How much do you think it would cost the health department of a major American city to reduce the amount of gonorrhea, Chlamydia, syphilis and possibly even HIV by 20%? More importantly, if you had to devise the simplest and most cost-effective way to do this, how would you do it?
Millions have been spent on print ads in magazines and newspapers, TV spots, billboards, and Internet messages. Additional monies have been spent for peer and provider education. Schools teach sexual health. Public health agencies spend millions more performing services such as partner tracking and notification. Despite all these efforts, sexually transmitted infections continue to plague our communities.
Perhaps another approach might be to seek out a subpopulation that has a higher than average prevalence of infections. Better yet would be if that population could be gathered into one location to streamline testing, diagnosis, treatment, and linkage to care. In most major metropolitan areas, such places exist: jails and prisons.
STI Testing Lessons
In Chicago, this very scenario played out in reverse. In April 2002 - March 2003 the Cook County Jail performed "universal voluntary screening" for gonorrhea and Chlamydia. More than 85% of men and women entering the facility participated in testing, leading to large numbers of diagnoses and treatment.¹ An estimated one in five cases of gonorrhea in the entire county was diagnosed and in most cases treated during incarceration at the jail.
Testing was switched to symptoms-based screening only in March 2003. In the following year, the number of cases of gonorrhea and Chlamydia that were diagnosed in the jail declined by nearly 80%! While this is not exactly comparing apples to apples, it demonstrates the power and dramatic impact opt-out testing can have on the community. All those undiagnosed and untreated patients are potential vectors of disease transmission in the community at large.
In 2007, all intake screening was discontinued, and the number of cases of gonorrhea diagnosed in the County reached its lowest point in more than seven years. This doesn't mean there was any less gonorrhea in Cook County. It just means that the largest single-site testing and treatment facility in the county had ceased to have an impact. All those previously diagnosed and treated cases were going untreated and ultimately returned to the community to be spread to new partners.
By 2008, the number of new cases diagnosed in Cook County had increased by nearly 10% in a single year. This was without having resumed large scale testing at the Cook County Jail. These were all cases diagnosed at the community-level clinics and other health care settings. It was clear that the jail served a massively important role in the cycle of transmission of sexually transmitted diseases. By focusing initiatives on correctional facilities, communities have that cost-effective magical constellation of high disease burden, captive audience, screening, treatment, and linkage to care.
Might jails and prisons be able to have a similar impact on HIV?
HIV Testing Behind Bars
HIV testing is generally considered to be cost-effective, but the biggest "bang for your buck" occurs when screening is applied to populations where the presence of disease is predicted to be higher than average. Correctional settings represent an ideal example of a population that may receive the biggest direct benefit from opt-out HIV testing. The U.S. prevalence of HIV is estimated to be between 0.3 to 0.5%, but in jails and prisons the rate is three to five times higher (as many as 2.5 people out of 100). The reason for the higher rate is because many people who are incarcerated have a higher prevalence of HIV risk factors (e.g., injection drug users, sex workers, the mentally ill, and "risk-takers"). Further, jails and prisons tend to represent a similar economic strata as those who do not routinely have access to health care in their communities (the un- or underinsured) and therefore are less likely to have been offered testing prior to incarceration.
It is estimated that as many as 25% of all Americans who are infected with HIV are currently unaware of their diagnosis. This means there may be more than 250,000 citizens who are not in care and therefore not on medications. An estimated 20% of all HIV-positive people will pass through a correctional facility at some point. Their health may be in jeopardy, but in a broader view, public health is also directly affected. HIV-positive patients not diagnosed and not on treatment are more infectious and may not be taking additional precautions to safeguard their partners (condoms, strategic positioning, serosorting, altering sexual practices, abstinence, etc.). The financial impact of delayed access to HIV treatment is also substantially greater. Presenting with advanced HIV leads to longer and more frequent hospitalizations, more medication expenses, more utilization of HIV primary care resources, and so on.
In 2006 the CDC issued a recommendation that HIV testing should be considered a routine part of an effort to diagnose and ultimately treat the "missing 25%." This included testing anyone ages 13-64 in all health care settings, increased frequency of screening for those at higher risk for HIV, eliminating separate written consent, eliminating the requirement for prevention counseling, including HIV testing in all prenatal panels, and utilizing opt-out testing wherever possible.
Opting Out
Opt-out testing is a method where everyone who engages a particular care setting will be tested unless they decline. Due to laws that vary from state to state, consent still must be acquired in most instances. Fortunately, verbal consent (which must still be documented in the medical record) is acceptable in most cases. This is important because high-volume settings such as jails and emergency rooms must have streamlined and efficient procedures to screen as many patients as possible. Any additional steps, such as finding and filling out a lengthy written consent form, adds substantial time to each patient encounter.
Once the patient has consented and agrees to participate in opt-out screening, they are sent for an HIV test. There are basically two major types of HIV tests that can be used in an opt-out setting: ELISA antibody tests (blood) or a rapid test (finger stick or oral swab). The advantages of rapid testing include being less invasive than a blood draw (no needles in veins), results in minutes, and most importantly, the ability to give the preliminary result to the patient before they are gone. The advantages of plasma ELISA testing include lower cost, delayed results (a benefit if patients are not stable enough to hear results immediately), and less utilization of space and staffing in a busy intake setting.
Delivering test results may seem like it should not be an issue in a jail setting where you have a captive audience to give results from a slower test such as an ELISA. The reality is that many detainees leave jails in hours to days depending on their charges, are released on home-monitoring, or are bailed out. Waiting even two or three days may mean up to 30% of those tested might not receive their result. Furthermore, is a jail intake facility an ideal place to tell someone for the first time they probably have HIV? Intake facilities are generally hot, crowded, high-pressure environments where there is little real privacy, if any. Incoming detainees are often intoxicated or coming down from a high, possibly angry about being arrested, mentally unstable (especially the people with severe mental health concerns), and physically and emotionally exhausted. Imagine a health care provider telling you your result, then sending you back out into a bullpen with 60 other detainees who are yelling, jostling for space, and maybe even reading the new look of shock on your face.
In a prison setting, most inmates have a clearly defined sentence. The health care staff knows the exact date of release from the facility, and therefore, there's a higher probability that those who are tested will receive their result. Additionally, by the time inmates reach prison, they are usually sober, better rested (as compared to the day they went to jail), and more emotionally and mentally stable. In resource-limited settings, including correctional facilities, screening with a less-expensive test (ELISA) may make expanded screening via opt-out more palatable to the budget-makers. Lastly, with known discharge dates, linkages to HIV care in the community become at least a little easier than they are in a jail setting (where one never really knows if or when the patient will be leaving).
Community Benefits
As a real-world example, in 2006-2007, Washington, D.C. began expanded routine HIV screening in health care settings, including jails. The number of HIV tests performed increased by more than 68% in just one year simply by implementing the 2006 CDC recommendation for opt-out HIV screening.² Not only were more tests conducted, but more results were available and delivered. This ultimately led to more patients becoming linked to care in their communities, and this led to more diagnoses made in an earlier stage of the disease (the average baseline CD4 went from 262 to 332 in the first year alone). In addition, more people aware of their status means more people on treatment. More people on treatment means less chance of infecting new partners. That was clearly shown with HPTN 052, a study of more than 1,700 couples in which successful treatment of the HIV-positive partner led to a 96% decrease in transmission. Awareness of one's HIV status also often means behavioral changes to protect partners. Fewer newly infected people means additional benefits to the community at large.
With renewed support from the county government, the Cook County Jail in Chicago began opt-out HIV and STI (sexually transmitted infection) screening in April 2011 for females entering the facility. More than 7,000 female intakes occurred from April through the end of 2011. More than 50% agreed to participate in HIV opt-out screening, and more than 60% in gonorrhea and Chlamydia screening. This process nearly tripled the number of HIV, syphilis, and GC/Chlamydia tests performed in the full calendar year of 2010. Many of these women remained in the facility long enough to not only receive their results, but to complete treatment (in the case of GC/Chlamydia) or linkage to care (in the case of those diagnosed with HIV). With "second-chance" testing offered at later times during their incarceration, an additional 20-30% of women ultimately agreed to be tested. The Chicago Department of Public Health was notified of any women leaving the jail before their results were available in order to attempt to locate them in their communities to provide treatment, as well as to notify sexual partners.
You might still be asking, "So why does this matter to me?" Remember, the majority of men and women entering a jail do not go to prison or otherwise just disappear. They return to their communities, bringing any untreated communicable diseases they have with them. With government budgets stretched thin, focusing limited resources to sites with the ability to have the greatest impact is wise. Some people may harbor resentment that tax dollars are being used to improve the health of people who may have broken the law, but this is shortsighted. In the long run, spending your tax dollars in jails and prisons for HIV and STI testing and treatment has a major downstream benefit to the broader community.
Chad Zawitz, M.D., is Attending Physician and Clinical Coordinator of HIV/Infectious Disease Services for Cermak Health Services at the Cook County Jail, providing care to HIV-positive detainees and inmates there and also at his continuing care clinic at the CORE Center. In 2005, he received the HIV Leadership Award as Up and Coming Physician from The Body.com. Dr. Zawitz has written for Positively Aware on a variety of topics, including the physician's comments in the 2006 10th Annual HIV Drug Guide_._
References
The Pew Center on the States. One in 100: Behind Bars in America 2008. 2008.
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Hader S. 16th CROI; 2009; Montreal. Abstract #57
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