Sedwards{at}cichs-tr.nthames.nhs.uk
Dear Dr Yarney,
RE: Issues in the management of HIV infected prisoners: the Kings College Hospital HIV prison service(total word count = 599).
Many thanks for considering the above paper for publication as a short report.
We have read and agree with many of the comments of the referee and have made the appropriate changes to the paper.
| 1. | In response to the referees comment "the authors state that concern has been raised about the quality of healthcare provided in prisons", it is important to clarify that the statement was derived from a Joint Prison Service and NHS Executive Working Party document and was not our own. We acknowledge that the inferior care does not specifically relate to the management of HIV infection in prison. The working party recommendations were for a formal partnership to be developed between the NHS and Prison healthcare service. Our paper describes the unique experience of such a partnership and discusses some of the practical issues encountered by an NHS service working within a prison environment |
| 2. | The referee suggested that we compare our experience to an outpatient cohort and we have therefore included comparisons to our local clinic with reference to attendance and proportion taking antiretrovirals and published data with reference to adherence. In order to make certain comparisons we have altered the format of the data presentation. Whilst we have included our figures for comparison we feel that, overall, HIV positive outpatients are not a comparible control group as there are significant differences. Direct meaningful comparisons are not possible and therefore, in certain situations, we have not performed statistical comparisons. |
| 3. | The referee requested clarification as to what the number 21 referred to at the bottom of page 1. The text has been changed from "Fourteen of twenty-one who declined testing" to "Fourteen of the remaining twenty-one who declined testing". This makes it clear that the 21 refers to those prisoners who were neither confirmed to be HIV positive or HIV negative. |
| 4. | The referee asked for more information regarding those not taking antiretrovirals in the era of highly active antiretroviral therapy. We have reanalysed the data looking at inmates incarcerated after 1996 and explained why not all prisoners were initiated on therapy. Comparing antiretroviral uptake in the prison population to an outpatient cohort is difficult. We are able to state what percentage of prisoners were on antiretrovirals at the time of incarceration. However, as we do not have a detailed antiretroviral or CD4 history, we are unable to comment on how long they have been eligible for therapy. Our comparison with an outpatient cohort states "76% (493/649) of outpatients were already taking or started ART within 6 months of their CD4 count dropping below 350x106/l. |
| 5. | We agree that our sentence regarding compliance is misleading (the referee is concerned that 63% is very high). By analysing the data differently we are able to show that prisoners actually adhere to drugs better than outpatients. The sentence now reads "Self-reported adherence to antiretrovirals exceeded 90% which compares favourably to that reported from a London outpatient cohort". However we would still like to point out the reasons for non-adherence as they are unique to a prison environment. |
| 6. | We agree with the referee that confirmation of HIV status is and should be routine practice. However the frequency of false claims in an outpatient setting is very low as compared to the exceptionally high number (25-32%) we encountered within the prison setting. We thought this information (and the reasons cited) would be of interest to your general readership and to health professionals working within a prison environment. |
| 7. | Finally the referee comments that the proportion not receiving antiretrovirals does not reflect poor access to HIV care. We agree with this comment and have subsequently removed it from the article. |
I hope these changes satisfactorily address the concerns expressed by the peer reviewer.
Yours sincerely,
Simon Edwards