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Rapid HIV testing underused in jails
Obstacles include consent, counseling laws
For correctional settings in many states the biggest obstacles to implementing an opt-out, rapid HIV testing program are state laws regarding HIV testing and counseling.
Without such legal barriers, rapid testing could be easily implemented, says Frederick L. Altice, MD, professor of medicine and director of clinical and community research, section of infectious diseases, AIDS program, at the Yale University School of Medicine in New Haven, CT.
Altice and co-investigators will be writing a manual on how to conduct HIV rapid testing in jail settings.
For example, in Connecticut, state laws require that all HIV testing is done with both pre-test counseling and post-test counseling, and a licensed tester has to administer the test, Altice says.
This makes it difficult to follow the new guidelines by the Centers for Disease Control and Prevention (CDC), which promote HIV, opt-out testing in various settings for better public health policy.
Without these state requirements, a correctional facility nurse could swab an inmate's mouth, get the results, and make referrals to care if the results were positive for HIV infection.
"The affinity with which you can do these things depends on how many barriers you have," Altice says.
Altice and co-investigators have studied the process of making HIV rapid testing a routine part of the inmate's medical check in jail.
For their study, when inmates went to the nurse for a visit, the nurse would ask a few questions about risk behavior involving drugs and sexual activity. Then the nurse would say, "We're going to put a skin test on your arm for tuberculosis, and we'll do an HIV test with a quick swab in your mouth," Altice says.
The inmate could opt out at that point, but most wouldn't, he notes.
Since the study was taking place in a state that required pre-test counseling, investigators would have to follow-up with the mouth swab and say, "In order to do this properly, we have to do HIV testing and ask you a few questions and get you to sign a consent form," Altice explains.
"We have had a handful of people who did not want to stick around, and they flat-out said, 'No, I won't spend 20 minutes dealing with paperwork,'" he says. "So we'd toss the swab."
Impediments to treatment?
What this showed investigators is that more people could be tested if there weren't pre-counseling and consent document requirements.
"This is why we need to get rid of the impediments to rapid HIV testing because we have the ability to test people, identify them as positive, and get them into treatment more quickly," Altice says.
Altice and co-investigators' latest research, which featured women in jail, also pinpointed the ideal time for offering HIV testing to inmates.
"We ended up having the highest rate of uptake 24 hours after they came in to the facility," Altice says. "When women came into the facility after being in a holding pen all day, they were exhausted and said, 'Leave me alone.'"
The rate of women who'd have the rapid HIV test was 50% for that group.
When investigators waited a week before checking with women in jail, they found that a large number of them were gone and not available to be tested, but those who were there had a high rate of acceptance of the test, Altice says.
So the optimal time period was to offer the test at 24 hours after the woman was admitted to the jail, he adds.
The study showed that 73% of women offered the test at 24 hours were swabbed for the rapid HIV test.1
"This gave women time to sleep and get rest, so the day after they came into the jail seemed to be the time when you had the highest uptake [of HIV testing acceptance]," Altice says.
Another reason why HIV rapid testing is not being used widely in jail settings is because of concerns about tracking down inmates who are HIV-positive for medical care and follow-up, Altice notes.
"Say we do the rapid test and have its preliminary positive result, then what happens is the next day when we want blood work drawn, the person has been bonded out or went to court or was released," Altice explains. "So we're stuck with this person who potentially is HIV positive, and we never can give them the results of the [Western blot] test."
This means that someone, and ideally this could be handled by a community HIV service organization, needs to track down the people who had preliminary positive tests, have them confirm the results, and assist them with finding medical care, he says.
With some of Altice's research, people who were found positive by the rapid HIV test proved very difficult to find once they were released from jail.
"It took us a year or so to get them hooked up with a doctor," Altice says.
"So if you identify people as HIV positive, there's a benefit to society," he adds. "But you have to make sure there's no cost to society with the person continuing to infect other people."
In Connecticut, there's a program called CARE that primarily helps people infected with HIV disclose their status to other people and suggests their sexual partners be tested, as well, Altice says.
CARE also has helped link HIV-positive people released from jail to medical care and testing follow-up, he adds.