What is the Program?
Between October 2011 and March 2012, Halton Region Health Department offered anonymous, rapid point-of-care (POC) HIV testing to inmates at Maplehurst Correctional Complex and Vanier Centre for Women, two provincial correctional facilities that share a campus in Milton, Ontario. HIV testing was coupled with testing for gonorrhea and chlamydia to enhance confidentiality for inmates accessing these services in a setting where privacy may be difficult to maintain.
The Ontario Ministry of Community Safety and Correctional Services, the Ontario Ministry of Health and Long-term Care’s AIDS Bureau, Halton Region Health Department, Maplehurst and Vanier collaborated on this pilot project. The objective of the pilot project was to increase access to HIV testing through anonymous, rapid POC testing services provided by a local public health unit. The pilot project included an evaluation component and was funded by the AIDS Bureau.
The pilot project demonstrated that offering anonymous, rapid HIV testing, using a POC test, to inmates in a provincial facility was not only feasible for a public health unit but also acceptable to prison healthcare providers and, critically, to inmates.
Although this pilot took place at both Maplehurst and Vanier institutions, this case study focuses on the work at Maplehurst, where most of the tests were performed. A short section at the end of the case study describes the work at Vanier.
Why Was the Program Developed?
Prisoners are considered an important population to whom anonymous, rapid POC HIV testing should be offered because they may be at high risk of infection, may not have sought access to testing services while incarcerated, and may experience challenges testing through standard laboratory tests. This is especially true at the provincial level, where correctional services work with a population of inmates who are in transition (e.g., who are on remand (awaiting a court appearance or a transfer to another facility) or who are serving short sentences (to a maximum of two years less one day)). Delivering healthcare to a transient population such as this one can be challenging. This challenge can be overcome by providing rapid POC HIV testing because results can be offered at the same time as testing occurs.
How Does the Program Work?
Developing the project
One of the central components of the pilot’s success was the collaboration between staff from the Ministry of Community Safety and Correctional Services and staff from the AIDS Bureau. This relationship was built on the ministries’ pre-existing work on prison health issues. Leveraging this good relationship allowed staff from the two ministries to work together to find a health region and a facility within that region that could host the pilot.
Choosing the location of the pilot
Representatives from the AIDS Bureau and the Ministry of Community Safety and Correctional Services worked to identify a site that could host the pilot project. Both ministries looked for health units that could offer anonymous, rapid POC HIV testing and correctional facilities that had the infrastructure to host public health staff.1
Representatives from both ministries reviewed all of the correctional facilities in the province and all of the health units to determine if there was a correctional facility that could host the pilot within the jurisdiction of a health unit with staff designated to perform anonymous, rapid POC HIV testing.
Halton Region, which lies to the west of Toronto and which had expressed interest in providing HIV testing in their local correctional facilities, was chosen as the site of the pilot. There were several reasons Halton Region was an ideal location for the pilot:
- Halton Region Health Department had the capacity to offer anonymous, rapid POC HIV testing.
- Maplehurst and Vanier institutions both had healthcare staff eager to support the pilot.
- Both facilities had private areas for testing.
- Staff from Halton Region Health Department and Maplehurst and Vanier institutions already had good working relationships as a result of Halton staff offering follow-up services to inmates with sexually transmitted infections.
- Halton Region staff already had security clearance, which allowed them to access the facilities more easily.
Developing an evaluation framework
Given that this was a pilot project, the Ministry of Community Safety and Correctional Services, the AIDS Bureau and Halton Region were interested in including an evaluation component in the project. The goal of this evaluation was to determine how best to deliver the testing service to inmates, to promote testing within this population at high risk of contracting HIV. A self-administered and self-reported survey (available in the Program Materials section of the case study) was developed to be offered to all inmates at the end of their testing session.
The senior medical consultant from the Ministry of Community Safety and Correctional Services led the evaluation, with help from the Ontario HIV Treatment Network for the data analysis.
Once the discussions between the two ministries were completed and Halton Region was identified as the site for the pilot project, representatives from the ministries, Halton Region and both institutions held an initial meeting to lay the groundwork for the development of the project. Subsequently, representatives from Halton Region (the manager of the Sexual Health and Needle Exchange Program, a public health nurse and an outreach worker who would be performing the tests), and Maplehurst and Vanier (the healthcare managers of the two institutions, senior nurses and representatives of the institutions’ senior management) met several more times to determine how the pilot could be implemented. They discussed the objectives of the pilot and how the role of public health would complement the role of prison healthcare providers. From the very beginning, all parties were supportive of the pilot project, and very few challenges to implementation were experienced.
Developing an implementation plan
Maplehurst’s healthcare manager, the point person within the prison for the pilot, determined that the best way to implement the pilot would be to, as much as possible, work within the institution’s existing structures and protocols. This meant that testers would come during visiting hours and inmates would ask to see Halton Region testers using the same health request form they would have filled out to see prison healthcare staff. Relying on existing structures eliminated the need to develop new procedures, which might have taken significant time to be approved.
Preserving client anonymity
A major concern throughout the planning process was how to preserve the anonymity of a client accessing an anonymous, rapid POC HIV test in an environment that is not designed to maintain anonymity. Testers were very clear with clients that their full names and any other identifying information would not be attached to the test or the results and that the prison staff, either health or correctional, would not be informed of the results. Clients were also assured that any information they shared with the testers would not be shared with anyone else. All records associated with the testing initiative, including client information, were kept by Halton Region.
HIV testing was coupled with testing for gonorrhea and chlamydia as one way to maintain anonymity in the delivery of HIV testing. Only the tester and the inmate knew if an HIV test was performed during a session, which preserved as much as possible the privacy of the inmate. Testing for gonorrhea and chlamydia was chosen over hepatitis testing, for example, because testing for these infections does not require a blood sample and can be conducted in the limited time testers had with each client.
A public health nurse authorized to offer sexually transmitted infection testing, diagnosis and treatment and an outreach worker were assigned to the pilot project. Both the nurse and the outreach worker were certified to offer anonymous, rapid POC HIV testing. It was key that both staff had experience working in the prison setting, which can be intimidating for outside service providers. Both testers were comfortable in the setting as a result of their previous work and this allowed them to build a rapport with clients who may have been nervous about getting tested.
Both testers also had security clearance, which allowed them to go to the main doors and avoid the line to access the prison. This clearance also let the testers go to their assigned unit without an escort.
The testers carried into the prison everything they needed to offer testing. Two tool boxes were used to carry testing kits, blood-draw equipment, urine sample bottles, treatments for chlamydia and gonorrhea, gloves, and juice for inmates who wanted it. The tool boxes also contained all paperwork—requisition forms and surveys—that the testers needed to provide testing and complete the evaluation.
Testing time and location
The testers worked within each prison’s normal routine to reduce disruption. Testers visited the prison campus during predetermined visiting hours (2 pm to 3 pm), three times per week. Initially, Vanier scheduled testing on Mondays, and Maplehurst scheduled testing on Wednesdays and Thursdays. Uptake at Vanier was low so on days when there were no tests requested there, the testers went to Maplehurst instead.
Maplehurst is an institution with 11 units, and tests were requested for a variety of units in any given week. This meant that the testers could not set up at the same location at every visit. Instead, testing was offered on one or two units per visit in one of the private rooms in the unit’s program area. A unit’s program area is where inmates see lawyers, case managers and police officers.
Over the six-month pilot period, there were nine times when the testing clinic had to be cancelled because all of the private rooms were already in use and several times when lockdowns prevented testers from entering the prison. On as many of these occasions as possible, Maplehurst’s healthcare manager informed the testers before they arrived that a testing clinic could not take place on that day.
It sometimes happened that inmates scheduled for testing were not available to be tested, although the healthcare manager worked to avoid this as much as possible. Cancellations reduced the number of people who could test, because a cancelled appointment could not be filled by another inmate on short notice. Over the course of the six months, 37 appointments were missed or cancelled.
Word of mouth was the most important way in which the testing pilot was advertised at Maplehurst. Many clients said they decided to get tested after someone on their unit told them about their experience. In a closed environment like Maplehurst, where an inmate could share his bad experience with fellow inmates, it was key for uptake of testing that inmates who had sought testing told others about their positive experience.
The pilot project was also advertised through flyers printed by the AIDS Bureau. Prison healthcare staff posted these flyers in places around the prison they felt prisoners would be most likely to stop and read them. They also told any prisoner who sought healthcare during the pilot about the pilot project.
One of the prison nurses also took the time to read out the flyer in the common area on her unit. Low literacy in this population was a concern and this provided all inmates, regardless of reading ability, the chance to hear about the project. Forty-two requests from that unit were generated from that nurse’s announcement.
Requesting a test
When inmates want to access any healthcare services, they submit a healthcare request form. For the period of the pilot project, the healthcare request forms at Maplehurst included an additional line that allowed inmates to tick off a request to see staff from Halton Region. Adapting pre-existing forms (rather than developing a new form) was one way to increase the confidentiality of inmate information. This form was placed in an internal mailbox and processed by Maplehurst’s healthcare manager. It was destroyed once the appointment was made.
Coordinating inmate access to testing
The healthcare request forms were processed by Maplehurst’s healthcare manager. It was the healthcare manager’s responsibility to schedule inmates for testing on the basis of the inmate’s schedule and how many other requests had been made on that unit. The healthcare manager then booked rooms in the program area on the specific unit for the testers. The morning of the testing clinic, the list of inmates would be delivered to the nursing staff on that unit so that they could give it to the testers.
Nurses did not note the testing session in inmates’ charts. This supported the anonymity of the test because no record of it was kept in the prison health system. All health information about each inmate’s test was documented by Halton Region.
Typical testing appointment
Appointments were scheduled at 30-minute intervals. Each tester tested two clients per day. During the session, only the tester and the client were in the counselling room.
Testers performed a streamlined pre-test counselling session (please see the Program Materials section of the case study for the intake form), focusing only on the essential questions. This protocol was followed so that testers could perform more than a single test during one session. Testers also discussed core elements of the post-test counselling, including information about confirmatory testing, treatment and risk reduction. They answered any questions inmates had about prevention and treatment of HIV and other sexually transmitted infections.
The tester then performed the test. Once the results were read, clients were offered gonorrhea and chlamydia testing. This aspect of the pilot was not anonymous, as these tests, unlike anonymous HIV testing, cannot be performed without a person’s full name attached. During the final minutes of the session, clients were asked to complete the anonymous evaluation survey.
Confirmatory testing and linkage to care
In the event of an HIV POC reactive result (preliminary positive), clients were offered a confirmatory test immediately. Results were communicated to the client on a return visit to the prison by the tester. Linkage to specialized HIV care, including treatment, if the inmate wanted it, would be coordinated through the prison healthcare system. Testers were also prepared to offer advice on seeking treatment in the community upon the inmate’s release. During the pilot, one reactive result was returned. The client declined confirmatory testing and linkage to care, as he indicated during the counselling session that he was knowledgeable about where to obtain support and care in the community.
Vanier Centre for Women
Testing at Vanier was scheduled in the facility’s program area on Mondays. The pilot project was advertised in the same way that it was at Maplehurst. Inmates had to fill out a healthcare request form, submit it to healthcare staff in the prison and then wait to have their appointments scheduled with the testers. One of the testers would contact the facility’s healthcare manager on Monday morning to determine if any testing requests had been submitted.
Testing numbers were low at Vanier. Although the reason requires further inquiry, it may be that inmates at Vanier have more timely access to healthcare generally than inmates at Maplehurst. It may also be that women involved in the prison system are, on average, older than their male counterparts and may have had other opportunities to be tested.
- AIDS is a reportable disease under Ontario legislation (Health Protection and Promotion Act, HPPA). People who test HIV positive are reported to public health officials. There is, however, a section of the HPPA that permits some clinics to test clients anonymously: no identifying information about the client is collected. Only HPPA-designated clinics are authorized to provide anonymous testing in Ontario. Fifty sites across Ontario are permitted to provide anonymous testing.
- Strong relationship between policy-makers in the ministries responsible for public health and correctional services.
- Strong relationship between public health testers and prison healthcare providers and buy-in from senior correctional service management.
- Committed healthcare staff to coordinate inmate requests for testing.
- Sites designated to offer anonymous HIV testing.
- Testers certified to perform the rapid POC HIV test and with some experience in prison settings.
- Mini portable clinic with all the supplies necessary to perform rapid POC HIV testing.
- Timing. Working around the routine of the prison was challenging. The window of opportunity for testing (visiting hours) was short. In addition, testers could have to wait for up to 45 minutes for inmates to be escorted to the testing room. Some appointments were missed as a result of inmates being released, being in court or being moved at the last minute.
- Space. Testers did not have dedicated space at Maplehurst to offer HIV testing. Nine times during the pilot project, there were no rooms available for the testing to take place and the clinic was cancelled.
- Low testing volume at Vanier. Testing rates at Vanier were very low. Although this needs further inquiry, it may be because inmates at Vanier have more timely access to healthcare or because they have already been reached with testing.
The HIV testing pilot was evaluated in two ways: through a self-administered client survey and through an analysis of HIV testing data. Seventy-eight percent of inmates completed the qualitative survey offered at the end of each testing session.
HIV testing data were submitted to the Ontario public health laboratory for collection and tracking. At the end of the project, the number tested, number positive, exposure category and other demographic information were reviewed as part of the evaluation.
The evaluation results demonstrate that access to anonymous, rapid POC HIV testing filled a gap in testing services for prisoners:
- 156 inmates tested through the project.
- 98% of those who completed the survey said they were completely satisfied with the HIV testing service.
- 42% of those who accessed this service reported they had never before tested for HIV. This result suggests the pilot reached an at-risk population in need of testing services.
- 52% of those who were tested said they chose to be tested during this project because the results were available immediately.
- 41% said they chose to test because they could do so anonymously.
The number of reactive results was lower than anticipated for this high-risk population (only one reactive test occurred). However, the HIV positivity rate for the project was 0.60 percent, which is three-fold greater than the positivity rate for standard nominal testing in Ontario, suggesting that a broader program may have resulted in greater numbers of HIV diagnoses.
Overall, the pilot pro ject was considered a success. It demonstrated that it was feasible to offer anonymous, rapid POC HIV testing in a prison setting in Ontario. The Ministry of Community Safety and Correctional Services, the AIDS Bureau and Halton Region believe that this pilot showed that public health and correctional services can partner effectively to lower barriers to anonymous, rapid POC HIV testing for inmates.
On the basis of the evaluation of the pilot project, the AIDS Bureau and the Ministry of Community Safety and Correctional Services are committed to providing logistical support to health units that want to incorporate anonymous, rapid POC HIV testing into their work. As of March 2014, there are two health units in Ontario seeking this support.
- Build strong relationships between prison staff and public health staff. This pilot was a success because of the careful planning that occurred at the provincial and regional levels.
- Use the existing institutional framework. The pilot project worked within the established framework of institutional life rather than changing already existing processes. This eliminated the need to develop new procedures, which may have taken significant time to approve and implement.
- Use testers who will provide positive experiences to inmates. It was key that both testers were familiar with the institution and were capable of offering non-judgemental, supportive testing to inmates. Word of mouth in a closed environment such as a prison is a powerful way to recruit potential clients. If an inmate did not have a positive testing experience, it is unlikely that other inmates would have sought testing.
Sue Gallaher, public health nurse
Adam Higeli, outreach worker
Halton Region Health Department
1151 Bronte Road
Oakville ON L6M 3L1
905-825-6000 ext. 4543 or 3490
firstname.lastname@example.org | email@example.com
Ken English, senior program consultant
AIDS and Hepatitis C programs, Ministry of Health and Long-term Care
Dr. Lori Kiefer, senior medical consultant
Ministry of Community Safety and Correctional Services