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