A. Immediate clinical management issues

Inmates newly diagnosed with HIV infection should be provided with the following as soon as possible:

• HIV prevention counseling.
• Referral for mental health support as indicated.
• Medical evaluation including staging of HIV infection and diagnosis of co-morbidities and opportunistic infections.
• Referral to an HIV provider or specialist depending on the HIV provider’s experience, the stage of HIV, and complexity of medical issues.
• Expedited care may be necessary for special clinical circumstances including acute HIV infection, HIV infection with an acute opportunistic infection, and HIV infection during pregnancy.

Information on HIV/AIDS treatment, prevention, and research can be found at the National Institute of Health’s AIDS info.³²

1. Medical evaluation

The medical evaluation should begin immediately by the medical provider, prior to the first appointment with an HIV provider. Start the evaluation promptly upon diagnosis so that information related to HIV stage and the presence of other co-morbidities can be gathered to expedite the appropriate care of the individual.

A list of the diagnostic and screening tests that should be considered on an individual newly diagnosed with HIV infection is available from the HIV Medicine Association of the Infectious Diseases Society of America. (See HIV Medicine Association (HIVMA).)³³

At a minimum, the medical provider should order a CD4 count and an HIV viral load to allow for staging of HIV infection. These results will determine the need for antiretroviral therapy and for prophylaxis against opportunistic infections. Review the test results, in conjunction with an HIV provider if necessary, prior to the inmate’s evaluation by the HIV provider in order to identify and address any immediate clinical needs and determine if a referral to an HIV specialist is needed.

Additional clinical resources for health-care professionals can be found at the National HIV/AIDS Clinicians’ Consultation Center.³⁴ A HIV consultation “warmline” for physicians is also provided at 1-800-933-3413.

2. Immunizations for HIV-infected inmates

The current CDC-published Recommended Adult Immunization Schedule–United States, October 2007–September 2008³⁵ includes recommendations for adults with HIV infection.  Initiate the hepatitis B immunization series for persons who are non-immune to facilitate completion of the vaccination series. Consider an accelerated schedule if the inmate will be released in less than six months.

3. Special circumstances

Medical providers need to be aware of several clinical circumstances that warrant expedited medical evaluation by an HIV provider or specialist. These may include:

Acute HIV infection

Acute infection can present diagnostic challenges since antibody tests may be negative or indeterminate. Persons with acute HIV infection may present with symptoms of “acute retroviral syndrome,” which is often characterized by fevers, pharyngitis, and lymphadenopathy although the symptoms can vary and many persons with acute infection may be asymptomatic. HIV nucleic acid testing (e.g., plasma viral load) can be used to assist in the diagnosis of acute HIV infection when antibody testing is negative or indeterminate. It is important for clinicians to recognize acute HIV infection given the increased infectiousness of a person during this time. During the acute phase, circulating levels of HIV are many times greater compared to a person with chronic infection. High levels of circulating virus lead to increased rates of HIV transmission between the inmate and sexual and needle-sharing partners. If an inmate is suspected of having acute HIV infection, the physician should immediately refer the inmate to an HIV provider or specialist to confirm the diagnosis and for further evaluation.

Acute opportunistic infection

Inmates may already have advanced HIV disease, which puts them at risk for opportunistic infections. If there is evidence of an opportunistic infection, the physician should refer the inmate to an HIV provider as soon as possible.

Signs and symptoms of HIV opportunistic infections may include (but are not limited to) shortness of breath, cough, diarrhea, swollen lymph nodes, persistent or high fever, focal neurological signs, altered mental status, visual complaints, pain or difficulty upon swallowing, and abdominal pain.

Pregnancy

All females diagnosed with HIV should have a pregnancy test completed at the initial evaluation. Pregnant inmates who are infected with HIV should be referred to an HIV specialist. Initiation of antiretroviral therapy is indicated (regardless of the inmate’s CD4 count at the time) with the woman’s consent to minimize the risk of mother-to-child HIV transmission. Prevention counseling should be initiated and the inmate should be linked with custody-based or community-based HIV care.

B. Linkage to appropriate medical care

1. During incarceration

Health care, including access to antiretroviral medications, should be made available to all HIV-infected inmates. After the immediate clinical issues are addressed, the inmate should be scheduled with a provider with HIV experience for initial assessment and to provide routine follow-up. If possible, the initial visit with an HIV provider should be face to face. Depending on the inmate’s medical complexity, the stage of HIV infection, the need for antiretroviral therapy, and the initial HIV provider’s level of expertise, referral to an HIV specialist with more advanced training may be warranted initially or later in the course of disease as clinical circumstances change.^36,37,38,39

HIV specialists may not be available on site in every facility, so arrangements may have to be made for specialized HIV care when needed. The HIV specialist can be a correctional system employee, a contract provider, or a provider within the community. Consultations with the inmate and specialist can be conducted face to face, or via telephone, telemedicine, or video conferencing, depending on clinical need and available resources. Since many facilities do not have an HIV specialist on site, it remains important that all health-care providers have HIV resources and ongoing education available.

2. Upon release from custody

When HIV -infected inmates are released to the community, it is important to link them to medical services in the community. The transition for prisoners from confinement to community is often chaotic and difficult, and health-care concerns often assume a lower priority than housing and food, employment, mental health and substance abuse treatment, and childcare. If such immediate needs are not met, there is less chance that HIV-infected inmates will make it to or stay engaged in follow-up medical care,⁴⁰ much less maintain any of the health advances achieved during confinement.^41,42 There is also evidence that discharge planning programs may reduce the rate of recidivism.⁴⁰,^43,44,45 Although there are inherent challenges and resource limitations, efforts should be made by both custodial and medical staff, ideally as a joint team, to address as many re-entry needs as possible.

• Develop a list of medical providers in the community to which the inmates will be returning.
  • Many states have resource manuals listing HIV care providers.
  • Contact your local or state health department for assistance with locating providers who are willing to accept uninsured persons.
  • Most HIV-infected inmates will qualify for free or low-cost medical treatment at clinics federally funded through the Ryan White HIV/AIDS Treatment Modernization Act of 2006.⁴⁶
• Assist the inmate with scheduling an appointment with the community care provider. If possible, allow the community care provider to visit the inmate before release. Research has shown that face-to-face contact before release results in increased likelihood of continuity in the community.⁴⁷ Having the inmate talk to a provider, a nurse, or a counselor at the follow-up clinic may help with concrete linkage to services. If appointments cannot be made in advance, make walk-in arrangements with clinical providers.
• Provide the inmate with date, time, and location of first post-release appointment in writing. Stress to inmates the importance of attending their first scheduled appointment in the community, and the appointment should be as early as possible after release.
• Provide the inmate with a copy of the relevant medical record or clinical summary free of charge. Alternatively, send information to the community provider after obtaining written consent for release of information from the inmate.
• Collaborate with state and local offices administering benefit and entitlement programs to facilitate pre-release applications and benefit reinstatements. Some correctional systems have arranged partnerships to allow processing of Social Security Administration (SSA) and Medicare applications before release, as recommended by the SSA and the Centers for Medicare and Medical Services.
• Complete applications for medical services in conjunction with the inmate.

C. Linkage to HIV case management services

Some communities will have agencies that provide HIV case management services to inmates. These agencies can help HIV-infected inmates with accessing services after they are released and may be able to assist with pre-release planning as well.

• Collaborate with local agencies to develop a list of available agencies that provide HIV case management for released inmates.
• Provide inmates with contact information for local AIDS service organizations and the local health department.
• Assist inmates with making appointments with case manager before release from custody. If possible, arrange for the inmate to meet the case manager before release, or schedule an appointment with the case manager as soon as possible after release.
• Complete applications for other services following release in conjunction with the inmate.

D. Provision of HIV medications

Inmates who are taking HIV medications should continue taking their medications after release from custody, unless a community HIV care provider advises otherwise. Since interruptions in HIV therapy can increase the chance of HIV resistance to the medications, correctional facilities should dispense enough medication upon release to bridge the gap until the patient can see a community HIV provider.

• Follow your state’s regulations concerning provision of HIV medications to released inmates. This will allow inmates to continue on their medications until they are able to access services in the community.
• Explore with state agencies or drug manufacturers the feasibility of accepting applications for provision of HIV medications before release. This will facilitate continuation of access to medications in the community.
• Inform inmates that all medications should be taken as prescribed.
• Inform inmates how to get emergency supply of medications to avoid a lapse in HIV therapy.

E. Partner Services and disclosure

Partner Services (PS) is the process of informing past and present sexual and/or needle-sharing partners of HIV-infected individuals that they may have been exposed to HIV. It is a confidential service created for persons who are infected with HIV to have their partners notified of a possible exposure. PS activities for persons with HIV include assessing medical and social service needs, facilitating linkages to community resources, eliciting partners, developing a plan to locate and notify partners, and offering testing to the partners. Benefits for notified partners include education on HIV/AIDS prevention, risk behavior and risk reduction strategies, and referral and access to HIV testing so that they may learn their HIV status. If a partner tests positive for HIV, he or she can take advantage of health-extending therapies, learn to protect themselves from further exposure to HIV and other STDs, and learn how to prevent exposing others to HIV.

PS has three main purposes:

• To prevent HIV transmission;
• To identify new infections; and
• To assist persons with HIV and their partners in accessing needed services.

PS, which is usually carried out by the state or local health department, plays a vital public health role in breaking the cycle of HIV transmission. In many states, a state health department disease intervention specialist (DIS) will meet with the individual after an HIV diagnosis to gather information concerning sex and drug-using partners. In some states, prior to any partner notification, screening for domestic violence for each partner is conducted to ensure the safety of the individual who is infected with HIV. DIS officers attempt to locate all identified partners in order to notify them of a possible exposure to HIV and to offer HIV counseling, education, and testing. Some states have mandatory reporting of known partners, and statutes in most states provide PS programs confidential access to persons with HIV and other STIs. Consult with your state or local health department on how to refer HIV-infected inmates to PS. In correctional facilities that permit conjugal visits, PS and partner notification can be incorporated into the program.

Special considerations for correctional settings

•  HIV-infected inmates may be unwilling to reveal their sex and drug partners to health-care staff who are employed by the correctional facility since partners may include another inmate or correctional staff member. Therefore, inform inmates verbally or via written material about partner notification options that are available that do not involve correctional staff.
• Provide private space for PS staff to conduct interviews with inmates for partner elicitation and counseling to take place.
• If the inmate is transferred or released from the facility before their confirmatory tests results are available, PS program staff can assist in notifying the inmates of their test results.

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