Correctional Settings

Caring for the HIV-infected incarcerated patient is complex and challenging. For many of these patients, the prison health service provides their first opportunity for access to health care. HIV seroprevalence rates among inmates in the United States are 5 times higher than in the nonincarcerated population (CDC, 2001). Within the prison system in the United States, mortality due to AIDS has dropped dramatically since the advent of effective combination antiretroviral therapy (ART), with the number of AIDS-related deaths decreasing by 72% in state prisons between 1995 and 2002 (Maruschak, 2001).

Often, behaviors that lead to incarceration also put inmates at high risk for becoming infected with HIV, hepatitis C virus (HCV), and other infectious diseases. These risk factors may include unsafe substance use behaviors, such as sharing syringes and other injection equipment, and high-risk sexual practices, such as having multiple sex partners or unprotected sex. Many inmates also may have conditions that increase the risk of HIV transmission or acquisition, such as untreated sexually transmitted diseases (STDs).

Of the approximately 1.8 million inmates in the United States, 30-40% are infected with HCV. The incidence is 10 times higher among inmates than among noninmates and is 33% higher in women than in men (Nerenberg et al, 2002). Chronic hepatitis B virus (HBV) infection and tuberculosis are substantially more common in the incarcerated population than in the general public. The presence of any of these conditions should prompt HIV testing (Nicodemus and Paris, 2002).

Women represent 5-10% of the prison population in the United States. The HIV epidemic in the United States increasingly affects women of color, and this trend is reflected in HIV rates among the incarcerated. Incarcerated women have higher HIV seroprevalence rates than incarcerated men (3% vs 1.9%). Several risk factors for HIV are present in abundance among female inmates, including the following:

	History of childhood sexual abuse and neglect
	History of sex work, with increased frequency of forced, unprotected sex
	High rates of STDs
	High rates of mental illness
	History of injection drug use (IDU) and/or sex partners with IDU history
	Poverty

Among all women entering a correctional facility, 10% are pregnant (De Groot and Cu Uvin, 2005). These women should be offered HIV testing, and HIV-infected pregnant women should be offered ART immediately to prevent perinatal HIV transmission. Many incarcerated women will receive their first gynecologic care in prison. Because the incidence of cervical cancer is higher in women with HIV, referrals for colposcopy should be made for any HIV-infected woman with an abnormal Papanicolaou test.

The correctional facility is an ideal location for identifying those already infected with HIV, HCV, and/or HBV, and for preventing infection among those at highest risk for these diseases. The corrections setting is often the first site at which an HIV-infected person interacts with the health care system, making it an important avenue for HIV testing. HIV testing policies in correctional facilities vary from state to state and among local, state, and federal penal institutions. Depending on the setting, policies may require testing of inmates upon entry, upon release, or both. Testing may be based on clinical indication or risk exposure during incarceration, and may be voluntary or mandatory (Bartlett et al, 2000). The U.S. Centers for Disease Control and Prevention (CDC) recommends routine counseling and testing in settings with an HIV prevalence of 1% or higher. In high-risk settings such as correctional facilities, routine, voluntary HIV testing has been shown to be cost-effective and clinically advantageous (Paltiel, 2005).

Testing and treatment of HIV-infected inmates prior to release is critical. Given the high HIV seroprevalence rates among inmates, the reentry of inmates into the community presents the danger of spreading HIV and other infectious diseases, and thus is a public health concern. Inmates need adequate HIV prevention counseling before release both to protect themselves and to decrease transmission of HIV to others in their communities (Gaiter, 1996).

Health care providers in correctional settings are in a key position to evaluate inmates for HIV risk factors, to offer HIV testing, and to educate and counsel this high-risk group about HIV. Inmates often are hesitant to be tested for HIV because of fear of a positive diagnosis and because of the potential stigma involved. Often, they lack accurate information about HIV, including awareness of behaviors that may have put them at risk and knowledge of means for protecting themselves from becoming infected.

The World Health Organization (WHO) has stated: "All inmates and correctional staff and officers should be provided with education concerning transmission, prevention, treatment, and management of HIV infection. For inmates, this information should be provided at intake and updated regularly thereafter" (see: http://www.who.int/en/). Risk reduction counseling addresses specific ways the inmate can reduce the risk of becoming infected with HIV. If already HIV infected, the goal of counseling is to reduce the risk of infecting others or becoming infected with a drug-resistant strain of HIV. Education should focus on the use of latex barriers with all sexual activity. Although condoms and dental dams are not available in most prisons and jails, the inmate should receive education regarding their proper use.

Inmates with a history of IDU should be educated that needle sharing conveys a high risk of transmitting HIV, HCV, and HBV. Substance abuse treatment should be provided when appropriate.

Recovery from addiction often is a chronic process and relapses are common. In addition to treatment, risk reduction strategies should include planning for support after release. For example, prior to release, inmates should be provided with information about needle exchange or clean needle access programs in their communities. These programs have proved to be quite effective in decreasing the rate of parenteral HIV transmission (CDC, 1999).

In correctional facilities, as in any setting, a consideration of HIV treatment must begin with educating the patient about the risks and benefits of treatment and the need to fully adhere to the entire regimen, as well as with an assessment of the patient's motivation to take ART.

Correctional facilities have two medical policies for dispensing medications. Each has advantages and disadvantages that can impact treatment adherence.

Directly Observed Therapy

Directly Observed Therapy (DOT) is the system in which the inmate goes directly to the medical unit or pharmacy for all medication doses. This system offers the advantage of more frequent interaction between the patient and the health care team, allowing for earlier identification of side effects and other issues. In general, patients have better medication adherence in this system, resulting in better control of HIV. For some inmates, however, the need for frequent visits to the medical unit or pharmacy may be a barrier to treatment, particularly if they are housed at a distance from the unit. Another disadvantage of DOT is the potential loss of confidentiality, as many inmates feel that the frequency of treatment and the large number of pills they must take will reveal clues that they are HIV infected. In addition, this system puts the inmate in a passive role in terms of medication treatment and does not foster self-sufficiency.

Keep on Person

Keep on Person (KOP) is the system that allows the inmates to keep their medications in their cells and take them independently. Monthly supplies are obtained at the medical unit or pharmacy. This system offers greater privacy and confidentiality regarding HIV status. It also allows the inmate to develop self-sufficiency in managing medications, which may facilitate improved adherence upon release. However, as the KOP system involves less interaction with medical staff, problems with adherence can be more difficult to identify (Ruby, 2000). In a study comparing DOT in HIV-infected inmates with KOP in nonincarcerated HIV-infected patients receiving ART as part of a clinical trial, a higher percentage of DOT patients achieved undetectable viral loads compared with the KOP patients (85% vs 50%) over a 48-week period (Fischl, 2001).

Adherence is one of the most important factors in determining success of ART. For the HIV-infected inmate starting ART, a number of issues can affect medication adherence. These include patient-related factors, factors related to systems of care (including the medication dispensing systems described above), and medication-related factors. The following are suggestions for supporting adherence to ART.

Patient-Related Factors

Provide alcohol and substance abuse treatment prior to initiating ART. Without appropriate treatment during incarceration, linkages to supports, and follow-up treatment upon discharge, the inmate is at risk for returning to high-risk behaviors that may interfere with adherence to ART. Utilize mental health consultation to identify inmates with psychiatric needs. Treatment for underlying mental health disorders should precede or occur simultaneously with the initiation of ART to ensure successful adherence. Depression and other psychiatric illnesses are more prevalent among inmates than among the general population (Maruschak, 2001). Correct misconceptions about HIV and ART that are common among inmates and could affect adherence adversely. The inmate should be educated about the disease process and the role of the medications, along with the potential risks and benefits of taking ART. Encourage participation in peer support groups. These can be effective ways to foster self-esteem, empower inmates to come to terms with a positive diagnosis, allay fears and correct misconceptions about HIV disease, and aid adherence. Upon release, telephone hotlines may be available to provide follow-up support and linkages to community services. To the extent possible, family and friends should be included in the education process. Use teaching tools that are appropriate in terms of language and reading level. Illiteracy and low-level reading ability are common among inmates. Diagrams and videos may be more effective than reading-intensive material in some cases. Basic HIV education prior to initiation of ART should include: How the medications work Consequences of nonadherence Names and dosages of all medications Potential side effects with strategies to manage them

Factors Related to Systems of Care

Educate security staff about the importance of timely medication dosing, and communicate with other facilities in advance of a transfer; this can eliminate or limit missed doses. Schedule frequent follow-up medical visits in the early weeks after ART is initiated; these can make the difference in whether or not patients "stay the course." Consult with an HIV specialist, if possible. If a facility's medical provider lacks experience in treating patients with HIV, the results may be undertreatment of side effects, or ART prescribing errors. Because caring for HIV patients is complicated, HIV specialists can provide assurance that patients are receiving proper care. Of particular concern are patients whose current ART regimens are failing, those who are declining clinically, and those who are coinfected with other infectious diseases such as tuberculosis, HCV, and HBV.

Medication-Related Factors

Any consideration of HIV treatment must begin with educating the patient about the risks and benefits of treatment and the need to fully adhere to the entire regimen, as well as with assessing the patient's motivation to take ART. Aggressively monitor and treat side effects. The most common barrier to adherence to ART is side effects from the medications. The inmate should be educated in advance about potential adverse events to observe and report. In the first weeks after starting a new ART regimen, patients should be assessed frequently for side effects. For treating gastrointestinal toxicities, antiemetics and antidiarrheals should be available on an as-needed basis. As with all patients on ART, inmates should have appropriate laboratory monitoring. Be aware of food requirements. Various food requirements must be considered carefully when administering ART. This can be especially challenging in the correctional environment, particularly if the facility does not allow inmates to self-administer medications. Make arrangements with prison authorities to provide food when inmates are taking medications that require administration with food. Avoid complex regimens and regimens with large pill burdens, if possible. Simple regimens with few pills appear to help improve adherence. Avoid drug-drug interactions. Some antiretroviral medications have clinically significant interactions with other drugs (eg, methadone, oral contraceptives, cardiac medications, antacids). These interactions may cause failure of either the antiretroviral drug or the other medication, or may cause additional toxicity. Consult an HIV specialist or pharmacologist for information on drug interactions. The patient should be questioned about medication adherence at each appointment. ART regimens need to fit into each patient's schedule and lifestyle. This becomes a bigger issue when the inmate is close to release. Education about HIV management, including ART adherence, should begin well before the inmate is discharged back to the community. At the time of discharge from the correctional facility, all HIV-infected inmates should have a discharge plan that addresses: Housing Health insurance 30-day supply of HIV medications Follow-up appointments for medical care and, if necessary, psychiatric and substance abuse care A number of HIV education resources for inmates and correctional health care providers are cited on Albany Medical College's Web site at http://www.amc.edu/patient/hiv/index.htm (go to the section on correctional education). Chapter contributors Minda Hubbard, ANP-C, Research Nurse Practitioner; Douglas G. Fish, MD, Medical Director; Sarah Walker, MS, Correctional Education Coordinator; and Abigail V. Gallucci, Director of HIV Education--Albany Medical College's Division of HIV Medicine (Upstate Local Performance Site and Regional Resource for Corrections, New York/New Jersey AIDS Education & Training Center)