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The implementation of HIV and STD screening programs in the correctional setting is an important approach to reducing the annual number of new HIV infections in the United States. The correctional system in America is a patchwork of a wide variety of settings such as state and federal prisons, local jails, juvenile detention centers and they include the legal constraints of state laws. One process for HIV testing would be unlikely or even possible in all correctional settings.

There is an inherent difference in the jail versus the prison setting that merits infectious disease testing at the jail level. Jails are largely used to hold offenders who have been charged but not convicted of a crime. Local jails admitted an estimated 11.7 million persons during the 12-month period ending June 30, 2013. The average weekly turnover rate was 60.2 percent. Implementing HIV, HCV and other STD screening programs at the jail level is an effective way to detect disease before an infected individual is released back to the community and is able to transmit disease.

Universal screening methods have proven very effective in certain circumstances. For example screening among blood donors has all but eliminated transmission of HIV through blood transfusions. Another example is the reduction of perinatal transmission with the introduction of routine screening for pregnant women. The benefits of a introducing a routine screening program include: •	Increasing diagnosis of new cases of HIV infection; •	Preserving staff resources by streamlining the process; •	Reducing stigma associated with testing •	Potentially diagnosing HIV infection earlier for the inmate in the course of disease; and •	Improving access to HIV clinical care, medication and prevention services.

1.1 HIV/AIDS In 1996, the CDC revised its’ recommendations to incorporate diagnostic HIV testing and opt-out HIV screening as a part of routine clinical care in all health-care settings while also preserving the patient's option to decline HIV testing. The recommendations are intended for all health-care settings including hospital emergency departments, urgent-care clinics, inpatient services, STD clinics or other venues offering clinical STD services, tuberculosis clinics, substance abuse treatment clinics, other public health clinics, community clinics, correctional health-care facilities, and primary care settings. (The guidelines address HIV testing in health-care settings only; they do not change existing guidelines concerning targeted testing of persons at high risk for HIV who seek HIV testing in nonclinical settings such as community-based organizations, outreach settings, or mobile vans.)

The new CDC guidelines state “in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13-64 years. Health-care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. In the absence of existing data for HIV prevalence, health-care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is <1 per 1,000 patients screened, at which point such screening is no longer warranted.”

Additional recommendations for juveniles that are incarcerated in adult jails include the following: •	Know that incarcerated adolescents may be unaware of their rights concerning medical care, privacy, and confidentiality; therefore, it is especially important that adolescents be informed of their rights and that these rights are respected. •	Follow state or local laws that require parental consent or notification for HIV testing and/or HIV-related health-care services for minors. If required, obtain consent for testing  and/or health-care services from the adolescent’s parent or legal guardian prior to providing that service. Consent can be obtained directly from an emancipated minor as defined by state law. •	Inform adolescents that the medical information, including HIV test results, will not be disclosed without their consent, except as required by law. •	Inform adolescents that, as with all inmates, their HIV status will not adversely affect their medical care during incarceration or their legal rights.

A 2004 survey of inmates at state prisons and local jails revealed a self-reported HIV positive rate of 1.9% and 2.5% respectively. Sixty-nine percent of state inmates reported being tested since admission to the system while only 18.5% of those in the jail reported being tested. This suggests that expanded jail testing could increase the number of previously unidentified cases of HIV. In prisons, where inmates are incarcerated for more than a year, testing should take place at the medical evaluation. In jails, where a majority of inmates bail out between 72 hours and seven days, routine testing should ideally take place at the intake evaluation. This may not be possible if the inmate is under the influence of drugs or alcohol or is otherwise mentally unstable. While medical evaluations typically occur within 10 days of detention, some inmates may have been released and thus, won’t get tested.

Procedures for offering support to the inmate who receives a diagnosis of HIV should be in place to assure they can manage the infection. Privacy in a correctional setting is difficult, but the inmate should be assured that his medical information is confidential. The following are CDC recommended procedures for inmate support: •	Provide education to patients about HIV infection, AIDS-related symptoms, and the significance of any laboratory testing done. •	Inmates diagnosed with HIV infection may require short-term mental health support. •	Inmates with mental health conditions may require increased monitoring and intervention for these conditions. •	Inmates may be reluctant to access or possess HIV educational materials due to concerns about disclosing their HIV infection. Strategies to provide HIV education and counseling for HIV-infected inmates can include HIV educational sessions and support groups. •	Facilities should have HIV medical information and periodicals available in prison libraries and medical clinics. •	Facilities should have chronic disease management programs for HIV-infected inmates. •	Facilities should have a discharge-planning program for HIV-infected inmates.

Linking inmates to HIV care services when they are quickly released back to the community from a local jail can be difficult. Often they can be more concerned with finding a place to live or finding money to pay their legal fees. But upon giving an inmate a diagnosis of HIV, steps should be taken immediately to ensure that an appointment has been made with a provider, that contact information for a health department or community-based organization case manager is available to help them navigate the healthcare system. Several studies indicate that follow-up care for HIV positive women may correlate with a reduction in recidivism. Correctional facilities should have the following CDC recommended procedures and resources in place for inmates being discharged from custody: •	Provide a list of available agencies that provide HIV case management for released inmates. •	Provide contact information for local AIDS service organizations and the local health department. •	Assist inmates with making appointments with case manager before release from custody. If possible, arrange for the inmate to meet the case manager before release. •	Complete applications for other services following release in conjunction with the inmate. •	Provide medications if the inmate has started therapy.

1.2 Hepatitis C Limited testing for hepatitis C virus (HCV) in three North Carolina jails have shown a prevalence rate of approximately 7% for HCV. The primary barrier is the cost of additional tests needed beyond a screening test. However, some hematologists believe a screening test should be done regardless of ability to pay for follow-up care as a means of changing behavior (for example, refraining from alcohol or not sharing needles). Studies have shown that knowledge of disease status can change behavior with HIV infection. It is estimated that 80% of people with HIV who inject drugs also have hepatitis C virus. HIV coinfection more than triples the risk for liver disease, liver failure, and liver-related death from HCV.

2 Differences in funding for sexually transmitted diseases treatment In North Carolina, the state Department of Health and Human Services Division of Epidemiology works with the federally funded AIDS Drug Assistance Program to help pay for HIV medication for incarcerated persons in county jails. In order to qualify, county detention centers must complete an application for funds that includes the jail health budget to show need. Additionally, Duke University and UNC-Memorial Hospitals have collaborated with one jail’s HCV positive inmates for further follow-up testing and care.

4.2 Possible solutions The high rate of turnover in local jails as opposed to prisons may make it difficult to implement a routine testing program at intake or on a scheduled basis. In cases where testing all incoming inmates is not possible, there are alternative approaches that can be used individually or in combination with other approaches. One alternative approach could include risk-based criteria screening. The CDC recommends that jails routinely offer HIV testing to inmates who fall under one or more of the following criteria: •	Injection drug use (IDU); •	Men who have sex with men (MSM); •	Sex with an IDU, MSM, or HIV-infected partner; •	Multiple sexual partners; •	Exchange of sex for money, drugs, or other goods; and •	Diagnosis of another sexually transmitted disease.

The limitation with this screening approach is that risks are self-reported by the inmate. One study suggested that up to 42% of inmates diagnosed with HIV reported no risk factors.

A second alternative approach is clinical screening based on HCV, HBV or STD infection. The presence of any of these diseases increases the likelihood of acquiring or transmitting HIV disease. Clinical criteria for screening include: •	Pregnancy; •	A diagnosis or history of sexually or parenterally transmitted infections (e.g., HBV or HCV, syphilis, genital herpes, gonorrhea, chlamydia, trichomonas infection); •	Mycobacterium tuberculosis (MTB) infection or active TB; •	Track marks indicative of illicit drug injection; •	Signs or symptoms suggestive of HIV infection or acute retroviral syndrome.

A third alternative approach for screening in the jail setting is based on demographics such as zip code of residence, age, gender and race or ethnicity. When using this approach, providers in correctional settings should with their state or local health department to determine the demographics of HIV for their population. Criteria for demographic screening could include: •	Residence in low-income areas/zip codes; •	Residence in known high-HIV prevalence areas/zip codes; •	Female sex; •	Age 25–44 years; and •	Transgender identity (male to female).

There is also some evidence that screening based on type of arrest could indicate higher rates of HIV infection. For example a study by the Department of Justice found that HIV infection is more often associated with property and drug-related crimes.

Because there is a high-volume turnover rate of inmates in the jail system, some inmates who are tested for HIV, HCV or other STDs may have been released before receiving their results. Correctional facilities should assure that all cases of newly diagnosed infectious diseases are reported to the state or local health department for assistance with notification of results, counseling, partner services and linkage to care.

The CDC advocates a syndemic approach to intervene in the transmission of HIV, HCV and other STDs. This approach includes “combining services to minimize missed opportunities” to detect disease. This approach calls for a collaborative effort between agencies to address high incarceration rates and other social justice issues such as poverty.

CDC Definitions •	Diagnostic testing: Performing an HIV test for persons with clinical signs or symptoms consistent with HIV infection. •	HIV-prevention counseling: An interactive process of assessing risk, recognizing specific behaviors that increase the risk for acquiring or transmitting HIV, and developing a plan to take specific steps to reduce risks. •	Informed consent: A process of communication between patient and provider through which an informed patient can choose whether to undergo HIV testing or decline to do so. Elements of informed consent typically include providing oral or written information regarding HIV, the risks and benefits of testing, the implications of HIV test results, how test results will be communicated, and the opportunity to ask questions. •	Inmate: A person incarcerated in a local jail, state prison, federal prison, or a private facility under contract to federal, state, or local authorities. •	Jail: A confinement facility usually administered by a local law enforcement agency that is intended for adults, but sometimes holds juveniles, for confinement before and after adjudication. Such facilities include jails and city or county correctional centers; special jail facilities, such as medical treatment or release centers; halfway houses; work farms; and temporary holding or lockup facilities that are part of the jail’s combined function. Inmates sentenced to jail facilities usually have a sentence of 1 year or less. Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont operate integrated systems, which combine prisons and jails. •	Opt-out screening: Performing HIV screening after notifying the patient that 1) the test will be performed and 2) the patient may elect to decline or defer testing. Assent is inferred unless the patient declines testing. •	Prison: A long-term confinement facility, run by a state or the federal government, that typically holds felons and offenders with sentences of more than 1 year. However, sentence length may vary by state. Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont operate integrated systems, which combine prisons and jails. •	Screening: Performing an HIV test for all persons in a defined population without regard to the individual’s characteristics. •	Targeted testing: Performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of behavior, clinical, or demographic characteristics.