HIV Treatment in Correctional Facilities
HAART within correctional facilities has been shown to result in impressive viral load suppression and increased CD4+ T-cell counts in HIV-infected prisoners. When appropriate clinical HIV care is provided within corrections, outcomes are comparable to community cohorts. Success of HIV treatment in prisons, as well as improvements in antiretroviral therapy in general, is evidenced by the dramatic decrease in AIDS-related deaths as a percentage of total deaths in state prisons from 34.2 to 4.6% between 1995 and 2006. Despite documented feasibility of managing HIV within corrections, standardized care is still not the norm. A study in Texas, USA, found that only a third of inmates who met Department of Health and Human Services (DHHS) criteria for initiation of HAART were actually on therapy. While some facilities employ dedicated HIV specialists from the community to provide optimal care for prisoners, many facilities lack even an onsite physician. This tremendous variability results in dramatic differences in the provision of care and health outcomes.
While successful treatment of HIV in prisons is clearly possible, it carries with it a unique set of issues that must be addressed and managed. Maintaining confidentiality surrounding HIV care is important in all settings, but particularly within corrections where people may be stigmatized or even subjected to violence. Guaranteed confidentiality, as well as the opportunity for treatment, is also crucial in convincing prisoners that HIV testing is beneficial. Confidentiality can be difficult to maintain within correctional facilities. Issues, ranging from rules prohibiting physicians from closing the door to speak to a patient privately to crowded medical facilities where other patients and correctional officers may be within earshot, can challenge confidentiality. In addition, if inmates are called down for HIV care at different times from when the general population is called down for medical care this alone may destroy confidentiality. To this end, HIV care should be administered at the same times and in the same infirmary where general care is provided, and inmates should be taken into examination rooms, ideally with doors, and out of earshot of other inmates.
Another issue related to confidentiality is the provision of medication. While newer regimens offer once-daily dosing, some inmates on HAART still require dosing of medications several times a day. Being called to the medication line multiple times a day may highlight their disease, making some reluctant to take medication while incarcerated. An alternative to this is 'keep-on-person' medications that the inmate can take on his or her own. Clearly the disadvantage to this is the inability to monitor for adherence, and studies have demonstrated improved outcomes with directly administered therapy. However, wide variation exists in the provision of directly observed therapy between systems, and directly observed therapy does not guarantee adherence. In addition, some facilities rely on correctional officers to administer medication, which results in dramatically reduced adherence owing to inmates' mistrust of correctional officers and fear concerning the lack of confidentiality. Given the lack of standardization in distribution and issues of confidentiality, keep-on-person medications may be the better option for treatment and is preferred by many prisoners. In addition, while some high-risk patients in the community setting receive directly observed therapy, the majority do not and it is reasonable to treat prisoners with the same standard of care. As the vast majority of prisoners will be released to the community and will have to manage their own medications, keep-on-person medications are also more similar to what most inmates will experience once released.
Interruption to therapy is a very real dilemma in caring for incarcerated individuals with HIV. Frequently, medications are not continued at the time of confinement and often antiretrovirals are not available immediately onsite; for example, in Rhode Island, the Department of Corrections contracts with an out-of-state pharmacy that ships medications overnight. This arrangement results in a minimum of 24 h of interruption in therapy. In addition, frequent transferring between facilities, court appearances and punitive detention in segregation may all result in treatment interruption.
Another important issue that arises in continuing HIV treatment at the time of incarceration is ascertaining whether individuals were adhering to medication regimens prior to incarceration. In community samples, HIV-infected individuals across the board average a 70% adherence rate with medication. Disadvantaged populations, such as those with mental illness or addiction, the unstably housed and women from ethnic minorities, have all been shown to have lower adherence rates.[15–17] Given that these populations are all over-represented within corrections, it is likely that adherence is lower among incarcerated individuals even prior to confinement. While longer prison sentences allow time for providers to access medical records and determine treatment adherence, this can be difficult in jail populations. Partnerships between correctional facilities and community and academic medical centers can help bridge this gap, both in attaining preincarceration records and in ensuring postrelease care.
Potential interruption in therapy and lower levels of adherence after release are important considerations in choosing HAART regimens for HIV-infected prisoners. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) in particular have an unfavorable adherence–resistance relationship, where even single-dose or short-term therapy is enough to cause resistance to the whole class. This is thought to be due to a combination of factors. NNRTI resistance requires only a single point mutation, in contrast to the multiple mutations required for resistance to most other antiretrovirals. In addition, NNRTIs have a long plasma half-life and remain in the system for extended periods of time, enabling the virus to replicate in the setting of suboptimal drug concentrations.
In general, approaches to antiviral therapy are otherwise the same in the incarcerated setting as they are in the community, and standard guidelines should be followed. Specialized issues other than the need for strict confidentiality and avoidance of resistance to NNRTIs include the use of generic medications and special considerations near the time of release. With antivirals coming off patent, and the fact that HIV medications are second only to psychiatric medications in total expense to most US correctional facilities, many more expensive fixed-dose medications will be broken into their component medications to decrease costs. This can confuse some patients about their medications. In addition, given the predictable chaos and dramatic change of routine immediately after release, sometimes it may be advisable to delay initiation of antiviral medications until after they are stabilized in the community. Conversely, from a public health perspective, being on antivirals with an undetectable viral load may reduce HIV transmission and, therefore, given the high rates of risky sexual and drug-using behavior after release, it may be the optimal time to be on antivirals. Obviously, these are issues that need to be addressed individually between the provider and the patient.
HIV Ther. 2010;4(4):505-510. © 2010 Future Medicine Ltd.
Cite this: HIV Treatment in US Prisons - Medscape - Jul 01, 2010.