Background:  As part of a strategy to identify those with HIV-infection the US Centers for Disease Control (CDC) in 2006 recommended adoption of an Opt-Out approach to HIV testing in health care settings, wherein the test is performed unless the patient declines. Few data exist from the US available to determine if Opt-Out HIV testing increases either HIV screening rates or the number of HIV-infected persons identified. The relatively high prevalence of HIV among inmates and the common practice of screening for infectious diseases in prisons and jails make correctional facilities ideal settings to examine the effect of Opt-Out testing on HIV detection.

Methods:  HIV testing data from the North Carolina Department of Correction, the state prison system, were analyzed. These data included the proportion of inmates entering the system who were HIV tested at entry and the number of these tests that were HIV seropositive from 1 May 2008 to 1 June 2009. HIV testing of state prisoners in NC is voluntary and prior to 1 November 2008 prison policy was for all inmates to be asked to consent to HIV testing (Opt-In). After that date, an Opt-Out policy was instituted calling for HIV testing to be performed unless the inmate, after being informed that the test was voluntary, requested not to be tested.

Results:  From 1 May 2008 to 1 November 2008, under Opt-In testing: 14,331 inmates (88.7% men) entered prison. Of these, 8,795 (61.4%) were HIV tested and 1.8% were HIV⁺. Among men, 56.6% were tested with 1.8% testing HIV⁺. Among women, 92.2% were tested with 1.7% testing HIV⁺. The median CD4 cell count of all of individuals testing positive during this period was 420/uL. From 1 November 2008 to 1 June 2009, under Opt-Out testing: 16,867 inmates (87.5% men) entered prison and 15,258 were HIV tested with 1.3% found to be HIV⁺. Of the men, 91.1% were tested with 1.2% testing positive and 86% of the women were tested with 1.9% testing positive. The median CD4 cell count of all of persons testing positive during this period was 381/uL.

Conclusions:  Opt-Out HIV testing in a large state prison system in the US South dramatically increased the proportion of individuals entering prison who were tested for HIV. Further, as the prevalence of infection remained relatively stable, increased testing was able to identify HIV-infected individuals who would not have been tested under Opt-In conditions. These results support the CDC’s recommendation for Opt-Out HIV testing, especially in correctional and other settings where HIV may be prevalent.