Correctional settings have several available HIV testing strategies from which to choose. Two HIV tests are typically used in combination, with the second test providing confirmation of an initial reactive screening test. In this section, available HIV testing algorithms are reviewed as well as a description of the advantages and disadvantages of specific testing algorithms for use in correctional systems.

A. Conventional HIV testing algorithm

The conventional HIV testing algorithm consists of two tests: an HIV enzyme immunoassay (EIA) capable of identifying HIV-1 and HIV-2 antibodies and an HIV-1 Western blot or immunofluorescence assay (IFA) used for confirmation. This is the “gold standard” HIV testing algorithm and is the most widely used in the U.S. If the initial EIA is positive, the Western blot or IFA is performed by the laboratory in order to confirm the EIA result. The test results are reported as positive, negative, or indeterminate. A “window period” exists during early HIV infection when the EIA may be non-reactive but true HIV infection is present, which may result in a false-negative test result. This window period is typically during the first 8–12 weeks following infection with HIV. However, the “window period” during which false negative HIV antibody tests occur has decreased with newer generation EIAs. Conventional HIV tests can be performed with plasma or serum specimens.

Advantages for the correctional setting: This “gold standard” for HIV antibody testing very accurately detects established HIV infection. Confirmation is built into the testing algorithm without need for further specimen collection. This conventional HIV testing is relatively inexpensive and commonly available.

Disadvantages for the correctional setting: The turnaround time for obtaining conventional test results ranges from several days to weeks. This may limit the opportunity to deliver HIV test results to inmates who are released from the facility within two weeks.

B. Additional HIV tests currently available 

1.Oral Fluid HIV test

The oral fluid HIV test identifies HIV-1 antibodies from an oral fluid specimen (oral mucosal transudate collected using an OraSure® collection device), thus eliminating the need for venipuncture. After specimen collection, the oral fluid collection device is placed into a vial containing a preservative and is sent to a central laboratory where an EIA is performed. If reactive, confirmatory testing is performed. The results, reported as positive, negative, or indeterminate, are then sent from the central laboratory to the clinical site where the testing was performed. As with conventional HIV testing, the “window period” applies to OraSure testing too. Test results are typically available in 3–5 business days.

Advantages for the correctional setting: This is an accurate HIV testing algorithm for established HIV infection (similar to conventional HIV testing) with a built-in confirmatory test. The test is less hazardous because blood collection is not required and no laboratory infrastructure is required. These factors may be significant advantages to small correctional facilities that have limited medical services.

Disadvantages for the correctional setting: OraSure is more expensive than the conventional blood sample HIV testing, and it is slightly less sensitive during early seroconversion.

2. Rapid HIV testing

Currently six FDA-approved rapid HIV tests are available in the U.S., including OraQuick Advance Rapid HIV-1/2 Antibody Test, Reveal G3 Rapid HIV-1 Antibody Test, Uni-Gold Recombigen HIV Test, Multispot HIV-1/HIV-2 Rapid Test, Clearview HIV 1/2 Stat Pak, and the Clearview Complete HIV 1/2. These tests differ with respect to:

• ability to detect HIV-2 antibodies;
• the specimen required to perform the test (whole blood, serum, plasma, oral mucosal transudate);
• CLIA (Clinical Laboratory Improvement Amendments) categorization;
• ancillary equipment needed to perform the .test; and
• time for test to develop. Details regarding each of these rapid tests can be obtained from the CDC Web site at “General and Laboratory Considerations: Rapid HIV Tests Currently Available in the United States”

Rapid HIV tests can be performed at the point of care and results are generally available within 10–30 minutes. These tests are simple to perform and require minimal equipment. The rapid test detects HIV-antibodies analogous to the conventional HIV antibody testing, and, therefore, the “window period” applies to rapid testing as well. Rapid test results are reported as reactive (also called preliminary positive), non-reactive, or invalid. Repeat rapid testing is required if an invalid result is obtained. Preliminary positive rapid HIV tests must be confirmed with either an HIV Western blot or IFA. Therefore, testing sites that conduct rapid HIV testing should have the capability to obtain blood or oral fluid samples for confirmatory testing.

Advantages for the correctional setting: Rapid testing provides real-time, point-of-care testing for inmates that facilitates delivery of rapid test results to the inmate. Inmates can be provided the result (negative or preliminary positive) of the rapid test while waiting in the medical unit. Confirmatory HIV testing can be initiated for inmates with a preliminary positive result, therefore eliminating additional staff time. Studies have shown that rapid HIV tests can effectively be used in jails.^14,27

Disadvantages for the correctional setting: Additional samples must be collected to conduct confirmatory testing for persons with preliminary positive results. Results from confirmatory testing are usually available in 3 to 10 business days during which time some inmates will be released. The initial testing process is more time-intensive compared to conventional HIV testing because the rapid test is performed and results are obtained and can be delivered within the initial testing encounter. Rapid HIV testing requires greater material costs compared to conventional blood testing, and this may not be justified if rapid turnaround time is not required.

C. Evolving rapid testing strategies

Performing a combination of rapid tests from different manufacturers can be a strategy to increase the positive predictive value of the initial reactive rapid test. For example, if a Uni-Gold rapid HIV test is performed and the result is a preliminary positive, an OraQuick rapid test could then be performed. If both rapid tests are preliminary positive, there is an increased likelihood that the inmate is HIV-infected. However, the second rapid test does not replace the need for confirmatory testing with an HIV Western blot or an IFA. Confirmatory testing still needs to be completed. The benefit of performing a second rapid test is to estimate the likelihood of true HIV infection which can impact subsequent referral. Due to the high sensitivity and specificity of rapid HIV tests, while awaiting confirmatory test results, an inmate with a reactive rapid test could be immediately referred for counseling and scheduled for a clinical evaluation with an HIV clinical care team. For jail inmates who are to be released, appropriate evaluation with delivery of confirmatory test results could be scheduled in the community.

Correctional HIV testing algorithms

D. Considerations for HIV testing in correctional settings

Routinely providing opt-out HIV screening to jail inmates upon intake provides the most comprehensive HIV testing strategy. However, not all jails provide medical screening tests to all incarcerated inmates. In addition, at intake, inmates may be under the influence of drugs or alcohol use or withdrawal or emotional distress. These may limit the inmate’s ability to make an informed decision regarding consent for medical screening, including HIV testing. Providing screening during the initial comprehensive medical evaluation is an alternative strategy and may address some of the challenges of obtaining informed consent, but some inmates will have been released before undergoing such an evaluation. In prisons, where inmates are typically incarcerated for a year or longer, HIV testing should be completed during the initial medical evaluation to facilitate referral to HIV care.

• Correctional medical staff and HIV clinical care providers should be included in the discussions of when and how to test for HIV in the correctional setting.
• HIV information should be provided to inmates along with other medical information upon intake into the correctional facility. Information could be provided in a variety of strategies, such as discussions with counselors, classes, videos, pamphlets, or posters. HIV medical information should also be provided in the jail or prison library and medical clinics. Information should include the availability of medical care for inmates with HIV, opt-out HIV screening, and future HIV testing for inmates.

E. Interpretation of HIV test results

The conventional HIV-1 testing algorithm consists of initial screening with an EIA to detect antibodies to HIV-1. If the EIA is negative, the result is reported as negative and no further testing is conducted. Specimens with a reactive (positive) EIA result are tested again in duplicate in the laboratory. When the result of either duplicate test is reactive, the specimen undergoes confirmatory testing.

Rapid HIV tests are highly sensitive (very few false negatives) and highly specific (very few false positives). Rapid HIV tests yield a non-reactive (negative) result or a reactive (preliminary positive) result. When the test result is negative, no further testing is needed and the result is reported as negative to the individual. A reactive rapid HIV test result is considered preliminary positive, and confirmatory testing must be conducted to provide a definitive diagnosis.

Confirmatory HIV Testing

Tests used to confirm HIV infection are the Western blot and IFA. These confirmatory tests are more specific than screening tests and are reported as negative, positive, or indeterminate.

Inmates with a preliminary positive rapid HIV test or EIA and a negative HIV confirmatory test should be offered repeat confirmatory testing approximately 30 days after the date of the initial confirmatory test if recent infection is suspected. Inmates with two negative confirmatory test results 30 days apart after a preliminary positive rapid test or EIA without risk in the past 90 days are considered HIV negative. A negative confirmatory test may occur after a preliminary positive rapid test for several reasons: the inmate has been recently infected with HIV and is in the process of developing antibodies to HIV; the inmate could have Acute HIV Infection (AHI), as identified by Nucleic Acid Amplification Testing (NAAT); the inmate is not HIV-infected but may have an underlying health condition that is affecting the HIV screening test result; the inmate is not HIV-infected and the screening test was a false positive result; or a specimen mix-up could have occurred.

A confirmatory test result may be indeterminate after a preliminary positive rapid test or EIA. This result might represent either an incomplete antibody response to HIV in specimens from infected persons or nonspecific reactions in specimens from uninfected persons. Although IFA can be used to resolve an indeterminate Western blot sample, this assay is not widely used. Generally, 30 days after the initial Western blot a second specimen should be collected and tested. Although much less commonly available, NAAT (e.g., viral RNA or proviral DNA amplification method) could also help resolve an initial indeterminate Western blot. A small number of tested specimens might provide inconclusive results because of insufficient quantity of specimen. In these situations, a second specimen should be collected and tested for HIV infection. If the test result is repeatedly indeterminate, the inmate should be referred for further medical evaluation. An inmate with a positive confirmatory HIV test on re-analysis (Western blot or IFA) is confirmed to be HIV-infected.

Additional testing procedures

After rapid HIV testing, providers may choose to obtain a CD4 count at the same time a specimen is sent for confirmatory HIV testing. If the expected length of stay is greater than 48 hours, it may be advantageous to order a CD4 count test as this allows for early linkage to care. In addition, appropriate prophylactic medications can be initiated in a timely manner.²⁸ Another option is to perform a second rapid HIV test from a different manufacturer immediately after a preliminary positive rapid HIV test result. If this test is also positive, initiation of staging with CD4 count testing (if available at the facility) and linkage to care may be considered. However, a confirmatory test still must be performed based on the result of the first rapid test and irrespective of the result of the second rapid test. If conventional HIV testing is done, most laboratories reflexively do confirmatory testing with the initial blood sample if the EIA is positive. Therefore, the CD4 cell count and other baseline testing (e.g., viral loads) can be sent as a separate order as soon as the results of the positive confirmatory test are obtained.

F. Providing HIV testing results

1. Principles of Providing HIV Test Results

• Provide HIV test results in a confidential and timely manner.
• Communicate results in a manner similar to other serious diagnostic/screening tests. Clearly explain test results to the inmate.
• Inmates with a negative result may receive information in person or through confidential written notification. Review this process on a regular basis to ensure the appropriate test result information is received in a timely manner, the results are understood by the inmates, and that confidentiality is maintained.
• Inmates with positive results should be notified only in person in a private setting. During this confidential encounter, allow the inmate time to understand the meaning of the positive test result, determine the next steps for his or her clinical management, and provide mental health or social services support as needed.
• Follow all applicable state and local laws and regulations related to reporting of HIV/AIDS cases. For specific requirements about reporting HIV/AIDS cases, contact your state or local health department’s HIV/AIDS surveillance section.

Practical mechanisms of providing HIV test results to inmates vary by correctional setting. In prisons, those who test positive for HIV should be scheduled to see a trained health-care provider for notification and counseling in a confidential setting. To notify inmates who are HIV-negative, correctional systems may consider written notification to inmates when all medical reception lab tests are normal. This can be accomplished by staff providing a notice that indicates “your test results are normal” without specifying any tests, including HIV tests. This approach presumes other medical test results are also normal. The disadvantage to this approach is that there is no confirmation that the inmate received written test results or an opportunity for individualized education and prevention counseling. However, opt-in counseling can be available upon request.

High turnover of inmates in jail settings present challenges to ensuring that inmates are notified of test results prior to their release. Therefore, procedures should be developed and inmates informed of how to receive test results following release. Use of rapid HIV tests offers the opportunity for immediate notification of result, counseling, and referral to community resources, ensuring that a greater number of inmates are aware of their diagnosis prior to release.^14,29

3. Prevention counseling

Prevention counseling is an interactive process between the counselor and an individual. The goal of prevention counseling is to help the persons assess his or her risk, recognize HIV risk behaviors, and develop a plan to take actions to reduce risk behaviors.³⁰

In prisons, prevention counseling can be conducted when providing the inmate with their test result or at a later time. Prevention counseling can be provided in one or several sessions. In jails, prevention counseling should be provided at the time of result notification because of the short duration of incarceration. Additional guidance on prevention counseling can be obtained from CDC “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-care Settings”³¹ While prevention counseling should not be a barrier to providing HIV testing during routine medical screening, some inmates will benefit from prevention counseling. Therefore, prevention counseling ideally should be available to inmates undergoing HIV screening.

When providing prevention counseling for inmates infected with HIV:

• Discuss modes of transmission and natural history of HIV.
• Discuss importance of routine medical care.
• Discuss Partner Services options.
• Provide female inmates with HIV infection information on family planning, contraception, prenatal care, and breastfeeding.

4. Providing support for individuals who test positive for HIV

Individuals who receive a positive HIV test result should receive support in managing this information. For example:

• Provide education to patients about HIV infection, AIDS-related symptoms, and the significance of any laboratory testing done.
• Inmates diagnosed with HIV infection may require short-term mental health support.
• Inmates with mental health conditions may require increased monitoring and intervention for these conditions.
• Inmates may be reluctant to access or possess HIV educational materials due to concerns about disclosing their HIV infection. Strategies to provide HIV education and counseling for HIV-infected inmates can include HIV educational sessions and support groups.
• Facilities should have HIV medical information and periodicals available in prison libraries and medical clinics.
• Facilities should have chronic disease management programs for HIV-infected inmates.
• Facilities should have a discharge planning program for HIV-infected inmates.

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