Developing an exemplary intervention in Germany

If carefully undertaken, VCT in prison needs a lot of time. Physicians in prison with their multitude of other responsibilities sometimes do not have adequate amount of time.

First lessons

1. The implementation of such a project requires an analysis of the situation and thorough discussions. The time required to get support from the MOJ and to find project partners in prison should not be underestimated.
2. To limit possible negative consequences for prisoners, VCT testing programs should be established by NGOs (with NGOs involvement) that know the system and already have experience working in prison.
3. The programs should establish good cooperation between NGOs and prison health authorities/staff members.
4. A nice atmosphere in the space where VCT should be created.
5. Informational materials and condoms must be provided.

The concept

After its development, the concept described here was shared with the Ministry of Justice. Its purpose was to convince prison health authorities to participate as partners and to explain certain measures planned. The original concept is available in German language only.

Aim of the intervention

If carefully undertaken, VCT in prison needs a lot of time. Physicians in prison with their multitude of other responsibilities sometimes do not have adequate amount of time. The intervention aims include:

• to reduce the work load for physicians and health care personnel by offering complementary HCV/HIV VCT
• to prisoners carried out by external NGOs/physicians;
• to establish examples how VCT guidelines can be utilized in prison settings; and
• to offer prisoners time to discuss questions related to: risk behaviour patterns; testing procedures; risk reduction strategies (safer sex, safer drug use); risks related to incarceration.

The ultimate aim is to identify new HIV/HCV-infections, reduce the amount of late HIV presenters and close the gap in the care system (linkage to care).

Preconditions and preparation

Initially, an analysis of the situation should be written up including a concept explaining the aims and tasks as well as the willingness of all parties involved (MOJ, prison health authorities, NGOs with good contacts within prisons) to cooperate and agree on the aim and tasks in accordance with agreed procedures and standards. As a safeguard, all needs should be documented and an agreement between the parties involved reflecting a common vision of these should be signed. To secure the cooperation and limit risks, trainings on the aims and the scope of the intervention and themes relevant to it, such as: basic information on HCV/HIV, prevention, risk situations, harm reduction, safer use, safer sex etc. should be offered to everyone involved (including prison heath authorities, staff, guards, NGO participants etc.).

The participation of prisoners must be voluntary. The cooperating partners inside prison should advertise among prisoners, communicating the dates of the intervention and procedures and bring prisoners with the interest to participate in the agreed appointments. Leaflets and other advertising materials, test-kits and other materials may be supplied by the NGO. The cooperation of partners inside the prison should guarantee that prisoners are not pressured to participate. A clean room (if possible with a wash basin) that guarantees anonymity between prisoners and test counsellors should be provided.

Regular consultation hours for pre- and post-test counseling and testing

Consultation hours are often made available for three hour periods and should be offered on a regular basis, for example every 14 days. The dates and hours should be convenient for prisoners and prison staff. Prisoners willing to participate have might have one to three appointments.

Rapid test. The first appointment is for pre-test counseling (and testing if the prisoner decides he or she wants to get tested – should a rapid test be used (and in case the test is not reactive, the test result will be delivered during the same appointment, in such cases only one appointment is necessary.

Laboratory. The second appointment is to present and explain the test result (in case no rapid tests were used or a rapid test needed to be confirmed) and to talk about treatment options.

Follow-up consultation. A third appointment may be arranged in cases where the prisoner has further questions related to risk behavior, consequences of the test results, further diagnostics, treatment options and linkages to care, and or to discuss next steps etc.

Prisoners should be given opportunities to tell prison staff that they want to participate. Prisoners should not have to explain why they want to participate. After the first meeting, prisoners should receive a card with a code and the date for the next appointment. This is for logistic reasons only; there should be no other information on the card to secure the confidentiality (other inmates, prison staff). The usage of the program is completely voluntary, without any pressure. Prisoners should be able to decide at any point to end their participation.

BEST TIME FOR COUNSELING AND TESTING

The time to deliver VCT services in prison needs to be considered. Many prisons offer tests during medical examinations at entry, which is certainly a good idea when health problems or acute symptoms appear, however:

• The best time for HIV/HCV VCT in prison is some weeks after incarceration: Prisoners, familiar with the new environment, are emotionally more balanced, which is an important pre-condition to digest information delivered or test results. Even if HIV/HCV+ test results are now much less dramatic: coping with test results varies among individuals, and it depends as well on the knowledge prisoners have.
• A good time for VCT counselling is after prison-specific risks are taken counselling (on safer use and safer sex): offers chances to change risky behaviours, which fosters the safety of the prisoner, other inmates and staff alike
• Another good time for VCT is close to release: this offers chances to prepare drug consuming prisoners with information related to referral and support structures (housing, linkage to HCV treatment etc) available outside and risks related to drug relapse, new psychoactive substances, overdose etc.

PRE-TEST COUNSELING, CONTENT COVERED

Community counselors or a physician may be involved in confidential pre-test counselling. Translators should be offered and arranged beforehand if needed. The average time allocated for counselling is about 20 minutes, depending on knowledge and information needs of the prisoner. The basis of the counselling is a 13-page-long anonymous questionnaire assessing knowledge and risky behaviour that serves as a guideline for the consulter through the consultation. The main topics covered in the questionnaire relate to knowledge, questions and risks related to:

• basic information on HIV/HCV (treatment options);
• risky situations (sex, drug consumption, tattoo, piercing) in the past and in prison;
• transmission routes (HIV, HCV, other STI if needed);
• safer use, safer sex, personal risk behaviors, emotional stability.

Based on the information related to risks and questions raised by the prisoner, information about the tests used, next steps, possible other diagnostic tests (including for STIs) and the relevance of hepatitis A/B vaccination should be delivered, including: 

• information about test results and procedures;
• advantages and disadvantages of tests provided;
• information around procedures, waiting hours and possible emotional challenges related to a positive test result (Elisa, PCR);
• information on next steps should a test be positive (next diagnostic steps, treatment options within prison, the possibility and freedom to include the prison doctor based on the individual decision,
• relevance of confidentiality;
• compulsory registration by the laboratory of newly detected HCV/HIV cases to the national health surveillance authorities.

The counselling session will include information about possible negative consequences within the prison system should the test be positive. Emotional capacities and coping strategies should be addressed should the test be positive. The ultimate aim is to secure that the prisoner can make an informed decision to take or not to take the test (informed consent).

TESTING, BLOOD EXTRACTION

Tests should only be carried out with the approval of the prisoner and after all information is provided and discussed. All tests performed should be coded and kept anonymous according to the usual processes used outside prison.

• Tests should be carried out by an external cooperating physician (or under close surveillance of him/her).
• Test samples (Elisa tests, PCR) should be send to local laboratories (the result should never be shared with the prison health authorities, unless the prisoner allows it in order to secure further diagnostics and treatment etc.)

POST - TEST COUNSELING / REPORT THE RESULTS

The prisoner should come to an appointment with the code provided in the first meeting.

• Test results should only be delivered face to face by the physician involved.
• The information about the test results should only be given to the prisoner.
• The decision to communicate the test result to others should only be made by the prisoner. No one should no pressure the prisoner about decisions related to communication about test results.
• Enough time will be granted to discuss questions related to next steps, other diseases (STIs) etc. 
• Results from rapid tests should be presented immediately. Should the test be reactive, the result and possible next steps (confirmation tests: Elisa, if necessary PCR) should be explained to the prisoner.
• Blood extraction for the confirmation test should be offered of the test is positive but this can be done at the next appointment should the prisoner need time to decide upon next steps as well.
• Should the HIV/HCV test be positive, treatment options, next necessary steps and/or other tests to clarify the health status, the importance of HAV/HBV vaccination etc. should be explained/discussed. Since treatment is only possible within the prison system, it is obvious that good cooperation between the initiators of the intervention and prison health authorities is key.
• Possible benefits of disclosing the result to the prison health authorities (for example to initiate treatment) should be explained to the prisoner. Again here, no pressure should be applied: the decision should be made solely by the prisoner.
• Information should only be delivered to the prison health authorities if the prisoner releases the involved parties from the confidentiality agreement.
• Meetings between the prisoner, the prison health authorities and the physician involved in the project can be initiated to discuss next steps, possible treatment options, compliance etc.

The points raised here clarify the importance of mutual respect and good cooperation between all parties involved in the project. Huge disadvantages for the prisoner can be created should this not be guaranteed.

COSTS

All costs related to the intervention in Germany are covered by the initiator (Deutsche AIDS-Hilfe). This relates as well to costs for the development of the project, materials for advertisement and information, educational purposes for the involved participants and travel costs.

Every 14 days, for pre- and post test counseling and testing are made available for 4 hours. The costs involved include: the physician: 53.- Euro/ hour and costs for counselors (external social workers): 30.- Euro/ hour. If necessary the costs for translators are provided for on an hourly basis.

Expenses for tests carried out (rapid tests, Elisa, if necessary PCR tests) are covered by the initiators of the project as well.

BEFORE PLANNING A SIMILAR INTERVENTION, ORGANIZERS SHOULD CONSIDER ALSO SOME OTHER COSTS:

• 7,20 Euro - HIV Rapid Test
• 17,20 Euro - HCV Rapid Test
• 5,25 Euro - HIV Antibody Test
• 28 Euro - Western Blot
• 7 Euro - HCV Antibody Test
• 38,50 Euro - HCV PCR Test