When HIV Meds Are Locked Up: The Challenge of Adherence in Jails and Prisons

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From The Body:


Kerry Thomas already knew that he was HIV-positive when he entered the Idaho State Correctional Center (ISCC) in Boise. So did prison officials, both from his health records from a previous prison term and from the publicity of his HIV criminalization case. When he arrived, however, prison medical staff said that they did not have his antiretroviral medications and were unsure when they would be able to provide them.

Fortunately, Thomas maintains a good relationship with his doctor in the outside community, a connection not dampened by his imprisonment. He called his doctor to ask if he would send his medication to the prison until its clinic could provide it. In response, the doctor called the prison and asked why Thomas was not being provided his medication. Half an hour later, Thomas was called into a prison office and, he recalled, “somewhat reprimanded because I called my doctor in the community versus just waiting.” But his call worked. “They were motivated from that point on to have the medication.”

In Rhode Island, Dr. Timothy Flanigan, a professor of medicine at Brown University’s Alpert Medical School, developed the HIV Core Program, which provides care to people with HIV in that state’s prison system and links them to community-based resources upon release. He has seen people enter prison with the name and phone number of their pharmacy memorized, enabling the prison’s nurses to call and confirm the medications immediately. “It’s important to know where you got your meds and the phone number of the pharmacy,” he emphasized. Otherwise, patients may experience a gap in medications.

In many U.S. jails and prisons, people with HIV face similar institutional obstacles in adhering to medication regimens. Thomas described the ISCC process for refilling prescriptions: “You get a 30-day supply of the medications. Then, for the last 10 to 14 days left on the medication, you submit a request to let the clinic know that you’re almost out.” But medical staff do not always order a refill before those 30 days are over. When that happens, Thomas explained, the patient must put in a request for a medical visit, a process known as “sick call,” which can take up to 48 hours. At sick call, the nurse refers to the patient to a medical provider, which takes another week. When the patient sees the provider, he is often told: “Your prescription has expired. We’ll have to reorder it.” Then he must wait another several days before his order comes in.

The result, said Thomas, is “almost a two-week turnaround.”

Gaps in medication can have significant consequences. Missed doses can lead to the development of drug resistance, which can make HIV treatment ineffective. Even if they don’t result in resistance, treatment lapses can make it difficult to maintain undetectable viral load. One benefit of an undetectable viral load is a drastic reduction in the likelihood of transmission of HIV to others, which could make it a vital HIV prevention strategy in the vast majority of prisons and jails that ban safer sex and injection equipment.

Idaho’s prison medication delays are not unique. New York’s prisons have the highest concentration of HIV-infected people in the country, amounting to 17% of all people with HIV in state prisons nationwide. In 2009, New York passed the Department of Health (DOH) Oversight of HIV/HCV Bill, requiring the DOH to annually review HIV and hepatitis C care in state prisons, publicly report its findings and mandate improvements so that prison health care mirrors community standards. The DOH found that approximately half of all prisoners with HIV in New York State correctional facilities had not been identified by prison staff. Furthermore, of those identified, only 75% were receiving treatment. But, as Thomas’s experience shows, being on the treatment list is no guarantee of uninterrupted adherence. The Correctional Association of New York, which monitors prison conditions, found that a “significant portion” of the people they surveyed had concerns about getting their medications on time, including one person who, four times within a six-month time period, was forced to go without medications for a week, and another who experienced a four-month interruption.

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