Testing should be offered, not forced

N.C. prisoners and HIV

CHAPEL HILL -- The prevalence of HIV infection among state prison inmates is several-fold higher than that of the general population. This is no surprise to anyone with an understanding of the dual epidemics of imprisonment and HIV in the United States.

In both, black men are dramatically overrepresented. Though comprising only 13 percent of adult males, black men make up 40 percent of male prisoners. Nationally, HIV rates among black men are eight times those of white men.

A recent and troubling report from the Centers for Disease Control and Prevention found that 4 percent of black men in their 40s are HIV-infected. Many of these and other HIV-infected men pass through a prison or jail, and some -- just how many is unclear -- are unaware they carry the virus.

In response, some advocate for mandatory HIV testing of prisoners. Several states do mandate that all prisoners be HIV-tested, while others, including North Carolina, have voluntary programs wherein HIV testing is offered soon after entry.

Mandatory testing of inmates on face value seems attractive. Prisoners are a high-risk population, and testing can identify the unknowingly infected, leading to treatment and counseling to reduce risk of transmission.

However, the solution to the HIV epidemic is not mandatory HIV testing of inmates. Foremost, forcing an individual -- with physical restraints if necessary -- to have his blood tested for disease deprives that person of a basic autonomy that should not be lost with incarceration. The moral shadiness of such coerced testing has led the World Health Organization and the American Public Health Association to consider mandatory HIV testing of inmates unethical.

Further, forced testing is unlikely to stem the transmission of HIV in our state, just as mandating syphilis testing of prisoners has not led to a decline in that sexually transmitted disease.

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IN OUR EXPERIENCE, THE MAJORITY OF INCOMING HIV-INFECTED INMATES know of their infections, and once released they return to the same main sexual partners they had before incarceration -- partners who are very often aware of the former inmate's HIV status. In addition, there is no evidence that mandatory HIV testing of prisoners results in a reduction in HIV transmission. Several Southern states mandatorily test inmates yet continue to see increases in the rate of new HIV infections.

Forced HIV testing of prisoners can also have unintended consequences. HIV remains a stigmatizing condition, perhaps dangerously so in correctional settings, and mandating testing only aggravates this stigma. It also ignores data finding extremely high acceptance of voluntary HIV screening when the benefits of testing are explained and the risks of testing minimized. In North Carolina, more than 80 percent of incarcerated women consent to HIV testing, likely because the test is part of a package of preventive health screening offered to these women when they enter prison.

Finally, data from South Carolina, where HIV testing of prisoners is mandatory, suggest that in North Carolina few infected inmates remain unidentified: There, 2.3 percent of incoming inmates are HIV-infected, while here it is 1.8 percent -- a difference that may in part be explained by the higher prevalence of HIV in the general population in South Carolina.

Despite the ethical shortfalls and marginal benefit of mandatory testing, some state legislators propose compulsory HIV testing of North Carolina prisoners just prior to their release. This approach is particularly troubling because it offers no in-prison intervention to benefit the inmate or reduce his infectiousness -- it only passes the buck, literally, to communities that are often straining to deliver HIV services.