HIV testing in jails: Comparing strategies to maximize engagement in HIV treatment and prevention

Despite 15,000 people enter US jails yearly with undiagnosed HIV infection, routine HIV testing is not standard. Maximizing the yield and speed of HIV testing in short-term detention facilities could promote rapid entry or re-entry of people living with HIV (PLWH) into care. The goal of this study was to evaluate the impact of third generation, rapid point-of-care (rPOC) vs. fourth generation, laboratory-based antigen/antibody (LBAg/Ab) testing on the HIV care cascade in a large urban jail during a planned transition. We used aggregate historical data to compare rPOC testing and LBAg/Ab testing in the D.C. Department of Corrections. We examined two time periods, January to August 2019 when rPOC testing was performed, and October 2019 to January 2020 after LBAg/Ab testing began. We calculated monthly rates of HIV tests performed, HIV test results received, HIV test results received among those tested, antiretroviral therapy (ART) initiation, and proportion of PLWH receiving discharge planning prior to release. We then conducted an interrupted time series analysis to assess the differences between testing periods. There were 14,237 entrants during the first time period and 7,569 entrants during the second. Transitioning from rPOC to LBAg/Ab testing increased the rate of test uptake by 38.5% (95% CI: 14.0, 68.3), decreased the rate of test results received among those tested by 13.1% (95% CI: -14.0, -12.1), and increased the combined rate of HIV tests performed and results received by 20.4% (95% CI: 1.5, 42.8). Although the rate of HIV testing was greater under LBAg/Ab, PLWH received results immediately through rPOC testing, which is critically important in short-stay enviroments. Increasing rPOC uptake would increase its value and combined testing may maximize the detection of HIV and receipt of results among persons passing through jails.

Coping with COVID in corrections: a qualitative study among the recently incarcerated on infection control and the acceptability of wastewater-based surveillance

BACKGROUND

Correctional settings are hotspots for SARS-CoV-2 transmission. Social and biological risk factors contribute to higher rates of COVID-19 morbidity and mortality among justice-involved individuals. Rapidly identifying new cases in congregate settings is essential to promote proper isolation and quarantine. We sought perspectives of individuals incarcerated during COVID-19 on how to improve carceral infection control and their perspectives on acceptability of wastewater-based surveillance (WBS) accompanying individual testing.

METHODS

We conducted semi-structured interviews with 20 adults who self-reported being incarcerated throughout the United States between March 2020 and May 2021. We asked participants about facility enforcement of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, and acceptability of integrating WBS into SARS-CoV-2 monitoring strategies at their most recent facility. We used descriptive statistics to characterize the study sample and report on acceptability of WBS. We analyzed qualitative data thematically using an iterative process.

RESULTS

Participants were predominantly Black or multiple races (50%) and men (75%); 46 years old on average. Most received a mask during their most recent incarceration (90%), although only 40% received counseling on proper mask wearing. A quarter of participants were tested for SARS-CoV-2 at intake. Most (70%) believed they were exposed to the virus while incarcerated. Reoccurring themes included (1) Correctional facility environment leading to a sense of insecurity, (2) Perceptions that punitive conditions in correctional settings were exacerbated by the pandemic; (3) Importance of peers as a source of information about mitigation measures; (4) Perceptions that the safety of correctional environments differed from that of the community during the pandemic; and (5) WBS as a logical strategy, with most (68%) believing WBS would work in the last correctional facility they were in, and 79% preferred monitoring SARS-CoV-2 levels through WBS rather than relying on just individual testing.

CONCLUSION

Participants supported routine WBS to monitor for SARS-CoV-2. Integrating WBS into existing surveillance strategies at correctional facilities may minimize the impact of future COVID-19 outbreaks while conserving already constrained resources. To enhance the perception and reality that correctional systems are maximizing mitigation, future measures might include focusing on closer adherence to CDC recommendations and clarity about disease pathogenesis with residents.

Aiming for Zero: Reducing Transmission of Coronavirus Disease 2019 in the D.C. Department of Corrections

Background

Washington, District of Columbia lowered severe acute respiratory syndrome coronavirus 2 transmission in its large jail while community incidence was still high

Methods

Coordinated clinical and operational interventions brought new cases to near zero.

Results

Aggressive infection control and underlying jail architecture can promote correctional coronavirus disease 2019 management.

Conclusions

More intensive monitoring could help confirm that in-house transmission is truly zero.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail

INTRODUCTION

This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia.

METHODS

A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020.

RESULTS

Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system.

CONCLUSIONS

Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

Assessment and Comparison of Hepatitis C Viremia in the Prison Systems of New Mexico and Georgia

This cross-sectional study assesses and compares the prevalence of hepatitis C virus among criminal justice populations in New Mexico, a state with high hepatitis C virus prevalence, and Georgia, a state with low hepatitis C virus prevalence.

Establishing an HIV Screening Program Led by Staff Nurses in a County Jail

CONTEXT

Human immunodeficiency virus (HIV) testing in jails provides an opportunity to reach individuals outside the scope of traditional screening programs. The rapid turnover of jail populations has, in the past, been a formidable barrier to offering routine access to testing.

OBJECTIVE

To establish an opt-out, rapid HIV testing program, led by nurses on the jail staff, that would provide undiagnosed yet infected detainees opportunities to learn their status regardless of their hour of entry and duration of stay.

DESIGN

Jail nurses offered rapid, opt-out HIV testing.

SETTING

Fulton County Jail in Georgia, United States.

PARTICIPANTS

A total of 30 316 persons booked to Fulton County Jail.

INTERVENTION

In late 2010, we performed a preliminary evaluation of HIV seroprevalence. Starting January 1, 2011, HIV testing via rapid oral mucosal swab was offered to entrants. In March 2013, finger stick was substituted. Detainees identified as positives were assisted with linkage to care.

MAIN OUTCOME MEASURES

To estimate an upper limit of overall HIV prevalence among entrants, we determined seroprevalence by age and gender group. To measure program performance, we checked offer and acceptance rates for tests and rate of linkage to care among previously known and newly identified HIV+ detainees.

RESULTS

The initial seroprevalence of HIV in Fulton County Jail was at least 2.18%. Between March 2013 and February 2014, 89 new confirmed positives were identified through testing. During these 12 months, 20 947 bookings were followed by an offer of HIV testing (69.10% offer rate), and 17 035 persons accepted (81.32% acceptance rate). A total of 458 previously and newly identified persons were linked to HIV care. Linkage was significantly higher among those aged 40 years and older (P < .05).

CONCLUSIONS

A nurse-led, rapid HIV testing model successfully identified new HIV diagnoses. The testing program substantially decreased the number of persons who are HIV-infected but unaware of their status and promoted linkage to care.

Costs of Rapid HIV Screening in an Urban Emergency Department and a Nearby County Jail in the Southeastern United States

Emergency departments and jails provide medical services to persons at risk for HIV infection and are recommended venues for HIV screening. Our main objective in this study was to analyze the cost per new HIV diagnosis associated with the HIV screening program in these two venues. The emergency department's parallel testing program was conducted at Grady Memorial Hospital in Atlanta, Georgia starting in 2008; the jail's integrated testing program began at the Fulton County (GA) Jail in 2011. The two sites, four miles apart from one another, employed the same rapid HIV test. Ascertainment that cases were new differed by site; only the jail systematically checked identities against health department HIV registries. The program in the emergency department used dedicated HIV test counselors and made 242 diagnoses over a 40-month period at a cost of $2,981 per diagnosis. The jail program used staff nurses, and found 41 new HIV cases over 10.5 months at a cost of $6,688 per new diagnosis. Differences in methods for ascertainment of new diagnoses, previously undiagnosed HIV sero-positivity, and methodologies used for assessing program costs prevent concluding that one program was more economical than the other. Nonetheless, our findings show that testing in both venues yielded many new diagnoses, with the costs within the range reported in the literature.

A phase I/II study of continuous infusion suramin in patients with hormone-refractory prostate cancer: toxicity and response

INTRODUCTION

Suramin is a synthetic polysulfonated naphthylurea which has been used for the treatment of African trypanosomiasis and onchocerciasis, but since the mid-1980s has received attention as a possible antiretroviral and antineoplastic agent.

OBJECTIVE

This clinical trial of suramin was undertaken as a phase I/II study in patients with hormone-refractory prostate cancer, with the hypothesis that the intensity of therapy with suramin could be increased significantly if measures were undertaken to maintain the plasma concentrations of the drug under 300 microg/ml.

METHODS

We report the clinical results of this trial, wherein patients were treated at three different targeted plasma suramin concentrations (275, 215 and 175 microg/ml) for varying periods of time (2, 4 or 8 weeks), with delivery of the drug by continuous intravenous infusion.

RESULTS

The major toxicity observed in this trial was neurologic, consisting of a motor and sensory peripheral neuropathy that resulted in both paresis and paralysis of the limbs. Nearly all of this severe (CTEP grade III, IV) neurologic toxicity was observed in the patients treated at a plasma suramin concentration of 275 microg/ml for 4 or more weeks. A single patient treated at 215 microg/ml for 8 weeks developed moderate (CTEP grade III) proximal lower extremity weakness, and no patient treated at 175 microg/ml developed this toxicity. The second most common toxicity observed was infection of the central venous catheter. The overall response rate for all of the evaluable patients was 17% (13 of 75 patients). In addition, prostate-specific antigen (PSA)-defined responses were observed in six patients receiving therapy at 175 microg/ml, but these responses were confounded by cessation of therapy with flutamide during suramin treatment.

CONCLUSIONS

In summary, although plasma suramin concentrations were maintained below 300 microg/ml, neurologic toxicity nonetheless occurred with high frequency in patients treated at 275 microg/ml for 4 or more weeks. Therapy at 215 and 175 microg/ml was in general well tolerated, but central venous catheter-related infection, as well as the inconvenience and expense of continuous infusional therapy, make this method of drug delivery impractical. Only moderate antitumor activity was observed during this trial, but it is possible that both continuation of flutamide and flutamide withdrawal during suramin therapy confounded the assessment of suramin's activity in hormone-refractory prostate cancer.

Correlation of stromal cells by morphometric analysis with metastatic behavior of human colonic carcinoma

The cellular compositions of the inflammatory infiltrates in human colonic carcinoma in well-defined compartments have not been quantified previously. Morphometric analysis of this tissue revealed several relationships between the concentrations of different kinds of cells that may be an important first approach to understanding the nature of the host reaction in different groups of patients. Primary tumors without metastases differ from those with metastases in that those without metastases contain higher concentrations of plasma cells (P = 0.0019) and eosinophils (P = 0.0098) in sections taken at a location remote from the margin (tissue located greater than 1 cm from the margin) and increased concentrations of eosinophils (P = 0.0224) in sections of tumor contiguous to the margin (tissue 0-4.5 mm from the margin). In sections contiguous to the margin, the concentration of plasma cells is related to the concentrations of lymphocytes (R = 0.55, P = 0.0014), eosinophils (R = 0.46, P = 0.0085), fibroblasts (R = 0.47, P = 0.0075), and neutrophils (R = 0.63, P = 0.0001). In sections remote from the margin, the concentration of plasma cells is related to the concentration of lymphocytes (R = 0.36, P = 0.0442), eosinophils (R = 0.36, P = 0.0457), mast cells (R = 0.38, P = 0.0375), and neutrophils (R = 0.38, P = 0.0371).