however, the proportion of women has been steadily increasing in recent years.² Minority populations are disproportionately represented among people incarcerated, with recent estimates indicating that 12% of African-American males and 4% of Hispanic males in their twenties and early thirties are incarcerated.²

Prisons generally house individuals with sentences of 1 year or longer,³ and there are currently 1.3 million inmates housed in state and federal prisons.¹ Jails currently house roughly 600,000 inmates.2 Jails are operated by a city or county and house people awaiting hearings, trials, transfer to prison, or misdemeanor convictions. People detained in jails usually serve less than 1 year. The majority serve less than two weeks.³ Most inmates are eventually released, but many are re-incarcerated within six months..⁴ This results in 7.5 million people released annually.⁵

Many individuals entering correctional facilities have a history of high-risk sexual behaviors, substance abuse, or both. As a result, high rates of HIV and sexually transmitted diseases (STDs) have been documented among persons entering the correctional system.⁵ In 1999, there were more than 25,000 (2.0%) federal and state prison inmates, and more than 8,600 jail inmates (1.7%) known to be HIV-positive.6 In addition, the prevalence of AIDS among prison populations is 5 times higher than that in the general U.S. population (0.60% versus 0.12%).⁶ Recent estimates suggest that nearly 25% of people living with HIV pass through the correctional system.⁷ Currently, less than half of the prison systems and few jails routinely provide HIV testing on entry.⁸ Therefore, many individuals who may be infected are not routinely offered HIV testing. Correctional systems should routinely offer HIV testing as a component of the standard medical intake evaluation for all inmates. Routine HIV testing could either be in the form of standard enzyme immunoassay (EIA) and Western Blot testing or rapid HIV testing with appropriate confirmation testing. Health departments should initiate partner counseling and referral services (PCRS) for contacts of these HIV infected persons.

Persons incarcerated for less than 30 days may not receive traditional HIV counseling and testing (C&T), and, if they do, they are likely to be released before their test results are available. Use of rapid HIV testing could help ensure this population receives their test results. The RESPECT 2 study showed that HIV C&T that used a rapid HIV-screening test was as effective as traditional HIV C&T.9 Therefore, routinely providing rapid HIV C&T services for this population can greatly increase the proportion of persons tested and notified of their test results prior to release. Persons infected with HIV and persons at high risk for infection should be identified and referred to care, treatment, and prevention services in the correctional facility. For infected persons being released, referral and linkage to these services in the community is essential.

Objectives
The purpose of this document is to provide guidance to state and local health departments and correctional facilities to achieve

• Routine HIV testing during intake medical evaluation to identify new infections among inmates whose HIV status is unknown or has been negative on previous tests
• Routine HIV testing during intake medical evaluation to confirm HIV positivity for inmates who report that they are infected
• Confidential notification to all tested inmates of their HIV test results
• Referral of HIV-infected persons to appropriate antiretroviral care, treatment, and prevention services. If available, referrals should be made to programs and services in the correctional facility, the community, or both
• Referral of persons at high-risk of acquiring HIV to prevention services. Referrals include linkages to available programs and services both in the correctional facility and the community

Procedures
Steps for health departments

1. Work with state and local justice and corrections departments to develop policies and procedures for routinely offering HIV testing to all inmates during intake medical evaluation. Testing procedures should include standard EIA followed by Western Blot testing, rapid HIV testing, or both. The inmates projected length of incarceration should determine whether an EIA test or a rapid test is offered to the inmate.
2. Provide training to personnel from the correctional facility, the health department, or community-based organizations (CBOs) working in correctional facilities on the following:
   1. Confidentiality and data security issues related to HIV testing
   2. Routinely offering HIV testing, including rapid HIV testing, as part of the medical evaluation at intake
   3. Documenting test results and refusals of testing
   4. Understanding the meaning of test results, especially those from rapid HIV testing
   5. Providing inmates confidential notification of their HIV test results
   6. Conducting confirmatory HIV testing for inmates with a positive rapid test result
   7. Identifying care, treatment, and referral services in the correctional facility and the community for inmates who test positive for HIV
   8. Referring all persons with a positive test result and persons at high-risk for infection to care, treatment or prevention services
   9. Conducting partner, counseling, and referral services
3. Distribute to correctional facilities in their jurisdiction, an inmate information sheet on HIV testing and forms for documenting HIV test results or refusals to test.

Steps for correctional facilities

1. Provide HIV information sheets to all inmates arriving at the facility.
2. Routinely offer HIV testing to all inmates during the medical evaluation at intake into the correctional facility
3. Routinely offer prevention counseling in accordance with the CDC counseling, testing, and referral guidelines
4. Routinely provide confidential notification of HIV test results to all inmates tested
5. Establish a system to document consent for testing and test results, and to track specimens sent for confirmatory testing.
6. Notify all inmates whose rapid HIV test result is positive that the result indicates a preliminary positive result and that a confirmatory test needs to be performed. A blood specimen should be obtained from the inmate and confirmatory testing initiated
7. Establish procedures and responsibilities for reporting HIV cases to the health department and requesting assistance with partner counseling and referral services
8. Each correctional facility must specify written policies and procedures to
   1. Determine eligibility for EIA HIV testing and rapid HIV testing. In general, inmates who are likely to be released before results from EIA testing are available should be offered rapid testing during their medical evaluation.
   2. Ensure care and treatment is provided, based on the inmate’s projected length of incarceration.
   3. Ensure confidentiality and security of data related to HIV testing.
9. Initiate the referral process for all HIV-infected inmates and those at high risk of acquiring HIV infection by making the first appointment with an appropriate care provider, CBO, or both. Whenever possible, the initial appointment should occur while the inmate is in the correctional facility. If this is not possible, health department or CBO personnel should obtain contact information from the correctional personnel, initiate contact with the individual, and accompany the released inmate to appointments, if appropriate.
10. Work with participating CBOs to establish procedures and responsibilities for referral services for inmates as part of release planning.

Programmatic Considerations
Health departments should initiate discussions with correctional systems that do not routinely offer HIV testing to inmates during the intake medical evaluation to determine their willingness to implement routine HIV testing. Before establishing routine, HIV testing, health departments, correctional facilities, and CBOs must consider how to address relevant policy, financial, and resource barriers.

1. In circumstances where rapid testing is used in HIV screening in correctional facilities, legal and regulatory barriers, such as state prohibitions or health department policies on giving preliminary results, may challenge implementation. Consideration should be given to revising these prohibitions, where appropriate.
2. Linkages and resources for HIV care need to be in place for persons detained in the correctional facility and those released to the community.
3. A key contact should be identified at the health department and at each correctional facility and CBO to provide accountability and continuity in the collaboration.

Working with Partners and Integration into Existing Services

1. Collaboration between the health department, correctional facility, and CBO personnel is critical to the successful training and implementation of routine HIV screening and prevention services in correctional facilities and in the community. If facilities conclude that rapid testing is to be a part of routine screening in the correctional institution, specific training in rapid HIV testing must occur and collaboration with a laboratory must be in place.
2. Partnerships should be developed among health departments, correctional facilities, and CBOs so that individuals can be linked to care, treatment, and prevention services in correctional facilities and in the community. These relationships should be negotiated and formally documented in writing, e.g., a letter of cooperation, memoranda of agreement or understanding.
3. Additional partners with whom to collaborate may include state, county, and local police and sheriff departments.

Vignette
Individuals admitted to the Adult Correctional Institute in Rhode Island through intake undergo a medical evaluation.10 During this evaluation, inmates give a brief medical history, receive a brief physical examination, and undergo mandatory serum syphilis testing. Medical personnel answer questions related to HIV testing and encourage all inmates to routinely accept HIV testing during the intake process. Testing is not based on risk perception and is offered in a manner in which inmates have the opportunity to refuse HIV testing. Inmates are provided a standard written consent form before HIV testing. Although counseling before the test is not routinely provided at intake, over 90% of inmates are routinely tested for HIV. Test results are provided in a one on one session, by an HIV trained counselor. Through a demonstration project, Project Bridge,11 HIV-positive inmates are provided assistance with accessing medical and social services in the community. Enrollment occurs one to three months before release, and plans are made to obtain concrete services after release. Support is provided for 18 months after release. All health care information, including HIV test results, is kept secure at the medical clinic in the correctional facility. All participants sign consent and release forms granting permission to be participant in Project Bridge.

Monitoring Implementation
CDC grantees receiving HIV prevention funds will be required to routinely report the following indicators to monitor their HIV testing programs in correctional facilities.

CDC’s HIV Prevention Program Performance Indicators*:

1. Number and percent of newly diagnosed HIV infections in correctional facilities (B.1)
2. Number and percent of newly identified, confirmed HIV-positive test results returned to inmates (B.2)

Other program measures:

3. Number of persons with HIV who are referred for services during incarceration
4. Number of persons with HIV who use the services to which they are referred while incarcerated
5. Number of persons at high risk for acquiring HIV who are referred for services during incarceration
6. Number of persons at high risk for HIV who use the services to which they are referred while incarcerated
7. Number of persons who are retested for HIV due to reincarceration
8. Collection of HIV transmission risk data in accordance with CTR Guidelines

* The CDC Technical Assistance Guidelines for Health Department HIV Prevention Program Performance Indicators provides information on setting baseline, target, and indicator specification including appropriate data sources, calculations and reporting issues. Note: Performance indicators may have been modified to reflect specific population or setting characteristics.

References

1. Harrison P, Beck A. Prisoners in 2001. Bureau of Justice statistics bulletin, U.S. Dept of Justice, Office of Justice Programs. 2002;1-16.
2. Beck A, Karberg J, Harrison P. Prison and jail inmates at midyear 2001. Bureau of Justice statistics bulletin. Washington D.C.: U.S. Department of Justice, Office of Justice Programs. 2002;1-16.
3. 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.
4. Petersilia J. When prisoners return to the community: Political, economic, and social consequences. Sentencing & Corrections. Issues for the 21st Century. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. 2000;No. 9.
5. Hammett TM, Harmon P, Rhodes W. The burden of infectious disease among inmates of and releasees from U.S. correctional facilities, 1997. Am J Public Health. 2002;92(11):1789-1794.
6. Maruschak L. HIV in prisons and jails, 1999. Bureau of Justice Statistics Bulletin, Office of Justice Programs, U.S. Department of Justice. 2001;1-11.
7. 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.
8. Hammett TM, Harmon P, Maruschak LM. 1996-1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Washington, D.C.: U.S. Department of Justice, National Institute of Justice. July 1999.
9. Metcalf CA, Cross H, Dillon BA, et al. Randomized controlled trial of HIV counseling with rapid and standard HIV tests (RESPECT-2). XIV International AIDS Conference: Barcelona, Spain. July 7-12, 2002.
10. 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.
11. 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.

Resources

AIDS Education and Training Centers

Bureau of Justice Statistics

CDC. Revised Guidelines for HIV Counseling, Testing, and Referral.

National Commission on Correctional Health Care

Public Health and Corrections Collaboration

Rapid testing

CDC. Technical Assistance Guidelines for CDC’s HIV Prevention Program Performance Indicators.