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Recommendations for HIV-Positive Inmates

July/August 2001

Adapted and reprinted with permission from the 2000-2001 Medical Management of HIV by John G. Bartlett, M.D. and Joel E. Gallant, M.D., M.P.H., Johns Hopkins University School of Medicine. The "HIV in Corrections" chapter was written by William Rudy, D.O.; Louis C. Tripoli, M.D.; John G. Bartlett, M.D. and Ellen S. Rappaport, M.P.H. Copyright 2000 John G. Bartlett, M.D., published by Johns Hopkins University, Division of Infectious Diseases. Available online at http://hopkins-aids.edu.

At a minimum, the facility's primary care physician should evaluate asymptomatic [having no symptoms of disease] HIV-positive patients every three to four months. Between regularly scheduled visits the inmate may present to the nurse for multiple issues, including acute [new] signs or symptoms, medication issues, etc.

Adherence to complex pharmaceutical regimens has become a critical component of the nurse's role as educator and motivator. In some correctional systems the case manager may initiate adherence checks, which may be [called for] in the following instances:

  1. Inmate did not show for clinic appointment

  2. Inmate did not re-order medication on time

  3. Inmate did not pick up medication on time

  4. Viral load is increasing despite appropriate therapy

Because it is common to move inmates from facility to facility, nursing case management should be established system-wide. With a system-wide approach, inmates can be incorporated into a new facility's procedures without being "lost to follow-up." The following three intensive education sessions may be used by nurse case managers with a newly diagnosed HIV-positive inmate.


Session 1

  • Overall disease process

  • Acceptance of HIV diagnosis

Session 2

  • Required routine laboratory tests

  • Routine clinic visits

  • Willingness to take medication

  • Willingness to adhere to medication

Session 3

  • Antiretroviral medication regimens

  • Side effects

  • How to take medications correctly

  • How to re-order medication

  • How to pick up medication if in KOP [keep-on-person] program

  • Discharge/aftercare planning issues

Establishing community linkages is mandatory and might require face to face meetings. State Departments of Health are useful agencies for providing resource manuals of current AIDS service agencies available in the local areas.

A signed release of information form must be obtained prior to release of any information to outside community resources . . . Continuity of care is especially critical for patients receiving antiretroviral [drugs] and for those vulnerable to [opportunistic infections] due to low CD4 [T] cell counts.

Prisoners should be given medications and/or prescriptions to be filled in the community upon release. The critical issue of continuity of all antiretroviral agents should be stressed to the inmate and to the provider/organization providing post-release care. If therapy must be interrupted, it is often best to stop all antiretroviral agents. [Remember that Sustiva and Viramune must be stopped two days before the rest of the HIV medications are stopped, since it lasts longer in the body and should not be alone in your system, because you may develop resistance. -- EV]

In many correctional health care systems it is the primary care provider who decides when and if antiviral therapy will be offered. This decision, the [drugs] selected and other management decisions regarding HIV care should be based on recommendations of the DHHS or IAS-USA [see Resources for how to obtain a free copy] or other authoritative sources.

Dietitians should be available to advise inmates with HIV about nutritional aspects of wasting syndrome, lipodystrophy [high levels of triglycerides or cholesterol] and gastrointestinal intolerance of meds [such as nausea, vomiting and diarrhea].

[Housing and work] segregation may [lead people to] unscientific beliefs about HIV transmission.

The security staff, primarily the correctional officer (CO), plays an important role in case management. Many times it is the CO who recognizes early signs or symptoms of HIV disease progression. Similarly, COs learn which inmates require medications on a regular basis and can encourage inmates to be adherent. In addition, the health care staff must rely on the security staff to bring the inmate to the medical facility. The success of this depends largely on how informed the security staff is. [Editor's Note: According to the HIV Education Prison Project, in a report on mental health, "Inmates with unrecognized cognitive impairment as a result of HIV may be emotionally [unstable] and behaviorally unpredictable, inviting attacks from other inmates and punishment/retaliation from correctional officers who fail to understand the behavioral impetus. They may receive punishment for rule infractions that they were never entirely capable of understanding or remembering."]


Prison Information

  • Some states and the federal system have instituted co-payments for some health services.

  • Even when Medicaid funding is available, the inmate may have to wait 30 days to a year after release to become eligible.

  • Ryan White Care Act funds specifically target the inmate population and should be contacted regarding medical care and support services . . . Many of the pharmaceutical companies have made free medication available for inmates leaving prison for some defined period until they have sources of funding for their medications, but this availability still does not address the issue of the assignment of providers of care. [Check with advocacy groups.]

  • A frustrating but oft-repeated scenario is the inmate who receives state-of-the-art care for his [or her] HIV while in prison, is released, and presents again later to the prison with resistant virus from inconsistent medication adherence post release due to incongruous medical care.

  • It has now become increasingly apparent that clinicians should avoid initiating antiretroviral therapy that cannot be continued post release if release is anticipated relatively soon.

  • Programs that deal with the psychological and social aspects of HIV disease (and other chronic diseases) have been shown to reduce recidivism [returning to prison]. In general, recidivism [is related to] sub-optimal self care and increases the likelihood of poor disease outcomes.

  • Attempts to reduce drug addiction and recidivism have been generally disappointing. An exception is in Delaware where a "therapeutic community" (TC) model of substance abuse treatment and intervention with treatment during and after incarceration demonstrated durable reduction of recidivism in that state (Prison J 1999; 79:294) . . . Another potentially useful but controversial method of HIV intervention is to base medication administration for HIV around a methadone-maintenance program.


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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
 
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