Daniel M. Keller, PhD

October 29, 2010

October 29, 2010 (Vancouver, British Columbia) — Rapid HIV testing (RHT) programs in jails in 3 large cities identified 142 new diagnoses over 1 year. Several factors facilitated implementation of the programs, including local political support, use of electronic medical records to streamline testing, and general acceptance of RHT by detainees.

Newly diagnosed individuals were accommodated into existing HIV care services when they might otherwise have been unidentified, reported Curt Beckwith, MD, assistant professor of medicine at the Alpert Medical School of Brown University in Providence, Rhode Island, here at the Infectious Diseases Society of America 48th Annual Meeting.

Dr. Curt Beckwith

Dr. Beckwith and colleagues undertook a study of RHT programs in Philadelphia, Pennsylvania; Baltimore, Maryland; and Washington, DC, jails to gauge their efficacy and to identify challenges to and facilitators of implementing such programs in large urban jail systems.

Jails are an appropriate venue for RHT because detainees are held for short times, and the inmates are at risk for HIV and other infections often because of risky behaviors including substance abuse and unsafe sex before incarceration, as well as inadequate access to healthcare services (eg, because of poverty, health disparities, and substance abuse). RHT may extend screening to this transient population.

The investigators collected data on the 3 programs during a 1-year period. Testing was performed with an OraQuick (OraSure Technologies) test on either a blood or oral sample, depending on the city. Results were available immediately or in 1 to 3 days, with confirmatory results available in 7 to 14 days.

Baltimore and Philadelphia offered voluntary opt-out testing, and in Washington, voluntary "automatic" testing was done during intake. Before the RHT program, the cities tested 0.4%, 10%, and 14% of their jail populations for HIV, respectively. After implementation of the programs, the cities offered RHT to 12%, 100%, and 89% of jail admissions, respectively, and testing was completed in 22%, 69%, and 79%, respectively, of those to whom it was offered.

"So [there were] really dramatic increases in the penetration of HIV testing," Dr. Beckwith noted. "Across these 3 sites in a 12-month period, about 41,000 individuals were tested." There were 304 positive rapid HIV tests, and from those, 142 new infections were identified.

Of 72,000 jail admissions in Baltimore between May 2008 and April 2009, 7 new HIV diagnoses were made. The Philadelphia (n = 39,181 admissions) and Washington (n = 17,903 admissions) testing programs identified 75 and 60 new HIV diagnoses, respectively, in 2009.

Key stakeholders of each program summarized the challenges and facilitators of implementing an RHT program. Challenges included maintaining a confidential environment, given the space and staffing limitations at jails, early release preventing delivery of test results and performing confirmatory testing, unpredictable release compromising continuity of care, and providing staff and getting staff "buy-in" for RHT. Other challenges were obtaining informed consent for testing at the time of intake because of conditions such as intoxication or mental illness, and the ability of correctional institutions to provide HIV care to newly diagnosed individuals.

"[RHT] in jails is feasible, and if you implement such a program, you'll be able to identify new cases of HIV that were previously unrecognized," Dr. Beckwith concluded.

The 13 million people passing through US jails each year often go back into the community in as little as 24 to 48 hours, and rapid testing for HIV as well as other infectious diseases has important public health implications for the community.

Dr. Beckwith said that critical to all these programs was local political support from city governments and departments of corrections. "The financial resources need to be in place to conduct such programs, but we all think that this is very worthwhile and is cost-saving in the long run," he said.

Joel Gallant, MD, professor of medicine and epidemiology in the Division of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore, said widespread implementation of RHT programs should be feasible.

"The tests are not expensive. They're simple to do. The existence of the rapid tests makes this possible in jails where you could never have done it with the old, traditional tests because people weren't in long enough to wait for results," Dr. Gallant said. "But with rapid testing, I think [this is] a great population to be testing. There are probably a lot of high-risk patients in that setting, and you get results, and you can make a real difference."

Testing implies that treatment will be available for people with positive results, and Dr. Gallant said someone has to make referrals, and a system has to be in place in the community to accept them. In the case of inmates going on to prison, they can be referred to the prison medical system.

Dr. Beckwith has disclosed no relevant financial relationships. Dr. Gallant has received grant support and consulting fees from Gilead Sciences. He also has received consulting fees from Abbott Laboratories and has been a scientific advisor to Bristol-Myers Squibb, Merck, Sangamo Biosciences, and Tibotec.

Infectious Diseases Society of America 48th Annual Meeting: Abstract 1068. Presented October 23, 2010.