HIV Treatment in Prison
by Enid Vázquez
We can’t list everything
you may need to know on this page, so check out the Inmate's
Resource Guide. Don’t forget to let your health care workers
know of the organizations which will provide HIV information
to them, including a treatment hotline. And by the way, prison
health advocates maintain that treating yourself treats the
outside community, as well. People coming in and out of the
corrections system need treatment and education to help avoid
spreading illnesses when they’re out.
Testing
Prison staff cannot take
the word of an inmate that he or she has HIV. You may have
to be re-tested to confirm your status, or have your health
records forwarded.
People who don’t know their
HIV status, but believe they may have been at high risk of
getting HIV, may want to get tested and if positive, take
medication. This may keep them from getting seriously ill
while locked up. The last place anyone wants to be when very
sick is in a prison. Remember, many people feel fine until
their immune system is so badly battered that they find out
they have HIV at the point that they have developed AIDS.
In fact, many of these people—primarily people of color—die
at the time of their AIDS diagnosis. Ironically, only prisoners
have a right to free health care in the United States, and
practically every prison provides standard-of-care HIV drug
combinations.
Drug Combinations
You can get a “regimen,”
but it may not be the HIV drug combination you want. Also,
not all HIV drugs are available in every institution.
Confidentiality
You know better than we do
what goes on in your institution. What we can say is that
there is no national plan or advocacy drive to change prison
procedures for clinic visits or handing out medications. Again,
you can seek help from advocacy groups. A letter from them
to the staff can really help. However, one prisoner advocate
points out that there’s really no such thing as confidentiality
in prison. Word gets out. (If you think you can keep your
confidentiality, remember that there’s one HIV triple drug
combination in one tablet, taken twice a day: Trizivir, as
in tricycle. See Retrovir, Epivir and Ziagen in the 2001 Drug
Guide for the three drugs that make up Trizivir, to see if
this med might be good for you.)
Side Effects
Ask your health care provider
what side effects are associated with the medications being
recommended and get tips for how to deal with them if they
occur. You can request a prescription to treat some common
side effects before going on your meds (such as a sleeping
aid to help with Sustiva or Imodium to help with other HIV
drugs—write to us for a copy of the annual HIV drug guide
from Positively Aware for more suggestions). Remember that
you may not experience any side effects at all, so don’t jinx
yourself. Psych yourself up instead. Then, too, remember that
many side effects often go away within a couple of months.
Some quick tips:
• Make sure you’re taking your
meds correctly! You could be overdosing yourself. Also,
some meds cannot be taken together. Remember, health care
providers make mistakes, too. Check the bottle and package
insert, the drug guide or whatever you can. Drugs that cannot
be taken together are called “contraindicated.”
• Taking medications with food
helps prevent nausea. But Videx and Videx-EC must be taken
on an empty stomach, and Crixivan may be taken with a very
low-calorie, no-fat meal (no cream in that coffee, no butter
on that toast), unless you’re taking the Crix along with
Norvir or Rescriptor.
• Remain sitting or standing up
after dosing. Lying down right away may promote nausea.
• To control nausea, try accupressure.
Locate the indentation on the inside of your wrist (measure
about two fingers down from the palm of your hand). Apply
fingertip pressure for three minutes on each side.
• Get a prescription for an anti-vomiting
or anti-nausea medication (such as Compazine, which also
treats vomiting). Double check that the medicine does not
counteract against your HIV drugs.
• For diarrhea, get an anti-diarrhea
medicine, cut back on your fat and sugar intake, and try
fiber supplements or Tums. Tums contain calcium, which has
been shown, in some people, to reduce the number of loose
stools from treatment with Viracept. For both vomiting and
diarrhea, don’t forget to drink extra water and juices,
and also have soups. The nutrients you are losing need to
be replaced so that you can avoid illness.
To DOT or not to DOT?
In directly observed treatment
(DOT) a health care provider watches you take your medicines.
On the one hand, you may lose confidentiality, plus the opportunity
to learn how to take your meds correctly and the ability to
control your doses, such as saving them for dinnertime or
breakfast. DOT is also authoritarian. On the other hand, you
may have a better chance at lowering the amount of HIV in
your blood (your viral load). A recently reported study of
50 inmates in Florida found that after a year of DOT, 100%
of them had undetectable viral load. In contrast, 81% of the
participants in a comparison group outside the prison was
undetectable.
Medication delay
“All or none is a good
message,” says a leading HIV specialist who’s a prison doctor.
In other words, temporarily stopping your meds is better than
spotty doses. To a large degree, HIV medications are about,
“Every dose, on time, under the right conditions.” The idea
generally hasn’t sunk in with all prison administrators and
correctional officers.
If you can’t take your entire
HIV drug combination, don’t just take the ones that are available.
Stop taking them all until you can be sure that you can take
each and every dose. If your viral load is undetectable, you
have a good chance of being undetectable again when you go
back on all the meds.
If your viral load is detectable,
you’re still better off stopping all the meds at the same
time. Taking only some of your drugs can make your virus develop
resistance, which might make the drugs ineffective. You also
increase the risk of transmitting resistant virus to someone
else. This limits treatment options for a newly infected person.
You may want to set aside
all your doses for the first few days you’re supposed to be
starting your combo, to save them in case the prison runs
out of one. It’s not legal, but there you go. Lots of people
use this trick.
Remember that Sustiva and
Viramune last a lot longer in the body than the other meds.
They should be stopped two days before the other meds are
(although there’s still no conclusive evidence that this will
actually help). Stopping them early, of course, may not be
within anyone’s control in a prison. All in all, the common
delays in giving medications is “a scary situation,” says
the prison doc.
Telemedicine
Telemedicine allows the prison’s
primary health care provider to communicate with an HIV specialist,
or the specialist to “see” a prison patient, without costly
and time-consuming travel to each other’s clinic. It involves
the use of “electronic information and communications technology,”
such as computers, telephone consultations and interactive
video cameras. This area of medicine is still being developed.
TB
Tuberculosis disease in the
lungs might be mistaken for other causes of pneumonia. The
TB skin test and the chest x-ray used to diagnose TB can be
falsely normal in people with HIV. A sputum test is recommended
when there are respiratory symptoms in HIV-positive inmates,
even if they were previously found to have negative tests
for TB. TB symptoms include fatigue, weight loss, fever, night
sweats, chest pain, coughing up blood and a cough that doesn’t
go away.
Rifabutin should be used
instead of rifampin for people taking protease inhibitors
(Agenerase, Crixivan, Fortovase, Kaletra, Norvir and Viracept)
or non-nukes (Sustiva, Rescriptor and Viracept) to treat TB.
Rifabutin dose must be cut in half with Agenerase, Crixivan
or Viracept, and it should not be given with Norvir or Rescriptor.
Centers for Disease Control and Prevention (CDC) recommendations
call for using a four-drug combination with rifabutin for
the first two months. After two months, if there is no drug
resistance the treatment can usually be decreased to two drugs.
(However, the CDC recently warned the public again about the
rare potential for hepatitis with the two-drug regimen of
rifampin and pyrazinamide). Healthcare workers can check the
March 1999 HEPP News for tables listing different regimens
and dosages to use. Pregnant women cannot take the oral drug
pyrazinamide (PZA) or the intramuscular injection drug streptomycin
(SM). Isoniazid should be given with pyridoxine to reduce
the risk of neurotoxicity. Treatment of active disease should
never be delayed because of pregnancy. Prophylactic (prevention)
treatment for those who are infected but do not have active
disease can be delayed.
Depression and stress
kills
Both inmates and people living
with HIV have higher rates of depression than the general
population. Prisoners also have higher rates of mental illness,
especially those with substance abuse. Substance abuse, for
anyone, is highly related to untreated underlying illnesses
such as anxiety disorders, and is also related to post-traumatic
stress disorders, such as surviving childhood physical and
sexual abuse. Some even argue that in fact, the U.S. uses
prisons as poor substitutes for mental health and substance
abuse care.
The anti-depressants in the
class of selective serotonin reuptake inhibitors (SSRIs) has
few interactions with HIV meds. These drugs include Zolof,
Paxil, Prozac and Wellbutrin. The tricyclic anti-depressants
(Elavil or amitriptyline) tend to suppress cognitive function
(thinking and analyzing abilities), and people with HIV may
already have their cognitive functions under stress. Health
care providers should look for underlying cognitive problems
in order to avoid a misdiagnosis of depression or other condition,
since neurological problems overlap with mental health difficulties.
Inmates with these problems may be subject to retaliation
from other inmates or prison staff because they fail to understand
or remember rules, and they may exhibit erratic behavior.
Drug use
It’s estimated that three
out of four people in prison have drug or alcohol problems.
People who continue to use when released have a greater risk
of returning to prison. They also have a greater risk getting
reinfected with hepatitis C, which may have already cleared
their body.
Inside prison, check out
drug treatment if you can get it. If you continue to use,
try not to share equipment. You need to try to avoid hepatitis
C as well as new strains of HIV. Again, this may not be in
your control, since condoms, dental dams and bleach are contraband
in the vast majority of prisons, and methadone is not always
available. (Remember that full strength bleach is needed to
clean needles, with lots of rinsing—four shots of bleach,
each shaken and then rinsed.)
Release
If your system doesn’t help
plan for your health care after release (see “Recommendations
for Prisoners”), start planning on your own several months
before your parole date. Contact the advocacy groups in listed
in “Resources.”
Special thanks to Dr.
Joseph Bick, Director of HIV Treatment Services for the California
Medical Facility, California Department of Corrections, and
an editor of HEPP News, for reviewing this article.
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