HIV testing in prisoners: is mandatory testing mandatory?

We studied 977 newly incarcerated Oregon inmates to compare voluntary versus mandatory human immunodeficiency virus antibody (HIVAb) testing in the prison setting. All inmates were offered HIVAb counseling and testing. Blood drawn for routine syphilis serology from those who declined this offer was also tested for HIVAb after personal identifiers had been removed. Only 1.2 percent (12) prisoners were HIV positive. However, 62.5 percent (611) inmates were at risk for HIV infection by being an intravenous drug user, a male homosexual, or hepatitis B core antibody (HBcAb) positive. The ratio of at-risk, as yet uninfected inmates to those already HIV infected was 53 to 1. Two-thirds of all inmates including those at-risk chose to receive counseling and testing. In areas where most at-risk inmates are not yet infected, it may be more appropriate for HIV prevention activities in prison to focus on voluntary programs that emphasize education and counseling rather than mandatory programs that emphasize testing.     

The president's fiscal year 2007 initiative for human immunodeficiency virus counseling and testing expansion in the United States: a scenario analysis of its coverage, impact, and cost-effectiveness.

INTRODUCTION: When adjusted for inflation, the federal investment in human immunodeficiency virus (HIV) prevention in the United States has been trending downward for several years. However, for fiscal year 2007, President Bush has proposed to Congress a $93 million increase in HIV prevention efforts focused on HIV counseling and rapid testing in high-risk communities. OBJECTIVE: Here, we estimate the coverage level of an investment of $93 million for rapid testing and counseling services, estimate the number of HIV infections that might be expected to be prevented by this initiative, and calculate the cost-per-infection-prevented. METHODS: Standard methods of scenario and cost-effectiveness analysis were employed, and a 1-year time horizon was used. Calculations were done assuming both a societal perspective and a payor perspective. RESULTS: Assuming full societal perspective costs, about 1.4 million clients could be reached, but if the payor's perspective is used (and clients are assumed to absorb the costs of their time spent and transportation), then coverage could expand to 2.9 million clients. Depending on the perspective used, it is estimated that between 13,014 and 26,984 persons living with HIV could newly learn their serostatus, and that between 1,223 and 2,537 HIV infections could be prevented as a function of the initiative. Under both societal and payor perspectives, the gross cost per infection averted is less than the medical care costs for one case of HIV disease. CONCLUSIONS: We conclude that the president's proposed $93 million initiative for HIV counseling and rapid testing in the United States would have favorable public health benefits and be cost saving to society (even if it does not address all unmet HIV prevention needs in the United States). However, future research should seek to determine whether rapid counseling and testing are the optimal use of a new $93 million investment in HIV prevention.     

Prevalence and Correlates of HCV,HVB, and HIV Infection among Prison Inmates and Staff,Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.     

HIV transmission among male inmates in a state prison system--Georgia, 1992-2005

The estimated prevalence of human immunodeficiency virus (HIV) infection is nearly five times higher for incarcerated populations (2.0%) than for the general U.S. population (0.43%). In 1988, the Georgia Department of Corrections (GDC) initiated mandatory HIV testing of inmates upon entry into prison and voluntary HIV testing of inmates on request or if clinically indicated. GDC offered voluntary HIV testing to inmates annually during July 2003-June 2005 and currently offers testing to inmates on request. During July 1988-February 2005, a total of 88 male inmates were known to have had both a negative HIV test result upon entry into prison and a subsequent confirmed positive HIV test result (i.e., seroconversion) during incarceration. Of these 88 inmates, 37 (42%) had had more than one negative HIV test result before their HIV diagnosis. In October 2004, GDC and the Georgia Division of Public Health invited CDC to assist with an epidemiologic investigation of HIV risk behaviors and transmission patterns among male inmates within GDC facilities and to make HIV prevention recommendations for the prison population. This report describes the results of that investigation, which identified the following characteristics as associated with HIV seroconversion in prison: male-male sex in prison, tattooing in prison, older age (i.e., age of >26 years at date of interview), having served > or =5 years of the current sentence, black race, and having a body mass index (BMI) of < or =25.4 kg/m2 on entry into prison. Findings from the investigation demonstrated that risk behaviors such as male-male sex and tattooing were associated with HIV transmission among inmates, highlighting the need for HIV prevention programs for this population.     

Implementing a Routine, Voluntary HIV Testing Program in a Massachusetts County Prison

Although U.S. prison inmates have higher rates of HIV infection than the general population, most inmates are not routinely tested for HIV infection at prison entry. The study objective was to implement a routine, voluntary HIV testing program in a Massachusetts county prison. During admission, inmates were given group HIV pre-test counseling and were subsequently offered private HIV testing. This intervention was compared to a control period during which HIV testing was provided only upon inmate or physician request. Between November 2004 and April 2005, 1,004 inmates met inclusion criteria and were offered routine, voluntary HIV testing. Of these, 734 (73.1%) accepted, 2 (0.3%) were HIV-infected, and 457 (45.5%) had been tested for HIV in the previous year. The testing rate of 73.1% was significantly increased from the rate of 18.0% (318 of 1,723) during the control period (p<0.001). Among the inmates tested for HIV in the prior year, 78.2% had received their last HIV test in the prison setting. Careful attention should be paid to prevent redundancy of testing efforts in the prison population. Implementing a routine HIV testing program among prison inmates greatly increased testing rates compared to on-request testing. Liddicoat is with the Department of Medicine, Greater Los Angeles Veterans Administration, Mail 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Zheng, Freedberg, and Walensky are with the Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Freedberg and Walensky are with the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Zheng, Freedberg, and Walensky are with the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Internicola and Golan are with the Suffolk County House of Corrections, Boston, MA, USA; Golan is with the Department of Infectious Disease, Tufts University Medical School, Boston, MA, USA; Rubinstein is with the HIV/AIDS Bureau, Massachusetts Department of Public Health, Boston, MA, USA; Werner and Kazianis are with the Massachusetts State Laboratory Institute, Boston, MA, USA.     

The cost of inaction on HIV transmission among injection drug users and the potential for effective interventions

Estimated and potential medical costs of treating patients infected with human immunodeficiency virus (HIV) in urban areas of high HIV prevalence have not been well defined. We estimated the total medical cost of HIV disease among injection drug users in Vancouver, British Columbia, Canada, assuming stable and increasing HIV prevalence. Total medical costs were estimated by multiplying the average lifetime medical cost per person by the number of HIV-infected individuals. We assumed the cost of each HIV infection to be $150,000 (Canadian), based on empirical data, and HIV prevalence estimates were derived from the Vancouver Injection Drug Users Study (VIDUS) and external data sources. By use of Monte Carlo simulation methodology, we performed sensitivity analyses to estimate total medical cost, assuming the HIV prevalence remained stable at 31% and under a scenario in which the prevalence rose to 50%. Expected medical expenditures based on current HIV prevalence levels were estimated as $215,852,613. If prevalence rises to 50% as reported in other urban centers, the median estimated medical cost would be approximately $348,935,865. This represents a difference in the total costs between the two scenarios of $133,083,253. Health planners should consider that predicted medical expenditures related to the HIV epidemic among injection drug users in our setting may cost an estimated $215,852,613. If funding cannot be found for appropriate prevention interventions and the prevalence rises to 50%, a further $133,083,253 may be required.     

HIV epidemiology and risk behavior promoting HIV transmission in Austrian prisons

In 1989, 1990 and 1992, 19%, 15% and 10%, respectively, of all prisoners newly admitted to prisons and penitentiary institutions in Austria underwent HIV antibody tests. Based on the HIV test outcome in prisons in which more than 80% of the newly admitted inmates were tested, annual HIV prevalences among prison inmates in Austria were determined. These were 0.5% (11/2,223), 1.3% (19/1,466) and 0.9% (14/1,509) in 1989, 1990 and 1992, respectively. The prevalence rates among prison inmates in Austria are thus 5 times higher than those in the general Austrian population. About 5% of all inmates belong to the high-risk group of intravenous drug users. Inquiries into HIV risk behavior among prison inmates showed that, in Austrian prisons just like in those of many other countries, intravenous drug use and sexual contacts are common practices. As disposable needles and condoms are not available to prison inmates, these practices carry a particularly high risk of HIV transmission. The data collected can be taken as a basis for developing strategies which are designed to reduce the risk of HIV transmission in prisons and which have a major bearing on the development of the HIV pandemic.     

Cost-effectiveness of interventions to reduce vertical HIV transmission from pregnant women who have not received prenatal care.

To evaluate the cost-effectiveness of rapid HIV testing followed by treatment with zidovudine, nevirapine, or combination therapy for women presenting in the United States in active labor without prenatal care, the authors developed a decision analytic model from a societal perspective comparing 2 basic strategies: 1) not testing for HIV and 2) offering rapid HIV testing and treatment to women testing positive. HIV transmission rates, test characteristics, and costs were derived from the literature and local sources. Outcomes included number of infected infants, costs, and incremental cost-effectiveness in dollars per quality-adjusted life year saved. The authors found that offering rapid HIV testing and administering zidovudine treatment to women testing positive would prevent 27 cases of HIV each year and save $3,000,000/year compared with no intervention. If more expensive treatments were used (e.g., zidovudine rather than nevirapine, or combination therapy rather than monotherapy), the relative risk reduction in HIV transmission for the more expensive strategies would need to be only slightly better to make the more expensive strategies relatively cost effective in comparison with the less expensive strategies. In an analysis including empiric nevirapine prophylaxis, the authors found that empiric therapy would prevent 32 HIV cases and save $2.1 million per year compared with no intervention. In conclusion, rapid HIV testing and treatment for women presenting in labor without prior prenatal care would prevent HIV infections and save costs. At sites where rapid HIV testing is not possible, empiric treatment would also prevent HIV infection and saves costs and is thus preferred to a strategy of neither testing nor treating. Effectiveness in reducing transmission drives the cost-effectiveness ratio much more so than drug cost and should be the basis on which a particular prophylactic regimen is selected.     

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention.

OBJECTIVE. To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections. METHOD. The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost. RESULTS. Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million. CONCLUSION. Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.     

Surveillance of HIV infection and related risk behaviour in European prisons. A multicentre pilot study

BACKGROUND: In order to demonstrate the feasibility of human immunodeficiency virus (HIV) infection and related risk behaviour surveillance in European prisons, a multicentre pilot study was undertaken. METHODS: A cross-sectional survey was carried out in six European prisons (France, Germany, Italy, The Netherlands, Scotland and Sweden). Inmates were invited to complete a self-administered and anonymous questionnaire and to give a saliva sample in order to test for HIV antibodies. RESULTS: Eight hundred and forty-seven out of 1,124 inmates participated in the survey (response rate 75%). Saliva from 817 inmates (73%) was collected and processed for HIV antibodies. Twenty-seven per cent reported that they had ever injected drugs and 49% of these reported they had injected whilst in prison. Eighteen per cent of inmates reported that they had been tattooed whilst in prison, which was found to be higher among injecting drug users (IDUs). One and sixteen per cent reported that they had ever had homosexual and heterosexual intercourse in prison respectively. The HIV prevalence among IDUs was 4% (versus 1% among non-IDUs) (p = 0.02). The proportions of inmates previously tested for hepatitis C and vaccinated against hepatitis B were 24 and 16% respectively. CONCLUSION: This survey demonstrates the feasibility of cross-sectional surveys in European prison inmates and highlights the importance of surveillance of HIV prevalence and related risk behaviour among inmates. The continuing high HIV prevalence and potential for HIV spread in prisons should encourage decision makers in implementing or enhancing harm reduction and education programmes and substance abuse treatment services in prison.     

Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons

OBJECTIVES: We evaluated prevalence and intraprison incidence of HIV, hepatitis B virus, and hepatitis C virus infections among male prison inmates. METHODS: We observed intake prevalence for 4269 sentenced inmates at the Rhode Island Adult Correctional Institute between 1998 and 2000 and incidence among 446 continuously incarcerated inmates (incarcerated for 12 months or more). RESULTS: HIV, hepatitis B virus, and hepatitis C virus prevalences were 1.8%, 20.2%, and 23.1%, respectively. Infections were significantly associated with injection drug use (odds ratio = 10.1, 7.9, and 32.4). Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV. CONCLUSIONS: High infection prevalence among inmates represents a significant community health issue. General disease prevention efforts must include prevention within correctional facilities. The high observed intraprison incidence of HBV underscores the need to vaccinate prison populations.     

Profile of HIV seropositive inmates diagnosed in Maryland's state correctional system.

Correctional systems increasingly serve as the health care nexus for the initial diagnosis and treatment of human immunodeficiency virus (HIV) infection, particularly among traditionally underserved populations. A survey was conducted to describe the clinical profile of inmates in a State correctional system diagnosed with HIV infection by various testing strategies. Approximately 50 percent of the inmates diagnosed were potential candidates for anti-retroviral therapy, and 17 percent were severely immunocompromised. Implementation of voluntary HIV testing at prison entry increased the number of persons identified with HIV infection; however, since volunteers at entry had higher CD4 cell counts compared with infected inmates diagnosed by other methods, there was not a parallel increase in the percentage requiring immediate medical treatment. These data are important for planning medical resources in the correctional setting and underscore the opportunity to provide prevention and therapy for a vulnerable population with HIV infection. Public health interventions within the correctional setting have a broader societal impact, since most infected inmates serve short sentences (median, 3 years). Clinical case management is critical for inmates with HIV infection released to the community so that linkages with primary care providers and support services can be established.     

Temporal trends in reasons for and result of HIV-testing among women in Rome, Italy

To describe the trend in the reasons for and result of women's HIV testing, systematic data was gathered for 11, 523 consecutive women during pre- and post-test visits at a major counseling and testing (CT) site of Rome, Italy, June 1985–July 1996. The number of tested women and the proportion of female clients attending the CT site significantly increased during the study period (p < 0.001), mostly because of reported sexual risk or when triggered by pregnancy. A significant increasing trend in the proportion of women who had one prior test (30% overall) was observed in all groups, apart from IDU. Newly diagnosed HIV infections were 319 (2.8%). The HIV prevalence was 27% in 1985–1987, when 66.7% of cases were IDUs, and decreased to 1.3% in 1994–1996, when 53.7% of cases were women reporting HIV infected partners.The findings suggest that information on the potential risk of HIV transmission has permeated the female population. The shift of newly diagnosed infections from IDUs towards women reporting sexual exposure, suggests the need for targeting preventive efforts to these population groups. Underlying reasons for multiple testing need further analysis.     

Gaps between HIV/AIDS policies and treatment in correctional facilities

In this article the authors examined correctional policy and its impact on the incidence of HIV/AIDS in prison population. Using data from the Florida Correctional System, they find that HIV/AIDS is still the leading cause of death. Improved treatment and care may have led to declines in AIDS-related mortality but the prison population continues to experience a much higher risk of mortality than he general population in spite of changes in the treatment and provision of care to infected patients. The dominance of HIV-related deaths indicates that treatment and voluntary testing policy have been ineffective. The authors argue that the persistence of HIV infections and AIDS-related deaths is largely attributable to continuing unequal distribution of health care resources between identified and unidentified HIV-infected inmates. Their analysis suggests that future changes in HIV/AIDS policy ib testing and treatment can contribute to improvement in health conditions of infected inmates.     

Results of a Pilot Study of Pre-release STD Testing and Inmates’ Risk Behaviors in an Ohio Prison

This study presents the results of a pilot study of mandatory pre-release testing for sexually transmitted disease (STD) and a behavioral risk survey for male inmates at an Ohio prison. Approximately 4–6 weeks prior to scheduled release, inmates took part in a mandatory blood test and optional genital swab and physical examination to test for STDs. At the time of testing, a voluntary behavioral and knowledge survey was administered to inmates. Pre-release testing identified 53 new cases of STDs among the 916 inmates (5.5%) scheduled for release during the pilot study period. Trichomoniasis and hepatitis C were the most common infections identified through pre-release testing. Nearly all inmates participated in the required blood test. Participation rates for the other testing methods averaged less than 45%. Inmates reported engaging in various risky behaviors during incarceration such as having sex (12.1%), tattooing (36.5%), and drug use (19.5%). Pre-release testing identified several new cases of STDs not identified through existing intake and for-cause testing procedures. Substantial useful information about the prevalence of STD risk behaviors can be obtained through a pre-release survey.     

Knowledge, beliefs and attitudes of inmates towards AIDS and HIV infection: a survey in a Marseille penitentiary center]

BACKGROUND: The objectives of our study were to evaluate knowledge, attitudes and beliefs of inmates toward HIV infection, and to compare them with those reported in the general population and according to injecting drug use. METHODS: Three hundred and seventy persons incarcerated in the prison of Marseille were invited, between December 1995 and March 1997, to answer a voluntary questionnaire offered by an independent staff. Odds ratios were estimated by logistic regression models adjusting for age, sex and type of questionnaire (self-administered for literate, face-to-face for illiterate inmates). The average scores among injecting and non injecting drug users (IDUs) were compared by analysis of variance adjusting for age, sex and type of questionnaire. These scores were also compared with those reported in a national survey (ACSF 1994), after adjustment for age, sex and educational level. RESULTS: The participation rate was 55%. Among the 202 participants, 152 answered a self-administered and 50 a face-to-face questionnaire; 45/202 (22%) were IDUs. The average scores of knowledge and tolerance towards HIV infected people were lower among inmates than in the general population. Furthermore, the scores of uncertainty towards HIV risk and unfavorable opinions about condom were higher than in the general population. While the average scores of knowledge, uncertainty towards HIV risk and unfavorable opinions did not differ between IDUs and non-IDUs, the score of tolerance towards HIV infected people was lower among non-IDUs than IDUs. CONCLUSION: That study shows that in spite of the high prevalence of at risk behaviors among people who are incarcerated, that population is not targeted enough by HIV prevention programs. Furthermore, the low level of tolerance towards HIV infected people among inmates, especially non-IDUs, is very likely an obstacle to health care management in that population with a high HIV prevalence. It is urgent to enhance the equality of access to care and prevention policy inside and outside prison.     

Budget Impact Analysis of HIV Testing in the VA Healthcare System

ObjectivesThe long-term cost effectiveness of routine HIV testing is favorable relative to other medical interventions. Facility-specific costs of expanded HIV testing and care for newly identified patients, however, are less well defined. To aid in resource allocation decisions, we developed a spreadsheet-based budget-impact tool populated with estimates of facility-specific HIV testing and care costs incurred with an expanded testing program.MethodsWe modeled intervention effects on quarterly costs of antiretroviral therapy (ART), outpatient resource utilization, and staff expenditures in the Department of Veterans Affairs over a 2-year period of increasing HIV testing rates. We used HIV prevalence estimates, screening rates, counseling, positive tests, Veterans Affairs treatment, and published sources as inputs. We evaluated a single-facility cohort of 20,000 patients and at baseline assumed a serodiagnostic rate of 0.45%.ResultsExpanding testing from 2% to 15% annually identified 21 additional HIV-positive patients over 2 years at a cost of approximately $290,000, more than 60% of which was due to providing ART to newly diagnosed patients. While quarterly testing costs decreased longitudinally as fewer persons required testing, quarterly ART costs increased from $10,000 to more than $60,000 over 2 years as more infected patients were identified and started on ART. In sensitivity analyses, serodiagnostic and annual HIV testing rates had the greatest cost impact.ConclusionsExpanded HIV testing costs are greatest during initial implementation and predominantly due to ART for new patients. Cost determinations of expanded HIV testing provide an important tool for managers charged with allocating resources within integrated systems providing both HIV testing and care.     

Patient risks, outcomes, and costs of voluntary HIV testing at five testing sites within a medical center

OBJECTIVES: The Centers for Disease Control and Prevention (CDC) recommends offering human immunodeficiency virus (HIV) testing to all patients in all high HIV-prevalence clinical settings. We evaluated programmatic aspects of HIV testing across multiple clinical settings within a single medical center. METHODS: We analyzed programmatic data of HIV testing in the Urgent Care Center (UCC), inpatient floors, outpatient primary care, a non-clinical Drop-In Center, and Emergency Department (ED). HIV testing was by oral mucosal transudate, venous blood samples, or rapid testing fingersticks, with Western blot confirmation. We compared the sociodemographics and behavioral risks of individuals undergoing HIV testing across the five sites and estimated costs per person tested and per HIV-positive test result. RESULTS: From 2002 to 2004, 16,750 HIV tests were conducted, with 229 (1.4%) previously unreported HIV infections diagnosed among 16,696 valid test results. HIV-positive prevalence was 1.5% for the UCC, 1.5% at the Drop-In Center, 1.4% for primary care, 1.2% for inpatient, and 0.6% in the ED. Behavioral risks were most prevalent in the UCC and the Drop-In Center. The cost per test was lowest in the UCC and highest in the Drop-In Center. The cost per previously unreported HIV infection was lowest in the UCC ($1,980) and highest in the ED ($9,724). CONCLUSIONS: Although a significant number of HIV infections were identified, the number of tests performed represents < 10% of all clinical visits. Due to personnel and time constraints, offering HIV testing to patients hierarchically in some settings of a high-volume medical center merits evaluation.     

Optimal pooled testing

This paper first characterizes three pooled testing techniques for generic testing conditions. It then applies these methods to demonstrate potential costs savings for universal HIV screening in the United Stated and Thailand. The success of these techniques in general is shown to be dependent on the prevalence as well as the disparity in prevalence between high and low risk groups. Further limitations on effectiveness include the potential impact of dilution on sensitivity. This and other limitations are addressed in the second section which focuses on applications of the techniques. Cost reductions are demonstrated to be feasible at prevalence of up to 30% and increasing dramatically at lower rates. Applying optimal pooled testing to universal HIV screening would result in an annual savings of over $1.4 billion in the United States and over $130 million in Thailand. Recent calls for universal HIV testing are based on the cost effectiveness of routine screening. These assessments may substantially overstate the cost of routine screening which strengthens the argument for universal screening.     

HIV and AIDS surveillance among inmates in Maryland prisons

The prevalence of those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) is higher among inmates of correctional facilities than among the general population. This raises the need to identify inmates living with or at risk of HIV/AIDS and to provide counseling and appropriate survices for HIV treatment and prevention. The Maryland Division of Corrections (DOC) offers voluntary testing to all inmates on entry and tests inmates when clinically indicated. We reviewed all 1998 HIV antibody tests and confirmed AIDS cases in the Maryland DOC. Inmate demographics, testing acceptance, rates of seropositivity, and AIDS cases and comparisons based on gender, racelethnicity, and age were examined. Comparisons were also made to HIV testing and AIDS cases from the nonincarcerated Maryland population. Trends in DOC AIDS diagnoses and AIDS-related deaths over time were also examined. Of the inmates, 39% were voluntarily tested for HIV on entry to the Maryland DOC in 1998 (38% of males and 49% of females). Overall, HIV seropositivity was 33% (5% for females and 3% for males). The 888 cumulative AIDS cases diagnosed in the DOC inmate population were concentrated among males (90% vs. 77% statewide), African Americans (91% vs. 75% statevide), and among IDUs (84% vs. 39% statewide). Due to high rates of HIV and AIDS, inmate populations are a crucial audience for HIV/AIDS testing, treatment, and prevention efforts, especially women. Prison-based programs can identify significant numbers of HIV and AIDS cases and bring HIV prevention interventions to a population characterized by frequent high-risk behavior.