Three Years Later, Opt-Out Testing the Norm in Cook County Jail

July 3, 2012

The Rev. Doris Green, AFC's director of correctional health and community health, discusses opt-out HIV testing in Cook County Jail.

By Sara Semelka

After three long years of perseverance by community advocates, detainees at Cook County Jail now  go through an opt-out – rather than opt-in – HIV testing process during intake, a change touted by national experts as one of the most effective ways to encourage at-risk communities to accept the offer of an HIV test.

Cook County Commissioner Bridget Gainer (at right), who led the effort at the county level, and the HIV health advocacy community hailed this new testing protocol as a tool beneficial to detainees, at-risk populations and the community at large. The opt-out system, which took years of collaboration with jail administration health care providers and HIV health advocates, has resulted in a new intake space that increases confidentiality and a new testing protocol that presents an HIV test as a standard of care for all detainees.

“Every action you take to bring HIV testing out of a stigmatized, isolating environment and into a public health context, that’s better for everyone,” Gainer said.


Gainer said she first became aware of opt-out HIV testing during her first weeks as a newly-elected commissioner after meeting with David Ernesto Munar, president and CEO of the AIDS Foundation of Chicago, and John Peller, vice president of policy at AFC. She was compelled by research that showed once people know they are HIV positive, they will change their behavior in ways that decrease the transmission of the virus to others.

“If we’re talking about trying to stop the spread of a disease that is difficult and expensive to treat, and we’re dealing with a population – detainees in jail – who are statistically more at risk, I asked myself ‘Why aren’t we doing this testing?’ ” Gainer said.

Outdated Practices, New Ideas

And so Gainer and the others began chipping away at the problem. What seemed like a simple change — to present the test as a standard of care rather than a detainee-initiated process — ended up taking three years of work. The Cook County Jail had well-founded concerns about the change, Gainer said, as the institution has been sued in the past for testing people for HIV without appropriate and full consent.

“We also bumped into a lot of … practices that had not caught up with society,” Gainer said. “There still are stereotypes and stigma associated with HIV, but it’s not 1990. … It opened my eyes that in the eyes of the law, an HIV test was treated differently than tests for other sexually transmitted” infections.

For three years, Gainer and advocates at AFC and elsewhere worked to implement this change at the jail. According to the Windy City Times, Gainer's office secured funding for the program by cutting spending on law firms outside the state's attorney's office. A resulting $1.2 million jumpstarted the testing program, as well as another program for incarcerated mothers.

The new system has required a lot of on-the-ground changes, including a complete overhaul of the intake space to allow more room for private space to facilitate the test  — an important change given the intake process is typically stressful, frenzied and not conducive to requesting a test for a virus that still carries stigma, Gainer said.

“Now detainees go into a small booth where no one else can hear them discuss their medical concerns,” Gainer said. “This will also help people who wish to disclose mental health concerns and other issues. That came out of the opt-out HIV testing change, and it helps the whole population.”

There are signs in the intake space informing detainees that staff will conduct an HIV test unless the detainee refuses, either verbally or with written communication. Staff will also verbally inform the detainee of the process, giving them the option to opt-out.

Gainer said the new testing process has luckily coincided with a parallel effort to digitalize medical records, so that it will be easier for staff to follow up with people who refuse the test the first time during the chaotic intake process and offer the test later.

Making Change Happen

Under the opt-in system, a detainee would have to initiate the process and request an HIV test. The barriers for someone to take this step are significant and powerful, Peller said. The stigma surrounding HIV and AIDS is prevalent, fueled by homophobia and prejudice against injection drug users.

With the opt-out process, an HIV test becomes the default.

“It’s not like you did X behavior, and therefore you need an AIDS test,” Gainer said. “You’re coming [into the Cook County Jail], and this is the suite of things you get done: an HIV test, a syphilis test, (a chlamydia test), a gonorrhea test. I think this is battling back against the stigmatization, and it absolutely has a health benefit as well.”

Institutionally de-stigmatizing the test opens the door for a whole new population to know their status, which can only lead to a better quality of life for the entire community. Nationally, one in five people with HIV do not even know they have the virus. Statistically, this means nearly 7,000 Cook County residents are unaware they have HIV, and therefore are not seeking treatment or changing behaviors to reduce transmission.

The Rev. Doris Green (at right), director of correctional health and community relations for AFC, has worked for 30 years as an advocate for people re-entering society after they have been incarcerated. This work has made clear to her how the health of people moving through corrections facilities has broad implications.

“The corrections population is the same population as our community,” Green said. “The corrections population comes from our community, and it will re-enter the community. I see the connection between the high rates of HIV in the corrections population and the African-American community. We need to put more programming and services in place in our corrections facilities, and that will improve the health of the overall community.”

Though three years may seem like a long time, Green said relative to when she began her work, this change happened rather quickly and it greatly encourages her.

“I used to feel like legislation and policy were just standing still,” Green said. “Corrections systems are layered, and you can’t just walk into a jail expecting to make a change. You have to build a relationship. The first priority for corrections facility is safety. I understand that. My priority is the medical needs of the population. We are both starting to see each other’s point of view, and I see us coming together to address the needs of this population.”


Sara Semelka is a policy intern for the AIDS Foundation of Chicago. Previously, she reported for the Chicago Reporter and the Columbia Daily Tribune.

Categorized under Inside Story.

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