Dramatic results for opt-out HIV testing in prison

Proportion of HIV tests increased quickly

States that do not require HIV testing in prison might consider an opt-out testing option that has been shown in North Carolina to dramatically increase HIV testing among inmates.

North Carolina state prisons switched from an opt-in HIV testing policy to an opt-out testing policy in 2008, and researchers studied the results of the switch.

Under an opt-in policy, inmates are asked if they would like an HIV test, and they're only given one if they request it. Under the opt-out policy, they are told that the HIV test is standard but they can decline it if they choose.

"Our data looked at thousands of people coming into prison, and about 60% said, 'Yes,' under the opt-in policy," says David Alain Wohl, MD, an associate professor at the University of North Carolina in Chapel Hill, NC.

When the opt-out policy was adopted, the percentage of inmates being tested for HIV increased to more than 90%, Wohl says.

The results confirm what other research has shown to occur when opt-out testing is employed, he notes.

"Our study follows a string of studies that look at opt-out in various circumstances," Wohl says.

"This is not a new phenomenon," he adds. "Anyplace you go where opt-out has been introduced, whether it's an STD clinic in Amsterdam or prisons in North Carolina, when you go from opt-in to opt-out, the proportion of people tested for HIV skyrockets."

The study found that 1.3% of those tested under the opt-out policy were found to be HIV-positive.1

Women inmates, who represented a minority of the inmates entering prison in the two time periods studied, were more likely in the opt-in period to be HIV tested, Wohl notes.

"In prisons they test women for chlamydia, pregnancy, and a comprehensive parcel of other tests, so women are more likely to do the HIV test too," he says.

Among male inmates, most young men and teenagers who were sent to special processing centers were not tested under the opt-in process, he says.

"We saw we could greatly influence the number of people being tested by going to a more streamlined policy based on what the Centers of Disease Control and Prevention (CDC) recommended," Wohl says. "We looked at the results by months and saw an immediate response, so the policy was embraced throughout the prison system."

During the opt-out testing period studied, 15,258 inmates were HIV tested. In the six month period of opt-in testing, 8,795 inmates were HIV tested.1

"We tested thousands more people, and there were some people whose HIV infection would not have been detected without opt-out testing," Wohl says. "Based on six months of data, we discovered 30 to 35 new HIV infections."

The opt-out program caught HIV infections among people who didn't have any idea they were HIV positive, he adds.

"There are significant benefits to identifying people who stay under the radar," he says.

Since all of the people identified as HIV positive were in the state prison system, they were immediately referred to HIV care and services.

"We have a model system where the University of North Carolina and the prison system have an arrangement where a handful of specialists from the university provide all the care, along with an HIV specialist in the Western part of the state, for the prisoners who test positive, Wohl says.

"They run clinics in prison, and these are geographically located at four different sites across the state," he adds. "We take care of all the HIV, and no one from the department of corrections has to prescribe antiretroviral therapy."

Patients in prison receive a specialized model of care, and all have access to HIV treatment once their infection is known, he says.

The opt-out policy relies on a uniform script in which inmates who were being processed were told that there were a number of different tests that would be done. These included physicals, mental health assessments, a tuberculosis test, and syphilis testing, which is mandatory in North Carolina.

The script went something like this: "Unless you say otherwise, HIV testing also will be done. If you don't want it done, then you can tell us you don't want to do it, and then we'll just ask you why you don't want to do it," Wohl says.

Those discussing tests with inmates read from a very short statement and then documented the response of inmates who declined HIV testing, he says.

"Inmates opting out of testing might say that they already know they're HIV positive or that they were just tested in jail," he adds.

For those receiving the HIV test, the logistics are fairly simple. The inmate's blood is collected for syphilis, and the excess blood is tested for HIV.

"They get their results very quickly," Wohl says. "We do this in a streamlined way."

Investigators will continue to study the opt-out policy, next looking at the people who tested positive to see if they understand the opt-out process and understand that they had a choice to opt out, he adds.


  1. Wohl D, Smith P, Green K, et al. Opt-out HIV testing on prison entry increases the proportion of individuals screened for HIV and the number testing seropositive. Poster: 1006. Presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI), Feb. 16-19, 2010, in San Francisco, CA.