Testing polices for HIV detections are highly variable between the federal, state, and local (jail) jurisdictions. Eighteen state prison systems mandate testing for HIV on entering the system, including New Hampshire, Rhode Island, Iowa, Michigan, Missouri, Nebraska, North Dakota, South Dakota, Alabama, Georgia, Mississippi, Oklahoma, Colorado, Idaho, Nevada, South Carolina, Utah, and Wyoming. Transmission of HIV in prison does occur, but accurate quantification of transmission rates has never been undertaken aside from several small studies.

Table 1: Summary of HIV serology testing policies

Several states -- Missouri, Alabama, Virginia, and Nevada -- also require inmate testing upon release. The Federal prison system test inmates upon release (but not on entry). Arkansas, Rhode Island, and Virginia test all inmates in custody. New York tests inmates at random. States also test selectively, according to circumstances. Forty states test based upon inmate request, termed "voluntary testing." There is an intermediate type of testing – between mandatory and voluntary -- termed "routine," in which testing is performed unless the patient refuses. Two states have routine testing on entry. No city or county jail system conducts mandatory testing.

Taken together, all state prison systems make HIV antibody testing available, but the circumstances under which testing occurs varies widely.

Guidelines for pre-test and post-test counseling (Based on recommendations of the NY State AIDS Institute 3/00 for testing of all persons)

HIV Pre-Test Counseling

Discuss with patient:

• prior history of HIV test counseling;
• nature of AIDS and HIV-related complications;
• benefits of diagnosis and medical intervention;
• HIV transmission and risk reduction behaviors;
• possible discrimination resulting from disclosure of HIV test results and legal protections against discrimination;
• for pregnant women: benefits of diagnosis for preventing perinatal transmission and for treatment of the newborn.

Informed Consent for HIV Antibody Test

• Obtain written informed consent, prior to ordering test, from patient or person authorized to consent.
• Provide patient with a copy of the consent form or document containing all pertinent information.
• Consider patient’s ability, to comprehend the nature and consequences of HIV antibody testing. If the patient’s ability to understand is temporarily impaired, defer testing.
• Explain test and procedures:

• purpose of the test;
• meaning of test results;
• testing is voluntary;
• consent may be withdrawn any time.

• Explain protections of confidential HIV-related information and conditions of authorized disclosure.
• A licensed physician or other person authorized by law to order a laboratory test must sign all orders for HIV antibody testing and certify the receipt of informed consent.
• Provide reassurance and/or referrals for emotional support for patient during the waiting period.
• Plan discussion of test results and post-test counseling (allow sufficient time for completion of confirmatory testing).

HIV Post-Test Counseling

For patients with a negative test result:

• discuss meaning of the test result;
• emphasize that a negative test result does not imply immunity to future infection;
• reinforce personal risk reduction strategies.

• discuss meaning of the test result;
• discuss availability of medical care including prophylaxis for opportunistic infections and antiretroviral therapy;
• with pregnant patient discuss and recommend use of antiretroviral agents, consistent with clinical practice guidelines, to reduce risk of maternal-child transmission;
• encourage partner/spousal notification;
• encourage referral of partners and children for HIV testing;
• provide counseling or refer to counseling:

• for coping with the emotional consequences of test result;
• regarding discrimination that disclosure of result could cause;
• for behavior change to prevent transmission of HIV infection;

• provide or refer to needed medical support services.

• discuss meaning of test results;
• encourage retesting;
• discuss availability of appropriate medical follow-up;
• reinforce personal risk reduction strategies

PREVALENCE OF HIV IN CORRECTIONS

The prevalence rate for HIV antibody in prisons and jails is 2.1%, according to the Department of Justice statistics (Maruschak LM: HIV in Prisons, US Dept Justice, Bureau of Justice Stastistics, 12/9/99, pg. 1). This prevalence has been roughly stable from 1991 to 1997. In 1997, the prevalence rate was 1.0% in Federal prisons, 2.2% in state prisons, and 3.4% in female inmates. (The true prevalence is underestimated because a minority of systems tests all entrants.)

Prisons: The Department of Justice listed the following jurisdictions with HIV-seroprevalence greater than 3% in 1997: New York 10.8% (decreased from 13.9% two years earlier), Connecticut 5.1%, Massachusetts 3.7%, Florida 3.6%, Maryland 3.5%, New Jersey 3.4%, and Rhode Island 3.2% ( ibid pg. 2). The prevalence rate in the Northeast region overall is 6.4%; the Midwest, 0.9%; the South, 2.0%; and the West 0.8%. The overall prevalence in the Midwest and West is very low (usually less than 1%), but some urban areas contribute numbers similar to the Northeast (West J Med 1990;153:394). Quite different seroprevalence are reported in the 1998 Corrections Yearbook (The Corrections Yearbook 1998, Camp CG, pg. 38). The following systems reported rates above 3%: Delaware 10.1%. Maryland 9.0%, Vermont 5.7%, Alabama 4.6%, South Carolina 4.2%, New Jersey 3.6%, West Virginia 3.6%, California 3.3%, and Pennsylvania 3.1%. (These studies were done on selected samples, and the figures do not represent the true prevalence rates because the samples may have been on entrants and not all inmates). Nine states reported ten or fewer HIV-positive inmates in their prisons: Alaska, Idaho, Kansas, Montana, North Dakota, South Dakota, Vermont, West Virginia, and Wyoming (Maruschak LM: HIV in Prisons, US Dept Justice, Bureau of Statistics, 12/9/99, pg. 3).

Studies by Vlahov, et al. have shown significant variability of rates of HIV seroprevalence among entrants to ten correctional institutions ranging from 2.1% to 7.6% for men and 2.5% to 14.7% for women (JAMA 1991;265:1129). Studies done in the last decade on entrants into the Maryland state prison system showed higher rates than current prevalence studies, but entry studies and prevalence studies on inmates are not directly comparable. Data from April to June 1985, 1986, and 1987 showed the crude prevalence of positive HIV serology was 7.1, 7.7, and 7.0%, respectively (JAIDS 1989; 2:283).

Jails: Based on Department of Justice survey statistics, the percentage of males in local jails who were HIV positive is approximately 2.1% + 0.6 (or 1.5% ─ 2.7%) (Maruschak LM: Update HIV/AIDS, STDs and TB in Correctional Facilities, US Dept Justice, Office of Justice Programs, Nat Instit Justice, 7/99, pg. 16). In general, the larger the size of the jail, the higher the percentage with HIV infection. This survey does not include inmates who are being detained for trial or sentencing.

Jails in large metropolitan areas, particularly in the Northeast, probably have a very high prevalence rate of HIV-positivity, but data are scarce. It is likely that estimates of the prevalence understate the true number in jails. According to a study in New York City the prevalence of HIV-1 positivity in entrants to the city jail was 15% (375/2479) in 1992 and 10% (544/5414) in 1996. In 1992, the prevalence in men was 12%, while that in women was 26%. By 1996, prevalence in men had declined to 7%, while that in women was 20% (5^th CROI, 2/98, Abst 142).

Incidence in Women: The Northeast has the highest proportion of female inmates infected with HIV, at 12.7% prevalence in 1997 (Maruschak LM: HIV in Prisons 1997, US Dept Justice, Bureau of Justice Statistics, 12/9/99, pg. 5). New York is the highest at 20.7%. Other states of high prevalence include: Connecticut, 13.1%, Massachusetts 8.2%, New Jersey 5.5%, Rhode Island 6.1%, Florida and 7.1%, Georgia and 4.2%, and Maryland 7.6%, and Nevada 4.9%. While caring for with HIV infection in general is becoming a specialized task, caring for female inmates with HIV disease requires further specialization.

Incidence of AIDS: From 1996 to 1997, the mortality rate from AIDS declined from 0.54 deaths per 1,000 inmates to 0.27 presumably due to improved treatment with HAART (The Corrections Yearbook 1998, Camp GM, pg. 35). The number of confirmed AIDS cases tripled from 1991 to 1997 to a total of 6,184 individuals at the end of 1997 (Maruschak LM, HIV in Prisons 1997, US Dept Justice, Bureau of Justice Statistics, 12/9/99, pg. 4 ). The overall percent of the population with confirmed AIDS was reported at 0.55%. The highest percentage of state prison population having confirmed AIDS was in New York (1.9%), followed by Rhode Island (1.4%), Connecticut (1.3%), Florida (1.3%), and Maryland (1.3%).

HOUSING ISSUES FOR INMATES WITH HIV AND AIDS

The separation of inmates with HIV infection from the general population is a controversial issue that has undergone significant change. Some jurisdictions segregate HIV-positive inmates for the purpose of preventing transmission of HIV, while other systems cluster HIV-positive or those with symptomatic HIV infection for purposes of treatment and allocation of medical resources.

A 1985 review of 51 state and federal prison systems showed eight systems had segregation policies for HIV-infected inmates, and 38 (75 percent) of systems had segregation policies for patients with AIDS. By 1997, the number of systems segregating HIV-infected inmates had dropped to two -- Mississippi and Alabama -- and 3 systems segregated inmates with AIDS: Alabama, Mississippi, and California (Hammett MH 1996-97 Update: HIV/AIDS, STDs and TB in Correctional Facilities, US Dept Justice, Nat Inst Justice, 7/99, pg. 63). In 1998, South Carolina adopted the policy of mandatory HIV serology of all state inmates with transfer of those with positive tests to a maximum security prison in Columbia.

The information from the Justice Department publications is somewhat misleading, because it gives the impression that Mississippi, South Carolina, and Alabama are the only states that practice separation of HIV-positive inmates from others, and California is the only one that separates those with AIDS. In reality, there are many states that separate inmates with HIV, and the reasons may be either medical or non-medical. The Criminal Justice Institute lists the following jurisdictions that segregate HIV-infected inmates in addition to those named above: Arkansas, Delaware, Illinois, Maine, Montana, Nebraska, Nevada, Ohio, Pennsylvania, Tennessee, and West Virginia (Corrections Yearbook 1998, Camp CG, 1998, pg. 38). In California, the housing of patients with AIDS is separate from the other inmates, but the daily activities of these inmates are mixed with the general population (AIDS Policy Law 1997;12:8).

It is important to distinguish between "segregation" and "clustering" or concentration of HIV cases. The key distinction is that with clustering, most HIV-infected inmates live in general housing. For the purposes of clarification, Dr. Larry Mendel proposes the following categories (personal communication):

1. Segregation of all HIV infected inmates.
2. Disciplinary segregation based upon prior behavior (after appropriate hearing).
3. Clustering of HIV cases to selected sites especially for complicated cases ("Centers of Excellence").
4. Transfer to a medical facility to provide for advanced care needs, especially daily living needs. Examples include New York Regional Medical Units, California Medical Facility, and Corrections Medical Center in Ohio .

The rationale for segregating HIV-positive inmates stated by Alabama in Harris v. Thigpen is that integrating HIV-positive inmates into the mainstream would pose a significant health risk to the other inmates. The state Department of Corrections presented data that indicated their policy reduced the rate of transmission. They indicated an annual seroconversion rate of 0.0006%/year in Alabama, compared to 0.19%/year in Nevada, 0.33%/year in Illinois, and 0.41%/year in Maryland (AIDS Policy & Law 1997 November 28; 12 (21): 1,14 – 5.)

It is widely assumed that the transmission rates of HIV within prison populations are low and segregation does not materially affect transmission. Three studies showed seroconversion rates of 1/200 to 1/604 person-years in prisons with seroprevalence rates of 2 – 4%( 1.Horsburgh CR Jr , Jarvis JQ , McArther T , Ignacio T , Stock P. Seroconversion to Human Immunodeficiency Virus in Prison Inmates. American Journal of Public Health 1990 February; 80 (2): 209-10.

2. Castro K , Shansky R , Scardino V , Narkunas J , Coe J , Hammett T: HIV transmission in correctional facilities. Centers for Disease Control, Atlanta, GA, USA Int Conf AIDS 1991 Jun 16-21;7(1):314 (abstract no. M.C.3067)

3. Brewer TF , Vlahov D , Taylor E , Hall D , Munoz A , Polk BF, Department of Health Policy and Management, Johns Hopkins University: Transmission of HIV-1 within a statewide prison system. AIDS 1988 Oct;2(5):363-7) . The rate of transmission seems to correlate with the baseline rate of infection, implying an exposure risk. Extrapolated to the entire population of 2.1 million inmates in the United States, 1 to 2 infections per 600 inmates per year would mean 350 to 700 HIV infections occur in incarcerated individuals per year.

Beyond the issue of transmission, theoretical advantages and disadvantages for grouping of HIV-positive inmates include the following:

Advantages: Aggregation helps patients with similar specialized care needs to obtain uniformity of treatment and enhance access to expert medical help.

1. Living in a therapeutic community may enhance patient education through peer counseling and support, and reduce stigmatization among the inmate population.
2. Concentration on special needs may promote institutional flexibility such as scheduling of meal times and medication administration to coincide with particular requirements for antiretroviral medications.

Disadvantages: Segregation of HIV-positive inmates has the following disadvantages:

1. Segregation may decrease HIV infected inmates' access to participation in programs that are not available at the institutions where they are housed.
2. There are problems associated with combining prisoners of varying security levels in the same unit (Lines R: The case against segregation in "specialized" care units. Prisoners With HIV/AIDS Support Action Network, Toronto, Ontario, Canada. Can HIV AIDS Policy Law 1997-98 Winter;3-4(4-1):30-5.).
3. Inmates with HIV may be separated from the proximity of family or support outside of their home region, or they may decline to be tested because of that concern. (Lines R: The case against segregation in "specialized" care units. Prisoners With HIV/AIDS Support Action Network, Toronto, Ontario, Canada. Can HIV AIDS Policy Law 1997-98 Winter;3-4(4-1):30-5.)
4. Segregation may inadvertently give credence to unscientific beliefs about HIV transmission.
5. Segregation may compromise confidentiality of HIV serostatus.

CHALLENGES AND OPPORTUNITIES WITH TREATING HIV IN CORRECTIONS

Treating HIV in a correctional environment can offer some distinct advantages and many challenges. The most significant advantage is the ability to offer therapy and to monitor patient adherence to treatment recommendations. In some systems, inmates must take antiretrovirals under the "directly observed therapy" (DOT) system, while others practice "keep on person," called "KOP" in prison parlance. The DOT method offers the unique opportunity to judge more accurately whether a regimen is failing due to issues of medication choice and not adherence. To date DOT for HIV therapy has been successfully implemented almost exclusively in the correctional system despite desirability of a much broader application.

Quality of care: It is difficult to evaluate the quality of HIV care in the correctional system. Possible advantages are that patients in the correctional environment often have access to health care resources that may not be readily accessible in the general population; and there usually are no financial barriers to obtaining care for chronic conditions such as HIV, though some states and the Federal system have instituted co-payments for some services. Inmates are rarely far from a medical resource, as long as they are allowed to access the resource. Most inmates would be Medicaid recipients or uninsured if not imprisoned; this is the category of patients identified by the Institute of Medicine report as having suboptimal care, a problem that is increasing under managed care.

Obviously, inmates have little choice regarding the health care providers they see. Therefore, entities undertaking prison health care should develop the educational and mentoring capabilities that are necessary to be sure the providers are able to provide high quality HIV care in the correctional environment. Several agencies exist that offer accreditation for correctional health care units including the National Commission for Correctional Health Care (NCCHC) and the American Corrections Association (ACA). These entities have their strengths and weaknesses, but they represent one way in which the quality of correctional health care can be monitored. It is equally important for health systems to have their own systems to monitor the quality of the providers, their credentials, their performance, the systems and processes in place to promote good health care, and – ultimately -- the health outcomes of the delivery system.

Post-release care: One of the greatest challenges facing prison health care is the continuity of care following release. It is often difficult for even highly-motivated inmates leaving prison to access medical services or funding for medications. Even when Medicaid funding is available, the inmate may have to wait 30 days to a year after release to become eligible. Ryan White Care Act funds specifically target the inmate population and should be contacted regarding medical care and support services. Many of the pharmaceutical companies have made free medication available for inmates leaving prison for some defined period until they have sources of funding for their medications, but this availability still does not address the issue of the assignment of providers of care. Several innovative projects are underway to address these issues, and a recent set of grants from the Department of Health and Human Services have challenged corrections and public health agencies to work together to solve these problems. A frustrating but oft-repeated scenario is the inmate who receives state-of-the-art care for his HIV while in prison, is released, and later presents again to the prison with resistant virus from inconsistent medication adherence post release due to incongruous medical care.

Recidivism: Many jail systems tend to interact with some people on an ongoing basis. These individuals often do not have access to continuous health care upon leaving the incarcerated setting, often due to the inability to qualify for state health care funding, or, more frequently, failure to access medical care due to an inability to understand how to enter the system or apply for help. This often arcane skill can represent a challenge even to educated and highly-motivated persons. Well-meaning providers in the jail setting often see it as their duty to initiate antiretroviral therapy when an inmate has HIV infection, but then fail to consider the consequences of this initiation once the patient leaves the institution. Some communities have few or no providers willing to take care of HIV infected former inmates, while in other communities access is limited due to lack of communication between the jail and the public health providers. It has now become increasingly apparent that clinicians should avoid initiating antiretroviral therapy that cannot be continued post release if this is anticipated relatively soon.

Jails: The question of who is responsible for the health care of the patients remains a difficult issue in many jails, and there is still a great deal of work to be done in coordinating care for chronic offenders in jail systems. It is important to remember that lengths of stay in jail system may average a few days to weeks, and many offenders are not actually convicted of crimes while they are in jail. This is an important issue because the jail may serve as an excellent site for testing and counseling, but the short stay with indefinite medical care follow-up may make the initiation of antiretroviral therapy unrealistic or even ill-advised. In 1997, the average length of incarceration of unsentenced prisoners released from jails was 38.6 days; sentenced prisoners stayed an average of 93.9 days, and the combined average stay for all jail inmates was 47.3 days (The Corrections Yearbook 1998. Camp CG, Camp GM. Criminal Justice Institute, Inc., Middletown, CT, 1998; p.229.). Medium-sized jails have an average length of incarceration of only 23 days (The Corrections Yearbook 1998. Camp CG, Camp GM. Criminal Justice Institute, Inc., Middletown, CT, 1998; p.228).

Social work and mental health issues: Programs that deal with the psychological and social aspects of HIV disease (and other chronic diseases) have been shown to reduce recidivism (Kim J.Y. et al., "Successful Community Follow-up and Reduced Recidivism in HIV-Positive Women Prisoners," Journal of Correctional Health Care 4 (1997): 5–17). In general, recidivism correlates with sub-optimal self care and increases the likelihood of poor disease outcomes. HIV and other chronic infectious diseases like Hepatitis C tend to be over-represented in persons who are likely to be incarcerated multiple times. According to a survey by the Criminal Justice Institute, jail systems often have programs for intervening in drug abuse problems, including group counseling in 81.7% of jails 82% of jails with 57% offering individual drug counseling (The Corrections Yearbook 1998. Camp CG, Camp GM. Criminal Justice Institute, Inc., Middletown, CT, 1998; p.254). The reader should keep in mind, however, the possibility that respondents to the survey that supplied these results may not represent the true rate.

Attempts to reduce drug addiction and recidivism have been generally disappointing. An exception is Delaware where a "therapeutic community" (TC) model of substance abuse treatment and intervention with treatment during and after incarceration demonstrated durable reduction of recidivism in that state (Martin SA, Butzin CA, Saum CA, Incardi JA, Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: from prison to work release to aftercare. The Prison Journal; 79(3) Sept. 1999 p.294-320). This model also demonstrated how partnerships between public and private entities can create synergy. Coupling HIV care with the treatment of substance abuse seems to be a promising method of encouraging and maintaining adherence, and it serves the interests of the state as well as the patient. Another potentially useful but controversial method of HIV intervention is to base medication administration for HIV around a methadone-maintenance program.

INITIAL MEDICAL EVALUATION: The following summarizes the basic elements of HIV care that apply to virtually all adult patients with HIV infection:

Medical history

• HIV serology with dates of positive and negative tests
• Transmission category
• HIV related history: CD4 counts, VL, HIV-associated complications
• Medical care: history of care and source, prior PPD, prior Paps, vaccinations: Pneumovax, tetanus, influenza, HBV, HAV
• Past medical history: cardiovascular risks (HAART candidates) – obesity, hypertension, smoking, family history, and blood lipids.
• Targeted history: TB exposure/risk, prior chicken pox or shingles, STDs, hepatitis A, B or C, gynecologic history, substance abuse
• Medications: HIV meds and adherence; OTC drugs, alternative therapy
• ROS: constitutional symptoms – fever, night sweats, weight loss, fatigue; GI: Anorexia, nausea, vomiting, diarrhea, abdominal pain; chest: cough, dyspnea, chest pain; neuro: headaches, extremity pain/parenthesis, mental status changes; miscellaneous: rashes, insomnia, adenopathy, vision

Physical exam

Counseling: Risk reduction, natural history of HIV, benefits of antiretroviral therapy and OI prophylaxis, nutrition, smoking risk

Lab tests: