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Since 2006, CDC has recommended routine, opt-out human immunodeficiency virus (HIV) screening for patients in health-care settings with a prevalence of undiagnosed HIV infection of ≥0.1%.1,2 Before September 2007, the Washington State Department of Corrections (WADOC) only provided HIV testing to inmates on request. In September 2007, WADOC began routine HIV opt-in screening in which inmates were notified that HIV screening would be performed during the prison intake medical evaluation if they consented. In March 2010, WADOC switched to a routine opt-out HIV screening model in which inmates are notified that HIV screening will be performed unless they decline. To assess the proportion of inmates screened and the number of infections diagnosed during the use of the three HIV testing policies, WADOC reviewed HIV testing data for male inmates undergoing intake medical evaluation during January 2006–December 2010. From January 1, 2006, to August 31, 2007, 5% of 12,202 incoming inmates were tested for HIV at their request during the intake medical evaluation, and three (0.50%) of those tested had newly diagnosed HIV infection. From September 1, 2007, to March 15, 2010, 72% of 16,908 inmates agreed to opt-in HIV screening, and 13 (0.11%) tested positive for HIV. From March 16, 2010, to December 31, 2010, 90% of 5,168 inmates agreed to opt-out HIV screening, and six (0.13%) tested positive for HIV. Compared with routine opt-in HIV screening, opt-out HIV screening was associated with a greater proportion of inmates tested, without decreasing the rate of case detection.
WADOC is a state prison system with 12 facilities for men and a daily male inmate population of approximately 15,000. Approximately 6,700 inmates are admitted each year, and a similar number released. The WADOC centralized reception center for men provides all incoming inmates with a medical evaluation within 14 days of arrival. The WADOC HIV testing program uses a conventional, laboratory-based enzyme immunoassay/Western blot algorithm on blood specimens.3 Based on serial, blinded seroprevalence studies, the prevalence of HIV infection in the male inmate population in WADOC has remained stable over the past decade at 0.6%-0.7% (M. Courogen, Washington State Department of Health [WADOH] personal communication, 2011). Oral informed consent is obtained before HIV testing, results are available in 7-14 days, and persons with a confirmed HIV-positive result are notified of their infection. Persons with HIV infection are reported to WADOH, provided HIV prevention counseling at WADOC, referred to specialized HIV care within the correctional facility, and linked to community health care on release.
Before September 2007, WADOC provided HIV testing only on request, if clinically indicated, or by court order. In September 2007, WADOC began to implement routine opt-in HIV testing, whereby nurses would routinely offer HIV testing to male inmates not known by WADOC to be HIV-infected during the intake medical evaluation, and inmates would provide their consent for the HIV test to be conducted. The infection control nurse promoted testing by telling inmates who initially declined testing that an HIV test could be performed at the same time they had blood drawn for routine syphilis screening. In mid-March 2010, WADOC began routine opt-out HIV testing during the intake medical evaluation. With the opt-out strategy, the infection control nurse informed incoming inmates not known by WADOC to be HIV-infected that an HIV test would be included among the standard screening tests unless they declined.
To determine how policy changes affected the proportion of inmates receiving HIV testing and the yield of newly identified HIV cases, WADOC reviewed its program data on HIV tests conducted from January 2006 through December 2010. A newly diagnosed case of HIV infection was defined as a confirmed diagnosis of HIV in a person at WADOC who had no record in WADOH HIV surveillance data of a previous positive HIV test result. Since implementation of routine (opt-in and opt-out) HIV screening, WADOC has conducted 16,820 HIV tests among 22,076 admissions; 19 (0.11%) tests were positive, resulting in five to six new HIV diagnoses per year. All inmates with newly diagnosed HIV infection were notified of their HIV diagnosis while still incarcerated, except one who was notified by the local health department following release.
The calculated annual number of tests performed increased with each change in testing strategy within WADOC, from 360 with testing on request, to 4,780 with opt-in screening, to 5,899 with opt-out screening. During the 20-month period in which HIV testing was available on request, an average of 5% of incoming inmates were tested each month within WADOC. During the 30.5-month period in which opt-in testing was in effect, approximately 72% of incoming inmates were tested. During the initial 9.5 months of the opt-out testing approach, 90% of incoming inmates were screened for HIV, demonstrating that an opt-out HIV testing strategy can increase acceptance of routine HIV testing.
The number of newly diagnosed cases detected per year also increased. Among the 604 HIV tests conducted on request before September 2007, three inmates were identified as having newly diagnosed HIV infection, a rate of 1.8 new HIV diagnoses per year. During the 30.5 month opt-in testing period, 13 inmates were identified as having newly diagnosed HIV infection, a rate of 5.1 new diagnoses per year. During the 9.5 months of opt-out testing, six inmates were identified as having newly diagnosed HIV infection, a rate of 7.6 new diagnoses per year.
Among the 19 inmates whose HIV infection was newly diagnosed during implementation of the opt-in and opt-out screening strategies, the mean CD4 cell count at the time of diagnosis was 422 cells/mm3 (range: 71-898 cells/mm3); nine had a CD4 cell count <500 cells/mm3, and three had a count <200 cells/mm3. The average age of the 19 inmates was 35 years (range: 20-58 years); three (16%) were American Indians/Alaska Natives, one (5%) was Hispanic, five (26%) were non-Hispanic black, and 10 (53%) were non-Hispanic white. Heterosexual sex was reported by eight (42%) inmates, six (32%) reported injection-drug use, four (21%) reported sex with men, and one (5%) reported both injection-drug use and sex with men.
Reported by: Lara B. Strick, MD, Washington State Dept of Corrections and Univ of Washington. Robin J. MacGowan, MPH, Andrew Margolis, MPH, Lisa Belcher, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Robin J. MacGowan, firstname.lastname@example.org, 404-639-1920.
CDC Editorial Note: Persons with HIV infection who are not aware of their infection are approximately three times more likely to transmit HIV than are persons who are aware of their infection.4 Routine HIV screening in correctional institutions can help identify cases of HIV infection, especially among persons who might not seek HIV testing in their community.5 In this report, inmate acceptance of HIV testing increased following changes to the WADOC testing policy. HIV testing increased from 5% to 72% to 90% when the testing policy was changed from on request to opt-in to opt-out. An opt-out approach helps destigmatize HIV testing.6
Routine HIV screening (opt-in and opt-out) detected 19 new cases of HIV infection during a 40-month period. The opt-out testing approach was the most effective at case detection. Even in low-prevalence correctional settings such as WADOC, an opt-out HIV testing approach can identify persons with HIV infection and provide opportunities to link them to health care and treatment.
Racial and ethnic minorities are incarcerated at a higher rate than whites in the United States, and they are disproportionately infected with HIV.7,8 This also is true for the WADOC male inmate population. Compared with the general prison population in WADOC (blacks 19.2%, American Indians/Alaska Natives 4.4%), blacks and American Indians/Alaska Natives were overrepresented among inmates who had newly diagnosed HIV infection (26% and 16%, respectively).9
In this analysis, 42% of the 19 male inmates who had newly diagnosed HIV infection identified heterosexual contact as their only risk factor for HIV acquisition. This finding is similar to those of prior studies of HIV testing in correctional facilities,10 and supports the CDC recommendation that all inmates be provided opt-out HIV screening during their intake medical evaluation to maximize case detection and help prevent HIV transmission. Some HIV risk behaviors (e.g., male-to-male sex and injection-drug use) might have been underreported because inmates might have been reluctant to disclose these socially stigmatizing behaviors. However, the findings in this report emphasize the importance of not relying on risk-based testing.
The findings in this report are subject to at least one additional limitation. The reported newly diagnosed infections do not account for inmates who previously tested HIV-positive but who had no record of HIV infection in the WADOH surveillance system, resulting in a potential overestimation of new cases detected.
The results of this study, together with published guidance from CDC,2 can be useful in developing and implementing comprehensive HIV services for prison inmates. Routine opt-out HIV testing in prisons potentially can increase diagnoses of HIV infection, thereby improving health outcomes of persons with HIV infection and preventing new cases of HIV infection within the United States, especially among persons who might be less likely to access traditional community-based testing services.
Gary Saucerman, Linda Newsom, D.D. Tucker, Washington Corrections Center, Washington State Dept of Corrections; Marc Stern, MD, School of Public Health, Univ of Washington. Craig B. Borkowf, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention, CDC.
What is already known on this topic?
Routine human immunodeficiency virus (HIV) screening increases the proportion of patients tested in medical settings and can result in detection of undiagnosed HIV infection.
What is added by this report?
Compared with opt-in screening, an opt-out policy for screening inmates for HIV infection during intake medical evaluation increased the proportion of inmates tested from 72% to 90%, whereas the percentage testing positive remained similar (0.11% versus 0.13%).
What are the implications for public health practice?
Routinely offering opt-out HIV screening to all inmates during the prison medical intake evaluation can increase HIV case identification, even in low-prevalence settings.
HIV Screening of Male Inmates During Prison Intake Medical Evaluation—Washington, 2006-2010. JAMA. 2011;306(16):1756–1757. doi:
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