NHS Trust

British Medical Journal
BMA House
Tavistock Square
London
WC1H 9JR
 
 

Dear Editor

Title: Issues in the management of HIV infected prisoners:
        The Kings College Hospital HIV prison service

Thank you for asking me to review this paper. I think that this paper could be sufficiently original for publication in the BMJ if they could contrast the management of the HIV-Positive prisoners to HIV-Positive people attending their own outpatient service. The paper indicated that prisoners have poor quality of health care but there is no evidence contrasting care the statement can't be confirmed. It would be incredibly valuable if prisoners who had not accessed the service were also questioned to see whether some had been denied access for any reason or they had not wished to have health care in the community.

The scientific reliability would be improved if it were compared to an HIV outpatient cohort during the same time frame.

Subject matter is important as the Authors State "concern has been raised about the quality of health care provided at prisons". The general public doesn’t know what quality of health care HIV patients receive in an HIV centre and this needs to be evident in the paper. The paper reads well apart from the last sentence on page 1, which starts with 14 of 21. I don’t know what the 21 refer to. I think it means 14 of 121. Does it mean that the only ones who gave information supporting their claim gave false information.

The particular areas to contrast with an HIV clinic elsewhere are the percentage of appointments not kept, the proportion of patients eligible for receiving antiretroviral therapy, not receiving therapy and the time that which they were identified. HIV treatment and willingness for people to take treatment has changed enormously between 1994 and 1999 with many patients in the earlier days choosing not to take treatment. Had the 35 prisoners who are eligible for therapy been seen elsewhere prior to being in prison and offered treatment? Why did only 11 of the 35 start treatment? Was this because of the explanation at the end of the paragraph? How many declined treatment?

63% reported occasions when they have not received the medication as prescribed. This seems extremely high but needs to be compared to an outpatient cohort, or inpatient care. 100% compliance with medication is unusual and we need to know whether complete doses or days were missed or medication given ½ hour out of the specific dosing time.

The recommendation for confirmation of HIV status in all prisoners is currently the recommendation in our own unit for all persons claiming to be HIV-Positive. This is because patients can give incorrect information and any diagnoses always needs written confirmation from elsewhere or tests to be repeated.

The penultimate paragraph states that only a 3^rd of eligible prisoners were receiving antiretrovirals however I think the figures are 35 of 57 were not receiving antiretrovirals which is over 50%. The paper does not give evidence that this highlights poor access to HIV specialist care as this information has not been given.

In summary, this information if expanded could be of interest to the General BMJ reader.

With best wishes,
Yours sincerely

Dr Fiona C. Boag
Consultant Physician
Department of HIV/GU Medicine