Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date. Dear Correctional Colleagues:
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. By 1996, however, antiretroviral combinations that included protease inhibitors led to a dramatic decline in the number of HIV-associated deaths in the United States. At the California Medical Facility in the California Department of Corrections, there were half as many HIV-related deaths in 1996 compared to 1995, an experience repeated in jails and prisons throughout the country. There are now 16 different FDA-approved agents available for the treatment of HIV, providing an opportunity for prolonged, productive lives for many of those infected with HIV.
As deaths due to HIV disease declined, those attributable to the sequela of chronic HCV increased. Now, recent advances in the treatment of chronic HCV raise hope for improvement in liver histology, delayed progression to end-stage liver disease, and perhaps, in some cases, actual cure from HCV.
Not everyone has benefited from the tremendous advances in HIV and HCV treatment witnessed over the past 10 years. Successful treatment outcomes demand rigorous adherence to therapies that can cause uncomfortable and sometimes life-threatening side effects. Strict adherence is difficult for even highly motivated, well-educated, mentally healthy individuals. The prevalence of mental illness among the currently and formerly incarcerated is strikingly high. Those of us working in correctional public health see firsthand how the co-morbidity of mental illness can negatively impact on the successful treatment of HIV and chronic viral hepatitis.
In this issue of HEPP Report, Dr. Robert Canning provides an excellent review of the challenges facing correctional public health clinicians who treat those with mental illness and other disorders affecting cognition. Dr. Eric Avery reflects on his personal experiences as a psychiatrist treating inmates in the Texas Department of Criminal Justice. And our "Ask the Expert" section features Dr. Karl Brown from Rikers Island Jail discussing a challenging case of a bipolar inmate co-infected with HIV and HCV provided by Dr. Frederick Altice of Yale University's AIDS program.
At the conclusion of this issue, readers should have a better understanding of typical mental disorders encountered by clinicians in the correctional setting, be aware of some useful screening methods for the presence of mental and cognitive disorders, and be familiar with some of the complexities of treating patients with coexisting HIV, HCV, and mental illnesses.
Joseph Bick, M.D. - Co-Chief Editor
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