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LETTER |
The authors are with the Rollins School of Public Health, Emory University, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to Ronald L. Braithwaite, PhD, Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE, Atlanta, GA 30322 (e-mail: rbraith{at}sph.emory.edu).
Mandatory HIV testing is a double-edged sword—you are damned if you do and damned if you don’t. As African American scientists living in the United States, we have observed that racial, gender, class, and age discrimination continues to be an integral part of the American fabric.
The current research literature documents the fact that racial and ethnic minorities are disproportionately overrepresented in the US correctional system (prisons, jails, detention centers, halfway houses, parole, and probation). We also know that blinded studies reveal a higher HIV prevalence than voluntary testing reveals.1–3 Compounding these observations is the fact that sexual encounters occur in correctional facilities, largely without the use of condoms.
So it comes down to the lesser of two evils: whether inmates should be allowed to remain undiagnosed and untreated or forced to deal with the discrimination that may result from a positive HIV diagnosis. Allowing inmates to remain undiagnosed and untreated reminds us of the infamous Tuskegee study. In that case there was a treatment of choice that could cure syphilis. With HIV, while there is no cure, there is a treatment of choice that can prolong life with reasonable quality. HIV is not a death sentence anymore. In the general population, racial/ethnic minorities are diagnosed late, are the first to present at hospital emergency rooms, have less access to state-of-the-art therapies, and are victimized by systemic discrimination.4 If inmates, who are disproportionately members of racial and ethnic minority groups, remain undiagnosed and untreated for HIV, this will only exacerbate the situation. Pick your poison.
All things being equal (which they are not), we agree with Weinstein and Greenspan that free choice is a good thing and that all people should have the right to make informed heath decisions. However, the medical care for HIV-infected inmates in long-term facilities is relatively good, and mandatory HIV testing has the potential to result in treatment and care for individuals who might not otherwise have access to these services. One might argue that the 34 states without mandatory testing are more concerned with the negative financial impact that increased case finding would have on their budgets than with inmates’ health.
Mandatory testing for tuberculosis exists in the majority of US correctional systems, in part because there are known methods for controlling the spread of this infectious disease in high-density populations. There are also known methods for preventing and controlling the spread of HIV. They include peer education, pre- and posttest counseling, staff training, access to condoms, and access to quality health care.
References
1. Braithwaite RL, Hammett TM, Mayberry RM. Prisons and AIDS: A Public Health Challenge. San Francisco, Calif: Jossey-Bass Publishers; 1996.
2. LaChance-McCullough ML, Tesoriero JM, Sorin MD, Lee C. Correlates of HIV seroprevalence among male New York state prison inmates: results from the New York state AIDS institute criminal justice initiative. J Prison and Jail Health. 1993;12:103–134.
3. LaChance-McCullough ML, Tesoriero JM, Sorin MD, Stern A. HIV infection among New York state female inmates: preliminary results of a voluntary counseling and testing program. Prison J. 1994;73(2):198–215.
4. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
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