• William Ruby, D.O.

Dr. Ruby gave a detailed overview of the management of HIV in the correctional setting, discussing clinical as well as ethical and administrative issues as they pertain to this special population.

Prevalence of HIV infection in correctional facilities has been stable at about 2.1% between the years 1991 and 1997. In 1997 seven states reported rates higher than 3%, specifically New York, Connecticut, Massachusetts, Florida, Maryland, New Jersey and Rhode Island. States with fewer than ten inmates identified as HIV seropositive included North Dakota, South Dakota, Vermont, West Virginia, and Alaska.

Jurisdictions differ on issues as basic as testing policies, and as complex as segregation of those identified to be HIV seropositive.

Testing policies include, in order of decreasing popularity

• Testing upon inmate request

• Testing only in the presence of clinical indication

• Testing upon involvement in an incident

• Testing all incoming inmates

• Testing all those perceived to be at high risk

• Testing all inmates upon release

• Random anonymous testing

• Testing all in custody

Housing of inmates with HIV varies by jurisdiction. In 1985 eight of 51 jurisdictions had a policy of segregating HIV-positive inmates, 38 had a policy of segregating those with AIDS. In 1997, two of 51 jurisdictions segregated those with HIV, and three jurisdictions segregated only those with AIDS.

The rationale for segregation used by the state of Alabama is to minimize health risks to other inmates. Alabama boasts a much lower rate of seroconversion among inmates (0.006%) than in some other states where the HIV-infected are not segregated (0.19%-0.41%). Three studies on seroconversion of inmates based on 1/200 to 1/604 person-years in prison with a prevalence of 2-4%, with extrapolation to the entire inmate population of 2.1 million, estimate 350-700 infections annually.

The advantages of segregation include uniformity of treatment and enhanced access of specialty care, opportunity for education and decreased stigma, and concentration on special needs of the HIV-infected, such as food and fluid restrictions with certain medications. Disadvantages include decreased access to particular programs such as drug rehab programs, problems inherent in combining prisoners of varying security levels, separation from family and support networks as some segregated facilities are far from main prisons, lending credence to unscientific beliefs about transmission and the compromise of confidentiality.

Dr. Ruby stressed the high quality of care in the prison systems with which he was familiar (New York, Maryland), noting that often inmates received standard of care, only to be released into communities where they received substandard care.

He described in some detail the different methods of dispensing medications. Keep-on-person (KOP) medications are administered in quantities for 2-4 weeks at a time. The inmate then assumes the responsibility of taking the medications as directed. Directly observed therapy, on the other hand, involves prison staff watching inmates to ensure that each dose is actually swallowed. He cited a study conducted by Margaret Fischl in the Florida DOC where 85% of inmates on directly observed therapy attained viral loads less than 50 at 48 weeks on therapy, whereas of those not on directly observed therapy only 50% achieved HIV RNA levels of less than 50.

Dr. Ruby concluded by discussing the role of telementoring and telemedicine in corrections facilities as they relate to specialty care of the HIV-infected.