HIV Testing: State HIV Testing: State Correctional Correctional InstitutionsInstitutions

Janet MohleJanet Mohle--Boetani, MD, MPHBoetani, MD, MPHCMO, Public Health UnitCMO, Public Health UnitCalifornia Prison Health Care ServicesCalifornia Prison Health Care Services

QUIZQUIZ-- what do the stars what do the stars represent?represent?

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OutlineOutline

HIV incidence and rate by stateHIV incidence and rate by stateHIV testing: optionsHIV testing: optionsHIV testing in state facilitiesHIV testing in state facilities

Bureau of Justice: 2006 survey of prisons, 2004 Bureau of Justice: 2006 survey of prisons, 2004 survey of inmatessurvey of inmates

Informed ConsentInformed ConsentHousingHousingHIV result notificationHIV result notification

Approach in CaliforniaApproach in California

Rate of HIV infection: Inmates in State Prisons, 2006

Source: KF and BOJ

Number of HIV Infections: Inmates in State Prisons, 2006

Source=KP and BOJ

HIV Testing in State HIV Testing in State Prisons, 2004Prisons, 2004

73% of inmates in state prisons stated 73% of inmates in state prisons stated that since admission their blood had that since admission their blood had been tested for HIVbeen tested for HIV964,200 inmates tested: 1.6% of these 964,200 inmates tested: 1.6% of these were infectedwere infected84% had physical exam84% had physical exam95% had TB skin test95% had TB skin test

Source: BOJ

Options for HIV TestingOptions for HIV Testing

Involuntary (Mandatory) vs. Voluntary (Offer)Involuntary (Mandatory) vs. Voluntary (Offer)On Entry: receptionOn Entry: receptionIn Custody: at medical homeIn Custody: at medical homeOn Exit: parole/releaseOn Exit: parole/releaseAll All ““high riskhigh risk””Inmate requestInmate requestMD recommendation (based on symptoms)MD recommendation (based on symptoms)After potential After potential bloodbornebloodborne pathogen exposure pathogen exposure incidentincident

HIV testing in State HIV testing in State Prisons, 2006 (NPSPrisons, 2006 (NPS--1)1)Policy for testingPolicy for testing Number of StatesNumber of States

High Risk InmatesHigh Risk Inmates 1616

All inmates: entry or during All inmates: entry or during custody or at releasecustody or at release

21162116

At releaseAt release 5: MO, AL, FL, TX, 5: MO, AL, FL, TX, NV (?GA, ?TN)NV (?GA, ?TN)

RandomRandom 4: NY, NV, AK, OR4: NY, NV, AK, ORAfter incidentAfter incident 4747HIV symptoms/requestHIV symptoms/request 4747

HIV HIV SeroprevSeroprev by Drug Use, by Drug Use, Federal PrisonFederal Prison

Drug UseDrug Use 19971997 20042004

NeverNever 1.71.7 1.31.3

EverEver 2.32.3 1.71.7

Mo before Mo before incarcerationincarceration

2.72.7 1.91.9

Use needleUse needle 4.64.6 2.82.8

HIV Mandatory Testing, HIV Mandatory Testing, 20062006

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HIV 2007HIV 2007 HIV in HIV in prison 07prison 07

% + in % + in prisonprison

Test allTest all

CACA 17,588*17,588* 1,1551,155 0.70.7 nono

NYNY 5,1975,197 4,0004,000 6.36.3 randomrandom

FLFL 5,1655,165 3,4123,412 4.14.1 releaserelease

TXTX 3,4953,495 2,6932,693 1.91.9 releaserelease

GAGA 3,2043,204 994994 1.81.8 ?release?release

*In CA HIV names reporting started 4/2006

Informed ConsentInformed Consent

Potential Negative Consequences of Potential Negative Consequences of testing positivetesting positive

Segregated (HIV only) housingSegregated (HIV only) housingNotification (Notification (egeg, warden, parole officer), warden, parole officer)

Benefits Benefits –– early identification and early identification and treatment, care by a specialisttreatment, care by a specialist

HIV Housing In CAHIV Housing In CA

10 of 30 institutions for men house HIV +10 of 30 institutions for men house HIV +3 of 3 institutions for women3 of 3 institutions for womenCCCsCCCs and camps: case by case basisand camps: case by case basisNo limitation on programming optionsNo limitation on programming options

Notification of HIV Results, Notification of HIV Results, 1999 (source=CDC)1999 (source=CDC)

Type of NotificationType of Notification No of StatesNo of States

Partners/ContactsPartners/Contacts(IDU, sex, assault)(IDU, sex, assault)

47%47%

Health DepartmentHealth Department 90%90%

Custody StaffCustody Staff 10%10%

Parole OfficersParole Officers 30%30%

California ApproachCalifornia Approach

Voluntary testingVoluntary testingModified Opt OutModified Opt Out

Provider initials key information points Provider initials key information points provided to inmate provided to inmate Verbal consent by inmate Verbal consent by inmate Provider signs form to indicate acceptance or Provider signs form to indicate acceptance or declinationdeclination

Pre-Test Counseling Checklist for HIV Antibody ScreeningNote to provider: California law requires providers to explain certain points about HIV testing before ordering the test. All of the following points must always be discussed withthe inmate in a language that is easy to understand.Initial that you have informed the inmate the following:

Inmate can decline HIV testTest results return in 1-2 weeksMeaning of negative HIV result (uninfected or newly infected)Meaning of Window periodHIV risk factors (e.g., having unprotected sex, sharing needles, getting tattoos)Meaning of positive HIV result Possibility of transfer to another prison if HIV-positive

Reporting requirements (by name)____ Local health department____ Warden ____ Correctional staff if exposed to blood or other bodily fluids____ Parole officer at time of parole____ Inmate’s primary doctor or nurse

By signing below, I acknowledge that I have provided the inmate patient informationabout the HIV test as well as discussed the advantages and disadvantages of getting HIVThe patient indicates that he or she understands the information.Inmate Accepts: The inmate-patient has accepted my offer for HIV testing.Inmate Refuses: The inmate-patient has refused my offer for HIV testing.Inmate Name and CDCR NumberSignature/Printed Name of Medical Staff

Best Approach??Best Approach??