HIV Jail POC-AgAB Testings

This study will be the first to assess the feasibility, process measures, and estimate cost-effectiveness of a rapid Universal Testing and Treatment (rUTT) intervention in a large urban jail located in Washington, DC - 1 of the 50 communities targeted for End the HIV Epidemic (EtHE) efforts. The aim is to determine the most effective HIV diagnostic test to use for routine opt-out testing in the correctional setting.

The investigators hypothesize that the combination of opt-out POC and Ag/Ab tests offered at intake will maximize the yield of PLWH detected, provision of test results, ART initiation, viral suppression, and cost-effectiveness.

The investigators will examine administrative, de-identified, aggregate data for approximately 3000 individuals (based on 500 individuals currently accepting HIV testing per month) over 6 months. For individuals who provide consent to release their jail medical records after incarceration, the investigators will retrieve the mean time from: 1) positive test to receipt of test results, 2) receipt of test results to first dose of ART in jail, 3) receipt of post-test counseling to meeting the discharge planner, and 4) ART initiation to viral suppression defined as a viral load <200 copies/mL. The investigators will calculate the implementation costs of each strategy using observation of staff time, market values for items used in the intervention, and process measure data collected through chart review (for individuals who consent to release their jail medical records after incarceration). Units of resource items, such as staff time and diagnostic tests, will be multiplied by their unit costs to calculate total costs.

This protocol does not constitute research involving prisoners (as outlined by the U.S. Department of Health \& Human Services Office for Human Research Protections - https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/prisoner-research/index.html) since the investigators will not be:

1. Obtaining identifiable private data or information about prisoner subjects through intervention or interaction with them while incarcerated.
2. Seeking the informed consent of prisoners to be subjects in research;
3. Using, studying or analyzing, for research purposes, identifiable private information about prisoners, or identifiable specimens obtained from prisoners; or
4. Surveying prisoners for this research study.

The overarching goal of this pilot study is to assess 3 HIV testing strategies as the entry point into a rUTT jail-based intervention to promote HIV viral suppression among individuals with undiagnosed and diagnosed HIV infections. Among individuals within the DC Department of Corrections (DC DOC) the investigators will examine whether opt-out Point-of-Care (POC) rapid testing, 4th generation laboratory-based antigen/antibody testing (Ag/Ab), or POC and Ag/Ab testing are most effective in identifying HIV infection upon entry into the jails, linking persons to care and obtaining viral load suppression. During the medical intake, jail nurses will sequentially use, for 2 month each: 1. POC only; 2. POC + Ag/Ab; 3. Ag/Ab only as part of standard clinical care (POC: INSTI® rapid test; Ag/Ab: ARCHITECT® laboratory-based test). Upon anticipation of release, those who are on ART will be invited to participate in a follow-up study regarding their coordination of care while in the DC DOC system and post-release, as well as their current viral load status.

The specific aims are: (1) Compare the feasibility of 3 testing strategies using administrative, de-identified, aggregate data to measure the number/percentage of entrants who do not opt out of testing and receive their test results in jail. (2) Compare 3 testing strategies for time to return of preliminary and confirmed test results, jail-based ART initiation (or reinitiation in known PLWH), and referral to discharge planners among justice-involved PLWH who consent to release their jail medical records after incarceration. (3) Assess the cost of implementing each testing strategy and relative cost-effectiveness of the 3 testing strategies in terms of process measures, time to ART initiation, and viral suppression.

Setting and location The DC DOC is a large urban jail with nearly 8000 intakes per year and an average daily population of approximately 2000 individuals. It is estimated that the HIV prevalence in this system is approximately 4% with a mean of 60 known PLWH in the population at any given time. About 1-3 new HIV diagnoses are made each month with the current POC HIV testing program in place. The patient population is predominantly racial/ethnic minorities (97% overall; 88% Black, 20% Hispanic - not mutually exclusive due to more than 1 race/ethnicity), and 91% are at or below the 200% poverty level (HRSA, 2017). As part of the Unity Health Care (UHC) clinical program, individuals with newly diagnosed HIV will be offered rapid ART initiation, ideally within 24-72 hours of diagnosis with an integrase inhibitor-based regimen as per Department of Health and Human Services(DHHS) guidelines ("Guidelines",2019). Individuals who are known to be HIV-positive through the electronic medical record (EMR) or self-report do not undergo HIV testing. For those who are ART-experienced, the individual's existing ART regimen is restarted. If ART-naïve, an integrase inhibitor-based regimen will be started within 24-72 hours. Community follow-up is offered within 1-2 weeks of reentry and supported by jail discharge planners and community health workers (CHWs). UHC recently began a new 5-year contract to provide jail health services, ensuring a consistent healthcare provider for the duration of this study. DC has expanded Medicaid, which is an essential to developing an rUTT model since it is imperative to ensure no break in ART coverage. Potential participants for this study will be recruited from the DC DOC system

It is estimated that aggregate-level data will be collected for 3,000 individuals who are admitted to the DC DOC system over the 6-month study period and accept HIV testing upon entry. Of those tested, preliminary eligibility will be based on the following criteria:

1. Admitted to DC DOC between October 14th, 2019 and October 31st, 2020
2. Has initiated ART by time of release
3. Being HIV-positive: confirmed either through HIV testing upon entry, was known to be HIV-positive through the EMR, or self-reported being HIV-positive

For the past 12 years DC DOC has offered opt-out POC testing with the INSTI® finger stick test at entry. During booking (in the intake medical evaluation unit, prior to processing individuals into jail) jail nurses will sequentially use, for 2 month each: 1. POC only; 2. POC + Ag/Ab; 3. Ag/Ab only as part of standard clinical care (POC: INSTI® rapid test; Ag/Ab: ARCHITECT® laboratory-based test). To assist UHC with this transition, the investigators have secured in-kind donation of INSTI® rapid test kits (see letter of support). Over 6 months of testing the investigators anticipate approximately 3000 individuals will be tested (based on 500 individuals currently accepting HIV testing per month). The number of new HIV diagnoses that will be made is not known; however, the investigators anticipate the number will be higher using Ag/Ab testing than the 1-3 new diagnoses that are made each month using the current POC rapid testing strategy.

After each of the 3 testing phases the project team will request, from DC DOC, data from their EMR. Specifically, they will request administrative, de-identified, aggregate data that does not contain any of the 18 Health Insurance Portability and Accountability Act (HIPAA) identifiers for: 1) the total number of entrants, 2) the number of entrants with HIV test results (indicating they have not opted out of testing), 3) the number of post-test counseling visits (indicating receipt of test results), 4) the number of positive HIV tests, and 5) the median and mean length of stay for the entire population. The individuals for whom these data are available and are on ART at time of jail release are considered "EMR-eligible participants." Aggregate-level data will be collected on all individuals admitted to DC DOC beginning January 15th, 2019.

Participants for the post-release portion of the study will be recruited at exit from the DC DOC system. Currently the DC DOC provides all patients who are on ART with a 30-day supply upon release. Inmates who are released and have entered the jail during the study period will receive an invitation letter to participate in the study that will be attached to their 30-day supply of ART, which they will pick up at release.

'Invitation to Participate Letters' from UHC will inform EMR-eligible participants that they may be eligible to participate in a paid observational research study about the effectiveness of opt-out rUTT strategies for HIV (see attached letter). Potentially eligible participants are instructed to contact the UHC research coordinator (RC) if they are interested in being a part of the study, or to find out more information. The letter will state that for this observational study participants will only have to continue their standard HIV care with their provider. They will only have to meet with the study team once in order to conduct the eligibility screening and sign the informed consent authorizing the study team to receive the participants EMR from DC DOC and their community provider for two years following their release.