Journal of Correctional Health Care - April 2023 - 157

IMPLEMENTING OPT-OUT HIV TESTING
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suggests that the majority of HIV-positive incarcerated
individuals contract the virus before incarceration (Hammett,
2006; Valera et al., 2017).
Correctional settings present a unique opportunity to
test and treat people living with HIV, many of whom are
unaware of their status before being incarcerated. Since
2006, the U.S. Centers for Disease Control and Prevention
(CDC) has recommended routine opt-out HIV testing-
where all patients are routinely tested for HIV unless
they explicitly opt-out, regardless of their reported risk
behaviors-in all clinical settings, including correctional
facilities (Branson et al., 2006; CDC, 2011; MacGowan,
2009). Routine opt-out testing in correctional settings
aligns with the National HIV/AIDS Strategy for the United
States 2022-2025 goal to reduce new HIV infections by
75% by 2025, in which correctional facilities are noted
as instrumental in the identification, engagement, and
reengagement of individuals in HIV care (The White
House, 2021).
However, local jails in the United States frequently do
not routinely test for HIV due to competing priorities,
concerns about funding for testing and treatment, stigma
among correctional staff, lack of recognition of need, and
low acceptance of routine HIV testing as an effective intervention
(Beckwith et al., 2012; Solomon et al., 2014).
The transient nature of people in correctional settings
makes HIV testing even more difficult. Nationally, the
median length of a jail stay is only 2 to 5 days, posing
a logistical challenge for a provider to administer a test,
receive results, and notify an individual of their status,
all before a person's release, particularly if the person
presents with other acute medical or mental health conditions
(Anderson-Minshall, 2016; Spaulding et al., 2011).
Alameda County Jails
Alameda County has two jails-the Santa Rita Jail in
Dublin and the Glenn E. Dyer Detention Facility, a
high-rise, maximum-security jail in Oakland, California.
Operated by the Alameda County Sheriff's Office, the
jails have the capacity to house 4,000 people daily.
Approximately 45,910 people were booked in the jails
in 2017, and the average length of stay was 23 days. Of
the total 2017 jail population, 49.0% of individuals
were Black, 26.5% Latinx, 17.1% white, 2.8% Asian,
and 4.6% identified as another race or ethnicity (Waldura,
personal communication, 2018). Approximately 1% of
individuals self-disclosed an HIV-positive status during
the intake process.
Between 2012 and 2017, the California Office of AIDS
(OA) was provided with CDC Category B HIV Prevention
funds to implement a routine opt-out testing program
in Alameda County jails. The program goal was to implement
and sustain routine testing to identify undiagnosed
cases of HIV, link those who were newly diagnosed to
care, and reengage those who were previously diagnosed
but not in care. Services (Cardea), in collaboration with
the Pacific AIDS Education and Training Center, provided
staff training, technical assistance on the development
and implementation of testing protocols, and data
collection and evaluation support.
Program data were analyzed to support program
implementation, assess whether testing was being implemented
routinely, and determine to what extent the program
was able to identify new cases of HIV and link
individuals to care. Using a continuous quality improvement
process based on the plan-do-study-act (PDSA)
model, testing data were reviewed with jail program
staff on a quarterly basis to examine trends in testing volume,
positivity rates, and linkage data. These data review
sessions were coupled with discussions on implementation
challenges, barriers, and successes, and led to identification
of strategies for program improvement.
The purpose of this article is to share findings and lessons
learned from data collected for evaluation and continuous
quality improvement of the routine testing
program in the Alameda County jails. Authors examine
whether routine testing in the jails is feasible to implement
and successful in both identifying new positive
HIV cases, using a benchmark of 0.1% positivity, and engaging
or reengaging those living with HIV in medical
care.
Summary of Alameda County's Routine Testing
Program
The routine testing program evolved over the 6-year period.
At the program's start, individuals in custody requesting
a medical visit, referred to as a ''sick call,'' were
offered an oral rapid test. After the first 2 years, testing
was also implemented during health and physical exams,
which are completed routinely for those housed in the
two jail facilities for at least 14 days. Testing at booking
into custody was not feasible due to the layout of the
jail's booking area and concerns with patient privacy.
All patients were informed that the HIV test was part
of the standard of care and would be conducted unless
they declined (opt-out screening strategy). Additional
written consent was not required, per state legislation
Assembly Bill 682 (A.B. 682, 2007). A conventional antigen/antibody
blood test was conducted for patients receiving
a blood draw as a part of their medical visit.
For all other patients, nursing staff or medical assistants
administered an oral rapid test.
The conventional blood test took 3 to 5 days for results
and patients were only notified of a positive or indeterminate
result. Rapid tests provided results within 20 minutes,
although nurses and medical assistants who administered
the tests did not read the results in front of the patients; instead,
individuals were told ''no news is good news'' and
those with a preliminary positive were contacted within
24 to 48 hours. For those with a preliminary positive
Journal of Correctional Health Care - April 2023

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