Dr Simon Edwards MRCP
Registrar in GUM/HIV, Caldecot Centre, Kings College Hospital
Dr Chris Taylor MRCP
Consultant in GUM/HIV, Caldecot Centre, Kings College Hospital
Dr Melinda Tenant-Flowers MRCP
Consultant in GUM/HIV, Caldecot Centre, Kings College Hospital
Professor Philippa Easterbrook
Consultant in Infectious Diseases, Caldecot Centre, Kings College Hospital
Joseph Buggy
Health Advisor, Caldecot Centre, Kings College Hospital
Peter Horne
Health Advisor, Caldecot Centre, Kings College Hospital
Nick Hulme
Manager Medical Care Group, Kings College Hospital
Correspondence to:
Dr Simon Edwards
32 Worlingham Road
East Dulwich
London SE22 9HD
Tel: 0181 355 7294
Pager: 01523 100678
Simon.edwards{at}virgin.net
Concern has been raised about the quality of healthcare provided to prisoners in England and Wales 1,2. The management of HIV infected prisoners is challenging: a high proportion are injecting drug users, there are issues regarding confidentiality, and administration of complex antiretroviral regimens may be difficult in a prison setting. We therefore reviewed our experience of providing specialist HIV care to prisoners between October 1994 and July 1999.
Subjects, methods and results
In October 1994, King’s College Hospital was contracted to provide HIV and STD care to male prisoners at Her Majesty’s Prisons Wandsworth and Brixton in South London. Prisoners access the service through self-referral or via wing officers and prison healthcare workers.
Between October 1994 and July 1999, 6 prisoners were newly diagnosed HIV-1 positive and 121 stated they had previously tested HIV positive. Of the 121, 75 were confirmed HIV-1 positive and 25 tested HIV-1 negative. Fourteen of twenty-one gave information to support their claim including their HIV treatment centre. This information proved to be false. Documented reasons for this subterfuge included the desire for a letter pleading mitigating circumstances in court or a request for food supplements, sedatives or opioids.
Of 81 confirmed HIV positive cases, 76% were Caucasian and 16% were black-African. The median age at first prison assessment was 33 years (range:23-65) and the main HIV risk factors recorded were injecting drug use (59%), and homosexual (25%) or heterosexual (19%) contact. The median CD4 count in clinic was 210x106/l (range: 4–740) and one-fifth were severely immunosuppressed (CD4<50x106/l). Twenty-one (26%) had a history of AIDS-defining illness, and 46 (52%) were co-infected with either hepatitis C (n=41) or hepatitis B (n=5).
Inmates were reviewed regularly to assess clinical status and adherence to antiretroviral therapy. Sixty-three (12.4%) of 509 appointments were not kept. Documented reasons included attendance at court/hospital or a legal/social visit (35%), transfer to another prison (25.4%), failure to locate prisoner (12.7%) and lack of clinic time (6.3%).
At the time of imprisonment, only 24/81 (30%) were receiving antiretroviral therapy. We identified a further 35 prisoners who were eligible for therapy according to national guidelines3 (CD4 count < 350x106/lor symptomatic disease) of whom 11 started treatment. Nineteen (63%) inmates reported occasions when they had not received their medication as prescribed. Reasons cited included confinement to cell and travel to court, hospital or another prison. Prescription error and drug unavailability was infrequently cited. Therefore, given the short duration of imprisonment for the majority of inmates (69% < 3months), initiation of therapy was frequently deferred until after release.
Fifteen (18.5%) inmates required at least one admission to hospital for a median of 7 days (range: 3-84). The spectrum of clinical problems included respiratory tract infections and the need to exclude Mycobacterium tuberculosis (n=12), treatment of lymphoma or KS (n=2), meningitis (n=2), hepatitis C complications (n=1) and neuropsychiatric problems (n=1).
Comment
We have shown that our HIV service is accessed by a high proportion of severely immunosuppressed prisoners who presented complicated management issues. Almost a quarter of prisoners who claimed to be HIV seropositive were in fact negative, although the proportion may be higher because a significant number declined confirmatory testing. We therefore recommend confirmation of HIV status in all prisoners.
The fact that only a third of eligible prisoners were receiving antiretroviral therapy prior to incarceration highlights their poor access to HIV specialist care. Although imprisonment presents an opportunity to provide specialist HIV care4, we identified several logistical problems that impacted on patient monitoring and antiretroviral adherence. The provision of services to HIV positive prisoners must be regularly audited to identify obstacles to effective healthcare delivery.
REFERENCES
Dear Editor,
Issues in the management of HIV infected prisoners: the Kings College Hospital HIV prison service
We would be grateful if you would consider the enclosed manuscript for publication as a short report in the BMJ.
We believe that this article is very relevant as it not only examines the complexities of providing care to HIV positive individuals within the prison setting but it is one of the first publications looking at an NHS service being provided within a prison service within the UK
The total word count is 600. We have decided not to include a table listing the details of hospital admission but have enclosed it for your interest. If included this could reduce the text.
There has been no funding for this research and there are no conflicts of interest.
We would like to suggest Dr Ray Brettle, Consultant in Infectious Diseases, Western General Hospital, Edinburgh to peer review the article.
I look forward to hearing from you.
Yours sincerely,
Simon Edwards MRCP