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| Correctional Health Care Providers Hone HIV Treatment Skills |
| By Michelle Gaseau, Managing Editor |
| Published: 09/29/2003 |
Correctional health care practitioners from across the country got a substantial dose of HIV education last week in Rhode Island at the HIV Mini Fellowship Program for correctional health care providers sponsored by the University of Texas Medical Branch at Galveston and the HIV Education in Prison Program at Brown University.The three-day program featured HIV treatment experts, correctional mental health care providers, infectious disease experts and ethicists who all discussed various aspects of correctional health care, primarily relating to HIV. David Paar, M.D., Program Director for the fellowship and Director of AIDS Care and Clinical Research for the Division of Infectious Diseases at UTMB, explained early on in the program that those who are infected with HIV have shifted from "men who have sex with men" to intravenous drug users, which has caused the concentration of HIV-positive prisoners with HIV to rise. "The shifting has put these people into prisons," Paar said, emphasizing the importance of HIV treatment education to corrections. UTMB, where Paar is also an assistant professor of medicine, provides health care for a large portion of offenders in the Texas Department of Criminal Justice. Also underlying the discussions was the realization of the unique role correctional health care providers play in comparison to physicians and health care providers on the outside. "There are conflicting values associated with treating in corrections. Corrections may confine, deprive and punish, but doctors diagnose, comfort and treat. We have an ability and a right to be there," said Paar. The mini fellowship offered providers a variety of information about HIV disease, from its beginnings and biology to its interactions with other prevalent diseases in corrections, such as Hepatitis C, and suggestions for treatment. HIV Updates Paar provided participants with an outline of the evolution of HIV disease, changes in its treatment and specific treatment ideas for inmates. In terms of behavior, Paar said noted one change that has affected the prison population -- the increase of injection drug use among minority populations and among women. As state and federal laws have focused on sentencing drug users for longer periods of time, more infected people have become incarcerated. "Our minority populations are really suffering. One bright light in this is that the prison population in Texas is largely Black and Hispanic, so we are getting a chance to treat them," Paar said. According to information collected by the TDCJ, 58.8 percent of the HIV-positive prisoners were intravenous drug users, men who had sex with men and used intravenous drugs comprised 24.1 percent, men who had sex with men made up 12 percent and 5.3 percent were categorized in "other" risk groups. Paar also reported that as physicians and correctional agencies have become more familiar with HIV treatment and as drugs have improved, the number of deaths related to HIV has decreased. In the TDCJ, for example, about 120 HIV-positive offenders died in 1995 versus fewer than 10 in 2000. These rates mirror the statistics nationwide as AIDS related deaths accounted for 28 percent of all prisoner deaths in 1991 versus 18.7 percent of deaths in 1997. Paar said as more doctors have used protease inhibitors sooner and more frequently, the number of AIDS deaths has dropped. "If you initiate drugs at the right time, it actually costs less than if you wait. We have to keep bringing this information to our administrators and our legislators," Paar said. Another area covered by Paar that generated much discussion was the difficulty in keeping offenders on their HIV medications both during and after incarceration. The issue of adherence can be complicated in a number of ways, Parr said: by the timing of the pill window where offenders receive their medications, by security staff who may not release an inmate from a work program to obtain their medications, by the side effects of the medications themselves, a distrust of doctors and the loss of confidentiality associated with going to a pill window in plain view of other offenders. Paar recommended that physicians and others who treat HIV-positive offenders first try to understand an offender's point of view and issues with taking medications, work with custodial staff to ensure that they understand the importance of offenders taking their medications on time, prescribe more simple regimens at first and to communicate with offender-patients to build their trust. Medications Both Paar and Frederick Altice, M.D., Associate Professor of Medicine and AIDS Program Director for the HIV in Prisons Program at Yale University, gave presentations regarding the drugs available for use in treatment of HIV and adherence issues. Program participants received an overview of the types of antiretroviral medications that are available for treatment, such as protease inhibitors, or nucleoside reverse transcriptase inhibitors (NRTIs), the specific drugs that fall in each category, the recommended dosing for each and the possible side effects associated with them. In Paar's presentation, he outlined possible side effects for HIV medications and symptoms of the diseases as well as offender behaviors that might be associated with obtaining certain medications and privileges. For example, some HIV patients may complain of peripheral neuropathy, which many patients know is associated with HIV disease in about a third of all patients, and may make false claims of sleeplessness to obtain sleeping pills or a low bunk assignment. Other side effects of the medications include a rash that can result from taking non- nucleoside reverse transcriptase inhibitors (NNRTIs), such as Nervirapine or Efavirenz, that needs to be watched for. Paar said treatment providers should also know that some HIV medications, such as Sustiva, actually have street value and that medications such as Efavirenz can show a false-positive marijuana test, which is important for offenders to understand if they are subject to frequent testing for drugs. Both Paar and Altice discussed adherence issues related to the medications and the powerful data that illustrates the need for adherence to remain healthy. According to a chart provided by Paar, a 95 percent or greater adherence rate to the Highly Active Anti-Retroviral Therapy (HAART) medication regimen meant fewer hospital stays and a much greater response rate to the medications than those adhering to regimens between 70 and 80 percent of the time. (Response rate was 81 percent versus 25 percent.) And, according to Altice, doctors need to be on top of possible non-adherence quickly. You need to explore non-adherence when there's a virologic failure and reassess [the medications] to see if they have depression or toxicity from the medications," he said. Altice also recommended that doctors seriously consider how a once-daily regimen might affect adherence. If an inmate's unit is placed in lock-down for example, then a once-daily regimen miss would have serious health consequences for an HIV-positive offender. He also reminded participants that HIV medication regimens must be considered and re-considered regularly not only for adherence, but also for toxicities and effectiveness. "Most importantly, we have to individualize," he said. HIV/HCV One concern in correctional medical care that was often raised during the three-day mini-fellowship was the prevalence of hepatitis C (HCV). Not only did the speakers refer to HCV as a disease that corrections has yet to fully respond to, but they also talked about the issues that arise from co-infection of HCV and HIV. Dr. Shannon Schrader, of the Schrader Clinic in Houston, spoke to participants about the aspects of treating HCV and HIV together. Schrader first said that although HCV is known to be a slow-progressing disease, when combined with HIV, the progression of the disease is increased five-fold. Schrader also said that the prevalence of HCV among HIV-positive patients is increasing, especially among intravenous drug users, and the percent of liver-related deaths among HIV-positive patients in the U.S. increased between 1995 and 1999 from five to about 12 percent. Another study, done at the Shattuck Hospital in Massachusetts, tracked a significant increase in end-stage liver disease among HIV patients from 11.5 percent in 1991 to 50 percent in 1998-99. "Hepatitis C may soon be the leading cause of death in HIV patients," he said. He also emphasized the need for assessment for each disease and the severity of each prior to determining the proper medical regimen for a co-infected patient. Highlighted during the session were medical regimens to consider for the HIV and HCV-infected patient and the difficulties in obtaining a high response rate among those patients using traditional regimens. Schrader also discussed some of the drug-drug interactions between common HIV-therapy medications and HCV therapy and the side effects that can specifically hit co-infected patients. Special Populations The fellowship also covered the treatment and care of certain inmates whose mental health and special medical needs are important to understand in relation to HIV and other infectious diseases. Eric Avery, Associate Clinical Professor of Psychiatry and Director of Psychiatry Services for UTMB at Galveston, discussed the mental health barriers to treating HIV in prisons. Avery told the group that with the prevalence of mental health disorders in prisons and jails, psychiatric diagnoses have become a major barrier to HIV medication adherence. "In order to get your viral loads down, you have to take 95 out of 100 pills. For depressed patients it's hard for them to get up in the morning and get to a pill window," he said. Avery told the audience that there are more than 280,000 offenders or 16 percent nationwide with mental disorders. In Texas there are about 8,400 prisoners on the psychiatric case load, which costs the TDCJ an average of $238,000 a month. He predicted that the actual number of offenders with mental health problems in prison is actually higher, but because of the high cost to treat these patients, the numbers on the psychiatric case loads may be kept low. Avery also emphasized the correlation between psychiatric disorders among HIV patients and mortality, stating that HIV not only increases the risk for psychiatric illness but effective treatment of psychiatric illness can also improve patient outcomes. "Certainly if you have HIV you are under enormous stress," he said. Avery suggested that doctors pay close attention to the signs of depression and help their patients with depression receive treatment for it first, if they want to see positive medical outcomes with their patients. "You really are going to have to advocate for this. People who are depressed die sooner from HIV than those who aren't," he said. Avery suggested that depression-screening questions for HIV patients would be one way to determine the mental health status of patients. He also advocated screening for depression at the initial stage of HIV disease. If a person is at a later stage of HIV disease, then he may need concurrent initiation of antidepressant therapy and antiretroviral therapy. In addition to special medical interactions associated with other diseases, HIV providers must also understand the special needs and requirements of another group of offenders that is growing inside correctional facilities: women. Jennifer Clarke, MD, Assistant Professor of Medicine, Obstetrics and Gynecology at Brown University and a physician at the Rhode Island Hospital, spoke to participants about her observations of female offenders. Clarke discussed the rising female population in prison as well as the common issues they present with upon incarceration. She said, as in other jurisdictions, women may come into the Rhode Island prison with issues that include substance abuse withdrawal, mental health problems, positive pregnancy test, a lack of education, a history of domestic violence abuse and they may have several children. She said that educating these women on how to take care of themselves and getting them tested for sexually transmitted diseases so they can be properly treated are the first steps to helping them become healthier inside the prison and after release. Planning for Release Dr. David Wohl, Clinical Assistant Professor, University of North Carolina at Chapel Hill, shared with participants the result of research conducted in North Carolina regarding the activities of inmates after release and the correlation to the spread of HIV in the community. The study included incarcerated African-American men who were HIV-positive and awaiting release about their sexual habits, partners and plans for sexual activity in the future. One group had been incarcerated previously and the other group had not. While many of the respondents in both groups said they had both main sex partners and multiple sex partners, the surprising data showed that despite their knowledge of HIV status, many in the recidivists group expected to have unprotected sex with multiple partners. Close to 50 percent of those who had been incarcerated previously said they expected to have unprotected sex and 33 percent said they thought they would infect their main partner. In follow-up interviews after release, 48 percent of those interviewed reported they had sex within an average of 9 days, 93 percent had sex with their main sex partner, but 60 percent of the recidivists said they had unprotected sex with their main partner and only 37 percent of them had told all their partners that they were HIV positive. "Both prior and following incarceration, people are having unsafe sex," said Wohl. Wohl used the information to emphasize the importance of treating for HIV and reducing HIV risk for incarcerated patients and for those unsuspecting sex partners in the community. Wohl stated that behavioral changes for this population are difficult to change, but if correctional health care providers focus on increasing access to care, then the same result - reduced risk factors - may still be accomplished. One way that correctional providers plan to do this in North Carolina is through a case management model that coordinates social, medical and mental health services in the correctional facility and after release. Armed with a grant, N.C. correctional providers are hoping for a positive outcome that mirrors the results of similar approach in Rhode Island (See profile). "It is commonly misunderstood [by the public] that they get HIV in prison. It's the OZ mentality - but they don't get raped in prison [and get HIV], they come into prison with it," Wohl said. That is why many correctional HIV providers are paying close attention to what happens both in the facility for treatment and in the community to address the spread of the disease. Resources: To reach UTMB, AIDS Care and Clinical Research, call 404-747-8769. For more information about the HIV Education in Prison Project at Brown University, visit the website at www.hivcorrections.org |
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