Abstract
Prison and jail inmates tend to be involved disproportionately in behavior that places them at risk for HIV transmission. The state of New Jersey, and its urban areas in particular, has a high rate of African American residents living with HIV or AIDS. In an effort to reach several urban areas where individuals have not yet been diagnosed, a southern New Jersey county jail has begun offering free rapid HIV tests on a voluntary basis. Results indicate that correctional facilities were among the most common places for inmates to receive testing and that those tested were involved in numerous high-risk sexual and/or drug activities. Recommendations for future testing and education programs are provided.
Since the first reported case of an AIDS infected patient residing inside a correctional facility in 1983 (Spaulding et al., 2002), the transmission of HIV, medical treatment of infected inmates, and the safety of staff and noninfected inmates has been a concern of corrections administrators worldwide. The number of identified inmates with HIV/AIDS grew rapidly during the 1980s and 1990s, stabilizing in the 2000s. On December 31, 2008, state and federal prisons in the United States held nearly 22,000 inmates who were HIV positive or had AIDS. These inmates comprise 0.8% of the federal and 1.6% of the state prison populations (Maruschak, 2009). However, these statistics do not count any of the more than 800,000 inmates housed in jails on any given day or the 13 million who pass through the doors of jails in the United States annually.
The Centers for Disease Control (2007) found that 54% of male adults and adolescent HIV transmission cases in 2005 were likely a result of males having sex with males (MSM), 21% from injection drug use (IDU), 8% a combination of IDU and MSM, and 7% from other high-risk sexual contact activities. Female transmission likely involved IDU in 36% of the cases and high-risk sexual contact in 8%.
High Risk Behaviors Among Inmates
Bauserman and colleagues (2003) noted that HIV infection rates tend to be higher among incarcerated populations for two reasons. First, males and African Americans tend to be at higher risk for HIV transmission, and these two groups are also disproportionately represented in the incarcerated population. Second, inmates tend to be involved in the high risk activities that are associated with HIV transmission. Gough et al. (2010) conducted a systematic review of HIV prevalence and found a rate of .02 per 100 residents in the general United States population compared to 0.08 per 100 for people who are continuously incarcerated and 2.92 per 100 for people who are released and then reincarcerated. Begier et al. (2010) estimated that the HIV prevalence for individuals entering New York City jails was 2.5 to 3.5 higher than the general population for males and 14 to 20 times higher for females.
Moseley and Tewskbury (2006) surveyed inmates residing in three prisons in Louisiana and received 2,287 usable responses. During the month prior to their most recent incarceration, 18% of the respondents reported participating in IDU, more than one-third (35.4%) gave money or gifts in exchange for sex, and 16% gave sex for money or gifts during this time. Seventy-nine percent of the male respondents reported having heterosexual sex without a condom in the month leading up to the most recent incarceration. During their incarceration, 5% reported anal sex without any type of protection, and 2.2% reported anal sex with some sort of protection. Nearly three percent of respondents reported IDU during incarceration, with 2.3% reporting sharing needles.
Hoxie and colleagues (1990) examined the HIV test results of nearly 2,000 inmates who volunteered for testing in Wisconsin during 1987 and 1988 and found that HIV infection was strongly associated with IDU. Inciardi et al. (2007) discussed a dangerous practice called “booting” or “kicking” that is sometimes performed by IDUs. Booting involves drawing some blood into the syringe, mixing the blood with the drug, and then injecting the drug into the vein. This is done so the user can confirm that he or she actually has the needle in the vein. Some drug users also believe that mixing the drug with blood increases its effect. Typically, there are traces of blood left on the syringe. If the syringe is shared with others, this can increase the chance of HIV transmission.
Stanton-Tindall and colleagues (2007) conducted focus groups with 36 female inmates in correctional facilities in Kentucky and Delaware. Several of the women admitted to high-risk sexual behavior and attributed their participation in that activity to alcohol and drug use. Some inmates noted that they were not very concerned about HIV infection, despite their high-risk behavior, because they believed that it happens to “other people.” They also reported that they shied away from being assertive about the use of protection during sex out of fear of being rejected by their partners. The result of their fear, denial and drug and alcohol use is their continued participation in activities that are associated with HIV transmission. McClelland, Teplin, Abram, and Jacobs (2002) interviewed 940 women in the Cook County Jail (Chicago) about their high-risk behaviors and found that 8.5% reported sharing needles. Thirty-two percent who had vaginal sex reported never using condoms, while 50% who participated in oral sex and 74% who had anal sex also reported never using protection. One third of the women interviewed had traded sex for money or drugs.
Swartz, Lurigio, and Weiner (2004) surveyed inmates serving time in the Illinois prison system about how they might react to various high risk situations. Half of the 630 participants reported that they believed they already participated in activity that could have led to exposure to HIV. More than one third (34%) of respondents said that they would have unprotected sex with a new partner even if the partner objected to using a condom. Twelve percent reported intravenous drug use. Of the inmates who admitted to IDU, 23% said that they would share needles in order to avoid withdrawal symptoms. Sixteen percent of the inmates agreed with the statement that “my gut feeling is I’ll get AIDS someday, no matter what I do,” indicating that they believed that becoming HIV positive was a matter of fate rather than a matter of prevention.
Benefits of HIV Testing in the Correctional Setting
HIV tests are offered at a variety of locations, including physicians’ offices, hospitals, health clinics, specific HIV testing facilities, and clinics specializing in the treatment of sexually transmitted diseases. One of the most important and utilized locations for HIV testing is inside correctional facilities. Desai, Latta, Spaulding, Rich, and Flanigan (2002) studied a voluntary HIV testing program at a Rhode Island men’s prison, comparing the characteristics of inmates testing HIV positive to those who tested positive in the community. During the 10-year study period (1989-1999), one third of all HIV positive tests in Rhode Island came from inside the state correctional facility, which held both pretrial and sentenced inmates. An important finding of this study is that, when compared to the other testing sites, the correctional facility reported more HIV positive tests for African American males and reported intravenous drug users. Desai et al. (2002) suggested that this can be explained by the infrequent contact that these groups have with medical professionals outside prisons and jails.
While testing in correctional facilities has been an important strategy for identifying and treating people with HIV, the majority of inmates do go through the correctional system without ever being tested. Duffus et al. (2009) studied HIV transmission in South Carolina and found that 48% of individuals who were both HIV positive and had criminal records had been arrested at least once prior to testing positive. Of these people, 65% (1,268) had been arrested after the time they were likely infected, but they were released from custody without being diagnosed. The New York Department of Health and Mental Hygiene incorporated the offer of a HIV test as part of the intake routine for New York Jails in 2004.
In a four-state study, Kacanek and colleagues (1997) interviewed prison inmates who had been tested for HIV while incarcerated. They also found that having the test available in prison gave inmates access to a health system that they did not have in the community. When asked why they agreed to be tested in prison, some responded that this is the only location where they ever receive HIV testing, since they did not visit doctors and only went to the hospital for emergencies. Incarceration can also provide inmates some time to reflect on their actions and the consequences of those actions. Spaulding and colleagues (2002) noted that “incarceration often awakens a person to acknowledge that the behavior that led him or her to be incarcerated—such as drug use or commercial sex work—may have placed him or her at risk for HIV infection” (p. 307) What is clear from the existing research is that HIV testing in the correctional setting allows health professionals to reach out to groups (African Americans and IDUs) who otherwise would not pursue testing in the community.
HIV correctional testing programs have the potential to address two important issues that can impact the chances of inmates’ contracting HIV in the future. The first issue is failure to receive the test results. Sullivan, Lansky, and Drake (2004) studied failure to return for HIV test results among community high risk groups. The researchers interviewed volunteers from gay bars to represent the males having sex with males groups (MSM), recruited intravenous drug users and went to clinics to interview high-risk heterosexuals. Of the 2,241 respondents, 10% of the MSM group, 27% of the intravenous drug users and 20% of the high risk heterosexuals reported failing to return for HIV test results at least once. Of those who failed to return for results, 29% assumed that the testing center would search for them if the test was positive, 31% cited fear of the results, and 43% responded that they were too busy or forgot. 1
One potential HIV testing complication in the correctional setting is the possibility that inmates will be released prior to the test results being processed. The Rhode Island Department of Corrections has been offering HIV testing to inmates in prison and jail for several years. Unfortunately, due to the quick turnover of jail populations, many inmates have been released prior to receiving results. Rarely do these inmates contact the correctional facility following their release to inquire about their test results. When interviewed upon reincarceration, they justified their lack of inquiries because “no news is good news” (Beckwith et al., 2007). Failure to return or call for test results is harmful for two reasons. First, as the Beckwith et al. results suggested, some people will interpret the lack of information as a clean bill of health and will continue to participate in high-risk activities. Second, inmates who do not receive test results are unable to benefit from risk reduction counseling that tends to take place at testing centers where people return to receive their results (Beckwith et al., 2007; Kacanek et al., 1997). Researchers have suggested that the best way to avoid failure to return is to use rapid testing equipment in (Beckwith et al., 2007; Sullivan et al., 2004). Beckwith et al. (2010) evaluated a jail-based HIV testing program where inmates were randomly selected to receive either the rapid results test or the traditional HIV test. All inmates subject to the rapid results test receive their results prior to release, whereas only 28% of the traditional test group was informed of their HIV status.
The second benefit of prison and jail testing programs is that it presents an opportunity to educate inmates about healthy practices. Correctional facility staff members responsible for testing programs can build an HIV-awareness program around the tests. As was noted earlier, prison and jail inmates generally have high-risk lifestyles where they repeatedly engage in behaviors that could expose them to blood or other bodily fluids (Krebs, 2002; Martin, Cayla, Moris, Alonso, & Perez, 1998; Moseley & Tewksbury, 2006).
Researchers have cited a number of obstacles to HIV prevention work with offenders. One problem is the prison or jail culture itself. The inmate subculture tends to promote antisocial thoughts and behaviors, and inmates frequently talk to each other about their plans for their first few days out on the streets (Inciardi et al., 2007). These plans often include behavior (sex and drug use) that places them at risk for exposure to HIV. Another problem is that there are misconceptions about HIV and its transmission. Researchers who have interviewed offenders have reported that they often believe one can tell from a person’s appearance if he or she has HIV/AIDS (Decker & Rosenfeld, 1995; Stanton-Tindall et al., 2007). Additionally, some believe married people, regardless of their fidelity to the marriage, cannot contract HIV (Decker & Rosenfeld, 1995). Still other males inside corrections facilities and in the community consider male-male sexual contact to be heterosexual behavior for the person performing the insertive role (Donaldson, 1993; Lichtenstein, 2000; West, 2001). The most damaging misconception, however, is the belief that HIV transmission is a matter of fate rather than a matter of education and prevention (Swartz et al., 2004) or that some individuals are somehow immune from HIV transmission (Stanton-Tindall et al., 2007). Inmates who believe that they have no control over their fate may know the facts about HIV transmission but still hold the opinion that none of the information applies to them. All of these issues can be addressed in either pre- or post-test counseling sessions.
Existing Testing Programs
The Centers for Disease Control (CDC) provided funding to state health departments in Florida, Louisiana, New York, and Wisconsin with the goal of providing rapid HIV testing to jail inmates between December, 2003 and May, 2006. The jails involved in the project booked approximately 550,000 people during the study period, and 33,211 voluntary tests were performed (6% of bookings). Of the 33,211 rapid tests, 440 (1.3%) were positive. Four hundred, twenty-two inmates (96%) accepted the offer for a confirmatory test. Of those tests, 409 (97%) were positive, 8 (2%) were negative, and 5 (1%) were inconclusive. MacGowen and colleagues (2009) conducted multivariate analyses to identify characteristics of inmates who tested positive. Age (35 years or older), race (Black), male-to-male sexual contact, sex with an at-risk partner, and male-to-male sexual contact plus IDU were associated with higher odds of HIV transmission. For female inmates, sex with an at-risk partner and race (Black) were related to odds of HIV transmission.
The Rhode Island Adult Correctional Institution includes an optional HIV test as part of the processing procedure for sentenced inmates. Between 1998 and 2000, medical personnel conducted 5,390 HIV tests on 4,269 male inmates. Two percent of the inmates tested positive for HIV. Those who tested positive were more likely to be Black or Hispanic, to be more than 40 years old, and to be involved in IDU (Macalino et al., 2004).
The Georgia Department of Corrections initiated a mandatory HIV testing program for inmates entering the system in 1988. Jail inmates were tested if they volunteered or were referred by medical staff member. Between 1988 and 2005, 88 inmates tested negative upon prison entry but tested positive during their sentence. It is possible that some of these inmates were infected prior to entering the prisons but that seroconversion did not take place until sometime during incarceration. It is also possible, though, that some of these inmates became infected during incarceration. The CDC found that HIV seroconversion in this study was associated with male-on-male sexual contact in prison, prison tattooing, and having served at least five years of the current sentence. Other variables associated with positive test results were age (above 26) and race (Black; Centers for Disease Control, 2005).
Kacanek and colleagues (1997) interviewed inmates who were nearing their prison release date in California, Mississippi, Rhode Island, and Wisconsin. The participants were asked about their feelings on voluntary HIV prison testing. Inmates who chose to take the test did so because it was free, they were curious about their HIV status, it was convenient, they thought it was mandatory, and because prison is their primary source of medical care. Several of the inmates remarked that prison was the only place where they had been offered free tests.
Beckwith et al. (2007) found that there are challenges to convincing inmates, regardless of their risk, to participate in the testing programs. The researchers recruited volunteers from the Rhode Island Department of Corrections to take an HIV test and complete a survey about their high-risk activities. Those who did not participate and get the HIV test declined because some did not want to know the results. Others declined because they did not want to miss dinner or their shower time, or they preferred to play cards during the time when the test was being administered.
The HIV Testing Program at the Atlantic County Jail
The Atlantic County Jail in southeastern New Jersey subcontracted with AtlantiCare Health Services to offer HIV testing to inmates housed at the jail beginning in April 2009. The jail was awarded a grant to set up the testing program due to the county’s high HIV transmission rate. The New Jersey Department of Health and Senior Services (2008) reported that there were more than 70,000 cases of HIV/AIDS in New Jersey by December 2007, and more than half of the New Jersey infection cases include non-Hispanic Blacks. Additionally, four out of five New Jersey females living with HIV/AIDS are minorities. Notably, New Jersey ranked fifth among the fifty states in the number of African Americans living with AIDS as of 2001. Atlantic County has one of the highest numbers of people living with HIV/AIDS in the state, with 1,775 residents. One in 33 African American men in Atlantic City is living with HIV/AIDS, and this is second only to Newark, where one in 30 African American men are infected.
An AtlantiCare case manager has been working with the inmate jail services staff to offer inmates free HIV tests. Jail personnel allow inmates to enter the jail, go through initial intake, and then wait for 24 to 72 hours to sober up, detox, and adjust to being in jail. After that period of time, the jail administers a biopsychosocial instrument to assess inmates’ needs. During that time, the staff members offer inmates the free rapid HIV test. Inmates who consent are placed on a list and called to testing in the order in which they requested the test. When the time comes for those individuals to be tested, they are brought in small groups (average of 5 inmates per group) to the jail inmate services section. The case manager reminds the inmates that the decision to take the HIV test is theirs, and they are asked again whether they want to consent. Inmates who refuse to stay for the counseling and test are told that they may come back later if they change their minds. If inmates refuse the test due to already having been tested, the case manager reminds them to follow up with that testing agency for the results.
Inmates who choose to remain for the counseling and testing are told about why HIV testing is important, what is involved with the testing procedure, and the confidentiality of testing. At that point, the inmates separate and the case manager administers the test to each inmate individually in a private area. While the inmates await results, the group is convened so the case manager can begin the education portion of the program. This involves a review of the group’s knowledge base, providing positive feedback for accurate information and corrections when they are misinformed. The case manager discusses behaviors related to increased risk for contracting HIV, especially behaviors that are common among incarcerees, such as “jail house tattoos” and fighting and biting. This counseling program lasts approximately 20 min, which is long enough for the test results to return. The inmates again separate and the case manager meets with each inmate individually to discuss the test results. When the result is negative, the case manager discusses the 14-week seroconversion period and that individual’s specific risks that were self-reported on the risk assessment form. Inmates who are close to release are encouraged to engage in a conversation about the jail’s reentry program. If inmates indicate interest, they are given referrals to mental and/or physical health treatment, infectious disease clinics, drug and alcohol treatment services, needle exchange programs, and other reentry services. They also receive a list of health service providers in the community. Those who expect to be incarcerated for a longer period of time are referred to appropriate services within the jail. Inmates who are close to being transferred to state prison are encouraged to seek services at the new facility.
All inmates who test positive on the initial test receive a confirmatory blood test that takes 7 days for the results to be processed. Those who test positive on the confirmatory test are given counseling and medical treatment. The drug regimen is part of the other medications the offender receives, so it is not apparent to other inmates that the individual is being treated for HIV. Once released, the inmates who do not have commercial health insurance are offered community-based resources through an AtlantiCare office in Atlantic County.
Method
All participating inmates were asked by jail staff members responsible for administering the HIV tests to consent to share their information with two researchers from a local college. Participants were promised confidentiality and were assured that their information was to be used exclusively for research purposes. Those who consented to the HIV test did have the option of continuing with the test without participating in the research. The researchers developed a short instrument that included demographic information as well as questions about reasons for wanting to be tested, their HIV test history, and self-reported high-risk behavior.
Testing began on April 30, 2009, and the researchers collected data through December 31, 2009. The jail did not keep precise records of the numbers queried for their interest in an HIV test. However, the staff members reported that approximately half of those who were asked expressed interest. Approximately 1,700 inmates initially agreed to undergo testing. They were asked if they would like to be put on the testing list when they went through initial jail medical intake. Inmates typically had to wait 1 to 3 days, and sometimes longer between the time of their initial consent and the time that the case manager administering the test was able to meet with them. The grant provided funding for only one case manager to participate in this project, so the tests were only administered by one person during normal business hours, and no tests occur when that person was out sick or on vacation. Between the time of initial consent and the time that the test was to be conducted, 75 inmates changed their minds about being tested. An additional 624 inmates were released from jail before the testing could be conducted. A total of 956 inmates consented and remained in the jail long enough to be tested. Of these, 26 received multiple tests at the jail, with 25 inmates receiving two tests and one inmate being tested three times. In sum, 983 HIV tests were administered during the data collection period. Of the 956 inmates who participated, 698 (73%) consented to releasing their personal information for the study. Those who declined to share their information with the researchers reported concerns about confidentiality. Some inmates commented that they knew faculty and staff at the college where the two researchers worked, and a few of those who declined to allow researchers access to their information noted that they knew the two researchers.
Results
Frequencies
Again, 75 inmates changed their minds between their needs assessment and the time when they were called to take the test. The reasons why they declined the test after initially consenting varied. As was noted earlier, the wait between agreeing to the test and being called to take it varied from one day to several days, depending on the number who wanted to take the test and the availability of the case manager. The result is that inmates had a few days to reconsider their decision. Some began to think about what they perceived as the “dangers” of testing and might have been discouraged by other inmates who were against the testing program. One reason given for refusing the test was the belief that the jail already took too much blood from them (a likely reference to the mandatory syphilis test). Other reasons were related to inmates believing that the test was inconvenient. Some declined because they were asked to go to the testing area while they were watching a favorite television show, the inmates were sleeping, or they did not want to enter the testing area because it is cold. Some female inmates experienced delays in testing because they needed to be escorted past the male housing areas, so it was necessary to find officers who could handle the escort.
Of those who consented to testing and releasing their information for the study, 90% (598) were New Jersey residents, with 36% residing in Atlantic City (Table 1). Five percent (30) of participants were from Pennsylvania, 2% (15) resided in New York and 3% (22) were from outside of the tristate area. Females (20%) were overrepresented in the participant group. Seventy-nine percent (546) were males and 1% identified as transgender. Nearly 90% (608) of the participants reported that they were not homeless at the time of their most recent incarceration. Slightly more than half of the participants were Black, 34 % were White, 2 % were Asian, 1% American/Pacific Islander and 10% identified themselves as another race. One hundred fifteen respondents identified themselves as Hispanic. Of those inmates, 76% were Puerto Rican, 10% were Mexican, 6% were Central/South American, 4% were Cuban, and 4% traced their heritage to another country. Most participants (86%) identified English as their primary language. Eight percent use bilingual (English and Spanish), 4% identified Spanish as their first language, and 2% indicated that another language was their primary. Slightly more than three-quarters (77%) were single at the time that the test was taken. Eleven percent were married, and 9% were separated, divorced, or widowed. Three quarters of respondents were unemployed prior to their incarceration. The mean age of participants was 32 (SD = 10.72).
Descriptive Statistics for Jail Inmate HIV Testing Program (N = 698)—Atlantic County, New Jersey
The researchers obtained demographic information of inmates residing in the jail during the study period. The inmate population consisted of 81.2% males and 18.8% females, so that females were only slightly overrepresented among HIV-test participants (78.8% males and 20.3% females released their information to researchers). The racial and ethnic composition of the HIV test participants was also similar to the demographics for the entire jail. Slightly more than one third of the test participants were White, compared to 35% of the jail population. Hispanics were slightly overrepresented among participants, with 16.5% of inmates who volunteered for testing self-identifying as Hispanic compared to 13% of the jail population. The average age for participants was 32.3, which was just slightly younger than the mean age of jail detainees (34.2). Overall, the group that consented to the HIV tests and shared their information with the researchers seemed to closely match the demographics of inmates housed in the jail during the study period. Sixty-five percent of the inmates received an HIV test for the first time. Of those who had tested previously, 384 (95%) had negative results on previous tests, 17 (4.2%) did not know their previous test results, and three (0.7%) had received positive test results. On average, those who tested previously participated in their last test more than 2 years ago (mean = 2.21, SD = 2.92). When asked about the location of prior tests, the modal response was a custodial facility (35.3%) with doctor offices, hospitals, medical centers and Veteran’s centers as a close second (34.3%). Sixteen percent of previously tested inmates visited a clinic, shelter or mobile unit. Eleven percent were tested at a rehabilitation center or half-way house, and 4% went to an AIDS center for testing. See Table 2.
HIV Testing Data for (N = 698)—Atlantic County, New Jersey
As was previously reported, 25 participants were either reincarcerated or remained incarcerated long enough to take additional HIV tests in the jail. Twenty-four of the 698 participants took two tests, and one person took three tests. Inmates were asked about why they were interested in being tested at this particular time. Eighty percent (501) responded that they were curious about their status. Approximately 15% indicated that they had been involved in high risk behavior including, unprotected sex (8.5%), drug use (2.6%), both sex and drug use (2.2%), his or her partner is HIV positive or the respondent was concerned about a previous rape, bite, or blood transfusion. Three percent replied that “there’s nothing better to do” or “it’s free,” and 2% replied “why not?” While the researchers were only able to obtain detailed information about 698 of the 956 inmates who participated in testing, jail staff members were able to provide the total number of positive and negative tests. Of the 956 inmates who took the test, three inmates (0.3%) tested positive for HIV. After these three people were informed of their positive test, two disclosed that they had previously tested positive.
Prior to testing, inmates were also asked specific questions about their sexual and drug use behavior. The results are displayed in Table 3. Inmates tended to be sexually active, with 20% reporting sexual contact with males and 82% reporting sexual contact with females. The 82% is likely an underestimation; when inmates were asked about recent types of sexual contact, 90% reported vaginal contact. Seventy-four percent of respondents reported oral sexual contact, and 18% reported anal contact. Eighty percent of respondents admitted to having unprotected sex. Two percent of participants reported sexual contact with someone known to be HIV positive, and 1% had male-male sexual contact. Thirty-eight percent had sex while intoxicated. Nine percent exchanged sex for drugs, 11% had sex with someone who had exchanged sex for drugs, and 11% reported sexual contact with an intravenous drug user. Sex with an anonymous partner was reported by 17% of participants. One percent reported sex with someone who has hemophilia or received an organ transplant or blood transfusion, and 1% reported having sex with a transgendered person. The mean time between last sexual contact and testing was 4 months, but the distribution was irregular (SD = 0.57). Slightly more than half (52%) of respondents reported that their most recent sexual contact occurred within the previous month. Eighty-six percent of respondents reported sexual contact within the past 6 months.
Sexual Contact Data for Jail Inmate HIV Testing Program (N = 698)—Atlantic County, New Jersey
Information regarding participants’ self-reported drug use is displayed in Table 4. Sixteen percent of respondents identified themselves as intravenous drug users, and 8% indicated that they have shared needles.
Drug Data for Jail Inmate HIV Testing Program (N = 698)—Atlantic County, New Jersey
Cross-Tabulations
Cross-tabulations with chi-square tests of independence were conducted to determine whether inmates who had tested previously were at a higher risk for exposure to HIV than those who decided to test for the first time in the jail. The results are displayed in Table 5. There were no significant differences in self-reported high-risk behavior of inmates who had been tested before versus those who were participating in testing for the first time.
Chi-square Tests of Independence Inmates Who Had Tested Previously Versus First Time Testers
A chi-square test was not conducted due to low expected frequencies.
Discussion
The results of this study clearly support the findings of other researchers that incarcerated populations partake in behaviors that put them at high risk for HIV transmission. The testing program at the Atlantic County Jail began in April 2009 and continues to operate today. Thousands of inmates are being offered the opportunity for free, confidential testing in a setting where they likely have fewer distractions than while residing in the community. Inmates are also promised free medical care for the duration of their jail stay, and those who live in the county and lack health insurance are assured that they will receive outpatient treatment from a local service provider upon release. The program recently received funding to expand testing to include other sexually transmitted diseases.
Custodial institutions are important testing centers, since they house captive populations who tend to live unhealthy lives and rarely receive regular health checks. Two-hundred forty-five inmates in this study were tested for HIV for the first time in the jail. An additional one hundred seventy-five inmates were tested before but had received those tests in either a custodial or rehabilitation setting. It is possible that some of these inmates would have sought HIV testing elsewhere, but these findings support previous research that found correctional facilities to be among the most popular testing centers for high-risk individuals (Desai et al., 2002; Kacanek et al., 1997). The use of the rapid finger-prick tests allowed the jail to address the problem of inmates being released prior to obtaining the result, thus eliminating the possibility that positive inmates assumed that they are negative because no one told them otherwise.
A surprising finding here was that only three inmates out of the 956 who were tested during the data collection period tested positive for HIV. As was noted earlier, The New Jersey Department of Health and Senior Services (2008) reported that New Jersey is ranked fifth among the states for African Americans living with HIV/AIDS, and within New Jersey, Atlantic City is second only to Newark for the proportion of African American men living with AIDS. In light of this information, it was expected that there would be more positive tests. One possible explanation is that inmates are selectively opting out of tests if they have reason to believe that they might be HIV positive. Andrus et al. (1989) did explore this possibility by comparing voluntary HIV test results to blood samples drawn from inmates who did not want to be tested for HIV but had to participate in syphilis testing in an Ohio prison. There appeared to be no significant differences in self-reported high-risk behaviors (intravenous drug use, homosexual activity, testing positive for hepatitis B) between the individuals who consented to the HIV test and those who declined. Inmates in the Andrus et al. study were asked if they thought they had been exposed to HIV, and 85% of the inmates who answered affirmatively chose to take the test. It is not clear whether these results are generalizable to other facilities and locations in the United States, but it does provide evidence that not all high-risk people avoid HIV tests. Ideally, the researchers of the current study would have liked to have been able to ask members of a comparison group about their high-risk activities. It is unlikely, however, that inmates who were concerned about privacy issues and did not trust the jail staff to do the HIV test would be willing to answer such personal questions about their sex and drug use behavior.
The extent of self-reported high-risk behaviors among those who volunteered to participate in the testing program underscores the need to educate inmates about unsafe sex and drug use behaviors. It is important to remember that some previous studies have found that some inmates have become fairly knowledgeable about what constitutes HIV high-risk transmission behaviors. A significant hurdle to transforming that knowledge into healthy practices, though, is the belief that either HIV transmission happens to other people or that transmission is a matter of fate. Until these beliefs are changed, warnings about the importance of safe sex and drug use practices will be considered irrelevant. The jail described in the current study provides a very short education program about HIV to those who participate in testing. While this program might provide inmates with some information about HIV and its transmission, such a short program is unlikely to be effective in changing the beliefs of people who think that transmission is a matter of fate rather than behavior. Time is always a challenge when working with transient jail inmate populations. While it would be difficult to develop and facilitate a course on healthy living practices, a much longer program that addresses the myths of fate and immunity as they relate to health and risky behaviors would likely do more to combat these beliefs than a 20 minutes overview of HIV. Previous research has emphasized the importance of culturally appropriate materials and the need to have instructors who are from diverse racial and ethnic backgrounds (particularly multilingual staff members), as this tends to increase the credibility of the program’s message (Kantor, 2006; Leh, 1999).
The CDC has recommended the adoption of opt-out HIV testing for corrections facilities. Under an opt-out screening system, HIV tests are handled as part of routine health screening, and inmates are informed that they will be tested unless they specifically decline. This can normalize HIV testing, increase diagnosis for HIV infection, and improve access to clinical care for those who are positive and prevention services to those who are negative. The HIV test is not part of routine medical screening, and those who agree to take the test must make a separate trip to the medical area and sign a consent form. As was noted earlier, this additional trip is considered an inconvenience to some inmates, and the consent form might scare inmates who are already suspicious of having to sign anything. Wisconsin and Rhode Island has been using opt-out screening for several years, but New Jersey has not yet adopted this system. A change to an opt-out system would likely increase the number of HIV tests performed at the jail each year, and the tests could be done more efficiently during the regular medical screening (CDC, 2008).
Limitations and Suggestions for Future Research
As in any jail evaluation, a systematic approach to data collection and storage is salient to the tracking of inmates and maintenance of records. The jail in this study suffers, like most, from understaffed and overworked conditions. As this particular HIV testing program moves forward, it would certainly help if the jail could either hire an additional case manager or bring in an alternate on the days when the full-time case manager is out sick or on vacation. During the 5 months that the researchers observed the program, more than 600 inmates volunteered for testing but were released from custody before the staff member was available to do the test. An additional 75 inmates had agreed to testing but then changed their minds while they waited their turn. More staffing dedicated to HIV testing might have resulted in testing of an additional 700 inmates who, at one point, were interested in receiving the test.
As this and other jails move forward with HIV testing, the educational component of this program is crucial in the prevention of future cases of HIV. The focus on HIV testing only covers one aspect of HIV transmission. The primary reason to test is to notify infected individuals so they will get treatment and prevent the spread of HIV. For those who do not test, educational counseling may be the only way to convey information to protect oneself from contracting HIV. As such, the educational counseling should be considered as both part of the testing sequence as well as a stand-alone session. Inmates who do not agree to be tested in the facility should have an opportunity to learn about HIV. Currently, the program in this jail is set up such that the “educational counseling” is given between the time when the blood is drawn and the results are ready. Inmates who are not tested do not have access to such counseling.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.