Introduction

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). ¹

HIV in TDCJ

The Texas Department of Criminal Justice (TDCJ) is responsible for correctional custody of "offenders", the preferred designation for Texas state inmates. Texas has the second largest incarcerated population in the U.S. (an estimated 135,407 offenders in TDCJ facilities and an additional 15,000 - 16,000 offenders who are housed in private correctional facilities)². Texas offenders diagnosed with chronic medical conditions are assigned to TDCJ facilities rather than to private correctional facilities, so that chronic care can be provided by a managed health care system.

Several independent managed healthcare contracts provide pharmacy services and medical care. Under these contracts each TDCJ facility has its own primary care health care delivery system which may be staffed by physicians, dentists, optometrists, mid-level practitioners (physician assistants, clinical pharmacists, nurse practitioners), Certified Medication Aids (CMAs), nurses, laboratory personnel, and other ancillary health care personnel. In contrast, outpatient specialty health care as well as inpatient hospitalization occurs at facilities located on Texas Tech and UTMB Galveston campuses.

With regard to Medical Care, the state is divided into eastern and western halves that are approximately equal in area, but unequal in terms of TDCJ offender population. University of Texas Medical Branch Galveston is responsible for the eastern half of the state, which houses approximately 104,264 offenders in CJ units. Virtually all HIV positive offenders are assigned to units in the eastern half of the state, which means UTMB provides CJ units. Virtually all HIV positive offenders are assigned to units in the eastern half of the state, which means UTMB provides nearly all of the HIV health care for TDCJ. Given the number of offenders in TDCJ, medical health care and pharmacy budgets are enormous. Delivery of services must be efficient in order to derive maximum benefit from these health care dollars (see Table 1 on page 2).

HIV Care Management

The HIV-Specific Infection Control Policy, developed and periodically updated by the TDCJ Office of Preventive Medicine in Huntsville, Texas, serves as a guideline for HIV health care and is reflective of local standards of HIV health care. The policy is comprehensive and covers a variety of HIV-related issues including the method of HIV testing offered, referral of HIV positive offenders for specialty care, baseline and follow-up clinical and laboratory evaluations, schedule of vaccine administration and periodic HIV-related health screening (PPD, pelvic examinations, retinal exams, etc.), initiation of prophylactic therapies to reduce the incidence of opportunistic infections, and initiation of antiretroviral therapy.

Testing

As of May 1998, TDCJ has offered "routine HIV testing" to offenders. Routine testing means that an HIV test is conducted, unless the offender refuses, for offenders:

• *who report a past history of HIV infection, hemophilia, or a history of high risk behaviors for acquiring HIV infection;
• *for whom live virus immunization is planned;
• *who have psychiatric disorders or display symptoms possibly consistent with AIDS-related dementia; and
• *who have certain indicator conditions (TB infection or disease, any sexually transmitted disease, cervical dysplasia, Hepatitis B and C infections).

Routine testing is performed at entry into the TDCJ and yearly thereafter. Verbal consent is required before HIV testing is performed and all tested offenders receive pre- and post-test counseling. Prior to May 1998, HIV testing was offered on a voluntary basis (see Tables 2 and 3 below).

The Treatment System

The Infection Control Policy specifies that TDCJ offenders with HIV infection must be evaluated and treated by a physician with expertise in HIV health care. As a result of recent endeavors to unify UTMB Galveston HIV Health Care and Unit-Based HIV Health Care, clinic visits at the two locations are linked so that offenders do not have to be transported as frequently as in the past, when Specialty Health Care and Unit-Based Health Care were isolated from one another. The current Infection Control Policy also specifies CID nurse visits every 60 days for HIV positive offenders.

The Infection Control Policy for vaccine administration, HIV-related periodic health screening, and initiation of prophylactic therapies are based on nationally published guidelines (1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus available at:
http://aepo-xdv-www.epo.cdc.gov/wonder/PrevGuid/m0048226/m0048226.asp

Similarly, initiation of antiretroviral therapy is based on nationally published guidelines (Report of the NIH Panel to Define Principles of Therapy for HIV Infection and Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents available at: http://www.aegis.com/pubs/mmwr/1998/RR4705.html. Antiretroviral therapy is individualized and based on informed decisions made by the treating physician and the patient. In other words, there are no set CD4 numbers or virus load values that automatically trigger or preclude antiretroviral therapy.

Administering and Monitoring HAART

The TDCJ Pharmacy and Therapeutics (P & T) Committee have developed policies regarding the administration and continuation of antiretroviral drugs. In recent years, the director of the AIDS Care and Clinical Research Program has been appointed to this committee which has allowed the input of treating physicians to shape policy. Several P & T policies affect the use of antiretroviral medication administration. The policies are as follows:

1. All antiretroviral agents are included on the TDCJ Formulary; new agents are usually approved for addition to the formulary within a month of receiving FDA approval.
2. Combination therapy that includes a protease inhibitor or nonnucleoside reverse transcriptase inhibitor is considered standard and is distributed by directly administered therapy (DAT) multiple times per day at pill windows. Monthly pharmacy computer reports are monitored and if an offender is found to be on suboptimal therapy (dual or single nucleosides), the pharmacy notifies a unit-based provider, who is asked to correct or justify the suboptimal therapy.
3. . A 10-day supply of medication is dispensed at release from prison and Texas AIDS Drug Assistance Program (ADAP) papers are completed and submitted by pharmacy personnel at release. The offender is given the responsibility of obtaining the medications by calling the ADAP program toll-free number and designating a pharmacy for dispensing of drugs.
4. Finally, an antiretroviral medication discontinuation policy has been implemented in which 80% of the scheduled doses of each antiretroviral medication must be taken in order for the offender to continue treatment.

Adherence

Adherence is documented by Certified Medication Aids (CMAs) who enter this data on the pharmacy computer system as they distribute medications to offenders at "pill windows" at the correctional units. Pharmacy personnel review adherence data every month. When an offender's adherence on any antiretroviral medication falls below 80 %, a unit-based provider is notified and asked to perform adherence counseling. During counseling, the offender is assessed for conditions that impair adherence: medication side effects, unreasonable medication combinations, and the occurrence of other activities (work, meals, school) scheduled simultaneously with pill window times. The medication discontinuation policy is also reviewed with the offender. Necessary adjustments are made to the antiretroviral regimen or related medications in order to minimize non-adherence due to drug side effects. When possible, daily routines are altered or medication passes are given so that non-adherence due to conflicting events is minimal. After 30 days, adherence is reassessed. If adherence remains below 80%, antiretroviral therapy is discontinued. The offender has the opportunity to resume antiretroviral therapy after a 90-day hiatus.

Upon initial review, the antiretroviral medication discontinuation policy seems unduly harsh and/or paternalistic. However, if one considers that poor adherence not only leads to drug-resistant virus which impairs treatment response for the individual, but may also lead to transmission of drug-resistant virus within and outside of the prison, this policy is beneficial to the individual who may accept effective therapy in the future and beneficial to the public health by reducing the incidence of treatment-resistant HIV infection.

Challenges and Solutions

Initially, our HIV clinic was at UTMB at Galveston, which made it difficult to provide optimal HIV care due to distance, staffing, and separation of care from the offender's home unit. Therefore, a Center for Excellence in HIV Care was established at the maximum security Stiles Unit in Beaumont, Texas is approximately 85 miles from Galveston. Currently 1,200 HIV positive men of various security designations are housed there. Security regulations were modified at this unit so that offenders with different security designations can be housed together in specified quarters that are centered around health care delivery areas where clinic and pill windows are located. The trip to UTMB takes a couple of hours and offenders return to Stiles the same day as their UTMB appointment. One of the Galveston ACCRP Physicians travels to the Stiles Unit one-day every other week to see patients and to consult with unit-based physician assistants who have reviewed medical and antiretroviral history on patients who are failing therapy and need to have medications changed. Similarly, the minimum security Texas City Women's Sheltered Housing Unit, only 15 miles from UTMB Galveston, houses minimum security female offenders with HIV infection. Another ACCRP AIDS specialist travels to Texas City every other week to see the offenders housed there and to see HIV positive female offenders who are transported to Texas City from other units of assignment.

Minifellowships for Better Providers

In order to provide HIV care training to Unit-Based Providers as well as to foster a mutually respectful relationship between the Galveston Specialists and the Unit-Based Providers, a three day "HIV Minifellowship for Correctional Care Providers" (18 category 1 CME hours) was developed and is conducted three times per year for 10 - 15 Unit-Based Providers per session. We need to establish a working relationship with 61 physicians, 73 mid-level providers, and 71 Chronic Infectious Diseases (CID) nurses in the TDCJ units in the Eastern Region. Although the course is intensive and consumes three eight hour days, having Galveston HIV Specialists serve as faculty as well as participate in evening recreational activities with the Unit-Based Providers has facilitated an appreciation for each others' roles and has definitely enhanced communication regarding HIV care of offenders between the units and Galveston.

Teleconsults

Unit providers who have completed the minifellowship and Galveston Specialists consult with one another regularly by telephone or by means of telemedicine video equipment - thus a system of communication and care delivery called "teleconsults" is evolving. Patient cases are summarized on data sheets and faxed to the Galveston HIV Specialist prior to the teleconsult session. During the session, the patient's course is discussed and revised treatment plans are developed. Twice weekly telemedicine clinics were developed and are being refined so that a Galveston specialist can use state of the art electronic equipment to evaluate inmates at remote sites across the state. To make telemedicine work, unit level laboratory capabilities had to be expanded so that viral loads and other tests could be performed there instead of UTMB Galveston.

Summary

The large geographic expanse of Texas and the sheer number of HIV positive offenders within the TDCJ are primary forces that made it necessary to change from a centralized HIV Health Care System based at UTMB Galveston to a cooperative system in which HIV Health Care responsibilities are shared by providers at the units. A uniform HIV-Specific Infection Control Policy, along with several Pharmacy and Therapeutics Committee Policies regarding antiretroviral medications, provided a foundation for this shared health care, but was not enough, by itself, to facilitate the transition. A three day "HIV Minifellowship for Correctional Care Providers" not only prepares unit-based providers to assume additional responsibility for HIV Health Care, but also facilitates a cordial working relationship between the Galveston HIV specialists and Unit-Based Providers. Telemedicine clinics have permitted UTMB Galveston HIV Specialists to evaluate offenders while they remain at remote sites throughout Texas, and a budding "teleconsult" clinic have enhanced efficiency without impeding quality of care. Finally, unit-based laboratory capabilities, in particular, the ability to collect and process viral load specimens were expanded in order to meet the needs of unit-based, specialty-driven, HIV care. The role of the CID nurse is being evaluated and hopefully, will be modified to become a crucial link between the units and UTMB Galveston. It has been useful to recognize that the analysis and revision of our HIV care delivery programs in a geographically large and populous institution like TDCJ is a process that moves slowly, but ultimately leads to more efficient delivery of quality health care.

References

1.Hammett, TM. Maruschak LM. 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities. U.S. Department of Justice. July 1999. NCJ 176344.pdf

2. Personal communication, Alan Sapp, Assistant Director for Administrative Services, Texas Correctional Managed Health Care Committee. 1999.

1999-1110
HEPP1999-1101

©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.

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