When she decided to become a nurse, Joni Nickens never imagined she'd end up in prison. But now that she has, there's no place she'd rather be.
Since 2000, Nickens, a nurse practitioner, has cared for HIV-positive inmates at Elayn Hunt Correctional Center (EHCC), a maximum-security facility for men in St. Gabriel, La. Although she has had her share of difficult patients, she says, most of the men she helps are extremely appreciative. "It is a very nice working environment, like a family," she says, without a hint of sarcasm in her thick Southern accent. The straightforward manner in which she speaks leaves no doubt that she's telling you exactly the way she feels.
As the HIV authority and primary HIV caregiver at EHCC, Nickens dedicates herself to ensuring that her patients adhere to their medications and are educated about HIV. She also ensures that her co-workers know the latest information about the virus and its treatment. As many as 90 of the prison's 2,000 inmates have HIV and turnover is frequent, so Nickens no doubt has her work cut out for her.
But she manages her workload well: Not only does she manage dozens of patients (most of whom have undetectable viral loads -- no small feat in a setting where it's notoriously difficult to ensure good HAART adherence), but she also acts as an advocate, and regularly gives educational talks to prisoners, correctional workers and the general public on a variety of HIV-related issues.
Nickens' humanistic approach to prison HIV care is in sharp contrast to a pervading feeling that inmates don't deserve anyone's help. Nickens realizes, as so many correctional healthcare workers do, that helping prisoners with HIV can be just as rewarding as helping anybody else -- and just as good for the community.
What is your patient demographic?
I work in a state prison. When I started there they had a huge need -- patients weren't getting follow-up. So I volunteered for the job. We get the intake (when a sentence has been set) from all the county prisons. We have 2,000 inmates at the prison and we keep 80 to 90 HIV-positive inmates at a time. The numbers vary month to month, with people leaving and coming in all the time. If someone is really sick, we keep them because there are only two prisons in the state that can keep really sick patients; the other one is Angola, but that is maximum security, so we will only send patients sentenced to life there. We perform all primary care services here: HIV, diabetes, STDs. We've developed the tele-medicine system to consult with the outpatient clinic at LSU regarding multi-resistant patients.
What is your biggest challenge?
My biggest challenge is getting the patients to adhere to medications. Everything is very regimented in the patient's lives, so it's hard to tailor a medication time to the most advantageous schedule. For instance, trying to get them to take a dose after they eat. Some patients don't like to take the last pill call, because it's very busy and the line is very long then. They may have to wait. so instead they just skip it, which causes more problems.
What is the biggest risk factor for HIV?
For my patients, the biggest risk factor is unprotected sex. They aren't allowed to have condoms in the prisons, but they do have sex. I think that people were scared at the beginning because people were dying so quickly, but now people are surviving on medications for many years, and people have gone back to having unprotected sex.
Are your patients proactive with their care?
A large portion of our patient population is undereducated, some have mental illness, but some patients are very proactive and are always seeking out new information. I have found that some of my patients just don't want to know anything about the disease. I try to get them to memorize their counts, because I might not be here someday and they will need to give that information to the next person who cares for them.
What would you change regarding prevention efforts?
If I could change something, I would have more sex education. We work with various agencies to get information to the inmates. It is mandatory that everyone goes at least once. There is a peer lecture where inmates talk to other inmates. In some ways they make a big difference; some of our peer counselors are also living with HIV.
What single change would you like to see in HIV care?
I think there needs to be better communication between different agencies. Our ability to treat patients is hindered when we get someone in who doesn't know anything about their health, and we have to go through a whole paper trail to get a release on their records, and then wait for the lab. If a patient looks sick to me I will draw a lab right then.
What kinds of education or counseling do you give to your patients?
I do all the counseling, mainly one-on-one. In terms of further education, beyond the mandatory health session, I have literature for the literate and videos for the illiterate.
What makes a successful health provider/patient relationship?
Honesty. I'm very upfront with the inmates about what is available to them and what is not. I don't try to make things to be easier than they are or smooth things over. For the most part, I get honesty back from my patients. They are pretty appreciative of anything someone does for them. If they try to lie about taking their medications, and their tests don't match with progress, I won't stop seeing them but I will take them off their medications. It may be three to six months before I give them another trial of medications.
Do you have a favorite patient?
A couple stand out, but there isn't just one. I had a great patient once, he was a drag queen and I remember he was very upset he couldn't dress up in prison. He would give me the best fashion advice. He was very sick, he had HIV and non-Hodgkin's lymphoma, and he was going through chemotherapy. He was always a very joyful person, always very positive. He liked to talk about when he got out, the next time Cher has a concert he was going to be there and look better then she does.
How do you maintain a positive outlook?
I stay positive because of the patients and the other employees. It is a difficult environment, but we always try to encourage each other when we have a particularly difficult patient.
When did you decide on nursing?
I wanted to be a chemist just like my father, but after going through chemistry in nursing school, I was glad I didn't do it. Nursing is so much a part of my life I will probably be one of those people that they have to push out the door.
How did you decide to work as a nurse in a prison?
It was a job that was available when I graduated, and now I just love it. The majority of the patients are so appreciative. I really feel like I am making a difference. It is a very nice working environment, like a family. We have had some people who are hard to work with, but thank goodness, they are few and far between.
Where are you from?
I was born and raised in Louisiana. I lived in Los Angeles for a year when I first got married. It was pretty scary, and I was glad to come home.
What kind of community do you live in?
I live in a little town called Galvez, a semi-rural community. We're between Baton Rouge and New Orleans. We've had an influx of subdivisions from the big cities. When I first got married I wondered where my husband was taking me -- out here in the middle of nowhere. And now I wonder what happened to the country. The most common roadblock before was a tractor, but now there is lots of traffic.
Do you have children?
I have two sons who are both in college, one in Louisiana and one in Boston. I definitely try to educate them as much as possible. My boys stopped bringing their friends over long ago because their Momma was always giving sex education talks. The girls seemed to like it, but the boys didn't.
How do you spend your spare time?
I don't have very much. I have a full-time job and I'm president of LANP (Louisiana Association of Nurse Practitioners). I go to meetings and events after my regular work hours. Whenever I do get a day off, I like to read. My husband and I like the blues so we might go out to a club or to eat.
What do you like to read?
Mysteries, the John Grisham type. I'm the type of person who will stay up all night reading and then complain the next day that I'm too tired.
What is the best vacation you've ever had?
The best vacation was when we went up to Boston to visit my son at school. That's the first time I had been up North and I just loved the weather. There was no humidity whatsoever, I just loved it to death. We did all the touristy stuff. We went around Boston and to all the historical sites. We went to Cape Cod and went whale watching. I loved all the flowers in bloom. I wouldn't want to live anywhere else but Louisiana, but I enjoyed how everything was all green and there were mountains up there. Down here in Louisiana everything is pretty flat.
Is there anyone you would like to dedicate this award to?
Pat Goody, the nurse practitioner at the LSU Science Center HIV outpatient clinic (HOP) in New Orleans. She has been my mentor and has helped me through a lot of tough spots. She is who I contact during my tele-medicine consultations. She trained me as an HIV nurse practitioner, and her guidance has been a strong influence on me.