HIV Testing in Prisoners: Is Mandatory Testing ...

HIV Testing in Prisoners: Is Mandatory Testing Mandatory? JON K. ANDRUS, MD, DAVID W. FLEMING, MD, CATHERINE KNOX, MN, ROBERT 0. MCALISTER, PHD, MICHAEL R. SKEELS, PHD, MPH, ROBERT E. CONRAD, PHD, JOHN M. HORAN, MD, MPH, AND LAURENCE R. FOSTER, MD, MPH Abstract: 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)

Introduction

Persons for whom HIVAb (human immunodeficiency virus antibody) testing is already mandatory in the United States include immigrants, blood donors, and military recruits. Prison inmates comprise a population at risk for HIV infection. Many are intravenous (IV) drug users and all are entering a setting where homosexual sex may occur. The American Medical Association has recommended that "testing for AIDS virus should be mandatory . .. for inmates in federal and state prisons. "' Currently, inmates in all federal prisons are tested. In 1986, three state prison systems required their prisoners to be tested for HIVAb; by 1988 this number had increased to 14.2.3 However, little data have been available to evaluate the usefulness of mandatory HIVAb testing in the prison setting. In 1987, the Oregon Health Division performed a study to evaluate the usefulness of a voluntary versus a mandatory HIVAb testing strategy in the Oregon corrections system. Methods All newly incarcerated inmates entering any of the five prisons of the Oregon State correctional system from September 1987 to January 1988 were enrolled in the study. Upon entry, each inmate was shown a 12-minute educational videotape on HIV infection and was then administered a standard questionnaire in private by a Corrections Department health care provider. Information collected from each inmate included: history of blood transfusion, sexual preference, IV drug history, self-assessed likelihood of HIV exposure, and HIV testing history. Additional information extracted from the records of inmates included: age, gender, race, education, crime, length of sentence, and history of sexually transmitted diseases. All inmates were then offered confidential HIV antibody testing and counseling. Inmates were categorized into those choosing testing and those declining confidential testing. From the Centers for Disease Control, Division of Field Services, Epidemiology Program Office (Andrus, Horan); Oregon Health Division, Portland (Fleming, McAlister, Skeels, Conrad, Foster); and Oregon Department of Corrections, Salem (Knox). Address reprint requests to Jon K. Andrus, MD, Division of Field Services, Epidemiology Program Office, Centers for Disease Control, 1600 Clifton Road, Atlanta, Georgia 30333. This paper, submitted to the Journal December 5, 1988, was revised and accepted for publication March 21, 1989.

840

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. (Am J Public Health

1989; 79:840-842.)

Inmates who declined were asked whether they would consider testing in the future if it could be offered in such a way that only they had knowledge of the results (anonymously). Those who would have considered anonymous testing were grouped separately from the rest of test decliners in some of the analyses. Blood specimens from inmates choosing testing were tested for HIV antibody and results were presented to the inmate, along with post-test counseling. Blood specimens from all inmates are routinely drawn and tested for evidence of syphilis infection. Using these sera, a 95 percent random sample of all inmates declining testing was also tested for HIVAb in a blinded fashion after syphilis testing had been completed. These HIVAb results, with linked questionnaire data, were sent only to the Oregon Health Division. The study design was approved by the Oregon Health Division's human subjects review board, which included a medical ethicist, a lawyer from the American Civil Liberties Union, and representatives from prisoners, gays, and a community AIDS-prevention agency. All specimens were also tested for hepatitis B core antibody (HBcAb). Hepatitis B and HIV infections are transmitted in the same way; we used HBcAb positivity as an objective, surrogate marker for a history of risk behavior for HIV infection. For purposes of this study, inmates were considered to be at risk for HIV infection if they had one or more of the following: IV drug use history, history of male homosexuality, or HBcAb positivity. Serum specimens were tested at the Oregon Public Health Laboratory. HIV antibody testing was done using the Genetics Systems* enzyme linked immunosorbent assay. Repeatedly reactive sera were confirmed by the indirect immunofluorescence test. HBcAb tests were done using the Abbott* enzyme linked immunosorbent assay. Black, Hispanic, and Native American inmates were grouped together as minority inmates. Male inmates were defined to have admitted homosexuality if they stated that they had ever had sex with men only or with both men and women. All statistical tests were performed using the Epi Info computer software package provided by the Centers for Disease Control. *Use of trade names does not imply endorsement by the Oregon Health Division or by the US Public Health Service.

AJPH July 1989, Vol. 79, No. 7

HIV TESTING IN PRISONERS

Results Seroprevalence

A total of 995 consecutively admitted inmates were enrolled; 18 of the test decliners were randomly excluded from HIVAb testing. The mean age of the remaining 977 was 30 years (range 17 to 71 years), 91 percent male, 74 percent were White, 16 percent Black, 6 percent Hispanic, and 2 percent Native American. Twelve inmates (1.2 percent) were HIVAb positive (Table 1). Inmates who were HBcAb positive were more likely to be HIV infected (2.5 percent, 9/357) than those who were seronegative for HBcAb (0.5%, 3/620) (RR = 5.2; 95% CL 1.6, 16.7). Persons who admitted homosexuality or IV drug use were not more likely to be HIVAb positive than those who did not admit these behaviors, although the small number of HIV-seropositive inmates limited our power to detect a difference. The risk of HIV infection was not associated with other inmate characteristics studied, including race, education, history of previous HIV testing, crime, length of sentence, history of sexually transmitted diseases. Risk Behavior and HIV Seroprevalence

Of the 977 inmates enrolled, 611 (63 percent) were HBcAb positive or reported a history of IV drug use or reported history of male homosexuality, and thus were at risk for HIV infection. This 63 percent does not include inmates who reported only a history of blood transfusion or sexually transmitted disease. Thus, 63 percent may be a conservative estimate of the proportion of inmates at risk for HIV infection. All 12 HIV positive inmates were in this group defined to be at risk. For every inmate infected, there were 53 others at risk, but as yet uninfected. Test Choice A total of 637 inmates (65 percent) chose to receive HIV counseling and testing. Of the 358 inmates declining testing, 98 (27 percent) would have considered anonymous testing, if

it had been available. Six of the 12 HIV-positive inmates voluntarily accepted an offer of confidential counseling and testing. HIV-positive inmates were not significantly different from HIV-negative inmates in the likelihood that they would choose to be tested TABLE 1-HIV Seropositivity in Inmates by Demographic Characteristics and Risk Factors, Oregon, 1988

Enrolled

HIV Seropositive (%)

977

12 (1.2)

893 82 2

11 (1.2) 1 (1.2) 0(0.0)

Mean 30 Range 17-71

Mean 31 Range 29-38

Total Sex Male Female Unknown

Age (years) Race White Black Hispanic Native American Unknown Risk Factors IV Drug User HBcAb Positive Male Homosexual Unduplicated Total


722 161 61 23 10

6 (0.8) 3 (1.9) 2 (3.3) 1 (4.4) 0 (0.0)

519 349 30 611

10 (1.9) 9 (2.6) 1 (3.3) 12 (2.0)

confidentially. Among the 340 test decliners, 67 percent (4/6) of HIV-positive inmates would have considered anonymous testing compared to 28 percent (94/334) of HIV-negative inmates (RR = 2.4; CL 1.0, 5.4). Test choice was not predicted by HBcAb status, admitted male homosexuality, age, gender, race, education, crime, and sentence. Seventy percent (361/519) of inmates who admitted to IV drug use accepted an offer of testing compared to 60 percent (276/457) of inmates who denied IV drug use (RR = 1.2; 95% CL 1.1, 1.3). Eighty-five percent (63/74) inmates who believed it likely that they had been exposed to HIV chose testing compared to 64 percent (566/885) of those who either did not believe or were not sure about HIV exposure (RR = 1.3; 95% CL 1.1, 1.6). In this study, 35 percent (340/977) of the inmates declined the offer of confidential counseling and testing. Of those who declined, 56 percent (192/340) were at risk by being HBcAb positive, an IV drug user, and/or a male homosexual.

Discussion Both mandatory and voluntary testing strategies have their inherent limitations.4'5 If the goal of testing is to identify all infected inmates so that they can be quarantined, then testing must be mandatory.6 However, in Oregon, prison officials decided to use a health facility model of infection control and to implement universal HIV precautions rather than try to identify and quarantine infected inmates. One reason for this decision was that the average prison stay in Oregon is only 16.8 months (Oregon Department of Corrections, Statistical Report, PP30TC1 1, May, 1988). A policy that isolates HIV positive inmates while they are imprisoned does little to prepare either the prisoner or society for the near future when they are released. Given these preconditions, the primary reason to test inmates in Oregon would be to inform them of the results, in hopes that this information would help them to implement risk reduction behavior. The data from this study provide insight into the kind of testing program that would most likely accomplish this goal. The prevalence of HIV infection among prisoners entering the Oregon correctional system at the end of 1987 was 1.2 percent. While this estimate is relatively low compared to infection rates of 15 percent-20 percent reported in prison populations in high AIDS incidence areas,3'7.8 it is probably more representative of that expected in most states. Oregon is nineteenth among states ranked by cumulative reported AIDS incidence rate.8 To date, prisoner seroprevalence data have been reported from 20 states; in 17 of the states (85 percent), seroprevalence was less than 2 percent.2 In contrast to the low HIV seroprevalence, 63 percent of inmates entering Oregon corrections system were either HBcAb positive or admitted to IV drug use or male homosexuality, all indicators of potential risk for future HIV infection. The ratio of uninfected to infected at-risk inmates was 53:1. The problem then is not that there are a lot of infected inmates that need to be identified. Rather, there are a lot of at-risk, as yet uninfected inmates that need to be convinced to change their behavior. To be effective, prevention programs must be specifically directed at this latter group. To our knowledge, the influence of mandatory HIV testing on subsequent behavior has not been evaluated. It seems particularly unlikely, however, that forced testing would significantly change the conduct of those testing negative. In 841

ANDRUS, ET AL.

contrast, multiple studies have documented that voluntary HIV testing and counseling can change behavior.9'5 More importantly, this intervention has specifically been shown to cause the at-risk client who tests negative to initiate risk reduction behavior.'o'4 When most persons at risk are not yet infected, voluntary HIV prevention programs that emphasize counseling may be more effective than mandatory programs that emphasize testing. Our study demonstrates that such a voluntary program can be successfully implemented in the prison setting. In Oregon, two-thirds of all inmates, including those at highest risk for HIV, sought HIV counseling and testing when given the opportunity. In conclusion, we believe this study shows that an effective HIV intervention program for Oregon's prisoners should contain the following components: general AIDS education for all prisoners to raise their basic awareness of the disease; counseling at the prisoners request, especially for those who indicate they may be at risk; and HIV testing, offered only as voluntary component of this counseling, so that testing cannot occur without counseling, but counseling can occur without testing. Anonymous HIV testing was attractive to some inmates who declined confidential testing and when feasible should be considered as a testing option. The Oregon Legislature has accepted these recommendations and approved the funding necessary to implement a comprehensive voluntary HIV counseling and testing program in Oregon prisons. ACKNOWLEDGMENTS

The authors would like to thank Roberta Pfeiffer of the Oregon Public Health Laboratory for her work with the preparation of specimens, Loraine

I

Good of CDC for her editorial contributions, and the health staff of the Oregon Corrections Department for their logistical support.

REFERENCES

1. JAMA Board of Trustees: Prevention and control of acquired immunodeficiency syndrome. JAMA 1987; 258:2097-2103. 2. Hammet TM: Update 1988: AIDS in correctional facilities. Washington, DC: National Institute of Justice (pre-publication) 1989; 27. 3. Hammet TM: AIDS in correctional facilities: Issues and options. Washington, DC: National Institute of Justice. 1988; 47-58. 4. Osborn JE: AIDS: Politics and Science. N Engl J Med 1988; 318:444 447. 5. Bayer R, Levin C, Wolf SM: HIV antibody screening, an ethical framework for evaluating proposed programs. JAMA 1986; 256:17681774. 6. Lewis HE: Acquired immunodeficiency syndrome, State legislative activity. JAMA 1987; 258:2410-2414. 7. Harding TW: AIDS in prison. Lancet 1987; 2:1260-1263. 8. CDC: Human immunodeficiency virus infection in the United States. MMWR 1987; 36:801-804, 807. 9. Schechter MT, Craib KJP, Willoughby B, et al: Patterns of sexual behavior and condom use in a cohort of homosexual men. Am J Public Health 1988; 78:1535-1538. 10. van Griensven GJP, de Vroome EMM, Tielman RAP, et al: Impact of AIDS antibody testing on changes in sexual behavior among homosexual men in the Netherlands. Am J Public Health 1988; 78:1575-1577. 11. McClusker J, Stoddard AM, Mayer KH, et al: Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. Am J Public Health 1988; 78:462-467. 12. Ostrow DG, Joseph J, Soucy J, et al: Mental health and behavioral correlates of HIV antibody testing in a cohort of gay men. Abstract 4082, presented at the IV International Conference on AIDS, Stockholm, Sweden, June 1988. 13. Fife KH, Jones RB, Marrero DG, et al: Behavioral changes among sexually active homosexual men after learning they are negative for HIV antibody. Abstract 6009, presented at the IV International Conference on AIDS, Stockholm, Sweden, June 1988. 14. van den Hoek JAR, van Haastrecht HJA, Goudsmit J, et al: Influence of HIV-Ab testing on the risk behavior of IV drug users in Amsterdam. Abstract 4541, presented at the IV International Conference on AIDS, Stockholm, Sweden, June 1988. 15. Cates W Jr, Handsfield HH: HIV counseling and testing: Does it work? (editorial) Am J Public Health 1988; 78:1533-1534.

Task Force Report on Clinical Preventive Services

The US Preventive Services Task Force recently completed a five-year review of numerous clinical interventions and presented their recommendations to Dr. J. Michael McGinnis, deputy assistant secretary for health (disease prevention and health promotion). Their report, entitled Guide to Clinical Preventive Services, was unveiled May 2 during a news conference in Washington, DC. The report is the work of a 20-member non-federal panel appointed in 1984 to develop age- and risk factor-specific recommendations for the delivery of preventive services in the clinical setting. The report addressed the effectiveness of over 100 clinical interventions for the prevention of 60 diseases. Its basic recommendation is that clinicians should tailor preventive examinations to the individual patient rather than routinely performing a battery of tests on patients which may be ineffective and could lead to inaccurate results. The report recommends four types of interventions in the clinical setting: screenings, counseling, immunizations, and chemoprophylaxis. Of these, said Robert S. Lawrence, MD, who chaired the task force, counseling patients about behavior modification can be among the most effective forms of preventive, adding that ". . . the key to improved health and disease prevention often lies in lifestyle changes made by patients rather than in the broad testing or sophisticated medical procedures performed by health providers." The all-volunteer task force was comprised of 14 physicians as well as specialists in dentistry, nursing, health services research, health education, health economics, and medical sociology. The report-Guide to Clinical Preventive Services-will be published by Williams and Wilkins of Baltimore, MD in late summer. For further information, contact the publisher at 1-800-638-0672.

842
