Opt-Out HIV and HCV Testing at the Dallas County Jail

An Interview With Carolina De La Flor, M.D., and Ank E. Nijhawan, M.D., M.P.H.

Ank E. Nijhawan, M.D., M.P.H.
Carolina De La Flor, M.D.
Terri Wilder) Ank E. Nijhawan, M.D., M.P.H. (Credit: Terri Wilder

Jails and prisons provide good opportunities to provide HIV and hepatitis C (HCV) testing for individuals who are hard to reach and may be at high risk. One study set out to examine how effective opt-out testing for HIV and hepatitis C could be among individuals who entered the Dallas County jail. Terri Wilder, M.S.W., spoke with study authors Carolina De La Flor, M.D., and Ank E. Nijhawan, M.D., M.P.H., at CROI 2017, in Seattle.

You can also read the study abstract and view the study poster.

Terri Wilder: Please take our readers through the background, objectives, methods, results, conclusions and lessons learned from your study.

Carolina De La Flor, M.D.: Of course. Basically, when we started doing some lead review for this poster, we found that, of course, the burden of HIV and hepatitis C [HCV] are much higher in correctional facilities. Jail and prison are good opportunities to perform hep C and HIV screening in hard-to-reach individuals and, of course, high-risk individuals.

In terms of background, the Centers for Disease Control and Prevention recommends routine opt-out HIV testing in jails and prisons, but only around 19% of our prisons in the States, and 35% of jails, offer this service. In terms of hep C, only 15 states in the U.S. report performing routine HCV screening. So, that was basically a little bit of the background that we did.

In terms of the objective, we wanted to describe the results of an opt-out combined HIV and hep C testing program in the Dallas County Jail and describe the prevalence and the demographic characteristics of the HIV and hep C positive population.

Before this study, a previous study was done, also in the same population. Instead of just offering the screening when the patients were in the intake process, we changed that to opt-out -- basically meaning that during any scheduled blood drawing the patients will be informed that by protocol HIV and hep C screening will be done unless they refuse.

TW: So, this was when they were entering jail?

CDLF: Yeah.

TW: Right. OK.

CDLF: When we switched from offering the test during the intake process, when we switched that to just offering the opt-out testing during our already scheduled blood drawing, our acceptance rate went from 13% to 80% -- which was huge. After that, we started collecting all of these data.

So, for both populations, we extracted basic demographics. For HIV positive, we looked at risk factors, prior engagement in care, reengagement in care. And for hep C positive, we looked at prior positivity by chart reviewing.

In terms of results, our HIV population, we test 3,155 individuals. We had a positivity rate of 1.3%. And, if you go only to your new diagnoses, it was 16. And overall, it was .2% of new diagnoses, which is kind of like what is reported in the literature.

We had a high false positive that we need to actually look into and study a little bit more.

Regarding baseline characteristics, I think interesting facts: most of the HIV positive were male; most of them were black -- which is the usual jail population. The most common risk factor was heterosexual transmission. Most of them, the ones that were already diagnosed, that came into jail with a known diagnosis, were already on treatment. But not all of them had undetectable viral loads.

Our engagement in care before jail was pretty high, I will say: about 60%. While they were in jail, all were seen by either a social worker or an HIV provider. And then, our engagement in care post-release, which is having been seen by any HIV provider in the next six months, was about 30%. Having that said, we have a big number of patients that didn't follow up in our system. They follow up in different systems, which we don't have access to, so we really don't know what happened to them.

In terms of hep C results, our positivity rate was 16%. Mean age was 49. Eighty percent were men. One-third had previously documented hep C antibody positivity, and this was done by chart checking. From all of our hep C population, only 52% were born in the baby boomer cohort -- which is actually an interesting fact. If we would have only tested them, we would have missed a lot of infections.

In terms of race, there were whites or blacks, but when we broke it down by birth cohort and race -- and these are actually really interesting results -- among the baby boomers, the ones who were born between 45 and 65, most of them were black -- 60% -- so, two times higher among black versus whites. Among the non-boomers, usually younger patients, they were most commonly whites -- which kind of plays against only screening the baby boomers.

TW: Correct. And I think there's a lot of conversation that is starting to happen around hep C screening. There was recently a hep C elimination summit in New York state, and they talked about seeing increasing numbers in younger people with hep C. It looks like that's what we're seeing here, as well.

CDLF: Yes. Exactly. It's been linked to IV drug use, really. I think the rates -- I don't have numbers on the top of my head, but numbers, rates -- of IV drug use are not as high in the South as in probably the Northeast. But that's very interesting data that we need to look into more closely, probably.

In terms of conclusions, routine opt-out testing in the Dallas County Jail identified multiple HIV and hep C infections. Our new diagnoses were relatively rare but still similar to numbers that are being reported in the literature. Our linkage to care and reengagement to care were really high, which is really positive. Our hep C antibody positivity -- and we didn't do reflex hep C RNA, so it's just the antibody -- was really high. One-third was already aware of this diagnosis. And testing only the baby boomer cohort would have missed approximately half of our infections.

That's basically it.

In terms of lessons learned, opt-out testing is definitely feasible in the correctional setting. We are doing a great job with our linkage to HIV care. Now, the next step of this project is to start hep C linkage to care. So, once they're diagnosed in jail, they need to be referred, and somebody needs to follow up on them to make sure that they touch base with clinic, and they get treatment if they qualify for treatment.

Hep C testing should be offered to everybody, regardless of whether they are part, or not, of the baby boomer cohort. And what we need to add, of course, are reflex hep C RNA.

TW: In terms of engagement with this particular community, sometimes it's hard to do research with populations that are incarcerated. Was this something that this correctional institution embraced as an added benefit of you guys coming in because it's going to help with something? Can you talk about that a little bit more -- about how you were able to negotiate that relationship to come in and do this?

Ank Nijhawan, M.D., M.P.H.: I think we've been very fortunate. We have a couple of unique things. One is that the health care at the jail is actually run by the county health system, which is Parkland Health and Hospital Systems. We're fortunate in that they're very interested in the outcomes in these patients, because they are also their patients in the community. The majority of the people getting released from jail are underserved, underinsured and going to end up in our safety net hospital system, anyway. So they've been very invested.

We have had a progressive medical director at the jail who worked very closely with the sheriff and with the security, which is really key to getting any research done in this setting. Certainly, things have to go through the institutional review board, and you need a prisoner representative. And you have to be particularly mindful of ethical issues and things like that. But I think we've set up a very good partnership with them and, in addition to this, have been able to conduct other research studies in the jail, in the criminal justice system, because of those partnerships and relationships.

TW: Just another question about engagement care post-jail, because we don't know where some folks went; we don't know what happened. And I'm curious, in this Dallas community, are there different programs that you have relationships with that are kind of a coming-home program that maybe social service staff who work in the jail system know to make referrals to -- so that those medical providers and social service staff are ready to catch those folks and help not only with their medical care but also with reentry services that are so key to folks being able to be successful?

AN: That's a very big area of interest of mine. I actually run, have run for the last four years, a stakeholder group of people who, in some fashion, come into contact with people, either during their incarceration or after, who are HIV positive and recently released. That includes people who are doing medical care. So, HIV care, but also people are providing housing, people are providing mental health care, substance abuse treatment, transportation.

Although there's not a dedicated program for recent releasees, there are all those organizations, which are often AIDS service organizations -- often Ryan White funded [but] not necessarily -- have come together and really recognize this as an especially vulnerable population.

We have recently started to look at: What is our linkage to care rate for folks coming out of the jail? It's about, within 90 days, it's about 30% overall, which is not stellar. So, I think we have a lot of room to improve because we have great stakeholders who invested. I think future projects must focus on: How do we improve that linkage to care? How do we improve the retention in care? And then, of course, virologic suppression in the HIV patients.

TW: Great. Thank you so much.

This transcript has been lightly edited for clarity.

Terri L. Wilder, M.S.W., is a director of HIV/AIDS education and training in New York City.