Important note: Information in this article was accurate in October 2002. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
|
"3% of Americans incarcerated...12 million released from jails and prisons every year... 35% of all cases of active tuberculosis identified among current/recent inmates...500,000 individuals with STDs and 500,000 with latent tuberculosis released every year...30% of all Americans with hepatitis C and 12-18% of those with HIV pass through our nation's jails and prisons every year..."
The above excerpt was part of the findings of the NCCHC/NIJ "Health Status" report released in May 2002. This national, 3-year-long study was the largest and most comprehensive of its kind ever undertaken. With funding from Congress through the National Institute of Justice, and with substantial support from the Centers for Disease Control and Prevention, the National Commission on Correctional Health Care convened expert panels that included the nation's most respected researchers, practitioners and scholars in the fields of public and correctional health care. The National Institute of Justice delivered the final report to Congress in May 2002 and is now available on the Internet at http://www.ncchc.org/pubs_stbr.html. This article provides highlights of the report and an abbreviated guide to the management of some of the infectious diseases facing incarcerated populations.
The NCCHC/NIJ report estimates that a number of HIV-infected inmates equivalent to 12% to 18% of the total HIV-infected population in the U.S. were released from prisons and jails in 1996 (98,000 to 145,000 inmates) and that 35,000 to 47,000 inmates in 1997 were infected with HIV (estimated rates are higher for releasees than for current inmates due to the rapid turnover and short lengths of stay in jails). Considering that many infected inmates are unaware of their HIV-positive status - and that jail or prison is often the first opportunity for routine health care - this report re-emphasizes the role of the correctional professional in the detection of new cases of HIV.
Correctional health providers are in a key position to provide three critical components of HIV and AIDS prevention: education, testing, and treatment. HIV testing is available at intake in most prison and jail settings, although many newly incarcerated individuals refuse testing at this juncture. Therefore, HIV testing should be easily accessible by request in correctional facilities, and should also be offered whenever a condition that might suggest coinfection with HIV is detected (thrush, shingles, recurrent bacterial pneumonia, STDs, hepatitis C, etc.) For more information on conditions that might flag co-infection with HIV, see the HEPPigram in the Aug/Sept issue of the HEPP Report. Counseling and educational programs, especially peer-led discussions of condom use and safe injection practices, are key components of working with inmates to reduce the risk of acquiring or transmitting HIV once they are released.
Acute HIV infection is often mistaken for another disease or for a minor, self-limited illness. Patients most commonly present with the following signs and symptoms: fever, fatigue, lymphadenopathy, pharyngitis, rash, and weight loss (see Table 1). Chronic infection, depending on the stage, may be symptom-free. Symptomatic HIV infection should be treated.
HIV diagnosis is most commonly made with a routine serology assay (ELISA and confirmatory western blot), although several HIV test technologies have recently been approved by the FDA for diagnostic use in the United States. These include rapid blood, urine and oral fluid tests (for a list of approved tests, go to http://www.fda.gov/cber/products/testkits.htm). The FDA is soon expected to approve a fast-response finger-prick HIV blood test, which requires only a drop of blood and produces results in less than an hour. These rapid tests may be particularly useful for jails in relation to occupational exposure to blood from a source of unknown HIV status, and in follow-up testing of those who have been exposed to HIV. During acute seroconversion, the serum ELISA and western blot are usually negative; whereas the quantitative HIV viral load will be positive, and is the diagnostic test of choice. Approximately 60 or more days after the acute infection, seroconversion should occur. All cases of chronic infection will have a positive HIV ELISA and western blot.
Highly Active Antiretroviral Therapy (HAART) is the standard of care for treatment of HIV infection. There are currently 19 approved antiretroviral agents, each of which has potential side effects and drug-drug interactions. Furthermore, HIV treatment recommendations continually evolve. For these reasons, HIV treatment should be overseen by clinicians with special expertise in this disease.3 A recent listing of HAART doses and side effects and a discussion of the latest antiretroviral drugs can be found in the May 2002 HEPP Report and the November 2001 HEPP Report. An update on HIV treatment news from ICAAC and IDSA will be available in the December issue of HEPP. For the latest HIV treatment guidelines, go to http://hivatis.org/trtgdlns.html#Adult.
The NCCHC/NIJ report recommends a strategy of education and screening to prevent and treat highly prevalent infectious diseases such as syphilis, gonorrhea, and chlamydia. Rapid screening tests are highly recommended, as they reduce the time between testing and the start of treatment, increasing the likelihood that infected patients will be treated before being released.
The CDC recently reported the prevalence of syphilis in women in three correctional facilities in the United States to be 35% of women at intake.4 Figures from the NCCHC/NIJ report are certainly consistent: between 46,000-76,000 inmates were infected with syphilis in 1997. Additionally, the CDC published newly-updated "Sexually Transmitted Diseases Treatment Guidelines" in May 2002, available online at www.cdc.gov/std/treatment/default.htm.5
Patients infected with syphilis may present with symptoms of primary syphilis (ulcer or chancre at the infection site), secondary syphilis (skin rash, mucocutaneous lesions and/or lymphadenopathy), or tertiary syphilis (cardiac, ophthalmic, auditory abnormalities, and/or gummatous lesions). The possibility of HIV infection should be considered whenever syphilis or any other STD is diagnosed. Testing for syphilis is performed routinely in most correctional facilities. A preliminary diagnosis is made by non-treponemal tests such as the Venereal Disease Research Laboratory test [VDRL] or Rapid Plasma Reagin [RPR] test. More specific tests (fluorescent treponemal antibody absorbed [FTA-ABS] and T. pallidum particle agglutination [TP-PA]) are used to confirm infection. Low titer false-positive nontreponemal test results are very common in the setting of HIV infection.
The preferred drug for treating all stages of syphilis is Penicillin G, administered intramuscularly (IM). For late latent syphilis or latent syphilis of unknown duration, the recommended regimen is benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals. Treatment of primary syphilis only requires one dose (2.4 MU IM). Alternative regimens for penicillin-allergic patients can be found at http://www.cdc.gov/std/treatment/default.htm.6
When syphilis must be treated during pregnancy, in a penicillin allergic patient, the recommendation is to desensitize the patient (to penicillin) and then follow the usual penicillin treatment recommendations. This desensitization should take place in a hospital as IgE mediated severe reactions can occasionally occur. Erythromycin is no longer recommended for treatment of pregnant women as it is considered unreliable for cure of the infected fetus.
Presumptive treatment for other STDs is usually carried out in conjunction with treatment for syphilis, since gonorrhea and chlamydia are "fellow-travelers." For all patients, including HIV-infected syphilis patients, careful follow-up of the RPR or VDRL, which should show decline over time, is essential. A decline of two tube dilutions is considered significant and should be seen by three months post-treatment.
Gonorrhea (GC) and chlamydia are highly prevalent in correctional populations - the NCCHC/NIJ report estimates that 18,000 inmates were infected with GC, and 43,000 with chlamydia, in 1997. The CDC report in 1998 documented rates in women of 27% and 8% for chlamydia and GC, respectively.7
Peer-led educational intervention has been proven to work in many communities, and culturally appropriate messages are most likely to be effective, according to the NCCHC/NIJ report. The connection between concurrent STDs and the increased risk of acquiring or spreading HIV needs to be clearly explained to patients to allow them to make informed decisions to protect their health and the health of those they care about.8 Both male and female condoms can be effective in decreasing the transmission of GC and chlamydia. Rapid testing methods are cost- effective and can be invaluable in the prompt diagnosis of chlamydia and GC.
Symptoms of GC and chlamydia-related urethritis and cervicitis can differ for men and women. Among men, asymptomatic infections are common. For women, GC is usually symptomatic, but C. trachomatis is often asymptomatic and can remain so for many years. Woman can present with mucopurulent cervicitis, characterized by a purulent or mucopurulent endocervical swab specimen. Woman can also present with salpingitis or tubo-ovarian abscess. Ligase chain reactions are simple tests than can be performed on urine samples negating the necessity of a pelvic exam in women or a urethral swab in men. These tests are more sensitive than traditional culture techniques for C. trachomatis and are currently the preferred means of detecting this organism. If diagnostic tools (e.g., Gram stain and/or culture) are unavailable, or if patients are unlikely to return for a follow-up evaluation, those with classic symptoms should be considered for empiric treatment for both GC and chlamydia.
Patients infected with N. gonorrhea are often infected with C. trachomatis, leading to a recommendation that patients being treated for gonococcal infection also be treated with a regimen effective against uncomplicated genital C. trachomatis infection. Routine dual therapy without testing for chlamydia can be cost-effective for populations (such as inmates) in which dual infection rates are high (over 10%).
Single-dose regimens should be provided by directly observed therapy (DOT) to ensure adherence. The recommended regimens are ceftriaxone 125 mg IM or cefixime 400 mg po or ciprofloxacin 500 mg po or ofloxacin 400 mg po PLUS azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days. These regimens cover both GC and chlamydia.
According to the Report to Congress, eliminating TB depends heavily on those working in correctional health care. Coordinated care and discharge planning to outside health department or health facilities for continuation of care are paramount in completing care. Thus educational efforts are best directed at health care and correctional staff. Intensified screening, treatment, and containment efforts among prisoners are vital components in the CDC's overall plan to eliminate TB in this country.
Nationwide, the rate of active TB cases in the incarcerated is 10-20 times greater than that in the general U.S. population. An increasing proportion of TB cases in this country are developing among the foreign born. During 2000, a total of 16,377 U.S. cases of TB were reported - 46% of those cases among foreign-born persons.9 Foreign born individuals often pass through correctional facilities if they are detained by the INS or for other reasons. As with STDs, screening for TB is usually routine at intake in jail and prison settings. In addition, correctional health providers should have a low threshold for repeating TB screening procedures during incarceration, so as to prevent repeats of outbreaks of TB in corrections.10 (See the PPD screening HEPPigram in the March 2002 HEPP Report, page 6)
At intake, all inmates should be interviewed and examined for signs and symptoms consistent with active TB: a productive, prolonged cough (a cough lasting for at least 3 weeks), hemoptysis (coughing up blood), fever, chills, night sweats, easy fatigue, loss of appetite, or weight loss. Those showing symptoms should be masked and placed in negative pressure respiratory isolation until active TB can be ruled out. PPD skin testing should be performed on patients with prior negative or unknown results; follow-up tests for individuals who have a positive PPD skin test may include posterior-anterior chest radiographs, sputum-smear and culture examinations. TB screening by PPD is usually repeated annually in prison settings. New PPD conversions may signal TB transmission within the facility.
TB can be difficult to diagnose in individuals infected with HIV, so all HIV-infected persons, regardless of whether they are symptomatic or have a positive skin test, should also be screened with a chest radiograph.11
Treatment consists of regimens that include four drugs at least until drug sensitivity is available. Isonazide, rifampin (RIF), pyrazinamide (PZA), and either ethambutol or streptomycin are first-line agents (for more information on managing TB in corrections, see the March 2002 HEPP Report or http://hivatis.org/trtgdlns.html#Tuberculosis. Pyrazinamide and streptomycin should not be used to treat pregnant women. TB-infected patients who are HIV-positive and are on a HAART regimen containing a PI or an NNRTI may need to receive rifabutin instead of rifampin, and may also require dose adjustments in their HIV medications. HIV infected patients diagnosed with active tuberculosis should be managed by someone expert in management of dually infected individuals as the treatment may become complicated.12,13,14
Since treatment of latent tuberculosis infection (LTBI) can reduce the risk of active TB disease developing by approximately 90%, the CDC and the Institute of Medicine strongly recommend prophylaxis.15 The recommended course is INH daily or twice weekly for nine months. Short course treatments with RIF and PZA or RIF alone can be used in carefully selected and monitored patients. Treatment of LTBI will protect not only corrections but also the communities to which releasees will return.
It is critical that inmates being treated for active TB are on directly observed therapy to ensure adherence to therapy. Inadequate or interrupted treatment can result in relapse, continued transmission, and the development of drug-resistant disease.
Hepatitis A is usually a self-limited illness and rarely requires supportive care. Approximately 33% of adults in the U.S. have evidence of past infection. There is no chronic phase of HAV infection. The most common route of infection is fecal-oral through contaminated food products, and sexual transmission, predominately among men who have sex with men (MSM) and among intravenous drug users. Though usually self-limited, HAV has been associated with severe symptoms, including death, in the elderly (>55 years) and in persons with chronic liver disease. Vaccination is the most effective means of preventing transmission of hepatitis A. Current vaccines include TwinRix (combination vaccine for both hepatitis A and hepatitis B), Havrix, and Vaqta.
The NCCHC/NIJ report estimated that more than 36,000 inmates - an estimated 2% of prison and jail inmates and releasees in 1997 - had current or chronic hepatitis B infection. Inmates released from prison who were HBV-positive represented 12% of the total number of cases in the U.S. Vaccination against the hepatitis B virus (HBV), available since 1982, has led to a decline in the prevalence of HBV in the general population. However, 20 to 80% of U.S. inmates have evidence of past or chronic HBV infection, and 0.8 - 1.4% of inmates acquire HBV while in prison.16, 17, 18 High rates of HBV infection occur in people who have multiple sex partners and share needles (including tattooing), and cellmates of inmates with acute or chronic HBV infection (analogous to household contacts) are also at risk for acquiring HBV. Since HIV and HBV have similar methods of transmission, coinfection is common.
While avoiding contact with contaminated blood, semen, vaginal fluids, and wound exudates is the only way to be completely protected against HBV infection, immunization is also an effective means of preventing infection, particularly among high-risk groups. Therefore, in a forthcoming issue of MMWR, the CDC is expected to recommend that inmates who participate in high-risk behaviors receive HBV vaccine while incarcerated. Recombivax HB and Engerix-B are two HBV vaccines available in the U.S. Needle exchange and clean needle programs are other important interventions that may reduce HBV risk in the community. Simultaneous protection against HBV and HAV can be accomplished with the combination vaccine, TwinRix.
Only 25 - 50% of cases of acute HBV infection are symptomatic; the remainder are asymptomatic or have inconsequential symptoms. After a one-week to six-month incubation period, symptoms include malaise, weakness, anorexia, nausea, vomiting, and right upper quadrant pain. The symptoms abate during the icteric phase (jaundice), lasting for approximately three weeks. The hepatic transaminases peak, and then begin to decline. During the convalescent phase, which may last for up to six months, symptoms completely resolve.
Most persons exposed to HBV have a well-defined immunologic response that results in the resolution of the infection and protective immunity. The first serologic marker of HBV infection to appear is Hepatitis B surface antigen (HBsAg), a protein on the surface of the virus. The antigen usually persists in serum throughout the period of clinical illness, and is commonly used to diagnose acute HBV infection. (Please see the HEPPigram for more information on HBV serologies during acute and chronic infection). The presence of anti-HBsAg, also known as HBsAb, indicates resolution of acute disease and development of immunity. Persistent HBsAg suggests the present of chronic infection.
While there is no specific therapy for acute viral hepatitis (other than supportive therapy), chronic HBV infections can be treated with one of three drugs: Interferon, Lamivudine, or Adefovir. Adefovir (made by Gilead Sciences Inc. and sold as Hepsera) was recently given FDA approval. Tenofovir, approved for use in HIV infection, also has significant anti-HBV activity. Patients with chronic HBV and HIV coinfection are less likely to respond to interferon treatment for chronic HBV infection. When lamivudine is included in an antiretroviral regimen in patients with HIV and HBV coinfection, HBV viral replication is often significantly reduced for the duration of lamivudine treatment.
The June/July 2001 issue of the HEPP Report discusses HBV infection in more depth. Guidelines for treatment of chronic HBV are on the web at www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm.
HCV is the most common blood-borne infection in the U.S, with nearly 4.5 million people infected.19 At least 303,000 - 332,000 prison and jail inmates were infected with hepatitis C in 1997, according to the NCCHC/NIJ report. The 17 to 18.6 % prevalence range of hepatitis C among inmates - which the study states may be an understatement - is 9 to 10 times higher than the prevalence of HCV in the nation's population as a whole. HEPP Report recently reviewed the problem of HCV infection in corrections (March 2002) and new guidelines on the treatment of HCV infection (August 2002).
The HCV test results can be used as an opportunity to educate inmates about the risks for acquiring HCV (if they are HCV negative) and the importance of avoiding alcohol to prevent progression of the disease, if HCV is diagnosed. Education also allows HCV-infected inmates to understand their illness, take better care of themselves, and prevent transmission to others.
All inmates should be evaluated for HCV risk factors; those with HCV risks should be offered testing. Current FDA-approved antibody tests for HCV are highly sensitive and specific (99%), reproducible, and inexpensive.
Most correctional facilities are in the process of developing protocols for triaging HCV-infected patients for treatment. Important changes in the management of HCV infection are reviewed in the August/Sept issue of the HEPP Report. Additional information on treating HCV, including dosing schedules, can be found in the March 2002 HEPP Report. Updated guidelines can be found at http://consensus.nih.gov/cons/116/116cdc_intro.htm. Currently, the best regimen for infected patients appears to be a 24- or 48-week course of the combination of pegylated IFN and ribavirin.
Whereas the NCCHC/NIJ report might seem to suggest that correctional health providers are sending patients home to their communities with infectious diseases, the problem is much more complex. Incarceration concentrates individuals who have had poor access to health care and extensive exposure to communicable diseases. Protocols to address these infections are being developed and many are already in place. Appropriate diagnosis and treatment should be provided, and discharge planning should be included in the overall plan to treat and contain infectious diseases. Improved communication between corrections and city and state departments of health is necessary. One example of this is illustrated by the New York City Department of Health involvement with correctional facilities in its sphere of influence, local departments of health can provide important assistance to correctional facilities by documenting rates of disease in incarcerated individuals and helping to coordinate the continuation of care and tracking of contacts within their communities. Much work remains to be done, of course, but protocols and procedures can be established to enable correctional providers to excel in their roles at the front line of community health.
* Nothing to disclose.
1. Perlmutter, BL, Glaser, JB, and Oyugi, SO. How to recognize and treat acute HIV syndrome. Am Fam Physician 1999 Aug;60(2):535-42, 545-6.
2. Vergis, EN and Mellors, JW. Natural history of HIV-1 infection. Infect Dis Clin North Am 2000 Dec;14(4):809-25, v-vi.
3. Valenti, WM. "The HIV specialist improves quality of care and outcomes", AIDS Read 2002 May;12(5):202-5.
4. CDC, "High Prevalence of Chlamydial and Gonococcal Infection in Women Entering Jails and Juvenile Detention Centers -- Chicago, Birmingham, and San Francisco, 1998," MMWR, Sep 17, 1999 / 48(36);793-796.
5. CDC, "Sexually Transmitted Diseases Treatment Guidelines --- 2002 " MMWR, May 10, 2002/51(RR6);18-33.
6. CDC, "Sexually Transmitted Diseases Treatment Guidelines --- 2002," MMWR, May 10, 2002/51(RR6);18-33.
7. CDC, "High Prevalence of Chlamydial and Gonococcal Infection in Women Entering Jails and Juvenile Detention Centers -- Chicago, Birmingham, and San Francisco, 1998," MMWR Sept 17, 1999/48(36);793-796.
8. CDC, "HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases -- United States Recommendations of the Advisory Committee for HIV and STD Prevention," MMWR, Jul 31, 1998 / 47(RR12);1-24.
9. CDC, "Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations --- United States, 2000," MMWR Feb 8, 2002 / 51(05);101-4.
10. CDC, "Tuberculosis Outbreaks in Prison Housing Units for HIV-Infected Inmates -- California, 1995-1996," MMWR, Feb 05, 1999/48(04);79-82.
11. Am Rev Despir Dis 1990; 142: 725-35.
12. CDC, "Prevention and Treatment of Tuberculosis Among Patients Infected with Human Immunodeficiency Virus: Principles of Therapy and Revised Recommendations," MMWR, Oct 30, 1998/47(RR20);1-51.
13. CDC, "Notice to Readers: Updated Guidelines for the Use of Rifabutin or Rifampin for the Treatment and Prevention of Tuberculosis Among HIV-Infected Patients Taking Protease Inhibitors or Nonnucleoside Reverse Transcriptase Inhibitors," MMWR, Mar 10, 2000/49(09);185-9.
14. CDC, "Notice to Readers: Acquired Rifamycin Resistance in Persons with Advanced HIV Disease Being Treated for Active Tuberculosis with Intermittent Rifamycin-Based Regimens," Mar 15, 2002 / 51(10);214-5.
15. Geiter, L. (ed.) Ending Neglect: The Elimination of Tuberculosis in the U.S. National Academy Press; ; 1st edition (Sep 15, 2000).
16. Sylvan S. Who spearheads global initiative to eradicate hepatitis B: Lakartidningen 2000 August 30;97(35):3738-40.
17. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Nov 1991;40(RR-13); 1-19.
18. Bader, TF: Hepatitis B in prisons. Biomed Pharmacother 1986;40(7):248-51.
19. CDC, "Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease," MMWR, Oct 16, 1998/47(RR19);1-39.
021010
HEPP2002-1001
©1997,1998,1999,2000,2001,2002. 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.
AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, Elton John AIDS Foundation, iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2002. This material is designed to support, not replace, the relationship that exists between you and your doctor.
AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1980, 2002. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content.
