No longer, says Anne Spaulding, MD, CCHP, team leader for the corrections and substance abuse unit at the CDC’s National Center for HIV, STD and TB Prevention.

"The CDC issued an important publication on HIV screening and we made it in," she says. "What’s exciting is that correctional facilities are acknowledged as key sites for testing people who are at risk for HIV."

The document, Revised Guidelines for HIV Counseling, Testing, and Referral, was issued last November along with a companion document titled Revised Recommendations for HIV Screening of Pregnant Women.

"These guidelines acknowledge that HIV prevalence is high in these areas, greater than 1%, and generally in sites where the prevalence is so high we recommend that all people should be approached, not just those who self-identify as high risk," explains Spaulding, who joined the CDC in November after six years of work in correctional medicine. Board certified in both internal medicine and infectious disease, Spaulding also is the new president of the Society of Correctional Physicians (www.corrdocs.org).

Just as important as the mention of corrections, Spaulding notes, is the guidelines’ emphasis on voluntary, informed, consent-based testing. The document addressing pregnant women, while it does not discuss correctional settings, provides good detail about how to do this.

"We should take the message of those recommendations and apply them in the same spirit when we approach men and women in correctional facilities," Spaulding says.

In the guidelines for screening of pregnant women, the CDC summarizes the major revisions from the previous set, issued in 1995. These include recommendations to . . .

1. Emphasize HIV testing as a routine part of prenatal care and strengthen the recommendation that all pregnant women be tested.

2. Simplify the testing process so that pretest counseling is not a barrier to testing.

3. Make the consent process more flexible to allow for various types of informed consent.

4. Explore and address reasons for refusal to test.

5. Emphasize HIV testing and treatment at the time of labor and delivery for women who have not received prenatal testing and antiretroviral drugs.

Acknowledging that correctional settings present unique challenges and, frequently, limited resources, Spaulding says that, "if it is at all feasible," testing should be offered as a routine component of medical encounters. "Everyone needs to know their HIV status but especially pregnant women. It would be extremely misfortunate for a woman to receive health services while incarcerated and leave the facility not knowing she has HIV. The new guidelines drive home the point that testing can save the life of her baby."

Elaborating on the notion of routine testing, Spaulding says it occupies a middle ground between voluntary and mandatory. "If we routinely give every inmate the opportunity to undergo testing, they’d still be able to opt out now and then be tested voluntarily later. But then we need to remove barriers to voluntary testing, as when, for example, somebody has to request a test in writing or come forward in a group."

Instead, she suggests, the offer to test can be routinized by making the test available during other health care interventions, such as whenever an inmate receives a tuberculin skin test or syphilis serologies.

Offering the test is just part of the solution, though, she cautions. Inmates must receive HIV counseling, and those who are tested must give explicit consent. Again, though, these steps must be simplified to prevent unnecessary barriers.

Both sets of guidelines are posted on the Web at www.cdc.gov/hiv/ pubs/guidelines.htm.

To contact Spaulding, send an e-mail to aws6@cdc.gov. Spaulding advises that she cannot answer specific questions about patient care, but welcomes correspondence concerning prevention of HIV and other infectious diseases among incarcerated people.