Point-of-care testing for HIV in an Irish prison setting: results from three major Irish prisons

Introduction

With early diagnosis and access to effective antiretroviral therapy (ART), morbidity and mortality related to HIV can be reduced, and survival approaches that of the general population. ¹ High-risk behavior is substantially reduced after people become aware they are HIV-positive, ² and they are substantially less likely to transmit HIV to partners if they are maintained on effective ART.^3,4

The Irish Prison Service caters for male offenders who are 17 years or over and female offenders who are 18 years of age or over. There are 14 institutions in the Irish Prison service of which 11 are traditional ‘closed’ institutions, two open centres, operating with minimal internal and perimeter security, and one ‘semi-open’ facility. Delivery of health care in the prison setting can be challenging, where the average inmate weekly turnover rate can be high and the majority of sentences are under three months. In 2012, there were 17,026 committals from 13,860 individuals (84% male) to the Irish Prison Service (Source – www.irishprisons.ie).

Prison inmates are at increased risk of blood-borne virus (BBV) infections compared to the general population. HIV is more prevalent in the prison population as are rates of other BBVs such as hepatitis B and C.^5,6 In the United States, it was estimated that in 1997, 20–26% of people living with HIV in that year passed through a correctional facility. ⁷ Similar data from the Republic of Ireland estimated that between 1987 and 1991, 168 known HIV-infected prisoners had been incarcerated in Dublin’s Mountjoy prison, constituting 16.6% of the total known HIV-infected population. ⁸ At present, prisoners are not routinely tested for HIV infection at prison entry. The current Irish Prison Healthcare Standards (2011) recommend that all persons who have a background history with risk factors for any infectious disease should be offered any available screening for that condition. Previous work in 1999 by Long et al. ⁶ sought to determine the prevalence of hepatitis B, hepatitis C and HIV and risk factors in entrants to Irish prisons. The prevalence of antibodies to HIV infection at that time was estimated to be 2%. Prior to our initial testing in 2010, it was estimated only 10% of the prison population of Wheatfield were aware of their HIV status.

Inmates also tend to have barriers that result in underutilization of ART such as mental illness ⁹ and substance use disorders. ¹⁰ Considerable stigma regarding HIV has been documented amongst inmates and staff in correctional facilities.^11,12 The prison system represents an important venue for delivering a variety of HIV services (including testing, treatment and organisation of follow-up care in the community post-release). Collaboration between clinical and prison personnel is an important component of service delivery. ¹³ Provision of these services can lead to improvement in the health of inmates, family members and communities into which they return.

Since 2007 a HIV and sexually transmitted infection (STI) consultant-delivered in-reach service has been provided by the Department of Genito Urinary Medicine and Infectious Diseases (GUIDE) at St James’s Hospital, Dublin. This service serves Cloverhill Prison (a closed, medium security prison for adult males; daily occupancy – 388 inmates) and Wheatfield Prison (a closed, medium security place of detention for adult males and for sentenced 17-year-old juveniles; daily occupancy – 431 inmates). The in-reach service provides testing for STIs and BBVs, as well as assessment and management of STIs and chronic diseases such as HIV, hepatitis B and hepatitis C. Mountjoy Prison is the main committal prison for Dublin city and county and is also a closed medium security facility with an operation capacity of 554 inmates.

Methods

In collaboration with the prison schools, health care facilities, prison authorities and Irish Red Cross inmate volunteer groups in all three Dublin male prisons, the GUIDE clinic developed a campaign with the objective of raising awareness of HIV, educating prisoners about HIV and tackling HIV stigma. The end of the awareness and education campaign was marked by the offering of HIV point-of-care testing to prison inmates on a large scale over a short period of time.

The point-of-care testing was planned to mark important dates in the HIV calendar: Irish AIDS Day 2010 in Wheatfield prison, Irish AIDS Day 2011 in Cloverhill prison and Irish AIDS Day 2013 in Mountjoy prison. Prior to testing in all three prisons, HIV medical and social work teams from the GUIDE clinic, working with the prison schools and inmate volunteers from the Irish Red Cross, provided education and raised awareness about HIV in an effort to reduce stigma and promote awareness of HIV and encourage HIV testing. This practical application was linked to the classroom learning that the inmate volunteers were receiving as part of their Red Cross Community Based Health and First Aid (CBHFA) course.

In 2009, Ireland became the first country in the world to have prisoners as volunteers of its national Red Cross Society, the Irish Red Cross. These volunteers provide peer-to-peer health awareness and education in all of Ireland’s 14 prisons as part of the CBHFA course and were very active in the HIV testing campaigns. The inmate Irish Red Cross volunteers organised group learning sessions and used multimedia materials including DVDs, posters and flyers for educational purposes with their peers within the prison landings. Information regarding limitations of the test and testing dates was disseminated. In all Irish prisons, the inmate Irish Red Cross volunteers are important community advocates in all relevant areas of health and well-being because of the power of peer-to-peer education.

In the run up to rapid HIV testing days, the volunteers did cell leaflet drops to estimate acceptability and uptake of HIV testing. In all three institutions returned leaflets suggested that large-scale rapid HIV testing would be acceptable with anticipated high uptake rates. Multiple planning meetings took place between prison authorities and health care personnel to ensure safe, efficient and confidential HIV testing. Prisoners were grouped and tested by level of security risk. Interview data were collated from discussion with prisoners prior to and on the testing days.

Health care staff involved in testing included members of medical and nursing staff from the GUIDE clinic and the Irish Prison Service. All health care personnel involved in testing received training on HIV, HIV testing, the tests being used (with particular emphasis on the window period for third-generation HIV tests) and the process for giving results, and worked in line with locally developed standard operating procedures. Inmate Irish Red Cross volunteers had no involvement in the clinical aspect of this project or access to any confidential information.

The Hexagon HIV test (Human, Wiesbaden, Germany) was used in testing in Wheatfield and Cloverhill prisons. This is a third-generation immunochromatographic rapid test for the detection of antibodies to HIV 1 and 2. A finger prick sample of whole blood (20 µl) is collected into a pipette and placed on a sample window leading to a test result in 5–20 min. The test was chosen to minimise waiting times and expedite prisoner flow during the testing process.

The OraQuickADVANCE® Rapid HIV-1/2 Antibody test (OraSure Technologies) was used during the testing in Mountjoy Prison. Testing was performed on oral fluid samples. Volunteers emphasised the need for nil orally (including washing teeth and mouth wash) for 30 min before testing.

Once test results were available, every individual received their test results individually and confidentially.

In the event of a reactive test or a persistent invalid test result, a serum sample was obtained for conventional HIV testing and the results were made available to all individuals within 24 h. Any individuals testing positive on conventional testing were to be linked with the HIV in-reach services within 48 h for appropriate support and medical assessment.

Testing was performed utilising a one-way system to ensure rapid and efficient inmate flow. Following an informal group discussion led by the medical social work team from GUIDE regarding HIV and testing, inmates were led to the testing waiting area. Following testing, they were led to the results waiting area, where interview data were obtained from inmates in small groups using open-ended questions. Inmates were asked a variety of questions including reasons for testing, anxieties regarding testing, prior and current knowledge of HIV and the stigma surrounding it and asked for general comments on the information dissemination and testing procedures. Once results were available, they were brought into individual rooms to obtain results and discuss any concerns. Inmates were then escorted back to their landing (see Figure 1). OPEN IN VIEWER

Results

From interview data prior to testing, it was apparent that prisoners had little knowledge regarding HIV testing, treatment and prevention and that the subject had always been somewhat taboo and rarely openly discussed. Following the campaign, it was evident from interviews and informal discussion that knowledge of HIV had disseminated throughout the prison and many simple but important misconceptions regarding HIV had been clarified.

Prisoners found the information campaigns ‘informative’, ‘well publicised’ and ‘definitely reduced stigma’. Prisoners said they were ‘more aware of HIV now’ that it was a ‘treatable’ condition and ‘not the end of the world’. Prisoners stated that HIV was ‘not really understood before this’ and was previously ‘a very taboo subject’. It was expressed that it was ‘better to know that you had it and not spread it’. Prisoners also stated they would ‘offer support to anyone who tested positive’. Prisoners now talk about HIV and openly request to be tested with the ethos that it is preferable to be aware of your status. During the campaign, HIV-positive inmates came forward and advocated testing uptake. All these measures served to reduce stigma regarding HIV.

In total, 741 inmates were tested in three major Irish prisons. One reactive HIV result was recorded. A total of 43 inmates had persistent invalid test results on point-of-care testing requiring formal laboratory serum testing for HIV. Four false-positive results were obtained on point-of-care tests. All four tested negative on formal laboratory testing.

In 2010, over four days of testing in Wheatfield prison, 248 inmates (50% of the prison population) were tested. A total of 35 inmates required laboratory HIV testing due to invalid results. No positive HIV results were recorded.

In 2012, 139 inmates attended for testing over two days in Cloverhill prison. Testing of 33 inmates resulted in invalid test results. All inmates were offered a further point-of-care test; however, two inmates refused further testing. Following the repeat point-of-care test nine inmates had an invalid second test. Eight inmates consented to formal laboratory serum HIV testing, while one inmate refused further testing. All eight inmates tested negative for HIV. One inmate had a reactive rapid test and subsequently tested positive for HIV. He was immediately linked with the in-reach HIV services.

In 2013, testing was carried out over two days in Mountjoy Prison. At the time, 536 prisoners were in custody. Forty-five were excluded due to a known HIV-positive status or a recent viral screen. A total of 354 (72%) of a target population of 491 were tested. Four inmates had a reactive result on the screening test, all of whom subsequently tested negative following formal laboratory serum testing. An overview of testing from all three prisons is outlined in Table 1.

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Table 1.

Summary overview of testing in the three prisons.

	Wheatfield	Cloverhill	Mountjoy
Year of testing	2010	2012	2013
Total prison population	495 a	433 a	536
Number tested	248	139	354
Invalid tests resulting in formal HIV testing	35	8	0
False positive results	0	0	4
Positive results	0	1	0

Discussion

We demonstrated that an awareness campaign coupled with large-scale point-of-care testing for HIV in the Irish Prison Service is achievable. Work performed by the Irish Red Cross raising awareness of HIV and reducing stigma prior to testing at all three sites served to encourage the prison community to attend for rapid HIV testing and counseling.

A total of 741 prisoners were tested in total and one positive result was obtained. We were surprised that there were not more positive results. There are several limitations to our study.

As security is of paramount importance in the prison setting, we did go to individual cells for testing of some of the high-security prisoners. This had an impact on timing and efficacy of the testing process.

HIV testing was by antibody testing only, which may have missed prisoners who had recently acquired HIV infection and were in the window period. This is of particular importance in the remand setting where individuals frequently come from a period of chaotic drug use to the prison setting.

A number of prisoners declined HIV testing making it difficult to estimate the true prevalence of HIV infection in the prison setting, although this was not an objective of our study. Reasons for refusal were not recorded. No data were collected regarding previous testing for HIV, sexual practices or intravenous drug use.

A large number of invalid tests were recorded with the Hexagon HIV test, necessitating repeat point-of-care testing in a number of prisoners, resulting in delays in our testing schedules and requirement for formal laboratory serum testing of 43 prisoners in total. Three prisoners declined further testing following receipt of an invalid result. Reasons for the invalid tests are unclear, but were felt to be secondary to poor technique with the pipettes and difficulty obtaining the required blood volume for the test. As technique improved, the number of invalid tests declined.

Four false positive results were obtained with the OraQuickADVANCE® Rapid HIV-1/2 Antibody test. The reasons for this are also unclear, but may have been due to inadvertent oral care product use or food and drink consumption within 30 min prior to testing.

Given the transient nature of the prison population, routine opt-out testing would be most appropriate for all prisoners; however, challenges remain in resources and linking patients to care both in prison and the community. ¹⁴

Future studies should look to ensure continued and sustained surveillance for HIV in this high-risk population, coupled with surveillance for other BBVs, and rates of uptake of preventative measures such as hepatitis B vaccination. We have demonstrated the importance of peer education and collaborative work in achieving large-scale point-of-care testing in the prison setting.