Recommendations for HIV-Positive
Inmates
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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