There are benefits to the community as well as the individual when a person learns of his or her HIV infection. Many people reduce their HIV risk behaviors to prevent transmission to their partners after being diagnosed with HIV infection,⁵ and they can begin the process of accessing care, treatment, and prevention services. Previous research has shown that men with a history of incarceration may avoid HIV testing while in the community⁶ and that inmates are more likely to receive voluntary HIV testing when prisons routinely provide (opt-out) HIV testing to everyone during the intake medical evaluation as opposed to prisons that rely on inmate-initiated (opt-in) requests for testing.⁷ Recent studies demonstrate that voluntary HIV testing is as cost-effective as other screening programs in health care settings in which HIV prevalence is as low as 0.1%. Since many incarcerated populations have a prevalence of diagnosed HIV infection >1%,8 HIV screening in prisons and jails is a highly cost-effective public health strategy.

With opt-out HIV screening, the inmate is informed that an HIV test will be performed unless he or she declines the test. This process preserves public health and medical staff resources and greatly increases the proportion of inmates tested due to the streamlined consent and counseling processes.⁹ Opt-out screening also helps normalize HIV testing by making it a routine instead of an exceptional aspect of health care. Opt-out HIV screening has been used in the Wisconsin prison system since at least 1986¹⁰ and Rhode Island system since 1988¹¹ and may be feasible and acceptable in many other correctional settings. Opt-out HIV screening has the potential to identify many more HIV-infected individuals who are currently unaware of their HIV infection than opt-in screening does.¹²

A. Benefits of adopting an opt-out HIV screening program

• Increases diagnosis of HIV infection;
• Preserves staff resources by streamlining the process;
• Reduces stigma associated with testing;
• Potentially diagnoses HIV infection earlier for the inmate; and
• Improves access to HIV clinical care and prevention services.

B. Basic principles of opt-out HIV screening

• HIV testing should be voluntary and free from coercion;
• Provide all inmates with information on HIV/AIDS and HIV testing upon entry into the facility;
• Screening should be performed only after notifying the inmate that an HIV test will be performed unless he or she declines (opts-out);
• Consent for HIV screening should be incorporated into the general informed consent (or other legal authorization) for medical diagnostic services;
• Separate written consent should not be required for HIV testing, unless required by state law; and
• Appropriate clinical care and support services to inmates diagnosed with HIV infection should be provided.

C. Alternative opt-out approaches to universal opt-out HIV screening

While opt-out HIV screening during a routine medical assessment is the CDC-recommended optimal approach to providing HIV testing, the logistics, security, and financial demands of routine opt-out HIV screening may make it necessary to implement alternative approaches. For example, the constant inflow and rapid turnover of inmates in jails may make it difficult for some jails to implement universal screening for all inmates who are booked into their systems.

Recognizing the need f or alternative approaches, this section is provided as a guide to assist correctional facilities in determining the opt-out approach that will efficiently identify the most previously undiagnosed cases of HIV among their inmate population while minimizing the burden to correctional staff and resources. Universal opt-out testing should still remain the ultimate goal when possible. Opt-in strategies have been found to miss diagnosing a significant number of HIV-infected persons and therefore are not the ideal.

1. Risk-based screening

Risk-based screening would routinely offer HIV screening to inmates with any of the following HIV risk characteristics in the last 12 months:

• Injection drug use (IDU);
• Men who have sex with men (MSM);
• Sex with an IDU, MSM, or HIV-infected partner;
• Multiple sexual partners;
• Exchange of sex for money, drugs, or other goods; and
• Diagnosis of another sexually transmitted infection (STI).

When implementing this strategy, the medical evaluation process should include risk-based questions to determine which inmates should be routinely offered screening. Medical staff must be trained in eliciting sensitive information in a nonjudgmental manner.

Recent studies in jail settings, however, indicate that risk-based or opt-in screening strategies may still miss identifying a significant number of HIV-infected persons. Two recent studies indicated that substantial portions of previously undiagnosed HIV-infected inmates did not report any HIV risk factors when screened. In a study by Harawa et al.,¹³ the prevalence of HIV infection did not differ between females responding yes to one or more HIV risk indicators and those responding no to all risk indicators. In a study by MacGowan et al.,¹⁴ 42% of the jail inmates who were newly diagnosed with HIV reported none of the following HIV risk behaviors: MSM; IDU; sex in exchange for drugs, money, or other items; history of an STI; having been sexually assaulted; and sex with a partner who injected drugs, was HIV-positive, or was an MSM.

2. Clinical screening

A number of clinical indicators may indicate higher risk of HIV co-morbidity or have severe implications if HIV infection goes undiagnosed and untreated. It has been estimated that 16% to 41% of prison inmates had serologic evidence of hepatitis C (HCV) infection and 13% to 47% had serologic markers for hepatitis B (HBV).¹⁵ Both HBV and HCV may be indicative of potentially risky blood-borne or sexual exposures, increasing the likelihood of possible HIV coinfection. Treatment for HCV and HBV may need to be modified in the setting of HIV, and, therefore, diagnosis of HIV infection is of the utmost importance. Individuals with other active STIs are also at risk for HIV coinfection. There is substantial evidence that the presence of STIs increases the likelihood of both acquiring and transmitting HIV infection,^16,17 and screening and treatment of STIs has been shown to lower the incidence of HIV infection.^18,19 There is a strong association between risky sexual behaviors and the use of illicit drugs (especially injection drugs, stimulants, and ecstasy) and alcohol abuse which leads to an increased risk for HIV infection.

Undiagnosed HIV infection may also cause additional complications. For example, persons coinfected with Mycobacterium tuberculosis (MTB) and HIV are at increased risk of progression to active TB disease, and pregnant women who are infected with HIV but not diagnosed cannot take advantage of therapies that could reduce their risk of passing the virus to their unborn child.

Clinical indicators for screening:

• Pregnancy;
• A diagnosis or history of sexually or parenterally transmitted infections (e.g., HBV or HCV, syphilis, genital herpes, gonorrhea, chlamydia, trichomonas infection);
• MTB infection or active TB;
• Track marks indicative of illicit drug injection;
• Signs or symptoms suggestive of HIV infection or acute retroviral syndrome (see Appendix B and the HIVMA Guide to Recognizing Acute Infection).

3. Demographic screening

Demographic factors, which include such factors as area of residence, age, gender, and race/ethnicity, may be associated with HIV infection among incarcerated populations. AIDS rates have been reported to be higher among inmates from residential areas with high poverty rates and relatively low median household incomes compared to the general population.^20,21 The bulk of estimated HIV/AIDS cases in the United States involve individuals ages 35–44 years, with the next highest number of cases (and potentially a larger number of undiagnosed cases) occurring in those ages 25–34 years.²²

The highest self-reported HIV prevalence among prison inmates involves inmates aged 35 years and older.⁸ In State and Federal prisons in the Southern and Northeastern United States, the HIV prevalence is 35% to 100% higher among female inmates than male inmates.⁸ Transgender inmates also have high HIV prevalence levels.^23,24,25

HIV infection is associated with race and Hispanic ethnicity; however, given many political sensitivities regarding race within both correctional and medical settings, using race or ethnicity as the sole HIV screening criterion may create barriers to implementing routine testing.

Jail and prison systems interested in using demographically-based screening criteria should identify factors for targeting HIV screening based on an evaluation of epidemiology data from their incarcerated population and the residential communities which feed their custody population.

Potential demographic screening criteria:

• Residence in low-income areas/zip codes;
• Residence in known high-HIV prevalence areas/zip codes;
• Female sex;
• Age 25–44 years; and
• Transgender identity (male to female).

4. Custody-based screening

Custody-based information may also help to identify inmates at risk for HIV. A few studies indicate that inmates who have been incarcerated multiple times, particularly parole offenders, are more likely to be infected with HIV than inmates who have not.^13,26 Preliminary data indicate that specific criminal charges may also be associated with higher HIV prevalence levels. Analyses of data from both State and Federal prisons and specific jails indicate variations in HIV prevalence by criminal charge with HIV infection most consistently associated with property offenses and drug offenses.^4,8 In a 2003–2004 study of newly-arrested Los Angeles jail inmates, drug-related arrest charges were associated with undiagnosed HIV infection in female but not male inmates.¹³

5. Multiple approaches

We suggest that incarceration systems that do not elect to implement a universal opt-out approach should collaborate with local public health entities to develop strategies for integrating multiple opt-out approaches in order to identify the greatest number of undiagnosed HIV infection. For example, one strategy could be to routinely offer opt-out HIV testing to all inmates with HIV clinical indicators, all women under the age of 45 years, and men who report specific characteristics not based on reported risks behaviors (e.g., location of residence or arrest). State and local HIV/AIDS surveillance data, information from HIV testing programs in prisons or jails in the region, and data from similar populations, including public STD clinic attendees, individuals receiving publicly-funded HIV testing services, and National HIV Behavioral Surveillance data, can inform the development of alternative HIV screening strategies in correctional settings.

D. Repeat screening

Persons at high risk for HIV (e.g., IDU and MSM) should be routinely offered opt-out HIV testing annually. In correctional facilities, this recommendation should also be followed for persons known or suspected to have engaged in drug use or sexual activity while incarcerated. In addition, opt-in HIV testing should be available upon request to inmates because inmates may not be forthcoming about their prior risk behavior and medical staff may not ask about risk behaviors during incarceration. In high prevalence communities, correctional facilities may also consider routinely offering HIV testing prior to release.

Go to Section III