AIDS Treatment News #161, October 16, 1992
Dave Gilden

In May 1991, AIDS TREATMENT NEWS interviewed the three doctors who then cared for Vacaville's known HIV-infected inmates [see AIDS TREATMENT NEWS #126]. At that time, we were impressed by the level of professional care for the inmates and by the personal concern these physicians felt for their patients.

It was also clear that the doctors were continually frustrated by the the prison bureaucracy's indifference to patients' needs. All three practitioners (Jessica Clarke, M. D., Jan Diamond, M. D., and HIV Director German Maisonet, M. D.) left Vacaville last spring. Dr. Clarke now heads the HIV program at a private San Francisco hospital. Dr. Maisonet is an infection control specialist at the minimum security federal prison in Pleasanton, CA. Dr. Diamond first went on maternity leave and then was transferred to the state prison in San Quentin. Her new role, to enhance the state of medical care in San Quentin, results from a lawsuit against conditions there.

Dr. Maisonet said of his decision to resign, "It hurt a lot to leave, but we were faced with an increasing number of patients and a decreasing amount of resources. I would have had to practice medicine at a level below the standard of care, and I wouldn't have been satisfied."

To get a sense of the underlying problems, we talked with a number of ex-inmates and Vacaville staff members. The picture that emerges is one of poor management and lack of planning compounded by AIDS phobia. Prisons have a custodial mentality; "people can wait" is their attitude even when confronted with acute disease.

The average age of prison doctors is 62. Many are ex- military officers in the prison system to collect a second pension.

"How will they come up to speed on AIDS care?" asked one staffer. Free AIDS training is available for the few with the energy and the interest, but there is little incentive. Physicians are so poorly supervised that no one checks up on whether they actually see patients or how well they do. Monitoring for toxic reactions has been a particular weakness.

This year, Vacaville received extra money from the state budget to hire three new AIDS doctors. In the meantime, Dr. Diamond is temporarily moving back to Vacaville. We talked to her about the general measures needed to improve HIV care at Vacaville and other California prisons.

According to Dr. Diamond, "The key to improving health care is more oversight. Patients' records should be regularly reviewed by a second physician. Providing good HIV care is quite possible in the prisons. Any drug you want is available, and if you just stick to medical care, it isn't that busy."

Asked about Vacaville's attempt to hire new HIV specialists, Dr. Diamond commented, "With the ever-growing health crisis and insurance mess, a lot of doctors in private practice are looking for other work. We should be able to hire physicians who are motivated to learn about AIDS and sensitive to treating inmates like people."

The chief hurdle to the conscientious physician is the absence of support services. "German would spend 20 hours a week doing what a social worker should do," Dr. Diamond noted.

In the past, no one did discharge planning for inmates with health problems. Released patients faced a bleak future unless their doctors shouldered the responsibility for finding them shelter and financial support such as disability payments. Partly due to the efforts of Drs. Maisonet and Clarke, the parole division of the Department of Corrections this year started a pilot discharge planning program for inmates from the Los Angeles and San Francisco regions.

Getting help for patients with psychiatric problems has been another trying experience. HIV-positive inmates reside in separate housing units without access to the standard mental health department. They get only intermittent assistance for mental problems, even though HIV disease creates its own psychiatric problems and aggravates new ones.

Those with advanced HIV dementia are generally warehoused in isolated cells known as "psychiatric management units." A violent prisoner affected by dementia is considered merely a disciplinary problem. Just breaking a window or throwing food at a guard can get someone placed in solitary confinement, which "can end up being quite damaging, quite inhumane," Dr. Diamond observed.

An inability to hire more nurses further increases doctors' burdens. The nursing shortage restricts the size of Vacaville's acute care unit, meaning that severely ill inmates have to be sent at enormous expense to outside hospitals, interrupting the consistency of care. Meanwhile, the absence of an out-patient infusion center keeps prisoners with CMV retinitis in the acute care unit indefinitely so that they can receive their daily maintenance infusion of ganciclovir. If it weren't for these one-hour infusions, they could return to the residence units

Inadequate support staff makes it hard to monitor for side effects. The number of treatments needed to manage AIDS- related conditions can multiply into the dozens, and many of these substances themselves require careful management based on frequent lab tests.

"There is not enough appreciation of AIDS drugs' toxicity," Dr. Diamond noted.

One area where she thinks too many drugs are given is in prophylaxis for candidiasis and cryptococcal meningitis. She feels that Pfizer Laboratories has promoted its product Fluconazole too aggressively for this use. Fluconazole costs $7 per day, and using it excessively might create resistant fungal strains.

The Vacaville HIV service tends to give fluconazole to everyone with T-helper counts less than 200. Dr. Diamond instead recommends frequent screening for cryptococcus until a patient's T-helper count falls under 50. Prophylaxis with fluconazole should begin only at this point, unless the patient is already taking the drug for recurrent esophageal candidiasis or other reasons. Of course, this approach depends on timely lab testing.

One way to overcome the lapses in staff support is to teach prisoners to recognize the symptoms of cryptococcal meningitis and other diseases so they can report them immediately. Prisoners could also learn to watch for signs of drug toxicities.

A special aspect of self-help has been Vacaville's Pastoral Care Service. Sponsored by a prison chaplain, PCS is run by inmate volunteers who provide comfort to terminally ill prisoners. Without PCS, sick inmates in the hospital unit would be alone almost all day. The volunteers help the sick with basic physical functions, keep them company and intercede with the nurses to obtain needed care. Members of PCS sit constant vigil with inmates in the final days of their lives.

"It's little short of a miracle that Father Leslie [the chaplain] got this done," Dr. Diamond commented.

But Michael Haggerty, an inmate who coordinated Pastoral Care until his release last May, complains that Vacaville's new chief and associate wardens are much less supportive of PCS than the previous administration. PCS activities became sporadic, as approval and training of new volunteers were stalled and access to clients' living quarters denied.

"It's hard for officials to see that inmates really want to help. It will be an ongoing proposition to get PCS entrenched," said Haggerty.

All these comments apply only to the identified HIV-positive inmates. The unknown ones receive no HIV care at all.

Surveys indicate that the total number of California prisoners with HIV is five to ten times the number known to be positive. Inmates avoid HIV testing because those found to be infected with HIV suffer from a variety of restrictions. The segregated housing units, bans on conjugal visits, and bans on working in food and medical department jobs discourage California inmates from obtaining what limited help there is for HIV-related conditions.

Vacaville Prison Seeks HIV Physician

The California Medical Facility in Vacaville seeks a physician with "good working knowledge of internal medicine and infectious disease in the HIV-infected patient. The physician will be administering health care to all categories of patient care from outpatient clinics, inpatient care, emergency services and screening examination of the HIV+ inmate."

The position includes liability coverage. "Additionally, there is no office overhead, malpractice insurance or salaries to pay, and no billing or collection problems."

For more information, contact Raymond L. Andreasen, M. D., Chief Deputy Warden(A), Clinical Services, P. O. Box 2000, Vacaville, CA 95696-2000. Or call Karen Huston, Examination Coordinator -- Personnel, 707/449-6532.

AmFAR Announces Community-Based Research Grants: Letters Due November 5

The American Foundation for AIDS Research plans to award up to nine Operating Grants of up to $50,000 each, and up to six Project Grants of up to $100,000 each, to community-based clinical trials organizations within the United States and its territories, or (exceptionally) in other areas. Letters of intent (which must follow a specified form, including cover page, abstract, biographical sketch, and list of participating physicians -- with ten copies in addition to the original) must be received by 5:00 Eastern Standard Time on Thursday, November 5. Those whose letters are accepted will be given about six weeks to submit a grant application.

For complete instructions on submitting the letter of intent, call the Community-Based Clinical Trials Program, American Foundation for AIDS Research, 212/682-7440.

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