Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review

Abstract

Background Prisons represent a unique opportunity to diagnose blood-borne viruses. Opt-out testing is receiving increasing interest, as a result of mounting evidence to suggest that the manner in which a test offer is delivered, affects test uptake. Although the effectiveness of opt-out testing within the prison setting has been established, robust explanations are required for the variation in outcomes reported. Methods Rapid-realist review methodology was used to synthesise the literature on prison-based opt-out testing. The review was carried out in three phases. Phase one: An expert panel provided literature relevant to the implementation of opt-out testing within the English prison estate. Unstructured searches were also conducted to identify other social programmes where “opt-out” had been used to increase uptake. Phase two: a systematic search of six peer-review and five grey literature databases was carried out to identify empirical data on opt-out testing within the prison setting. Phase three: Additional non-exhaustive searches were carried out to identify literature that reinforced emergent concepts. The development of programme theory took place with each iteration and was validated in consultation with stakeholders. Results Programme theory was constructed for two outcomes: the proportion of intake offered a test and the proportion offered that accepted testing. The proportion of intake offered testing was influenced by the timing of the test offer, which was often delayed due to barriers to prisoner access. The decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner’s personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer. Conclusions This review identified important implementation considerations that moderate the effectiveness of opt-out testing programmes. It also highlighted a lack of appreciation for the theoretical underpinnings of opt-out programmes and tension around how to implement testing in a manner that adheres to both default theory and informed consent. It is anticipated that results will be used to inform the design and implementation of subsequent versions of these programmes, as well as catalyse further in-depth analysis into their operation within the unique context of prison. Review registration CRD42017068342 . Electronic supplementary material The online version of this article (10.1186/s12913-019-3970-z) contains supplementary material, which is available to authorized users.

Detection, stratification and treatment of hepatitis C–positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

“…The refusal of prisoners to attend clinics also introduced delays 25 . Simple changes, such as ensuring clinics do not clash with other preferred prison activities like ‘association’ (socializing) or gym access, can help to encourage attendance 25 .…”

“…The refusal of prisoners to attend clinics also introduced delays 25 . Simple changes, such as ensuring clinics do not clash with other preferred prison activities like ‘association’ (socializing) or gym access, can help to encourage attendance 25 . Strategies such as making attendance at secondary screening mandatory in order to be medically cleared for work or gym attendance, or providing prisoners with incentives to attend, should also be explored.…”

“…Pathway redevelopment took place in March 2017, informed by an analysis of Phase‐1 outcome data and a realist process evaluation, which involved semi‐structured observation of pathway procedures, interviewing stakeholders (staff, commissioners and service users), and reviewing models of best practice reported in the literature 25 …”

“…To address this problem, prison healthcare staff who regularly ran secondary screening were offered two additional training sessions on delivering opt‐out testing (Figure 1). A script outlining a model opt‐out BBV test offer was also developed and disseminated across the prison 25 …”

Opt-out Testing Pilot for Sexually Transmitted Infections Among Immigrant Detainees at 2 Immigration and Customs Enforcement Health Service Corps–Staffed Detention Facilities, 2018

“…6 The Centers for Disease Control and Prevention and the National Commission on Correctional Health Care recommend screening for HIV via an opt-out testing strategy in correctional settings 7,8 to reduce the stigma of being infected with an STI, thereby increasing testing program participation. 9 Universal STI screening has never been applied to a US immigration detention setting; its acceptability, which relies on factors such as health literacy and trust in the custody health care setting, 10 remains in question.…”