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HIV in correctional settings is beginning to infiltrate our nation's political theater. In response to this new development, the National Commission on Correctional Health chose prominent political leader Reverend Jesse Jackson Sr. to open this year's National Conference on Correctional Healthcare (NCCHC), held September 9-13 in St Louis, Missouri.
NCCHC is the largest nationwide educational gathering of physicians, nurses, dentists, psychiatrists, psychologists, other health care professionals, administrators, attorneys, and others working in prisons, jails, juvenile confinement, and detention facilities. Participants had an opportunity to meet and network with experts as they discussed current correctional health issues. Recent developments in the management and treatment of HIV were featured in a special track of programs throughout the conference.
Illustrating correctional health care's most popular issues, the pre-conference seminars featured NCCHC's standards and mental health care guidelines, an introduction and an advanced look at quality assessment, practical preparations for NCCHC accreditation, and measuring outcomes of HIV interventions.
One way of measuring the potential success, or outcome, of an intervention is to count the number of individuals who volunteer to participate. Based on that measure, the HIV Behind Bars 2000 was a success: attendance at the annual symposium increased this year to more than 140 individuals, most of whom stayed for the entire 4 1/2 hour session.
The focus of the symposium was on "measuring outcomes." Previous "HIV/AIDS Behind Bars" sessions have described components of HIV management (from intake to discharge planning) and models of care. This year, following up on a challenge issued by organizer Anne De Groot at the 4th annual symposium (Ft Lauderdale, 1999), correctional providers who had performed an HIV management intervention in a correctional setting and had measured the impact of that intervention were invited to present their results.
What are outcomes studies? In the HIV/AIDS arena, outcomes research attempts to measure the impact of HIV management interventions on clinical and economic outcomes. Clinical outcomes are the clinical events and progression of HIV disease that occur in clinical practice, and economic outcomes are the economic events and progression of resource use in HIV disease that occur in clinical practice.1
Outside corrections, researchers have asked some hard questions about HIV treatment and outcomes. For example, given that the lifetime cost of HIV treatment averages $149,000 (starting at a count of 500 CD4 T cells2) or from $10,000 to $20,000 per year of life gained, researchers have compared this investment to other healthcare investments. As it turns out, HAART is less expensive, per year of life gained, than mammography ($40,0000) and much less expensive than coronary artery bypass (see Fig 1.) In fact, one notable (but less widely disseminated) outcome of HAART appears to be that the predicted lifespan of an individual on HAART with CD4 T cells > 100 is on par with the lifespan of an age-matched peer who is HIV-seronegative!3 Thus HAART lengthens lifespan more than most other medical interventions.
Other outcomes research has evaluated the impact of HAART and/or skilled HIV care on hospitalizations and the incidence of opportunistic infections, which is more in line with correctional budgetary concerns. HAART has clearly been shown in a number of studies to reduce the development of opportunistic infections4 and reduce costs associated with treating these infections. Therefore, most economic outcomes evaluations of HAART have reported that the increased cost of treatment was balanced by a reduction in expenses associated with hospitalizations and specialty consultations for opportunistic infections. Furthermore, care by experienced HIV/AIDS physicians has been shown to result in two thirds fewer hospital bed days and fewer specialty consultations than care by control (non-experienced) providers. This is most likely due to the specialists' ability to prevent illnesses and toxicities in their patients. Outcomes studies have also reported on the cost-effectiveness of interventions for opportunistic infections in HIV/AIDS patients. For example, treatment of PPD positive, HIV-infected individuals is an extremely cost-effective intervention. By providing $36 of medication per patient (INH, 300 mg PO QD for one year) TB cases can be reduced to neglible proportions (36% reduction).5
Other researchers have queried whether HAART prevents other budgetary outlays, such as hospitalization costs and treatment of opportunistic infection costs. Indeed, HAART results in a net savings, especially in terms of hospitalization costs, in studies conducted outside corrections.6.
However, as we're well aware, studies conducted in community settings are only an approximation of conditions for HIV-infected patients behind bars. What information is available for correctional settings, where the distribution of costs may be significantly different from the outlay that communities experience in providing HIV care?
The good news is that outcomes studies are being funded and performed in correctional settings and there is a new recognition of the importance of measuring the impact of an intervention (See Spotlight, Page 7). The bad news is that few outcomes studies have been performed and results are, as yet, unavailable for the largest of these studies. The HIV Behind Bars 2000 symposium featured presentations by a few "interventionists" who reported their results.
A number of the HIV "stars" of correctional medicine spoke at the HEPP symposium. Dr. David Thomas, Medical Director of the Florida Department of Corrections, Dr. Joe Bick, Medical Director of the HIV/AIDS facility at Vacaville, California, Dr. David Paar of Texas Department of Criminal Justice, and Dr. Lou Tripoli, Medical Director for Correctional Medical Services, all presented information on HIV-related interventions in their systems. Dr. Joseph Paris, Medical Director of the Georgia Department of Corrections moderated the symposium with characteristic tact and diplomacy, provided expert audiovisual support, and reported on outcomes measures for his state.
In keeping with the theme of the HEPP symposium, many other speakers at NCCHC addressed research in correctional settings. Steven Spencer, Jaye Anno, and Joseph Paris presented on "Emerging Research Topics/Issues in Correctional Health Care." Anno noted that correctional healthcare providers are 20 years behind other medical groups in terms of knowledge of our patients. Paris noted that there are unique medical issues in corrections with which community clinicians do not have to contend. Spencer sees an overall change in the trends of correctional research from measuring prevalence of certain conditions to actually measuring outcomes of corrections-based interventions.
Anno, Spencer, and Paris urged corrections physicians to conduct research concerning: inmate co-pay systems, obesity, dietary management (heart-healthy diet versus normal diet), conditions of confinement (such as the impact of having athletic facilities), the health needs of women, the impact of mental health problems on healthcare, dental needs, women's use of health services, parenting issues, and lastly, data management. Anno closed by addressing the fact that many correctional physicians claim that obstacles to care include insufficient staff, time, money, and commitment.
She asked the probing question, are these barriers or excuses?
There is much to do in the field of outcomes measures in correctional settings. As Jaye Anno noted, we as correctional healthcare providers know very little about our patients as a whole. We have seen, however, many promising HIV care interventions, and are learning which ones work best. Furthermore, judging by the number of participants at our NCCHC meeting, outcomes research is of increasing interest to our colleagues. For more information on grants for outcomes research, see our resources on page 8.
For a complete listing of the sessions or more information, contact the NCCHC at ncchc@ncchc.org.
* Consultant: Agouron Pharmaceuticals, Bristol-Myers Squibb
Speaker’s Bureau: Agouron Pharmaceuticals, Bristol-Myers Squibb, Glaxo Wellcome
1. Moore R. Cost-Benefits of Antiretroviral Therapy. The Brazil/Johns Hopkins University HIV/AIDS Conference October 20, 21 and 22, 1999, Rio de Janeiro. http://www.hopkins-aids.edu.
2. Moore, RD, Chaisson, RE, "Costs to Medicaid of advancing immunosuppression in an urban HIV-infected patient population in Maryland," J Acquir Immune Defic Syndr Hum Retrovirol 1997 Mar 1;14(3):223-31.
3. Justice A. CHORUS HIV Cohort. 39th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco September 25-29, 1999. Abstract 1158.
4. Gallant JE, McAvinue SM, et al., "The impact of prophylaxis on outcome and resource utilization in Pneumocystis carinii pneumonia," Chest 1995 Apr;107(4):1018-23.
5. Moore R. Cost-Benefits of Antiretroviral Therapy.
6. Gebo KA, Chaisson RE, et al., "Costs of HIV medical care in the era of highly active antiretroviral therapy." AIDS 1999 May 28;13(8):963-9.
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©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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