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Rapid HIV testing marks an important turning point in the annals of HIV testing and diagnosis—a major step forward that has already led to more testing, more people seeking care and a greater demand for HIV-related services. But the test’s greatest impact may be on our nation’s incarcerated populations—offenders in jails and other short-term facilities, in particular, where the average length of stay ranges from several hours to a few days.

In the past, many jails shied away from HIV testing, believing that the traditional Enzyme Linked ImmunoSorbent Assay (ELISA)/Western Blot tests were too cumbersome to administer in short-term facilities and even more importantly, that it took too long to obtain the results from the test—two weeks in most cases. “A lot of inmates agree to be tested in jail but unfortunately they leave before the two week period—before their test results come back,” explained Marlene LaLota, program administrator for the Bureau of HIV/AIDS within the Florida Department of Health. “That is very frustrating for public health, but it is also very frustrating for the inmates. They get tested and then they leave and sometimes, they stay in the county or they might leave the county. But if they test positive, we have to go and find them.”

The rapid test is administered at the point of care—a simple prick on the finger and a few drops of blood placed in a vial—that produces results within 20 to 40 minutes. This test, in turn, has given jails, public health officials and inmates in short term correctional facilities an opportunity for HIV testing that was not available before. Jails represent a “real rapid flow environment”—more than 50 percent of the people in this country are out of jail within 24 hours and many people do not spend more than a few hours in custody, according to Hugh Potter, PhD, Acting Team Leader for the Corrections and Substance Abuse Unit at the Centers for Disease Control and Prevention (CDC).

Yet, jails represent an ideal venue for HIV testing; offenders, on average, suffer from higher rates of mental illness, substance abuse and sexually transmitted diseases (STDs), including HIV. Twenty-five percent of the nation’s HIV population passes through a jail at some point, according to some estimates. CDC officials have been quick  to take advantage of the new testing technology, launching a two-year demonstration project in the fall of 2003 that provides funds to state health departments in Florida, Louisiana, Wisconsin and New York for the expressed purpose of working with jails to provide rapid HIV testing to inmates. The project, part of the CDC’s Advancing HIV Prevention (AHP) initiative, is designed to encourage greater cooperation between health departments and short-term correctional institutions, making it possible to identify more people with HIV/AIDS while they are in custody and thus enhancing public health in the long run, according to Potter.

The CDC testing project is indicative of an emerging trend among health departments and correctional institutions. Increasingly, jails and public health departments are turning to this new technology, using it as a basis to forge partnerships in order to test short-term offenders and to link those testing positive with services upon release. The Florida Health Department, for example, has been providing the rapid test to inmates at the Jacksonville Jail in Duval County, Florida since the summer of 2003, several months before the CDC project got underway. HIV counselors, hired by the Florida Department of Health, have administered more than 1,400 rapid tests at the jail during the past five months, identifying 35 HIV positive inmates in the process, according to Marlene LaLota of the Florida Health Department. The jail books about 54,000 people a year.

In January 2004, health department officials started another rapid testing program at the Broward County Jail, a project funded with CDC dollars from the agency’s correctional demonstration project. The Jacksonville Jail project serves as the model for the CDC-funded program at the Broward County Jail in Ft. Lauderdale. Not surprisingly, the testing projects at both venues are much more involved than a simple HIV test. The Florida Department of Health employs HIV counselors to meet with inmates at the Jacksonville Jail on a one on one basis and to provide them with HIV education as well as a risk assessment for HIV infection. Inmates are given HIV/AIDS education and made aware of the rapid test while receiving their physical examinations .“If the inmate wants the test, his finger is pricked—because that is how the rapid test works—and he is sent back to his cell,” explains LaLota. “When the results are ready, the inmate is called out, he is counseled and given the test results.”

Officials use the rapid test as a screening tool to identify inmates who are probably infected with HIV. If the rapid test is reactive, officials will schedule a follow up confirmatory test using a Western Blot, a test that requires a blood draw that is then sent to a lab for analysis. Even though the rapid test is nearly 100 percent accurate, the Western Blot serves as a way to absolutely confirm the positive results from the rapid test. “If the rapid test is reactive or positive, the inmate receives further counseling,” explains LaLota. “We will explain what this means—that the inmate is probably infected, but we have to do the other test to make sure.”

If an inmate leaves the facility before the final test results come back, health department officials make an appointment for the ex-offender at the local health department to obtain the results. If the ex-inmate fails to show up for that appointment, health department officials find the inmate and deliver the results, steering the HIV positive individual to HIV-related services in the community.

The rapid testing program at the Broward County Jail has been tailored to address the size and operations of that facility, making the program similar but different in some key ways than the Jacksonville program. The Broward County Jail is a huge facility, consisting of five sites that book more than 100,000 offenders a year. Even more significantly, turnaround times are faster than most jails—individuals are booked into the facility and then released within a few hours in many cases. This makes it incumbent on officials to tell inmates about the rapid test as soon as they are booked into jail, which is done with fliers and brochures announcing the availability of the test and the importance of testing. Inmates have to request the test. Unlike the Jacksonville Jail, the sheer size of the Broward County Jail makes it difficult, if not impossible, for HIV counselors to meet with inmates on a one on one basis to provide HIV prevention counseling. It is thus up to the inmates to tell officials that they want the rapid test.

Officials, though, remind inmates about the test during various times of their incarceration. Inmates are required to undergo a physical examination within 14 days of their incarceration, a time officials use to reinforce the testing message. Officials also tell inmates about the test when they come into the infirmary, during sick call and other times when inmates present with medical problems.

The CDC is providing nearly $600,000 for the Broward County project for the next two years, an amount that pays for four positions at the facility and covers supplies, equipment and travel—things needed to implement the rapid testing program. Officials expect to test about 10,000 offenders at the Broward County Jail during the next two years. Like the Jacksonville Jail project, inmates requesting an HIV test at the Broward County Jail receive HIV prevention counseling. HIV counselors explain the importance of taking the test, what the rapid test entails, what a reactive result means and why a reactive rapid test result has to be con firmed with a Western Blot test. “We make sure the inmates understand the process up front,” said LaLota. “We also explain that a negative test does not always mean you are negative—you could have been recently infected and your body hasn’t developed the antibodies yet.”

Like the other CDC funded projects, the Broward County Jail program includes a discharge-planning component that begins before the HIV positive inmate leaves. Officials make appointments for the departing inmate a few weeks prior to release whenever possible, telling the offender that he or she has an appointment with a case manager or a doctor soon after getting out. “We link them with services upon release—medical care and evaluation, case management, substance abuse treatment, even housing, ”LaLota explained.

Health department officials follow up with inmates six months after discharge, asking them how they are doing, whether they are accessing services and if they need any help.

Safe Guarding Public Health

LaLota is convinced that the rapid testing programs at the Jacksonville Jail and the Broward County facility represent a “real opportunity to decrease the spread of HIV infections among very high risk people and their partners,” serving as a way to safe guard public health. LaLota, like many other public health officials, is convinced that corrections and public health are inextricably linked, explaining that inmates cycle in and out of correctional facilities—jails in particular—on an regular basis, making it impossible to separate correctional health care from community health care. “If there are infections in the community, they are brought into the facility,” LaLota explains. “If there are infections in the facility, they are brought into the community.”

If nothing else, the HIV testing programs give offenders a chance to know their HIV status and to thus take precautionary measures if they are, in fact, infected. The HIV prevention counseling also helps to reduce the risk of HIV infection for high-risk negatives. “Most people are responsible and they will try and protect themselves and their partners,” said LaLota. “That is a benefit right there.”

The two testing programs at the Jacksonville and Broward County facilities have been well received thus far, according to LaLota. Offenders, for the most part, “want the test,” she said. “Some officials were worried about the impact of not having a two week waiting period and what that would mean emotionally, and mentally for someone to know within 20 minutes that they might have a potentially fatal disease,” said LaLota. “Without that two week waiting period, it was felt by some, that people would not be able to reflect on their behaviors and ask, ‘what did I do wrong and what should I do next time.’”“We were really concerned from a mental health perspective what hat was going to do to a person,” she added.

But by the same token, the two week waiting period was stressful for some offenders, LaLota said. “Some inmates would not test because they could not deal with the waiting,” said LaLota. “The rapid test helps those people.”

Expanding the Program

Inmates are also expected to embrace the HIV rapid test at the Orleans Parish Prison in New Orleans, a facility that primarily serves as a jail for the parish of New Orleans but which also houses state prisoners on a short-term basis from time to time.

The state health department started testing inmates at the facility in the summer of 2002, using a Western blot to test inmates with a positive skin test for tuberculosis, an illness sometimes found among people with advanced HIV disease. Officials conducted an average of 200 tests a week during the summer and fall of 2002,focusing solely on inmates with positive TB skin tests, and they quickly found HIV rates of about five percent, far greater than the average HIV rate of 1.2 percent for the rest of the state. That testing program is still on-going but is now supplemented by a CDC-funded rapid testing program that began in early January 2004.

“We wanted to expand the (initial) program, but our problem was money,” said Beth Scalco, Louisiana’s HIV/AIDS Director. “Our current budget only allows us to conduct 60,000 tests across Louisiana a year.”  More than 70,000 people are booked into the Orleans Parish Prison on a yearly basis, far more than the state could ever hope to test. Nevertheless, officials knew a large segment of the state’s HIV population passes through the facility annually, and they were determined to expand the program, this time using the rapid HIV test to determine the true extent of the problem. When the CDC announced the availability of funds for its HIV rapid testing demonstration program in the summer of 2003, the Louisiana Health Department jumped  at the chance, submitting an application that was subsequently approved and funded by the CDC.

“We already had a relationship with the jail,” Scalco explained. “The medical director and administrator of the jail were very interested in expanding the services. We were able to pull it together and fortunately, we got funded.”

The two year rapid HIV testing project, funded at $800,000 in CDC funds, targets inmates who remain in the jail longer than 72 hours – about 17,000 offenders who stay long enough to take both the rapid test and a confirmatory Western blot test, if the rapid test is positive.

 “If someone has a positive rapid test, we can get the confirmatory test done and the results back to that person before they are released,” said Scalco.

Health department officials expect to test about 5,000 of the 7,000 targeted inmates during the first year of the program and anticipate finding an HIV infection rate of about three  percent among those 5,000 inmates, a greater percentage than the overall HIV infection rate in the state but less than the five percent found among inmates with a positive TB skin test.

“Not all 17,000 inmates targeted by this program will be interested in taking the test,” Scalco said. “Some may already know they are positive.”

Joint Efforts

The rapid testing project is very much a collaborative effort between the state health department and the Orleans Parish Jail. “One of the things we needed to hear from the Orleans Parish Prison is that they would provide medical care and any medications needed for inmates testing positive,”  Scalco said. In many of the Parish Prisons, officials are reluctant to test for HIV because they do not want to assume the cost of HIV care, but that has not been the case at the Orleans Parish Prison. “The medical director is very committed to making sure that the jail is not only going to identify people who are positive, but they are going to assure they are provided with the appropriate care they need,” said Scalco.

At the same time, jail officials had to know the health department would be working to secure a seamless transition from incarceration to outside services for HIV positive inmates upon release, Scalco said. Health department officials have contracted with a community-based organization for a case manager, known in the local parlance as a case finder to work with HIV positive inmates and to help them access care upon release. “We are starting with one case finder and will probably work our way up from there,” said Scalco.

Unlike many jails, the Orleans Parish Prison operates an AIDS clinic within the facility, a clinic that has a case manager and relies on doctors and nurses from the Medical Center of Louisiana in New Orleans to provide care to HIV-infected inmates one day a week. Most inmates released from the facility return to the New Orleans area, and as a result, the same doctors and nurses providing care in the clinic also see many of the HIV positive inmates upon release, enhancing continuity of care, according to Scalco.

The HIV rapid testing program will give state officials a more definitive picture of HIV sero-prevalence rates at the Orleans Parish Prison for the first time, findings that will play a key role in determining whether state resources are re-directed to support more testing efforts at that facility and other correctional sites in the state.

“One of the things we did this year was really look hard at the testing sites we have and what their positivity rates were,” said Scalco. “If the testing sites had extremely low positivity rates we decided we were not going to keep funding that testing site.” The goal, Scalco said, is to “get the biggest bang for the buck and direct our testing where we can identify the largest number of HIV positives.”

In Wisconsin, health department officials are driven by a similar goal —to find as many people as possible with HIV disease in the state and link as many as possible into care. For state officials, that means providing access to testing in jails, among other venues. “Fifty-seven percent of our HIV cases here in Wisconsin are among racial and ethnic minorities,” said Jim Stodola, HIV Counseling, Testing and Referral Coordinator for the Wisconsin Department of Health. “We also know that jails house a disproportionate number of racial and ethnic minorities. We are just really trying to give people an opportunity to learn their status and to link those persons who test positive to medical care and evaluation.”

The CDC is funding three HIV rapid testing programs in Wisconsin, more than any other state in the country. Each program funds multiple testing sites. One of the programs, for example, funds rapid testing at three medical sites within a high HIV prevalence area and another pays for rapid testing at three sites within the state’s Partner Counseling and Referral Services, a program that contacts people who test HIV positive, provides referral services, and offers to inform and test their partners for HIV.

The third testing program funds rapid testing at two jails—the Milwaukee House of Corrections and the Rock County Jail in Janesville. The Milwaukee House of Corrections has an annual inmate population of 20,000 people—the number incarcerated at any one time. The Rock County Jail, a much smaller facility, has an annual population of 6,500 people.

Officials expect to test 6,500 inmates at the Milwaukee House of Corrections during the next two years and 1,500 inmates at the Rock County Jail. They are projecting HIV positive rates of about 2 percent at each facility, a relatively high number considering Wisconsin has one of the lowest HIV prevalence rates in the county. “Even though Rock County is a small county population wise in our state—it has the six largest highest HIV prevalence rate among our 72 counties. We are hoping to address that issue,” Stodola explained.

At the same time, more than half of the state’s HIV cases reside in Milwaukee, making the Milwaukee House of Corrections a logical place  to conduct rapid testing. “Sixty to 70 percent of the inmates in this particular jail come from the five zip code areas in the city of Milwaukee with the highest seroprevalence rate in the state,” Stodola said.

In each jail, inmates receive information about the benefits of testing and the importance of knowing your sero-status. Nursing staff at the two jails will ask inmates whether they want the HIV rapid testing during the medical intake, which happens a day or two after booking. STD Specialties, a sexually transmitted disease (STD) clinic that already conducts community HIV counseling and testing and provides HIV care, will conduct testing at the Milwaukee House of Correction. Health department officials are relying on clinic staff and an outside AIDS Service Organization (ASO) to provide counseling and rapid testing. Similarly, the state health department has contracted with an ASO to provide counseling and testing at the Rock County Jail. “At times, there can be a natural mistrust between inmates and any jail staff, including the medical staff. By bringing in outside agencies to do the testing, we are trying to eliminate that barrier,” explained Stodola.

Like other CDC funded projects, the two testing programs at the Milwaukee House of Corrections and the Rock County Jail have a discharge planning component, a component that links HIV positive inmates to medical evaluation and care and HIV case management services, Partner Counseling and Referral Services and prevention services upon release from the jails.

“The vast majority of these inmates will be released within 60 days, many of them within a much shorter time frame,” said Stodola. “That is why we want to have a discharge planner on site to meet with someone who has a reactive or positive test even before it is confirmed.”

The discharge planners will make monthly contact with released inmates with HIV for up to six months, asking them if they are encountering any barriers to care. “At three and six months, we will do a behavior risk assessment with persons who tested positive,” said Stodola. “We will also ask them to participate in an STD screening at six months as a biomarker for sexual risk.”

The goal is to identify potential risk and work with the person to overcome any potential barriers to reducing sexual and drug use risk. “People will receive stipends for participating in the evaluation component part of the demonstration project,” he said.It is also important to note that officials are offering discharge planning for high-risk inmates who have not tested positive for HIV, giving them the opportunity to access HIV prevention services which includes risk assessment and risk reduction planning

Stodola, like other officials in the state, expects the HIV testing projects to have a profound impact. “I worked at an ASO up until about one year ago, and I have seen the benefits of accessing early evaluation and care—the dramatic impact it has on people living with HIV,” Stodola said. “All of our testing programs are really geared toward we can do to help

people know their status, to know it as soon as possible, and link them to medical evaluation and care,” he added.