Control of epidemics by jails: lessons for COVID-19 from HIV
Authors: Tochi Ohuabunwa, Anne C Spaulding
Journal: The Lancet HIV (2020)

Of the 10·2 million people incarcerated worldwide, an estimated 3·8% of individuals are HIV-positive, a proportion that varies widely by region.1Dolan K Wirtz AL Moazen B et al.Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees.Lancet. 2016; 388: 1089-1102Summary Full Text Full Text PDF PubMed Scopus (428) Google Scholar To achieve the ambitious UNAIDS 90-90-90 target,2UNAIDSGlobal AIDS update 2018: Miles to go. UNAIDS, Geneva2018https://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdfDate accessed: May 15, 2020Google Scholar strategies must address incarcerated people with HIV, as well as those at liberty. Universal test-and-treat (UTT) interventions represent an important step towards achieving these goals; through earlier linkage to antiretroviral therapy (ART) and wider ART coverage among people with HIV, the spread of HIV could be prevented and potentially, the HIV/AIDS epidemic could be ended.3Baggaley RF Hollingsworth TD How universal does universal test and treat have to be?.Lancet HIV. 2020; 7: e306-e308Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar However, progress towards the HIV/AIDS 90-90-90 targets has not been equally distributed across subpopulations, demographics, or regions. Incarcerated people are especially disadvantaged and at risk.4Beyrer C Kamarulzaman A McKee M Prisoners, prisons, and HIV: time for reform.Lancet. 2016; 388: 1033-1035Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar In The Lancet HIV, Michael Herce and colleagues5Herce ME Hoffmann CJ Fielding K et al.Universal test-and-treat in Zambian and South African correctional facilities: a multisite prospective cohort study.Lancet HIV. 2020; (published online Aug 4.)https://doi.org/10.1016/S2352-3018(20)30188-0Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar report the clinical outcomes of a prospective cohort study at three correctional facilities in South Africa and Zambia, which show that UTT implementation is feasible and effective in prison settings. Over a 1 year period, the authors introduced a UTT intervention in adult correctional facilities and tracked time to ART initiation and viral load suppression at 6 months and 12 months follow-up visits. Herce and colleagues found rapid HIV testing could be followed by on-site, rapid initiation of ART care. 835 (86%) of 975 eligible participants enrolled initiated ART with a median time from enrolment to ART initiation of 0 days (IQR 0–8). The high rates of loss to follow up at the correctional facilities was a major limitation of the study. 415 (50%) of the 835 participants who initiated ART had left their initial facility at 6 months. However, 327 (95%) of 346 participants who remained incarcerated at 6 months were retained in care. Furthermore, of the 269 participants eligible for the 6 month follow-up analysis who had at least one viral load result documented, 262 (97%) had achieved viral suppression (<1000 copies per mL) at 6 months. Through early linkage to ART and high retention in care, the proportion of the prison cohort who achieved viral load suppression was similar to that observed in other African community-based trials for treatment-as-prevention (up to 88% of individuals achieved suppression).6Abdool Karim SS HIV-1 epidemic control-insights from test-and-treat trials.N Engl J Med. 2019; 381: 286-288Crossref PubMed Scopus (48) Google Scholar Our own experience has shown that rapid testing for HIV can also be successfully implemented in US jails. Our study done in Atlanta (GA, USA), using routine, rapid opt-out screenings at a county jail, showed that the strategy was both feasible and cost-saving compared with sporadic, laboratory-based tests. A higher number of individuals received new HIV diagnoses in the rapid screening group than did those who had sporadic laboratory-based screening (89 vs 15). All individuals who had rapid screening received their test result; and most could start treatment in jail.7Hutchinson AB, MacGowan R, Margolis A, Adee MG, Bowden CJ, Spaulding AC. Costs and outcomes associated with discontinuing a routine HIV screening program in a high volume jail. Annual Meeting of the Society for Medical Decision Making; Portland; Oct 20–23, 2019 (abstr PS 1–31).Google Scholar, 8Spaulding AC, Adee MG, Bowden CJ, et al. Routine, rapid HIV screening of jail entrants in Fulton County (GA, USA) not only links more people to care but also is cost-saving. Adherence 2019–International Association of Providers of AIDS Care; Miami; June 17–19, 2019 (abstr).Google Scholar Compared with the sporadic, laboratory-based screening, rapid screening resulted in a reduction of US$2·8 million in US health-care costs, when considering HIV diagnoses averted when a higher number of people were aware of their HIV status.7Hutchinson AB, MacGowan R, Margolis A, Adee MG, Bowden CJ, Spaulding AC. Costs and outcomes associated with discontinuing a routine HIV screening program in a high volume jail. Annual Meeting of the Society for Medical Decision Making; Portland; Oct 20–23, 2019 (abstr PS 1–31).Google Scholar Rapid ART initiation, which Herce and colleagues achieved, was not part of the Atlanta jail programme. The findings from Herce and coauthors might lead to replication of rapid UTT implementation in jails globally. Despite the evidence that UTT can be feasible and effective, such measures to end the HIV epidemic are rarely implemented in correctional facilities, often as a result of prejudice, disdain, and ignorance,4Beyrer C Kamarulzaman A McKee M Prisoners, prisons, and HIV: time for reform.Lancet. 2016; 388: 1033-1035Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar whereby the needs of incarcerated people are often overlooked. When will the health and wellbeing of incarcerated people no longer be ignored? The COVID-19 pandemic first affected incarcerated individuals in China, and now the same pattern has been observed globally, including in the USA.9Hawks L Woolhandler S McCormick D COVID-19 in prisons and jails in the United States.JAMA Intern Med. 2020; (published online April 28.)https://doi.org/10.1001/jamainternmed.2020.1856Crossref Scopus (156) Google Scholar, 10Akiyama MJ Spaulding AC Rich JD Flattening the curve for incarcerated populations–Covid-19 in jails and prisons.N Engl J Med. 2020; 382: 2075-2077Crossref PubMed Scopus (210) Google Scholar Herce and colleagues implemented the same standard of HIV care practised in the community into correctional facilities.5Herce ME Hoffmann CJ Fielding K et al.Universal test-and-treat in Zambian and South African correctional facilities: a multisite prospective cohort study.Lancet HIV. 2020; (published online Aug 4.)https://doi.org/10.1016/S2352-3018(20)30188-0Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar In the same way, as new approaches for managing the coronavirus epidemic in the community are developed—aggressive testing of symptomatic and asymptomatic people with contact tracing—the same standard of care will be needed in correctional facilities. Only by doing so can the role of prisons and jails as reservoirs of viral infection be minimised. Failure to control and prevent the spread of viruses within prisons and jails will undermine population-level targets, which could cost lives and result in health-care costs similar to that observed with COVID-19 disease in the past 3–4 months and the ongoing HIV epidemic for the past 3–4 decades. The idea of health for all must be adopted universally to prevent disease and to uphold human rights to health and dignity for individuals within and outside of prison walls. ACS reports grants and personal fees from Gilead, has served on an advisory board for Gilead Sciences, reports honoraria through third parties funded by Gilead, AbbVie, and Merck, personal fees from National Commission on Correctional Health Care, National Sheriff's Association, and Harris County Sheriff's Office, travel expenses from bioLytical Sciences and Guardian, during the conduct of the study; and research funding from Cellex. TO declares no competing interests. Universal test-and-treat in Zambian and South African correctional facilities: a multisite prospective cohort studyUTT implementation is feasible in correctional settings, and can achieve levels of same-day ART uptake, retention in care, and viral suppression among incarcerated people with HIV that are comparable to those observed in community settings. Full-Text PDF