Approximately one-third of hepatitis C- (HCV) infected persons in the United States passed through jail or prison facilities in 1997. In some states, the prevalence of chronic HCV infection among incoming prisoners is as high as 49% (see Table 1). Correctional healthcare providers are on the front line in the diagnosis and management of HCV in this country.
I am reminded of the problems addressed in this issue of the HEPP Report every time I visit the inpatient ward of my facility. Several of our ID clinic patients have become long-term residents of that ward, simply because their liver disease cannot be safely managed in the outpatient correctional setting. I have had to revisit published literature in order to learn to manage these patients more effectively.
Infections caused by methicillin resistant Staphylococcus aureus (MRSA) have long been a problem in hospitals and nursing homes. Over the past decade, MRSA has also emerged as a cause of skin and soft tissue infections in the community.
In 1988, the World Health Organization established World AIDS Day to focus global attention on HIV/AIDS. Although there have been some successes, 15 years later the pandemic continues to spread virtually unabated in much of the developing world.
Prior to the advent of Highly Active Antiretroviral Therapy (HAART) in 1996, opportunistic infections (OIs) were an inevitable complication of HIV infection, particularly in those patients with a CD4 count of less than 200 cells/mm3. Because of the considerable morbidity and mortality associated with OIs, medical research identified and developed drugs that were active against many of the infections that complicate AIDS.
As AIDS therapy marches into the new millennium, we have witnessed a dramatic decrease in AIDS mortality and a corresponding increase in the number of patients living with AIDS. There is no doubt that Highly Active Antiretroviral Therapy (HAART) has benefited HIV-infected persons over the years, however the number of AIDS cases is still high and opportunistic infections (OIs) are still a common occurrence, particularly in the correctional population.
Prior to the advent of Highly Active Antiretroviral Therapy (HAART) in 1996, opportunistic infections (OIs) were an inevitable complication of HIV infection, particularly in those patients with a CD4 count of less than 200 cells/mm3. Because of the considerable morbidity and mortality associated with OIs, medical research identified and developed drugs that were active against many of the infections that complicate AIDS.
A 35-year-old female prisoner presented to the infirmary with a complaint of fever and 22-pound weight loss. She denied cough, nausea, emesis, headache, diarrhea, skin rash, or recent change in medication. She stated that she had received treatment for tuberculosis several times over the past ten years, none by directly observed therapy (DOT). She states that she has never completed more than six consecutive months of treatment.
Last year, a group of segregated HIV-infected inmates filed a class action lawsuit against the Limestone Correctional Facility in Alabama. Their complaint - unconstitutional medical treatment and living conditions - paints a disturbing picture of gross neglect and poor medical care. The controversy surrounding this lawsuit has focused new attention on the issue of clustering, or grouping or segregating HIV-infected inmates to provide specialized treatment and management.
This month's issue focuses on sexually transmitted diseases (STDs) in jails. STD control is an issue in its own right as well as a measure to prevent the spread of HIV.
Correctional environments are increasingly being recognized as settings in which society's infectious diseases are concentrated. Most studies on infectious disease in correctional facilities address prisons, but infectious diseases are even more prevalent in jails. In particular, sexually transmitted diseases (STDs) may be more common in jail settings than in prisons, as inmates who are sentenced and sent to prison will typically have been in jail long enough to have been diagnosed and treated for some STDs.
A 27-year-old male presents to the prison infirmary with penile pain. He reports having had the pain for the past three days, ever since accidentally catching part of the skin of his penis in his pants zipper. The patient reports previous good health. He is mildly developmentally delayed and has bipolar affective disorder for which he takes Depakote. The patient arrived at this facility one week ago and is newly incarcerated. He denies any sexual activity since he arrived.
Because most of us who practice medicine in correctional facilities are currently prohibited from providing our patients the tools for PREP (pre-exposure prevention), it is our responsibility to be well versed in PEP (post-exposure prophylaxis) for potential bloodborne pathogen exposures. In this month's HEPP Report, Drs. Anne De Groot and Roland Merchant provide an excellent overview of this important topic.
HIV transmission is believed to be a rare consequence of blood or body fluid exposures in the correctional setting. However, if transmission occurs, the consequences are permanent and potentially deadly. Likewise, hepatitis C and hepatitis B transmission can lead to lifelong illness and sometimes a shortened life expectancy. Fortunately, post-exposure interventions that might reduce the transmission risk, and thereby diminish the consequences of an exposure, do exist and appear to be effective.
An inmate reports being raped (anally penetrated) by another inmate and is sent to a local emergency department (ED) within two hours after the assault. The assaulted inmate denies any past or current injection drug use (IDU) or sex with men (except the assault) and recently tested negative for HIV infection; the hepatitis B virus (HBV) and hepatitis C virus (HCV) serostatus is unknown. The assailant is a previous injection drug user. He is known to have chronic HBV and HCV infection, however his HIV status is unknown.
In this month's main article, Dr. Peter Piliero discusses mitochondrial toxicity, which is responsible for many of the long-term complications of antiretroviral therapy. These complications, along with the development of viral resistance, are the primary reasons for delaying the initiation of antiretroviral therapy in HIV-infected patients.
Soon after the introduction of the first antiretroviral (ARV) agent, zidovudine (AZT), drug-related toxicities became recognized and well-characterized. Things have since become more complicated; there are now 17 ARV agents in four distinct classes. This has led to both decreased morbidity and mortality from HIV infection due to immune reconstitution and viral suppression, and increasing recognition of both acute and long-term toxicities of ARV therapy (ART). Most clinicians agree that the benefits of ART generally outweigh the risk; however, patients who experience significant side effects sometimes disagree with this.
The sudden global emergence of Severe Acute Respiratory Syndrome (SARS) has sickened over 8,000 individuals, crippled health care delivery, and has had a devastating impact on the economy. The causative agent, a novel Coronavirus, is not previously known to cause disease in humans. Thus far, no specific treatment, vaccination or reliable and readily available diagnostic tests are available. Exactly where we are in the course of this epidemic is not yet clear.
Case presentation and discussion by Stephen Tabet, MD, MPH, Assistant Professor of Medicine, University of Washington, and Director, Northwest Correctional Medicine Education Program. A collaboration with the Northwest AIDS Education and Training Center, with Stephen Tabet, MD, and Kate Willner, trainer.
This month we have two substantive articles vital to all correctional providers. Dr. Joseph Bick gives a practical, erudite explication of providing palliative and end-of-life care in correctional facilities. Likewise, Dr. Stephen Tabet presents a case study of a patient with AIDS and widely metastatic lung cancer who has decided he does not want chemotherapy but is concerned about pain.
During the past decade, this country has witnessed an increased emphasis on pain management and palliative care. Clinicians are being encouraged to more effectively alleviate pain in terminally ill patients, and there has been an intensified effort to encourage individuals to establish advance directives such as resuscitation status, living wills, and power of attorney.
A 52 year-old African-American male inmate with Class B2 AIDS (CD4 cell count 421, HIV RNA 5,790) was diagnosed with widely metastatic non-small cell carcinoma of the lung. He is currently taking multivitamins, citalopram (Celexa), and doxepin. He is being followed for depression by the psychiatrist at the prison. The patient was seen by a community oncologist who explained treatment options and the prognosis.
The Society of Correctional Physicians (SCP) held its semiannual meeting in Baltimore, Maryland, on April 10. The theme, Correctional Care of Infectious Diseases and Mental Health Issues, attracted experts willing to share recent developments with the audience of correctional physicians.
As I contemplate the April HEPP Report articles, I have come to the conclusion that we could not have chosen two more controversial and current issues in health care today - the treatment of HCV infection in prisoners and the administration of smallpox vaccine to health care professionals.
As guidelines for the diagnosis, evaluation and treatment of chronic hepatitis C virus (HCV) emerge in the community at large, correctional medical communities are wrestling with the challenge of establishing an appropriate and consistent response to an epidemic that disproportionately affects incarcerated populations. Controversies regarding the management of HCV are brought to a head in jails and prisons, where there is a high prevalence of disease (12-35% according to Centers for Disease Control (CDC) estimates1) and a legal obligation to provide access to medical care.
While our nation's jails and prisons might appear to be a safe place to be to avoid the potential health risks associated with smallpox, this may not be the case. Many correctional employees serve as reservists in the military, while others are being trained to diagnose or treat individuals who are suspected of having smallpox. Both groups are among those who may be vaccinated against smallpox, which should be of concern to those providing health care to immunocompromised inmates. Transmission of the virus used for smallpox vaccination is a well-recognized phenomenon that can lead to devastating consequences in those with underlying medical disorders. This article is intended to provide a brief summary of what those responsible for correctional health care need to know about smallpox vaccination.
This issue of HEPP focuses on the 10th annual Conference on Retroviruses and Opportunistic Infections (CROI) held February 10-14 in Boston. The meeting opened with a well thought-out and charismatic speech on HIV, politics, and citizenship in the world by former President Bill Clinton. Clinton's accurate quotations of HIV statistics and grasp of the world AIDS problem was mind-boggling and inspiring. Clinton spoke of work that his own foundation is doing throughout the world to fight AIDS. He also praised President George W. Bush for pledging $15 billion dollars to help fight AIDS in the highest prevalence countries. Clinton did caution that systems need to be in place to ensure that countries that receive funding are prepared to spend it effectively.
The Conference on Retroviruses and Opportunistic Infections (CROI), despite its awkward and outmoded name, has become the most important venue for the dissemination of results from HIV-related research in the U.S. and, arguably, the world.
In addition to providing data on new antiretroviral agents in existing classes, the 10th Conference on Retroviruses and Opportunistic Infections (CROI) also featured information on novel therapeutic agents. All but one approved drugs for treating HIV currently target one of two viral enzymes (reverse transcriptase and protease); data was presented on new classes of agents that target other viral processes as well.
Despite the large impact HIV/AIDS is having on correctional populations - and the increasing attention this issue is receiving - only one oral session and one poster at the conference addressed HIV/AIDS among inmates.
In my infectious diseases referral clinic in a state prison in California, at least once a week I encounter a patient who has a chronic medical condition for which no treatment was pursued prior to incarceration.
Incarcerated persons are a population long recognized as being at higher risk for tuberculosis (TB) than the general population. Of the 15,989 reported cases of active TB in the U.S. in 2001, 3.3% were in residents of correctional facilities at the time of diagnosis.
A diverse group of correctional health care professionals from prisons and jails, federal representatives, academics, hepatitis C experts, lawyers, and public health advocates gathered recently for a key meeting on managing hepatitis C in prisons ("Management of Hepatitis C in Prisons 2003," January 25-26, 2003, San Antonio, Texas).
At the dawn of the last decade, there was only one FDA-approved medication for the treatment of HIV infection. The benefits of monotherapy with AZT were temporary at best, and the life expectancy for patients with CD-4 counts of <50 was less than 1 1/2 years.
The combination of incarceration and chronic illness can be a potent formula for mental health disorders. Even without the burden of a chronic infectious disease, inmates have a high prevalence of mental illness.
A 32-year-old female is admitted to the local jail. She is known to be HIV-infected and to have bipolar disorder. She is manic, paranoid and refuses to be examined.
The FDA approved a new "extended release" version of Bristol-Myers Squibb's Zerit (d4T, stavudine). The new formulation, which will be marketed as Zerit XR, has been shown to maintain measurable plasma concentrations in patients for 24 hours following the once-a-day dose.
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