Is Routine Testing Mandatory or Voluntary?

The AIDS Treatment Activists Coalition (ATAC) is a national coalition of AIDS activists, many of whom are living with HIV/AIDS, working together to end the AIDS epidemic by advancing research on HIV/AIDS. ATAC's Access to Health Care for the Incarcerated working group has the goal of increasing access to health care for incarcerated people through strategy coordination, information sharing, training, and advocacy for allied individuals, groups, and communities. The Access to Health Care for the Incarcerated working group opposes the call for routine HIV testing recommended in the recent editorial commentary entitled “HIV Infection Behind Bars” by Boutwell and Rich [1]. We believe that routine HIV testing in prison is virtually synonymous with mandatory testing. Prisoners often receive no pretest counseling or education about HIV infection; frequently, they are unaware of the implications of testing positive for HIV while incarcerated. Consent often means something completely different in prison than it does outside of prison. Many prisoners are unaware that they have consented to HIV testing—or that they actually were tested for HIV, despite the consent form. We agree wholeheartedly that identification of infected individuals is an important step in addressing HIV infection in any setting. However, prisoners do not have guaranteed access to the standard of care for HIV treatment, so beginning the process of addressing HIV disease behind bars must entail providing access to counseling, education, and the standard of care for HIV treatment, as defined by the Department of Health and Human Services' guidelines [2]. Without guaranteed access to quality care, any testing will only result in continued retaliation, stigmatization, threats, lack of confidentiality, and substandard medical care. The disproportionately high number of HIV-infected persons in our prisons is more than “a challenge to correctional health systems” and a “public health opportunity” [1]. It is a human rights catastrophe of vast proportions, and it challenges our society as a whole. Our priorities must be ordered by the thousands of prisoners whose lives are on the line. The commentary by Boutwell and Rich [1] echoes the unfortunate new position on mandatory testing for prisoners currently held by the Centers for Disease Control and Prevention (CDC). Although testing may have led to better treatment in Rhode Island (which, not surprisingly, has the smallest correctional system in the country), this is not the case in most state prison systems. The experience inside most prison systems is that testing does not lead to education, care, and treatment. It leads to discrimination, segregation, and just plain poor care. HIV-infected prisoners are not eligible for many prison jobs and programs, such as work-release programs and halfway house placement. Despite the success of peer education in the community, behind the walls, there are fewer HIV peer education programs than ever before. The reality is that testing positive inside feels like—and, in some cases, is—a death sentence. We must ask whether it is in anyone's interest for people inside the walls of prison to be treated any differently than people on the outside. Mandatory HIV testing is a vast departure from commonly held public health standards. Is this a precursor to a broader CDC policy that all people should be tested, regardless of consent? Right now, people outside of prison walls have the right to make informed decisions about whether to be tested for HIV. Prisoners deserve the same rights. Our first priority must be programming that provides education, counseling, and a continuum of quality care and treatment to inmates while they are imprisoned and after they have been released. Potential conflicts of interest. All authors: no conflicts.