Abstract
We used Centers for Disease Control and Prevention HIV Counseling and Testing System data from 2007 to determine the percentage and characteristics of persons newly identified as HIV-positive in US correctional facilities. The newly identified HIV positivity was 0.7%, and 30% of detainees newly identified with HIV were categorized as having low-risk heterosexual contact or no acknowledged risk. Correctional facilities should provide detainees with routine opt-out HIV testing, unless the prevalence of previously undiagnosed HIV infection has been documented to be less than 0.1%.
At the end of 2006, 2.1 million persons were detained in state and local correctional facilities in the United States.1 The overall HIV seroprevalence reported by the 50 state prison systems was 4.5 times as high as that for the general US population.2,3 Correctional facilities represent an important venue for delivering HIV services, especially for detainees who may lack access to primary care and prevention services in their communities,4–7 and for racial/ethnic minorities who are incarcerated at higher rates1 and who are disproportionately affected by HIV.3
In September 2006, the Centers for Disease Control and Prevention (CDC) released revised HIV testing recommendations to encourage HIV screening for persons aged 13 to 64 years in health care settings. Persons should be notified that testing will be performed unless they decline (opt-out screening) or the prevalence of previously undiagnosed HIV infection is documented to be less than 0.1%.8
HIV testing in correctional facilities benefits both detainees and the communities to which they may return.9 Early diagnosis of persons infected with HIV allows for linkage to care and treatment. Antiretroviral therapy reduces the patient’s viral load, improves health outcomes, and significantly reduces the risk of transmission to others.10,11
METHODS
We analyzed the CDC HIV Counseling and Testing System (HIV CTS) database to determine the newly identified HIV positivity and the characteristics associated with detainees being newly identified as HIV-positive in US correctional facilities in 2007. Data were included from 16 of 59 state or city health departments reporting complete test-level data on 1000 or more HIV tests conducted in prisons or jails. Data with missing values (e.g., missing test results) or out-of-range values for key characteristics (e.g., younger than 13 years or older than 64 years) were excluded.
Demographic characteristics included gender, age, race/ethnicity, and HIV test region (state and city health departments were grouped into US Census Bureau geographic regions).12 Risk category was ordered hierarchically based on the greatest presumed likelihood of HIV transmission.13 “Newly identified HIV-positive” was defined as a record for which there was a current HIV-positive test, but no history of an HIV-positive test. Multiple logistic regression models were constructed to determine the association of detainee characteristics with being a newly identified HIV-positive person.
RESULTS
The final dataset included 106 122 tests from 16 health departments. The overall HIV positivity was 0.9%, the newly identified HIV positivity was 0.7%, and 30% of newly identified HIV-positive detainees reported only low-risk heterosexual contact or no acknowledged risk (Table 1).
TABLE 1—
HIV Positivity by Demographic and HIV Testing-Related Characteristics for Tests Conducted at Correctional Facilities: 16 Health Departments, United States, 2007
| HIV-Positive |
||||
| Characteristica | Total Tests, No. (%) | Total, No. (%) | Previously Identified, No. (%) | Newly Identified, No. (%) |
| Total | 106 122 (100.0) | 1006 (0.9) | 251 (0.2) | 755 (0.7) |
| Gender | ||||
| Male | 80 278 (75.7) | 640 (0.8) | 177 (0.2) | 463 (0.6) |
| Female | 25 144 (23.7) | 347 (1.4) | 67 (0.3) | 280 (1.1) |
| Age group, y | ||||
| 13–19 | 11 448 (10.8) | 26 (0.2) | 5 (0.0) | 21 (0.2) |
| 20–29 | 41 001 (38.6) | 252 (0.6) | 53 (0.1) | 199 (0.5) |
| 30–39 | 25 784 (24.3) | 314 (1.2) | 82 (0.3) | 232 (0.9) |
| 40–49 | 21 378 (20.1) | 308 (1.4) | 73 (0.3) | 235 (1.1) |
| 50–64 | 6511 (6.1) | 106 (1.6) | 38 (0.6) | 68 (1.0) |
| Race/ethnicity | ||||
| White | 32 856 (31.0) | 215 (0.7) | 55 (0.2) | 160 (0.5) |
| Black | 50 308 (47.4) | 634 (1.3) | 141 (0.3) | 493 (1.0) |
| Hispanic | 19 333 (18.2) | 142 (0.7) | 49 (0.2) | 93 (0.5) |
| Asian/Pacific Islander | 718 (0.7) | 2 (0.3) | 2 (0.3) | 0 |
| American Indian/Alaska Native | 636 (0.6) | 5 (0.8) | 1 (0.2) | 4 (0.6) |
| Other | 2271 (1.4) | 8 (0.3) | 3 (0.1) | 5 (0.2) |
| Region | ||||
| Northeast | 30 793 (29.0) | 180 (0.6) | 62 (0.2) | 118 (0.4) |
| Midwest | 2404 (2.3) | 11 (0.5) | 6 (0.3) | 5 (0.2) |
| South | 60 491 (57.0) | 743 (1.2) | 167 (0.3) | 576 (0.9) |
| West | 12 434 (11.7) | 72 (0.6) | 16 (0.1) | 56 (0.5) |
| Risk category | ||||
| MSM/IDU | 681 (0.6) | 29 (4.3) | 13 (1.9) | 16 (2.4) |
| MSM only | 2330 (2.2) | 129 (5.5) | 46 (2.0) | 83 (3.6) |
| IDU | 13 672 (12.9) | 141 (1.0) | 45 (0.3) | 96 (0.7) |
| High-risk heterosexual contactb | 47 452 (44.7) | 348 (0.7) | 72 (0.1) | 276 (0.6) |
| Low-risk heterosexual contactc | 23 074 (21.7) | 193 (0.8) | 38 (0.2) | 155 (0.7) |
| No acknowledged risk | 12 049 (11.4) | 92 (0.8) | 24 (0.2) | 68 (0.6) |
| Otherd | 2704 (2.6) | 42 (1.6) | 5 (0.2) | 37 (1.4) |
| Testing history | ||||
| Previously tested | 75 696 (71.3) | 753 (1.0) | 251 (0.3) | 502 (0.7) |
| First-time tested | 30 426 (28.7) | 253 (0.8) | NA | 253 (0.8) |
| Provision of test results and posttest counseling | ||||
| No | 9038 (8.5) | 137 (1.5) | 69 (0.8) | 68 (0.7) |
| Yes | 94 667 (89.2) | 851 (0.9) | 180 (0.2) | 671 (0.7) |
Note. IDU = injection drug user; MSM = men who have sex with men; NA = not applicable. Data from the following 16 health departments were included: CA (excluding San Francisco and Los Angeles), DE, DC, FL, GA, LA, MA, MI, NY (excluding New York City), OH, OR, PA (excluding Philadelphia), TX (excluding Houston), VA, San Francisco, and Los Angeles.
The number of records for each variable does not sum to the total number of records because of missing data. The number (%) of missing values for the selected variables were as follows: gender, 700 (0.7%); race/ethnicity, 812 (0.8%); risk category, 4160 (3.9%); and posttest counseling, 2417 (2.3%).
Person reporting heterosexual contact who also reported any of the following: sex with partner at risk, a diagnosis of a sexually transmitted disease, exchange of sex for drugs or money, noninjection drug use during sex, or a victim of sexual assault.
Person reporting heterosexual contact and no other risk factor.
Person reporting other risk factors (i.e., perinatal exposure, hemophilia, receipt of blood transfusion, or health care exposure).
Characteristics most strongly associated with being newly identified HIV-positive included being female (adjusted odds ratio [AOR] = 2.30; 95% confidence interval[CI] = 1.94, 2.72), aged 40 to 49 years (AOR = 2.20; 95% CI = 1.80, 2.68), Black (AOR = 2.42; 95% CI = 1.99, 2.95), tested in the South (AOR = 2.20; 95% CI = 1.76, 2.76), in the men who have sex with men (MSM) and injection drug user (IDU; AOR = 5.44; 95% CI = 3.20, 9.25) or MSM-only (AOR = 8.14; 95% CI = 6.15, 10.76) risk categories, and first-time tested (AOR = 2.06; 95% CI = 1.75, 2.42; Table 2).
TABLE 2—
Characteristics Associated With Being Newly Identified HIV-Positive in a Correctional Facility: 16 Health Departments, United States, 2007
| Newly Identified HIV-positive Tests |
||||
| Characteristica | Total, No. | No. (%) | OR (95% CI) | AORb (95% CI) |
| Totalc | 105 871 | 755 (0.7) | ||
| Gender | ||||
| Male | 80 101 | 463 (0.6) | 1.00 (Ref) | 1.00 (Ref) |
| Female | 25 077 | 280 (1.1) | 1.94 (1.67, 2.26) | 2.30 (1.94, 2.72) |
| Age group, y | ||||
| 13–19 | 11 443 | 21 (0.2) | 0.38 (0.23, 0.59) | 0.36 (0.23, 0.57) |
| 20–29 | 40 948 | 199 (0.5) | 1.00 (Ref) | 1.00 (Ref) |
| 30–39 | 25 702 | 232 (0.9) | 1.87 (1.54, 2.27) | 1.93 (1.59, 2.36) |
| 40–49 | 21 305 | 235 (1.1) | 2.28 (1.88, 2.77) | 2.20 (1.80, 2.68) |
| 50–64 | 6473 | 68 (1.0) | 2.17 (1.62, 2.88) | 2.02 (1.52, 2.69) |
| Race/ethnicity | ||||
| White | 32 801 | 160 (0.5) | 1.00 (Ref) | 1.00 (Ref) |
| Black | 50 167 | 493 (1.0) | 2.02 (1.69, 2.44) | 2.42 (1.99, 2.95) |
| Hispanic | 19 284 | 93 (0.5) | 0.99 (0.76, 1.29) | 1.32 (1.00, 1.73) |
| Asian/Pacific Islander | 716 | 0 (0.0) | 0.20 (0.00, 1.07) | NA |
| American Indian/Alaska Native | 635 | 4 (0.6) | 1.29 (0.35, 3.39) | 1.59 (0.58, 4.35) |
| Other | 1457 | 4 (0.3) | 0.56 (0.15, 1.47) | 1.16 (0.42, 3.15) |
| Region | ||||
| Northeast | 30 731 | 118 (0.4) | 1.00 (Ref) | 1.00 (Ref) |
| Midwest | 2398 | 5 (0.2) | 0.54 (0.17, 1.30) | 0.52 (0.21, 1.28) |
| South | 60 324 | 576 (1.0) | 2.50 (2.05, 3.08) | 2.20 (1.76, 2.76) |
| West | 12 418 | 56 (0.5) | 1.18 (0.84, 1.63) | 1.10 (0.78, 1.55) |
| Risk category | ||||
| MSM/IDU | 668 | 16 (2.4) | 3.62 (2.01, 6.12) | 5.44 (3.20, 9.25) |
| MSM | 2284 | 83 (3.6) | 5.57 (4.20, 7.34) | 8.14 (6.15, 10.76) |
| IDU | 13 627 | 96 (0.7) | 1.05 (0.80, 1.36) | 1.36 (1.04, 1.78) |
| High-risk heterosexual contactd | 47 380 | 276 (0.6) | 0.86 (0.71, 1.06) | 0.96 (0.78, 1.18) |
| Low-risk heterosexual contacte | 23 036 | 155 (0.7) | 1.00 (Ref) | 1.00 (Ref) |
| No acknowledged risk | 12 025 | 68 (0.6) | 0.84 (0.62, 1.12) | 0.73 (0.54, 0.97) |
| Otherf | 2699 | 37 (1.4) | 2.05 (1.39, 2.96) | 1.36 (0.94, 1.99) |
| Test history | ||||
| Previously tested | 75 445 | 502 (0.7) | 1.00 (Ref) | 1.00 (Ref) |
| First-time tested | 30 426 | 253 (0.8) | 1.25 (1.07, 1.46) | 2.06 (1.75, 2.42) |
Note. AOR = adjusted odds ratio; CI = confidence interval; IDU = injection drug user; MSM = men who have sex with men; NA = not applicable; OR = odds ratio. Data from the following 16 health departments were included: CA (excluding San Francisco and Los Angeles), DE, DC, FL, GA, LA, MA, MI, NY (excluding New York City), OH, OR, PA (excluding Philadelphia), TX (excluding Houston), VA, San Francisco, and Los Angeles.
The number of records for each variable does not sum to the total number of records because of missing data. The number (percentage) of missing values for the selected variables were as follows: gender, 700 (0.7%); race/ethnicity, 812 (0.8%); and risk category, 4160 (3.9%).
The adjusted regression analysis included test history, gender, age group, race/ethnicity, region, and risk category.
Excludes 251 records with a history of an HIV-positive test.
Person reporting heterosexual contact who also reported any of the following: sex with partner at risk, a diagnosis of a sexually transmitted disease, exchange of sex for drugs or money, noninjection drug use during sex, or a victim of sexual assault.
Person reporting heterosexual contact and no other risk factor.
Person reporting other risk factors (i.e., perinatal exposure, hemophilia, receipt of blood transfusion, or health care exposure).
DISCUSSION
The newly identified HIV positivity in our report (0.7%), similar to other reports,14–18 supports routine opt-out HIV testing in correctional health care facilities.8,19 Detainees who were women, aged 40 to 49 years, Black, tested in the South, in the MSM and IDU or MSM-only risk categories, and first-time tested in a correctional facility were more likely to be newly identified as HIV-positive. The limited number of studies that previously determined characteristics associated with being newly identified HIV-positive reported similar results.14,15
Our study supports previous findings15 that a high proportion of HIV cases occurred among persons who might not perceive or acknowledge themselves to be at high risk (i.e., low-risk heterosexual contact, no acknowledged risk). A substantial proportion of newly identified HIV-positive detainees (30%) would not have been diagnosed if testing were conducted only among those who perceived and reported themselves as high risk for HIV.
Routine opt-out HIV testing could diagnose detainees infected with HIV who were not previously diagnosed in the community,18,20 could diagnose HIV infections earlier in the course of disease,21 and was generally acceptable to detainees.22 When testing was augmented with treatment and prevention programs, screening was cost-effective, and a substantial number of cases of HIV were prevented.23,24 Recent publications offer strategies for implementing routine HIV testing in correctional facilities, including guidance for integrating HIV testing into correctional facilities to balance individual and public health needs.25,26
Our findings were limited because test results could not be linked to unique individuals, and individuals might have received multiple tests. The type of correctional facility and the health care services available could not be determined from the data. Also, HIV CTS data from 16 US health departments might not represent all CDC-funded HIV testing in US correctional facilities.
Correctional health care facilities should provide detainees with routine opt-out HIV testing as recommended by the CDC, unless the prevalence of previously undiagnosed HIV infection has been documented to be less than 0.1%.8 Guidance from the CDC should be used to assist in developing and implementing an appropriate HIV screening program in correctional facilities.25
Acknowledgments
There are no conflicts of interest associated with this research or the submission of study findings.
Human Participant Protection
No protocol approval was needed for this study.
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