Evaluation of an Opt-Out HIV Screening Program in the Maricopa County Jails

Transcription

1 Evaluation of an Opt-Out HIV Screening Program in the Maricopa County Jails Item Type Thesis Authors Nelson, Erin DaHye Publisher The University of Arizona. Rights Copyright is held by the author. Digital access to this material is made possible by the College of Medicine - Phoenix, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author. Download date 30/04/ :19:14 Link to Item

2 EVALUATION OF AN OPT OUT HIV SCREENING PROGRAM IN THE MARICOPA COUNTY JAILS A thesis submitted to the University of Arizona College of Medicine Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine Erin Da Hye Nelson Class of 2017 Mentors: Melanie Taylor, MD, MPH and Charles Mullany, MB, MS

3 Acknowledgements I would like to acknowledge Jeffery Alvarez, MD, CCHP, Director of Maricopa County Correctional Health Services and Vince Gales, RN, BSN, CCHP, Infection Control Coordinator for their initiation of the project and continued support. Further, I would like to acknowledge the Ryan White Part A program. Individuals involved I want to thank are Jane Wixted, RN, MSN, MHSA, Nurse Case Manager and Rose Conner, RN, MEd, Program Manager. Furthermore, I want to acknowledge the following organizations: Maricopa County Public Health Department, Centers for Disease Control, and Health Resources and Services Administration.

4 Abstract Background and Research Question: Since inmates are a population disproportionately affected by HIV, correctional settings are important sites for delivering HIV services. The Maricopa county (Phoenix Area) jail system is the 4 th largest in the nation. In 2011, the Maricopa County Correctional Health Service implemented an opt out HIV screening program for individuals booked into the Maricopa County Jails (MCJ). The aims of this study were to determine for the years : The number of inmates screened for HIV The HIV positivity rate The number of newly diagnosed patients The clinical characteristics of the newly diagnosed HIV positive patients Methods: Five to seven days after booking, inmates are offered HIV screening. These laboratory records were used to determine the number of inmates tested and positivity. Prior history of previous HIV diagnosis was obtained from Maricopa public health records. Retrospective chart review of the MCJ health and case management records, including Ryan White forms, was performed to gather gender, age, race/ethnicity, sexual orientation, drug use, homelessness and co morbidities of newly HIV infected persons, such as Hepatitis C and prior STDs. Categorical factors were compared between groups with the Chi square test. Means were compared using a standard t test. P values 0.05 were considered significant. Results: A total of 319,575 persons were booked and 46,346 were screened (14.5%) for HIV during the study period. The majority of booked inmates were male (76.9%) and Caucasian (50.8%). The mean age of inmates was 36 years. There were 70 newly HIV diagnosed patients. Chi squared and t tests comparing newly diagnosed individuals to the general jail population revealed statistical significance for male gender (p=0.02), African American race (p=0.04), and age (p=0.003).

5 Conclusions: Undiagnosed HIV, including AIDS (CD4 counts <200), is an important issue among individuals booked into the MCJ. Compared to the general jail population, HIV is more likely to be diagnosed in males rather than females, younger patients, and African American patients. Additionally, IV drug use, polysubstance abuse, other STDs (particularly syphilis), high risk sexual activity, Hepatitis C and homelessness were common among HIV positive patients. Surveillance should be continued and include more patient education on the importance of screening. Furthermore, targeting high risk populations may result in even greater numbers of individuals being diagnosed and treated. Within the next year, all patients at the MCJ will also be offered screening for Hepatitis C, chlamydia, gonorrhea and syphilis. This may also result in more patients agreeing to be screened, and subsequently diagnosed with HIV.

6 Table of Contents Introduction... 1 Methods... 3 Results... 6 Discussion Future Directions Conclusions References... 26

7 List of Tables and Figures Figure 1. Flow chart of the number of individuals booked to the number of newly diagnosed as HIV positive, Table 1. Demographics of all inmates booked into the Maricopa County Jails... 9 Table 2. Demographics of patients who received a HIV screening test Table 3. Demographic information and clinical characteristics of newly diagnosed patients Table 4. First laboratory values available after diagnosis of individuals newly diagnosed as HIV positive... 17

8 Introduction Providing opt out HIV screening in jails is recommended by the Centers for Disease Control and Prevention (CDC). There is limited data about HIV screening in correctional settings and only 36% of jails offer routine HIV testing. 1 As such, correctional facilities represent an important site for delivering HIV services particularly for those with limited access to primary care and prevention services in their communities. 1,2 Persons engaging in HIV acquisition risk behaviors, including commercial sex work and intravenous drug use, commonly encounter corrections facilities making these locations important for identification of undiagnosed HIV infection among high risk populations. 3 In 2007, the CDC analyzed the HIV Counseling and Testing System database to determine characteristics associated with detainees newly identified as HIV positive. Data was used from 16 state or city health departments and included 106,122 tests. The overall HIV positivity was 0.9% with the newly identified HIV positivity rate being 0.7%. Characteristics most strongly associated with being newly identified HIV positive included being female, aged years, Black, tested in the South, risk category of men who have sex with men and injection drug user, risk category of men who have sex with men only, and first time tested. 4 The Maricopa County Jail system is the 4 th largest jail system in the country. 5 About 110,000 arrestees are booked into jail each year with the average daily population from years being approximately 8,000 inmates. The majority of persons processed through the MCJ are of minority race/ethnicity: Hispanic (36%), African American (14%) and Native American (4%). In addition, a significant number of individuals booked into jail have psychiatric illnesses, such that jails and prisons have become the de facto facilities caring for those who are mentally ill. Maricopa County Correctional Health Services (CHS) employs physicians, nurses, mental health professionals, technicians, and other support staff to provide health services at 9 clinics within 1

9 the 6 facilities. In November of 2011, CHS implemented the opt out HIV screening program. The aims of this study were to determine for the years : The number of inmates screened for HIV The HIV positivity rate and newly diagnosed HIV positivity rate The number of newly diagnosed patients The demographic, clinical, and laboratory characteristics of the newly diagnosed HIV positive patients 2

10 Methods The study plan (HSRB ) for this analysis was reviewed, identified as public health practice/surveillance, and determined exempt from IRB review by the Human Subjects Review Board of the Arizona Department of Health Services on June 26, Health screening and HIV specimen collection The HIV opt out screening program was initiated in the Maricopa County Jails in November of This analysis includes the screening period of January 1, 2012 through December 31, Persons booked into the six MCJ facilities of 4 th Avenue, Lower Buckeye, Durango, Towers, Tents, and Estrella Women s Facility that received a HIV screening test are included in the analysis. Five to seven days after booking, it was explained to a patient that, as part of their healthcare, a HIV screening test would be done unless he or she refused. For a period of time, grant funding was available for opt out syphilis screening tests that were performed in conjunction with HIV testing. On February 1, 2014, due to conclusion of the grant, routine syphilis screening was discontinued and continued to be performed on a case by case basis. Specimens were tested at the Maricopa County Public Health Department (MCPHD) laboratory. Those who refused the test were asked to sign a form declining this service. These forms were not available for evaluation of refusal rate. HIV Testing Serum specimens were transported to and processed by the Maricopa County Public Health laboratory within 24 hours of collection. HIV testing was performed using the 4 th generation Abbott Architect HIV Ag/Ab test. 6 Specimens testing positive by this assay were re run in duplicate. If repeatedly reactive on one or both of these two samples, the result was considered preliminary positive. Preliminary positive specimens were transported to the Arizona Department of Health Services Public Health laboratory for confirmatory western blot testing. Preliminary positive results that tested negative by western blot were sent for HIV viral 3

11 load testing. Confirmed HIV positive patients were those with a positive Architect Ag/Ab test and either a positive western blot or a detectable viral load as a confirmatory test. Data Collection and Analysis of the Total Inmate Population and Individuals Screened for HIV The only demographic data available on all inmates booked from was gender. The gender of all inmates booked was obtained from reports kept by the Correctional Health Services infection control coordinator. Because the MCJ electronic record was implemented in 2013, demographic data (age and race/ethnicity) was collected only on individuals booked into jail during the year This data was used as an estimate of the total population during our study time period. This data was exported from electronic record, then the mean and standard deviation of ages were calculated and race/ethnicity data was categorized in Microsoft Excel. Line listed testing and demographic data on patients tested for HIV was maintained by the MCPHD laboratory. These data included age and gender. Data were imported into Excel (Redmond, WA) and PASW (v. 18, Chicago, IL) for analysis. Comparative analyses were performed using Chi square to identify correlates of HIV positivity. The HIV screening rate was estimated by the number of persons referred for a health assessment that underwent HIV testing. Based on the number of total HIV positive test results and from records kept by the infection control coordinator indicating the number of individuals newly diagnosed, the newly diagnosed HIV positivity rate was estimated. Retrospective Chart Review of Newly Diagnosed Patients For the cohort of patients identified as newly diagnosed, retrospective chart review was performed to collect additional data. Medical records in the MCJ electronic health record system (TechCare), the BioReference laboratory records, and paper records kept by the nurse case manager employed by the Ryan White Part A office were reviewed. Information was obtained from MCJ intake and health assessment forms, physician s notes, case manager s notes, Communicable Disease Reports (CDR), and Ryan White forms. Demographic data 4

12 collected included gender, age, race/ethnicity, facility, and homelessness in addition to risk factors associated with HIV such as sexual orientation, intravenous drug use, types of drugs used, and blood transfusions. When defining homelessness, we included individuals who had "transient" listed on their CDR, were reported being homeless in their jail intake/health assessment screening forms, or were noted to be homeless in the case manager s notes. This included individuals who reported living "short term" with family/friends. Additionally, laboratory results of viral load, CD4 count, hemoglobin, white blood cell count, sexually transmitted disease screening tests, tuberculosis screening tests, and hepatitis panels were recorded. Statistical Package for Social Sciences (SPSS) software and Excel were used to summarize, categorize, and cross reference values for individuals who received a HIV screening test. STATA Data Analysis and Statistical Software was used to run chi squared tests to determine significance between the general inmate population and those newly diagnosed. 5

13 Results During January 1, 2012 through December 31, 2014, there were 319,575 persons booked into the MCJ facilities included in this analysis. Of these, 46,346 (14.5%) underwent HIV screening. There were 231 patients that tested positive; 70 tested newly positive and 161 were previously known infections. Our HIV positivity rate was calculated to be 0.5% (231/46,436) and the newly diagnosed HIV rate was 0.15% (70/46,346). Furthermore, 45,855 (98.9%) of the HIV tests performed were negative, 204 (0.4%) specimens were rejected, and 56 (0.1%) were missing values (Figure 1). Reasons a specimen may have been rejected include low blood volume in the collection tube, the collection tube broke or spilled, or possibility of spills or contamination from other specimens. 6

14 Figure 1. Flow chart of the number of individuals booked to the number of newly diagnosed as HIV positive, Total Booked N = 319,575 Received HIV Test N = 46,346 (14.5%) Positive N = 231 (0.5%) Negative N = 45,855 (98.9%) Specimen Rejected N = 204 (0.4%) Missing Value N = 56 (0.1%) Newly Diagnosed N = 70 (30.3%) Previously Diagnosed N = 161 (69.7%) Newly Diagnosed HIV Positivity Rate: 0.15% 7

15 Demographic Data of Inmates Booked from Of the 319,575 persons booked, 77.8% were male. The mean age for inmates booked during 2014 was 36 ± 11 (years ± standard deviation). The largest proportion of inmates were Caucasian (50.8%), followed by Hispanic (36.4%) and African American (15%) (Table 1). 8

16 Table 1. Demographics of all inmates booked into the Maricopa County Jails Variable Number (%) Gender N = 319,575 Male 245,656 (76.9) Female 73,919 (23.1) Mean Age ± Standard 36 ± 11 Deviation (2014) Race/Ethnicity (2014) N = 101,164 Caucasian 51,347 (50.8) Hispanic 26,750 (26.4) African American 15,175 (15.0) Native American 6,308 (6.2) Asian 836 (0.8) Other 748 (0.7) 9

17 Demographic Data of Individuals Who Received a HIV Screening Test There were 46,346 patients who received a HIV screening test; most were booked into the 4 th avenue jail facility (24.1%), followed by Durango (22.1%), and Lower Buckeye (21.9%). The majority of these individuals were men (77.8%) and between the age of years (39.1%) (Table 2). 10

18 Table 2. Demographics of patients who received a HIV screening test Demographics Number Tested (%) Jail Facility ( ) N = 46,346 4 th Avenue 11,172 (24.1) Durango 10,265 (22.1) Lower Buckeye 10,150 (21.9) Estrella 9,857 (21.2) Towers 3,091 (6.7) Tent City Estrella Section 1,638 (3.5) 4 th Avenue Intake 173 (0.4) Age Group (years) 19 1,808 (5.7) ,385 (39.1) ,046 (28.6) ,576 (17.6) ,325 (7.3) (1.4) Age Unknown 59 (0.2) Gender ( ) N = 31,636 Male 24,606 (77.8) Female 6,215 (19.6) Unavailable 815 (2.6) 11

19 Demographic and Laboratory Data of Newly Diagnosed HIV Positive Individuals A cohort of 70 patients were newly diagnosed through the opt out program. The median age was 29 (range 19 65); 62 (87.1%) were male; 24 (34.3%) were Caucasian, 17 (24.3%) African American, 25 (35.7%) Hispanic, and 4 (5.7%) Native American. Most patients were booked into Durango (31.1%) followed by 4 th Avenue (19.7%) and Lower Buckeye Jail (19.7%) (Table 3). The sexual orientation of 48 males was reported. Ten (20.8%) reported having sex with men only, 22 (45.8%) reported having sex with women only, and 16 (33.3%) were reported to have sex with men and women. Responses for 5 women were recorded, 4 who stated having sex with men and 1 reported having sex with both men and women. Of the 47 who answered whether they had ever had a blood transfusion, 42 (89.4%) responded no. Twenty six of 41 (63.4%) patients were determined to be homeless (Table 3). Further, data on drug use, method of use, and types of drugs was collected with information known about 59 individuals; 29 (49.2%) used intravenous drugs and 22 (37.3) used drugs but through other methods (i.e. smoking, snorting, etc.). The most commonly used drugs were methamphetamines followed by marijuana, heroin, and cocaine. Of the 51 individuals who were known to use drugs, 33 used 2 or more drugs. Another risk factor includes needle sharing among those reporting intravenous drug use, for which 5 of the 7 individuals did share needles (Table 3). Forty seven patients received a syphilis screening test (RPR), with 11 (23.4%) being positive. Thirty five patients had a hepatitis C laboratory result with 9 (25.7%) being positive. Nineteen had a gonorrhea and chlamydia urine test performed with 2 being positive. Three patients selfreported no history of STDs and 1 had a history of trichomonas (Table 3). Height and weight were often recorded in the patient s intake form or health assessment. Body Mass Index (BMI) was calculated from these values and 60% were considered to be in the 12

20 normal range. Furthermore, for the 19 patients in which co morbidity data was available, the most common was having a psychiatric diagnosis (57.8%) (Table 3). 13

21 Table 3. Demographic information and clinical characteristics of newly diagnosed patients Variable Number Positive (%) Gender N = 70 Male 61 (87.1) Female 8 (11.4) Age (years) (50) (31.4) (12.8) (2.9) 60 1 (1.4) Race/Ethnicity Caucasian 24 (34.3) African American 17 (24.3) Hispanic 25 (35.7) Native Am 4 (5.7) Jail Facility N = 61 Durango 19 (31.1) 4 th Avenue 12 (19.7) Lower Buckeye Jail 12 (19.7) Tents 9 (14.8) Estrella 5 (8.2) Towers 4 (6.6) Sexual Partners Males N = 48 Men who have sex with men 10 (20.8) Men who have sex with women 22 (45.8) Men who have sex with men and 16 (33.3) women Sexual Partners Females N = 5 Women who have sex with men 4 (80) Women who have sex with men and 1 (20) women Homelessness N = 41 Yes 26 (63.4) No 15 (36.6) Drug Use N = 59 None 8 (13.6) IVDU 29 (49.2) Other 22 (37.3) 14

22 Drug Types Methamphetamines 37 Marijuana 32 Heroin 17 Cocaine 11 Benzodiazepines 4 Prescription Opioids 6 Other 6 STDs N = 16 Syphilis 11/47 (23.4) Gonorrhea 2/19 (10.5) Chlamydia 2/19 (10.5) None 3/16 (18.8) Other 1/16 (6.3) Hepatitis C N = 35 Yes 9 (25.7) No 26 (74.3) Blood Transfusions N = 47 Yes 4 (8.5) No 43 (91.5) Tattoos N = 10 Yes 2 (20) No 8 (80) BMI N = 43 Underweight (2.3) Normal Weight (60.5) Overweight (27.9) Obese >30 4 (9.3) Comorbidities N = 19 Psychiatric Diagnosis 11 (57.8) Asthma 6 (31.6) Hypertension 5 (26.3) Obesity 3 (15.8) Diabetes 1 (5.3) Other 5 (26.3) Multiple Comorbidities 8 (42.1) Psychiatric and Medical 6 (31.6) Comorbidities 15

23 Laboratory Results of Newly Diagnosed HIV Positive Patients After receiving a positive HIV screening test result, most individuals had blood drawn for further evaluation. This included a viral load, CD4 count, complete blood count (CBC) and in some cases a hepatitis panel. However, there were some cases where HIV positive individuals left jail prior this, but were re arrested and had their blood drawn on a subsequent booking. Very few received care in the community between bookings. As such, the first laboratory results available after diagnosis for individuals who were not treated for HIV were included in the study. There were 56 patients for whom these data were available. The median viral load was 37,522 copies/ml (range 82 6,531,395) and median CD4 count was 496 cells/mm 3 (range ). The median white blood cell count was 5,690 cells/mcl (range 12 11,400) and hemoglobin 14.8 g/dl (range ) (Table 4). 16

24 Table 4. First laboratory values available after diagnosis of individuals newly diagnosed as HIV positive Median Range Viral Load (copies/ml) 37, ,531,395 CD4 (cells/mm 3 ) WBC (cells/mcl) 5, ,400 Hgb (g/dl) WBC = White Blood Cell Count Hgb = Hemoglobin 17

25 Comparison of the General Inmate Population and the Newly Diagnosed Demographics of the cohort of newly diagnosed and general inmate population were evaluated. The mean age of the 2 groups was compared using a standard t test with p values 0.05 considered significant. Mean age of the general population was 36 years and the newly diagnosed was 32 years. T test yielded p value of Further comparisons of gender and race/ethnicity were made using chi squared tests, again with p values 0.05 being significant. Comparison of male gender resulted in p value of 0.02 and for African Americans race, the p value was

26 Discussion These findings demonstrate the benefits of HIV screening in correctional systems in identifying previously undiagnosed persons with HIV. However, our data demonstrate a somewhat lower percentage of newly diagnosed cases from MCJ as compared to other correctional systems. Persons screened represented a relatively small percentage of the persons booked into the jail system (14.5%) and thus these percentages are likely underestimates. Undiagnosed HIV was more likely to be diagnosed in male, African American, and younger patients compared to the entire inmate population. Corrections systems offer a prime opportunity for HIV screening of high risk populations. These patients may have otherwise gone undiagnosed and may have contributed to ongoing HIV transmission. Patients newly diagnosed and previously known to be HIV positive can be linked to services while incarcerated and achieve viral suppression. Systematic review of current available literature revealed that of individuals known to be HIV positive, only 27% had an undetectable viral load upon entry to jail, but 52% achieve virological suppression during incarceration and suppression rates are higher with longer duration. 7 Our results identified 70 newly diagnosed HIV patients during this 3 year period who may have otherwise not undergone HIV testing in the community due to limited healthcare access. This emphasizes the importance of screening and ability to provide treatment in MCJ and in other correctional facilities. Since individuals booked into jail are there for a short period of time, linkage to care and the community upon release is vitally important. Literature on this topic shows individuals were less likely to be linked to care compared to the general population when entering jail and rates continued to drop after release from incarceration, which can subsequently lead to decline in treatment and viral suppression. 9 In the Maricopa County Jails, linkage to HIV care services is coordinated through the nurse case manager employed by the Ryan White Part A Program. The case manager will see patients while they are in the jail to assist with informing patients of their diagnosis, provide HIV education, explain treatment options, and coordinate services in the community when the patient is released from jail. 19

27 We found a newly positive diagnosis rate of 0.15%. Other studies have demonstrated higher percent positivity however these studies were performed in regions with higher background HIV prevalence such as the Southeast. One study performed in the Fulton County Jail in Atlanta, Georgia, after implementing a rapid HIV screening program, had a newly diagnosis rate of 0.4% however their overall HIV rate in Georgia is 28.3 per 100,000 people as compared to Arizona which has a rate of 12.7 per 100,000 people. 8,9 Similarly, Rhode Island has a HIV rate of 7 per 100,000 and found a new HIV positivity rate of 0.14%. 9,10 While our findings were different than initially hypothesized, our results may be related to the lower overall HIV rates in Arizona, which should be considered when comparing information across states. A significant finding from the study performed in Georgia was that the newly diagnosed patients identified in jail represented approximately 5.4% of all new HIV cases in Fulton county and 1.1% of all cases in the state of Georgia. 8 The study from Rhode Island also showed newly diagnosed patients through their HIV screening process represented 15% of all new HIV diagnoses in Rhode Island for the same time frame. 10 This emphasizes the importance of HIV screening in correctional facilities and that the HIV screening program in the MCJ may represent a significant portion of all new HIV cases in both Maricopa county and Arizona. Another possible reason our newly positive diagnosis rate was lower than expected could be related to relatively small percentage of persons booked in the MCJ system who underwent HIV screening. Some inmates refused the screening test. Unfortunately, data on refusal rates and exact reasons for refusal are unavailable. Reasons for refusing could include knowing their HIV status already or the stigma still associated with HIV. Many inmates are booked into jail, released, and then brought back to jail in a short amount of time in which they may have recently had a screening test performed, an occurrence which we could not track. Currently, at MCJ inmates are tested at their health assessment, which occurs 5 7 days after booking. For years the average annual number of detainees released within 48 hours was 9,530, with an even larger percentage released prior to day five. Thus, a large 20

28 proportion would not have undergone a health assessment nor screening. The Rhode Island Department of Corrections administers HIV screening tests within 24 hours of jail admission. They reviewed records over a 7 year period and determined if testing had been delayed for 48 hours, 29% of newly diagnosed patients would have been released before being tested and had testing had been delayed 7 days, 43% would have been released prior to receiving testing. 10 This has implications for reviewing the MCJ HIV screening process and the timing in which inmates receive testing. Implementing screening tests sooner after booking would likely capture a larger proportion of undiagnosed HIV positive individuals. The cost of screening inmates for HIV is currently covered by Ryan White Part A and the Arizona Department of Health Services, however resources might not allow for testing of the entire booked population. The cost charged to MCJ for a single preliminary HIV test is $6.51 equaling a cost of $301, for the 46,346 individuals tested and a projected $2,080, if all detainees were to be tested. From our comparison analyses, there was statistical significance for undiagnosed HIV being more common in males (p=0.02), younger patients (p=0.003) and African American patients (p=0.04). This mirrors nationwide findings that compared individuals newly diagnosed with HIV in correctional settings versus non correctional settings based on the CDC s National HIV Surveillance System. Limitations The only demographic characteristics available for all inmates booked into MCJ were gender, age, and ethnicity. Age and race/ethnicity data was available for inmates booked during 2014 to give an estimate, but thus may not reflect the entire jail population during our study time frame. Fifty six of the screening tests performed were missing values for which there was no result and were not counted among the specimens rejected. There was also discrepancy between the 21

29 total number of HIV tests performed as recorded by the MCJ and the MCPH laboratory. This discrepancy may represent some of the rejected specimens. Another possibility is that the difference stems from when the specimens were collected versus when the test was actually performed. Specimens should be processed each day, but may take up to 48 hours meaning the date the result appears is 3 days later than the date the specimen was collected. It could be that specimens collected at the end of December fell into the next year for the laboratory, but not for the jail. There were 204 rejected specimens representing 0.4% of all screening tests performed. Reasons specimens were rejected could be from low blood volume in the tube, the collection tube broke or spilled, or any sign of spill or contamination from other specimens. It is unknown if patients whose specimens were rejected were retested. Furthermore, because this was a retrospective chart review, not all data points could be collected for each of the 70 newly diagnosed patients. We were able to collect gender, age, and race/ethnicity for all 70. However, the rest of the data pieces were found using multiple sources including the MCJ electronic health record, case manager s paper records, and laboratory records. Similarly, not every patient could be found in each of these systems. In 2012, the MCJ was in transition from paper records to using TechCare, an electronic health record system. Thus, some patients who were booked in 2012 did not have records in TechCare. As well, some patients were not seen by the case manager and thus did not have a paper record. Reasons for this may be that the patient left jail or was sentenced to prison prior to the case manager being able to schedule an appointment. Another limitation is that not all patients had laboratory results available (for similar reasons as mentioned above). In a few situations, we found the patient was booked into jail, released prior to having labs drawn, but booked again within our time frame and had labs drawn on a subsequent booking. Majority of the time the patient did not receive care while in the community, which was deduced through reading case manager or physician notes. We decided 22

30 to then include these values in the analysis and reported it as first labs available after diagnosis. 23

31 Future Directions Continued evaluation of the opt out screening program should occur to find ways of capturing more individuals in a cost effective manner and possibly implementing more targeted screening. MCJ should consider performing HIV testing closer to when the inmates are booked preferably within 48 hours as many detainees are released in this time frame. Within the next year all booked inmates at the MCJ will be offered screening for Hepatitis C, chlamydia, gonorrhea, and syphilis. This may result in more patients agreeing to be screened and subsequently diagnosed with HIV. As well, data on rates and reasons for refusal could be analyzed to reduce barriers around HIV screening. Further comparisons using the demographic and lab data could be evaluated, such looking at the gender, age, and race/ethnicity of those with AIDS (CD4 count <200). Due to the limitations of our study, a prospective study would likely yield more complete data for analysis and identify ways to bridge gaps, such as patients released prior to receiving their HIV diagnosis. 24

32 Conclusions HIV Screening in MCJ remains a priority site for testing in Arizona. The relatively low percentage of newly diagnosed cases calls for ways to improve case identification at a lower cost. Opportunities to improve linkage and retention in HIV care remain paramount in this process as well given the challenges of newly diagnosed detainees related to housing, substance abuse, employment and mental illness. 25

33 References 1. Centers for Disease Control and Prevention. HIV testing implementation guidance for correctional settings. January 2009:1 38. Available at: testing/resources/guidelines/correctional settings. 2. Simonsen KA, Shaikh RA, Early M, et al. Rapid HIV screening in an urban jail: How testing at exit with linkage to community care can address perceived barriers. J Primary Prevent. 2015; 36: DOI: /s HIV Risk Behaviors. Centers for Disease Control and Prevention website. Updated December 4, Accessed November 14, VanHandel M, Beltrami JF, MacGowan RJ, Borkowf CB, Margolis AD. Newly Identified HIV infections in correctional facilities, United States, Am J of Public Health. 2012;102(S2): Maricopa County Facts and Figures. Maricopa County Sheriff s Office website. Accessed November 14, Abbott Architect HIV Ag/Ab Combo. U.S. Food & Drug Administration website. LicensedProductsBLAs/BloodDonorScreening/InfectiousDisease/ucm htm Updated November 11, Accessed March 15, Iroh PA, Mayo H, Nijhawan AE. The HIV care cascade before, during, and after incarceration: A systematic review and data synthesis. Am J Public Health. 105(7) e5 e16. doi: /AJPH Centers for Disease Control and Prevention. Routine HIV screening during intake medical evaluation at a county jail Fulton County, Georgia, MMWR 2013;62(24): HIV in the United States by Geographic Distribution. Centers for Disease Control and Prevention website. geographicdistribution.html. Accessed March 6,

34 10. Centers for Disease Control and Prevention. Routine jail based HIV testing Rhode Island, MMWR 2010;59(24):