Decrease in AIDS-Related Mortality in a State Correctional System -- New York, 1995-1998

The New York State Department of Correctional Services (NYSDOCS) administers one of the largest prison systems in the United States, with a population of approximately 70,000 inmates; in 1995, blinded seroprevalence studies indicated that an estimated 9500 inmates were infected with human immunodeficiency virus (HIV) (1). This report summarizes an analysis of death records of inmates, which indicate a substantial reduction in the acquired immunodeficiency syndrome (AIDS)-related deaths from 1995 through 1998 and describes the programs that may have contributed to this decline.

Cause of death was determined by comparison of death and autopsy reports by an analyst in New York and was confirmed by a second analyst. The first AIDS-related deaths occurred in the NYSDOCS prison system in 1981 (Table_1). Although the number of AIDS-related deaths continued to increase until 1995, most of the increase after 1985 reflected increases in the size of the prison population; the AIDS-related death rate was relatively stable. During the early 1990s, approximately two thirds of deaths occurring among inmates were AIDS-related. From 1990 through 1995, AIDS-related death rates averaged 36.4 per 10,000 inmates (range: 32.5-40.7). This rate declined to 26.3 per 10,000 inmates in 1996 and 8.6 per 10,000 inmates in 1997 (the first year since 1988 that AIDS was not the major cause of deaths in the NYSDOCS system). Based on data from January-November 1998, the projected annualized AIDS-related death rate for 1998 decreased to 6.1 per 10,000 inmates.

During 1993-June 1998, the annual death rate in the NYSDOCS system from causes other than AIDS has remained stable at an average of 22.4 per 10,000 inmates (range: 20.3-24.2). The number of inmates who met the statutory medical requirements (terminal illness and significant disability) for a medical parole related to HIV/AIDS has declined from 55 in 1995 to 32 in 1996, 13 in 1997, and seven in 1998.

Reported by: LN Wright, MD, New York State Dept of Correctional Svcs; PF Smith, MD, New York State Dept of Health. Div of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: As of December 31, 1995, 24,226 HIV-infected persons were incarcerated in state and federal prisons, corresponding to 2.3% of the state and federal prison population in the United States (1); 21% of these persons had a confirmed AIDS diagnosis. During 1991-1995, AIDS caused approximately one third of all deaths in U.S. prisons (1).

The decline in the AIDS-related deaths observed in the NYSDOCS is similar to that reported for the entire United States during the same time period (2) and corresponds to advancements in treatment of HIV infection (3-7). The finding that death rates for causes other than AIDS were stable suggests that increases in deaths from other causes in HIV-infected persons is not responsible for the decline in AIDS-related mortality. The decrease in the number of inmates granted medical parole related to HIV/AIDS suggests that severe HIV-related morbidity also has declined.

In 1983, the NYSDOCS opened the first in-house medical unit for treatment of prisoners with AIDS at Sing Sing Correctional Facility. The decrease in death rates observed since 1995 followed system-wide efforts in the 70 state prisons to standardize HIV care and to assure that antiretroviral medications and chemoprophylaxis of opportunistic infections are available throughout the system. These efforts included 1) in 1996, establishment of an HIV Treatment Guidelines work group in collaboration with the New York State Department of Health AIDS Institute to develop HIV treatment guidelines and regularly update them to be consistent with nationally recognized best practices; 2) in 1996, initiation of a quarterly live satellite videoconference series in collaboration with Albany Medical Center's Division of HIV Medicine and the New York State STD/HIV Prevention and Training Centers on "Management of HIV/AIDS in the Correctional Setting"; 3) in 1996, development of medical record flow sheets to monitor care being given to HIV-infected prisoners; and 4) in 1997, identification through the NYSDOCS pharmacy system of cases of apparently inappropriate care (e.g., monotherapy with protease inhibitors) and notification of other health-care team members for appropriate review and action.

Proper adherence to antiretroviral medications is essential to avoid development of resistant strains of HIV, but adherence to multidose treatment schedules with exacting requirements for dose-associated fasting or food may be more difficult in prison. Close supervision and intensive patient education is required to assure that prisoner patients understand how to take the medications correctly. Self-administration of medications and directly observed therapy can help resolve some of these issues.

Confidentiality may be more difficult to maintain in a corrections system than it is in other health facilities and may lead some inmates to refuse HIV testing, thus delaying effective HIV treatment. Another challenge is the frequent transfer of inmates from one prison to another, resulting in frequent changes of primary and specialty providers. Standardization and coordination of treatment across prisons is necessary to ensure optimal care.

One important limitation of the findings of this report is that the precise reason for the decline in AIDS-related deaths in NYSDOCS cannot be determined. The effect attributable to the systematic changes in education and management within the prison system cannot be differentiated from the advances in treatment. Nevertheless, the decline in death rates is associated with the timing of both of these events.

The findings of this report indicate that substantial decreases in AIDS-related deaths are possible in prisons that implement systems to provide up-to-date treatment of HIV infection. Health-care provider training, treatment protocols, and patient education programs that are consistent throughout the prison system can be provided to address the challenges of caring for HIV-infected patients in prisons.

References

1. Bureau of Justice Statistics. HIV in prisons and jails, 1995. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, August, 1997; publication no. NCJ-164260.

2. CDC. HIV/AIDS surveillance report. Atlanta, Georgia: US Department of Health and Human Services, CDC, 1997;9(no. 2):19.

3. Carpenter CCJ, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1996: recommendations of an international panel. JAMA 1996;276:146-54.

4. Carpenter CCJ, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1997: updated recommendations of the International AIDS Society-USA panel. JAMA 1997;277:1962-9.

5. CDC. Report of the NIH panel to define principles of therapy of HIV infection. MMWR 1998;47(no. RR-5).

6. CDC. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. MMWR 1998;47(no. RR-5).

7. Palella FJ Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998;338:853-60.

TABLE 1. Prison population, prevalence of AIDS, and AIDS-related deaths and death rate -- New York
State Department of Correctional Services, 1981-1997
=======================================================================================================
 Year   Prison population*   Prevalence of AIDS+  AIDS-related deaths   AIDS-related death rate&
-------------------------------------------------------------------------------------------------------
 1981         23,563                                        2                      0.8
 1982         26,721                                        4                      1.5
 1983         29,838                                       18                      6.0
 1984         32,630                                       57                     17.5
 1985         34,483                                       99                     28.7
 1986         36,670                                      124                     33.8
 1987         39,829                                      151                     37.9
 1988         42,293                                      158                     37.4
 1989         48,010                                      132                     27.5
 1990         53,806                177.9                 175                     32.5
 1991         56,292                166.5                 229                     40.7
 1992         60,121                215.1                 208                     34.6
 1993         63,489                230.3                 223                     35.1
 1994         65,676                236.3                 246                     37.5
 1995         68,164                223.6                 258                     37.9
 1996         68,744                217.9                 181                     26.3
 1997         69,786                216.1                  60                      8.6
1998@         69,835                219.4                  39                      6.1
-------------------------------------------------------------------------------------------------------
* Average daily population for the interval.
+ AIDS cases are calculated on a specified day each month and are averaged for the interval.
  Period prevalence is reported per 10,000 inmates and is calculated as ({the number of AIDS
  cases during the interval divided by the prison population} multiplied by 10,000). Information
  on the number of AIDS cases was not collected before 1990.
& Per 10,000 inmates.
@ Through November 1998. The number of AIDS-related deaths is the actual number of deaths
  through November. The AIDS-related death rate is annualized.
=======================================================================================================

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