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FELD ET AL.
Discussion
Between 2012 and 2017, Alameda County jails planned
and implemented a routine HIV testing program, administering
nearly 16,000 routine HIV tests. Results from the
pilot program show that conducting routine opt-out HIV
testing in the jails was feasible. The program successfully
identified undiagnosed cases of HIV and linked clients to
care, while also reengaging individuals who had been
previously diagnosed with HIV and had fallen out of
care. The program achieved a 0.55% overall positivity
rate, and a 0.27% positivity rate for newly identified
HIV-positive individuals.
The CDC has determined that a positivity rate equal to
or greater than 0.1% is cost-effective; collectively, the positivity
rate for newly identified cases through this pilot program
was nearly threefold that of the CDC's benchmark for
cost-effectiveness (Walensky et al., 2007). These results
also exceed routine opt-out testing seropositivity rates ranging
from 0% to 0.2% in primary care settings and 0.06%
to 0.22% in emergency department settings, suggesting
that funding HIV testing in the jail is a cost-effective
way to allocate HIV prevention dollars (Broeckaert &
Challacombe, 2017).
In addition to detecting new cases, the pilot program
successfully linked individuals to medical care, both inside
the jails and in the community. Nearly 80% of all
positive cases were linked to medical care within 90
days. Linkage to and retention in HIV care can be particularly
challenging among justice-involved individuals.
A recent study of formerly incarcerated people found
that just 21% were connected to long-term HIV care
within 2 weeks of release, underscoring the need for
strong transitional support and linkage to care networks
(Loeliger et al., 2018).
As part of the routine testing program, policies and
practices were established to strengthen linkage efforts
within the community. The jail's medical team spent extensive
time meeting with staff and visiting linkage program
sites to determine which sites would offer culturally
competent treatment and other services. They also created
a community task force to strategize solutions for individuals
who were lost to follow-up.
Previous studies of correctional testing initiatives have
explored challenges and barriers associated with implementing
HIV testing, and Alameda County jails experienced
similar challenges (Beckwith et al., 2011, 2012;
CDC, 2013; Louisiana Department of Health and Hospitals,
2015). Staff turnover in the jail was high among clinical
staff, and staff faced competing priorities. There was
persistent stigma around HIV among some clinic staff,
and several staff members initially doubted the feasibility
of routine opt-out HIV testing.
To support program implementation, Cardea facilitated
quarterly reviews of testing data with the jail's program
staff and other community providers that were
implementing their own routine testing initiatives. Jail
staff examined quarterly trend data, including overall
testing volume, stratified by demographic groups, and
linkage measures, and discussed barriers and successes
that informed testing trends. At these meetings, strategies
were identified to overcome barriers, which were then
tested using a PDSA cycle.
Through these continuous quality improvement efforts,
facilitators for successful program implementation
were identified. These included the importance
of ongoing group and one-on-one trainings with clinical
staff and the identification of champions within
the jail to advocate for the program. Sufficient funding
to cover the testing costs and support a program
coordinator position to oversee program operations,
schedule trainings, and collect data was also essential
to successful implementation. The quarterly quality
improvement meetings were also an important venue
to share case studies, address implementation challenges,
and establish relationships to support referral
and linkage efforts.
Findings indicate that the routine testing program in
Alameda County jails was an effective way to identify
new cases of HIV, as well as reengage those previously
diagnosed but not in care. There are opportunities to improve
the program model. The program screened approximately
5.6% of the total jail population, indicating
opportunity to further expand testing to more individuals
housed in the jails for less than 2 weeks.
Although Alameda County was not able to test at intake
due to privacy and consent concerns (e.g., for people
who are intoxicated or agitated upon booking), Spaulding
et al. (2015) have demonstrated high acceptability and
success in implementing a nurse-led testing program at
intake in the Fulton County Jail in Georgia without
impacting public safety operations. This model would
allow for testing of those who remain in the jail for
only a short duration, which accounts for a sizable proportion
of the jail population.
Funding to support testing programs is essential to the
sustainability and continuity of such programs. This
includes funding for the tests, staff to conduct routine
testing, staff to facilitate linkage to care and discharge
planning, and medication for those with a confirmed diagnosis.
In the Alameda County jails, when grant funding
for opt-out testing ceased after 2017, the testing program
was ultimately discontinued without the funds to support
continued testing.
Limitations to the data exist. The testing program did
not reach individuals whose length of stay was less
than 14 days and who did not request a sick call, so results
are not generalizable to the entire jail population.
Although a recent analysis of the Alameda County jail
population from 2018 to 2019 found that the average
length of stay in custody was 23 days, over half of
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