Voluntary HIV testing in prison: do women inmates at high risk for HIV accept HIV testing?

This study examined the proportion of women inmates who accepted HIV testing and the sociodemographic, criminal, and HIV-related risk characteristics associated with accepting such testing in a state prison offering voluntary HIV testing. A consecutive sample of 805 women felons admitted to the North Carolina Correctional Institution for Women between July 1991 and November 1992 was interviewed. Of these inmates, 680 (84%) granted permission to access their medical records and had complete information on relevant characteristics. Seventy-one percent of the women inmates accepted HIV testing. In multivariate analysis, the exchange of sex for money or drugs and the conviction for a drug crime were significantly associated with accepting HIV testing. Injection drug use, drug-injecting sex partners, and a history of a sexually transmitted disease were not significantly associated with accepting HIV testing. A prison-based voluntary HIV testing program appears to be reaching a substantial proportion of women inmates potentially at risk for HIV, especially women inmates who exchanged sex for money or drugs.     

Hepatitis C in correctional institutions

The prevalence of chronic infection with hepatitis C virus (HCV) is estimated to be 17 to 27 times higher among incarcerated individuals than in the general US population. To help stem the epidemic of HCV infection in the United States, correctional institutions and public health systems should be integrated. The incarcerated setting represents the first opportunity for many inmates to access health care. Correctional settings offer an important opportunity to diagnose, prevent, and treat HCV infection. In this article, we review HCV screening, testing, and treatment policies in US correctional institutions and discuss prison responses to the HCV epidemic and the feasibility of treatment within prisons and jails. Finally, we emphasize the importance of links to postrelease medical care for HCV-infected inmates and the necessity of comprehensive strategies to effectively manage HCV infection.     

HIV testing in correctional institutions: evaluating existing strategies, setting new standards

Before introducing an HIV testing protocol into correctional facilities, the unique nature of these environments must be taken into account. We analyze three testing strategies that have been used in correctional settings--mandatory, voluntary, and routine "opt out" testing--and conclude that routine testing is most likely beneficial to inmates, the correctional system, and the outside community. The ethics of pre-release testing, and the issues surrounding segregation, confidentiality, and linking prisoners with community-based care, also play a role in determining how best to establish HIV testing strategies in correctional facilities. Testing must be performed in a manner that is not simply beneficial to public health, but also enhances the safety and health status of individual inmates. Longer-stay prison settings provide ample opportunities not just for testing but also for in-depth counseling, mental health and substance abuse treatment, and antiretroviral therapy. Jails present added complexities because of their shorter stay with respect to prisons, and testing, treatment, and counseling policies must be adapted to these settings.     

Opt-Out HIV Testing of Inmates in North Carolina Prisons: Factors Associated with not Wanting a Test and not Knowing They Were Tested

Opt-out HIV testing is recommended for correctional settings but may occur without inmates’ knowledge or against their wishes. Through surveying inmates receiving opt-out testing in a large prison system, we estimated the proportion unaware of being tested or not wanting a test, and associations [prevalence ratios (PRs)] with inmate characteristics. Of 871 tested, 11.8 % were unknowingly tested and 10.8 % had unwanted tests. Not attending an educational HIV course [PR = 2.34, 95 % confidence interval (CI) 1.47–3.74], lower HIV knowledge (PR = 0.95, 95 % CI 0.91–0.98), and thinking testing is not mandatory (PR = 9.84, 95 % CI 4.93–19.67) were associated with unawareness of testing. No prior incarcerations (PR = 1.59, 95 % CI 1.03–2.46) and not using crack/cocaine recently (PR = 2.37, 95 % CI 1.21–4.64) were associated with unwanted testing. Residence at specific facilities was associated with both outcomes. Increased assessment of inmate understanding and enhanced implementation are needed to ensure inmates receive full benefits of opt-out testing: being informed and tested according to their wishes.     

Adherence to highly active antiretroviral therapy in HIV-infected inmates

Adherence to highly active antiretroviral therapy (HAART) has been scarcely studied in correctional settings. Our study aims to evaluate the relationship between adherence and virological outcome and to determine factors related to adherence in correctional settings. A cross-sectional retrospective study was performed in Topas prison (Salamanca, Spain). 50 inmates starting HAART were studied. Adherence was estimated through a self-report questionnaire and variables related to adherence (covering individual factors, the illness itself and the therapeutic regimen) were recorded. HIV-RNA levels and CD4 lymphocyte count were measured before starting therapy and six months after. Statistical analysis was performed using univariate and multivariate methods. 21 inmates (42%) were considered adherent and 29 (58%) were non-adherent. Adherence to treatment, as measured by our questionnaire, was the only significant and independent factor associated with an undetectable viral load at six months of therapy. Five variables were significantly associated with adherence to treatment, four of them as predictor factors for good adherence: an active occupation inside prison, the absence of HIV-related symptoms, a good or average acceptance of treatment, and a higher academic background; previous injection drug use as a risk factor for HIV transmission was associated with non-adherence. A simple self-report questionnaire may be useful for assessing adherence in prison inmates. Recognizing variables associated with adherence is essential to identify prisoners at high risk of being non-adherents in order to develop strategies for improving compliance.     

The associations of voluntary counseling and testing acceptance and the perceived likelihood of being HIV-infected among men with multiple sex partners in a South African township

This paper examines the socio-demographic factors and sexual risk behaviors (condom use, number of sexual partners, STI symptoms) associated with voluntary counselling and testing (VCT) acceptance and self-perceived risk of being HIV-infected among black men with multiple and younger sex partners in a South African township outside of Cape Town. Using respondent driven sampling, we interviewed 421 men, of whom 409 (97.3%) consented to provide a dried blood spot, 12.3% were HIVinfected (95% confidence intervals [CI.] 8.3, 16.9) and 47.2% (CI. 41.1, 53.6) accepted on site VCT. Twenty six percent (CI. 20.2, 30.7) reported having an HIV test in the past year. Few men perceived themselves as very likely to be infected with HIV (15.6%; CI. 10.4, 20.5). VCT acceptance was significantly associated with being older, married or living with a partner, having higher education, having four to six partners in the past three months and testing HIV positive. Self-perceived likelihood of being HIV infected was significantly associated with low condom use and having seven or more partners in the past three months, and testing HIV positive. These findings indicate that men correctly understand that engaging in certain HIV risk behaviors increases the likelihood of HIV-infection. However, those who perceive themselves at high risk of having HIV do not seek testing. Further investigation into the psychological and cultural barriers to reducing risky sexual behaviors and accessing VCT and other HIV services is recommended.     

Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda

OBJECTIVE: To assess the acceptance of voluntary HIV counseling and testing (VCT) and the effects of VCT on sexual risk behavior and HIV acquisition in Rakai, Uganda. METHODS: In a rural cohort, 10 694 consenting adults were interviewed, provided blood for HIV testing and were offered free VCT by community resident counselors. The proportions receiving VCT and the adjusted risk ratio (adj. RR) of VCT acceptance were estimated by log binomial regression. Risk behaviors and HIV incidence per 100 person-years (PY) in HIV-negative acceptors and non-acceptors of VCT were assessed prospectively. RESULTS: Although 93% initially requested HIV results, 62.2% subsequently accepted VCT. VCT acceptance was lower among persons with no prior VCT [Adj. RR = 0.88; 95% confidence interval (CI), 0.85-0.90], individuals with primary education (adj. RR = 0.94; 95% CI, 0.90-0.99) or higher (adj. RR = 0.91; 95% CI, 0.87-0.97), individuals who were HIV-positive (adj. RR = 0.72; 95% CI, 0.68-0.76), and persons reporting condom use in the past 6 months (inconsistent users, adj. RR = 0.95; 95% CI, 0.90-0.99; consistent users, adj. RR = 0.88; 95% CI, 0.82-0.95). VCT acceptance was higher among the currently married (adj. RR = 1.14; 95% CI, 1.08-1.20) and previously married (adj. RR = 1.11; 95% CI, 1.04-1.18). Receipt of results was not significantly associated with age, gender, and self-perception of HIV risk. There were no significant differences in sexual risk behaviors, or in HIV incidence between acceptors (1.6/100 PY) and non-acceptors (1.4/100 PY) of VCT. CONCLUSION: In this rural cohort where VCT services are free and accessible, there is self-selection of individuals accepting VCT, and no impact of VCT on subsequent risk behaviors or HIV incidence.     

The association of neoplasms and HIV infection in the correctional setting

HIV-associated immunosuppression has been linked to an increased risk of a number of cancers, including Kaposi sarcoma (KS), non-Hodgkin's lymphoma (NHL), and invasive cervical cancer. Because prison inmates constitute one of the highest HIV/AIDS prevalent populations in the US, understanding the link between HIV infection and cancer in the correctional setting holds particular public health relevance. The study population consisted of 336,668 Texas Department of Criminal Justice inmates who were incarcerated, for any duration, between 1 January 1999 and 31 December 2001. Inmates diagnosed with HIV infection exhibited elevated rates of KS, NHL, anal cancer, and Hodgkin's disease, after adjusting for age and race. The elevated rates of cancer among HIV-infected individuals, particularly prison inmates, may be mediated, in part, by high-risk behaviours. HIV-associated risk behaviours, including unsafe sexual practices, injection drug use, and prostitution may be associated with cancer-related risk behaviours, such as smoking, excessive alcohol consumption, and poor diet. It will be important for future investigators to examine the association between HIV infection and cancer risk with sufficiently large study cohorts and appropriate longitudinal designs.     

Prior opiate injection and incarceration history predict injection drug use among inmates

Aims To describe injection drug use among inmates, and to identify correlates of drug injection while incarcerated. Design Cross‐sectional survey. Setting Six provincial correctional centres in Ontario, Canada. Participants Face‐to‐face interviews were conducted with a random sample of 439 adult males and 158 females. Measurements Inmates were asked about drug use in their lifetime, outside the year prior to their current incarceration, and while incarcerated in the past year. Among the 32% (189 / 597) with a prior history of drug injection, independent correlates of injection while incarcerated in the past year were identified using multiple logistic regression. Findings Among all inmates while incarcerated in the past year, 45% (269 /597) used drugs and 19% (113 / 596) used non‐cannabis drugs. Among those with a prior history of injecting, 11% (20 / 189) injected while incarcerated in the past year. Rates of injection with used needles were the same pre‐incarceration as they were while incarcerated (32%). Independent correlates of drug injection while incarcerated were injection of heroin (OR = 6.4) or other opiates (OR = 7.9) and not injected with used needles (OR = 0.20) outside in the year prior to incarceration, and ever being incarcerated in a federal prison (OR = 5.3). Conclusions The possibility of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) or other blood‐borne diseases exists in Ontario correctional centres. In this setting, drug injection while incarcerated is primarily related to opiate use prior to incarceration. The correlation between injecting and extensive incarceration history suggests missed opportunities to improve inmates’ health.     

HIV rate in CA prisons higher than in community

Health officials in California have found that the HIV rate among the state's prison population has remained relatively stable since 1988. The most recent figures, which were gathered during a massive communicable disease screening of 118,000 inmates and employees of the state correctional system, indicate that 2.5 percent of male inmates and 3.2 percent of female inmates are HIV-positive. The health care workers were particularly concerned because both hepatitis B virus (HBV) and hepatitis C virus (HCV) are at significant levels in the prison population. HBV was found in 47 percent of the women and 32 percent of the men, while HCV was in 54 percent of the women and 39 percent of the men. Because both hepatitis and HIV are spread through sex and needles, the high hepatitis infection rate may indicate a future increase in the rate of HIV infection and AIDS cases.     

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.     

Costs and outcomes of VCT delivery models in the context of scaling up services in Indonesia

Objective To evaluate costs and outcomes of voluntary counselling and testing (VCT) service delivery models in urban Indonesia. Methods We collected primary data on utilization, costs and outcomes of VCT services in a hospital clinic (568 clients), HIV community clinic (28 clients), sexually transmitted infection (STI) community clinic (784 clients) and prison clinic (574 clients) in Bandung, Indonesia, in the period January 2008–April 2009. Results The hospital clinic diagnosed the highest proportion and absolute number of HIV infections, but with the lowest average CD4 cell count and with the highest associated travelling and waiting time. The prison clinic detected fewer cases, but at an earlier stage, and all enrolled in HIV care. The community clinics detected the smallest number of cases, and only 0–8% enrolled in HIV care. The unit cost per VCT was highest in the hospital clinic (US$74), followed by the STI community clinic (US$65), the HIV community clinic (US$39) and the prison (US$23). Conclusion We propose a reorientation of the delivery models for VCT and related HIV/AIDS treatment in this setting. We call for the scaling up of community clinics for VCT to improve access, promote earlier detection and to perform (early) treatment activities. This would reduce the burden of the hospital clinic to orient itself towards the treatment of AIDS patients. This is one of very few studies addressing this issue in Asia and the first of its kind in Indonesia, which has a rapidly growing HIV epidemic. The conceptual framework and overall conclusions may be relevant to other low‐income settings.     

An evaluation of awareness: attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV

The rate of HIV seroprevalence in Nigeria is troublesome because it is one of the highest prevalence rates worldwide. As in most developing countries, vertical transmission from mother to child accounts for most of the HIV infections in Nigerian children. The purpose of this study was to determine the awareness, attitudes, and beliefs of pregnant Nigerian women toward voluntary counseling and testing (VCT) for HIV. Two hundred forty pregnant women in Awka, Nigeria, completed questionnaires aimed at determining their willingness to accept or reject VCT. Furthermore, participants where questioned about their knowledge of HIV infection, routes of transmission, and treatment options. The majority of the women (87%) approved of VCT; of those who approved, 93% were aware that VCT could reduce the risk of transmission of HIV to their babies. All respondents who accepted VCT were willing to be tested if results remained confidential and 89% would accept if they were tested simultaneously with their partners. 69% of the women who refused VCT attribute their refusal to the social and cultural stigmatization associated with HIV. Overall, the acceptance of VCT appears to depend on the understanding that VCT has proven benefits for the unborn child. Sociocultural factors such as stigmatization of HIV-infected individuals appears to be the major barrier toward widespread acceptance of VCT in Nigeria, thus the development of innovative health education strategies is essential for providing women with information regarding the benefits of VCT and other means of prevention of mother-to-child transmission of HIV (PMTCT).     

The Role of Jails in Engaging PLWHA in Care: From Jail to Community

HIV testing in jails has provided public health officials with the opportunity to not only identify new cases of HIV but to also reestablish contact with previously diagnosed individuals, many of whom never entered care following diagnosis or entered care but then dropped out. The presence of inmates throughout the HIV/AIDS continuum of care suggests that jails can play a strategic role in engaging persons living with HIV and AIDS in care. In order to be successful in structuring HIV/AIDS programs in jails, health care and correctional officials will be well-served to: (1) understand the HIV/AIDS continuum of care from the standpoint of engagement interventions that promote participation; (2) be aware of jail, community, and prison interventions that promote engagement in care; (3) anticipate and plan for the unique barriers jails provide in implementing engagement interventions; and, (4) be creative in designing engagement interventions suitable for both newly and previously diagnosed individuals.     

HIV prevention services in correctional drug treatment programs: do they change risk behaviors?

This study evaluated receipt of HIV prevention services in correctional substance abuse treatment programs and examined their impact on short-term risk behaviors. The authors performed a secondary analysis of the National Treatment Improvement Evaluation Study (NTIES), a prospective cohort study conducted during 1993 to 1995. The sample included 1,223 adult non-HIV-positive inmates, enrolled in nine correctional substance abuse treatment programs. A composite index modeled after the validated Risk Assessment Battery measured HIV risk behavior at treatment entry and at 12-month follow-up. Overall, most inmates received HIV prevention services while in treatment. Controlling for potential confounders, HIV prevention services were significantly associated with reduced risk behavior among inmates who were out of custody at follow-up, but no such association was observed among those still in custody. This analysis suggests that HIV prevention services are beneficial in reducing risk behavior among incarcerated individuals whose discharge is expected in the near future.     

HIV risk behavior history of prison inmates in Hungary.

As part of an intervention in correctional facilities in Hungary, we conducted research on AIDS-related attitudes and the HIV risk behavior history of 551 male and 81 female inmates to assess needs for and to tailor AIDS education programs. Although lifetime injection drug use was uncommon (8% of men, 3% of women), many Hungarian inmates had engaged in unprotected sex and had had high-risk sex partners: a quarter of men had primary partners who sold sex, about half of them had sex with female prostitutes, 13% of women had worked as prostitutes, and 9% of all inmates indicated having had sex in prison. Because many prison inmates may constitute a potential bridge population for the sexual transmission of HIV between the general population and high-risk populations, interventions among prison inmates may provide an opportunity to reach an at-risk population and to prevent the wider spread of sexually transmitted HIV.     

Factors Related to Female Sex Workers’ Willingness to Utilize VCT Service: A Qualitative Study in Jinan City, Northern China

While national HIV prevalence remains low in China, female sex workers (FSWs) have become infected at high rates. Free voluntary HIV counseling and testing (VCT) has been offered in recent years; however, its utilization rate is low. This study explored factors related to FSWs’ willingness to utilize a VCT clinic. Qualitative interviews informed by the Ecological Perspective were conducted to interview 17 FSWs and 12 managers from 23 selected entertainment establishments in Jinan, the capital of Shandong province in northern China. While the majority of FSWs professed willingness to use VCT services, they described barriers to actual utilization of services which included: misunderstandings about HIV; low perceived risk and HIV prevalence; mistrust of the free VCT; and especially anxiety about the implications of possible test results. This research suggests that increasing FSWs’ utilization of VCT will require increased knowledge of HIV and VCT, and acceptance of testing and on-site VCT services.     

Feasibility and acceptability of rapid HIV testing in jail

For correctional HIV testing programs, delivery of HIV test results can be difficult because of short incarceration times for many inmates. Rapid HIV testing enables immediate delivery of test results and can be performed in conjunction with risk reduction counseling. The objective of this study was to determine the feasibility and acceptability of rapid HIV testing within the Rhode Island Department of Corrections jail. Jail detainees were randomly asked to participate in the study. The study included: (1) completing a questionnaire that investigated HIV risk behavior, incarceration history, HIV testing history, and attitudes toward routine HIV testing in jail and toward partner notification services; (2) individualized HIV risk reduction counseling; and (3) the option of rapid HIV testing with delivery of test results. One hundred thirteen inmates were asked to participate and 100 (88%) participated. Among the subjects, there was a high frequency of incarceration and subjects were at significant risk of HIV infection, yet there was low perceived risk. Ninety-five percent of participants underwent rapid HIV testing. Of those, 99% had negative test results and one subject had a preliminary positive result. All subjects received rapid test results and individualized risk reduction counseling. The majority of subjects supported routine HIV testing in jail and the concept of partner notification services. In this population of jail detainees, rapid HIV testing was feasible and highly acceptable. Further studies are needed to successfully incorporate rapid HIV testing into jail HIV screening programs.     

Predictors of voluntary HIV counselling and testing services utilization among people with disabilities in Addis Ababa,Ethiopia

The study investigated HIV testing prevalence and factors associated with the utilization of voluntary HIV counselling and testing (VCT) services among individuals with disabilities in Addis Ababa. The analysis was based on a survey of 209 men and 203 women with disabilities, aged 15–49, who had ever heard about HIV and AIDS in four sub-cities in Addis Ababa. HIV testing prevalence was 53.2%, with no significant difference between males and females. Comprehensive HIV knowledge, living with spouse, and religious affiliations positively predicted utilization of VCT services among participants. Living with both parents and having physical or mental/intellectual disabilities were negative predictors of VCT services utilization. More research on the predictors of utilization of VCT services by gender and urban/rural divides are needed among people with disabilities.