Correctional health care providers manage the care of a large number of individuals with communicable diseases in the U.S. A major portion of the nation’s Hepatitis B&C, HIV, STD and TB infected patients pass through prison and jail doors (see Heppigram). Moreover, many of these individuals also have other co-morbid conditions such as psychiatric illnesses, substance abuse and chronic medical conditions that thwart an integrated care approach for these patients in community settings.
With an area of 267,277 square miles and a population of 18.7 million inhabitants, Texas is the second largest and second most populous state in the U.S. The combination of multiple, large cities with attendant inner city conditions predisposed to high rates of HIV infection (socioeconomic impoverishment, low educational levels, illicit drug use) and a racially and ethnically diverse population disproportionately affected by the U.S. HIV epidemic account for a large HIV positive population in Texas jails and prisons. It follows that Texas prisoner populations have the fourth highest AIDS prevalence rate in the nation (1876 HIV or AIDS cases reported in 1996).
The 39th annual Interscience Conference on Anti-microbial Agents in Chemotherapy (ICAAC) was held in San Francisco September 25-29, 1999. From the correctional perspective, some of the most relevant HIV related topics that were discussed include: longer term follow-up of some previously reported highly active antiretroviral (HAART) trials, genotypic and phenotypic resis-tance testing, discontinuation of opportunistic infection (OI) prophylaxis, further elucidation of host factors involved in the immune response to HIV, and troubling information regarding side effects of HAART. One common theme was that the most important predictor of achieving an undetectable HIV viral load (VL) is patient adherence to therapy.
Prisoners, because of their relatively stable environments and availability, have historically been attractive, if not preferred, research subjects. Phase I drug toxicity studies, malaria treatment trials and radiation exposure experiments have notoriously been conducted utilizing prison inmates. However, with the evolution of research ethics and subsequent regulations, investigations involving prisoners have undergone fundamental changes over the past three decades.
The number of incarcerated individuals affected by HCV is high, regardless of the region of the country. For example, Texas reported that 42,000 inmates were infected with HCV (28.6% of the incarcerated population). Other states also report high infection rates among inmates: Connecticut (32%) , Virginia (30-40%), Maryland (38%) , and California (41%). In New Jersey, 929 inmates were tested for HCV in response to evidence of hepatic transaminase elevations, or co-infection with hepatitis B or HIV. 67.3% of these inmates tested positive for HCV antibody. Many states do not formally test for HCV infection in their populations unless medically indicated (for reasons such as elevated liver function tests), therefore, current estimates of the prevalence of HCV infection in some correctional settings may be artificially low.
The low number of women in prisons (6.4% of the prison population and 10.8% of the jail population) obscures the disproportionate impact of HIV infection on incarcerated women. In fact, prevalence of HIV infection among women is roughly two times higher than the rate among incarcerated men, and it's 35 times higher than the rate of HIV infection in non-incarcerated women.
Last month we brought you reports on immunology and new treatments from the 6th Conference on Retroviruses and Opportunistic Infections. This month we continue our synopsis with reports on HIV care utilization, viral load monitoring, and warnings about new clades and drug resistant HIV isolates.
How many of the talks and posters presented at the 6th Conference on Retroviruses and Opportunistic Infections dealt directly with prisons? Very few! However, many of the presentations reported on new drugs and described new insights in the immunopathogenesis of HIV, both topics that are relevant to the management of HIV-infected patients in corrections.
The incidence of tuberculosis (TB) is three times higher inside correctional settings than outside, making mastery of TB treatment guidelines a "must" for correctional HIV professionals. Updated guidelines highlighting new regimens and clinical practices for the treatment of tuberculosis (TB) and human immunodeficiency virus (HIV) co-infected individuals were just published (CDC, 1998). The guidelines re- emphasize previously well-recognized principles of TB treatment, and extend these concepts to TB in the context of HIV co-infection. The following article will review these recent developments and provide insight into the complex issues surrounding the care of TB and HIV infected individuals in the correctional setting.
It's late in the afternoon on Christmas Eve, and you receive a call that a correctional officer has just suffered a deep needle stick from a syringe found during a cell search. Are you prepared?
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