Donald I. Abrams, MD, Editor

Next Meeting

The next Community Consortium meeting will be a post-conference update dinner that will be held on Wednesday, July 18th at the Ritz-Carlton. The program will feature a panel providing a "Report Back from Buenos Aires". This is the first year for this International AIDS Society (IAS) meeting that is planned to occur in the odd years where an International AIDS Conference is not being held. The meeting will feature basic and clinical science.

This program is sponsored by the University of California School of Medicine at San Francisco (UCSF). UCSF is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The office of CME designates this continuing medical education activity on an hour-for-hour basis in Category I of the Physicians Recognition Award of the American Medical Association and the Certificate Program of the California Medical Association. In addition, nurses may obtain CEU credits but must keep a record of their own attendance. One hour of credit is available for this meeting.

Return to Top

Rejoin Today

As we begin the third decade of fighting the battle against HIV, the Community Consortium once again seeks your support to assist us in the work that we do for HIV care providers in the Bay Area and beyond. We appreciate the fact that there are many competing demands and requests for our ever shrinking resources, but we hope you will continue to be able to renew your Consortium membership to allow us to accomplish our goals and better serve your needs. We need to keep an accurate updated list of individuals interested in learning of Community Consortium activities (such as the Ritz-Carlton dinner), following our research endeavors and gleaning whatever gossipy tidbits Synopsis may otherwise have to offer. To this end, we ask for you to send back a membership application with the nominal fee that helps us with the printing and mailing of Synopsis and some of our other educational brochure material.

In addition, we have always claimed that our strength is in our numbers. When the Consortium takes a stance on an issue and, for example, writes a letter to an elected official, it behooves us to say that we are an organization of XXX HIV care providers in the San Francisco Bay Area. Obviously, the larger the number that fills in the blank, the more clout we have. The Community Consortium has much to be proud of. We have been a model for community based clinical trials and provider education in the country for over 15 years. We intend to continue our efforts for as long as they are necessary. We do need and appreciate your support! Please take a moment now to fill out and send back the enclosed 2001 / 2002 membership application. Thanks again for your continued support!

Return to Top

Dr. Estes began the evening by reading quotes from a New York Times editorial from two days earlier on AIDS in Prisons, again showing that Consortium educational programs are right at the cutting edge. The editorial commented that prisons are one of the most dangerous incubators in the epidemic. Healthy inmates run the risk of getting infected with HIV by either sharing needles or sexual contact. All of this occurs in the absence of bleach, condoms and medical care. Data on the frequency of such behavior is unavailable, as one cannot study illegal behaviors occurring in a prison. It has been estimated that 28% of inmates in Tennessee use intravenous drugs. From 9-20% of inmates report having been raped while in prison. Only Vermont and Mississippi have state mandates to offer condoms to prisoners. Others fear that they will be used for drug smuggling purposes if distributed. Offering condoms and/or bleach is largely viewed as sanctioning illegal behavior. It is estimated that there are up to 9000 HIV infected inmates in the state of New York. The editorial suggested that prisons may, in fact, be a good place to educate as well as to offer appropriate health care.

Milton stressed the significance of the problem of HIV in incarcerated populations. The incidence is estimated to be 5 to 10 times greater than in the general population. There is significant discontinuity of care as patients come and go in and out of the system. There is a high rate of transmission while incarcerated. These patients are most frequently untreated and poorly educated about the basics of HIV as they receive only episodic medical care.

Dr. Estes queried the audience. "How many of you think that you have not taken care of someone who has been incarcerated?" No one in the audience raised their hand! He pointed out that the two million individuals currently incarcerated in the United States represents 25% of all the people incarcerated in the entire world. Where the AIDS rate in the U.S. population is 31.4/100,000, it is 198.5/100,000 in correctional facilities. HIV reporting and data collection is not done, so these are the AIDS rates, not infection rates. The California Department of Corrections estimates that 43-47% of all California inmates are infected with hepatitis C virus- another enormous problem. Eighty percent of California inmates have current or a history of drug use. Twenty-five percent of those currently incarcerated are sentenced because of drug use. Incarcerated women are a lot more likely than women in the general population to have AIDS - again, no information is available on actual rates of HIV infection.

Some definitions were provided for those who are not hip to forensic terminology from watching television. Jail is under county control, operated by the Sheriff's Department. Individuals are jailed prior to formal sentencing. The time of incarceration in jail is less than one year. Jail is where misdemeanor offenders are housed. In contrast, prisons are under control of the state or federal government. Individuals are post-sentencing and terms generally exceed one year. A prison houses felons only. Probation is when one receives a conditional release instead of incarceration. Parole is a conditional release given after completing at least part of a term. Community service is mandatory work that is sentenced instead of incarceration. "Serving time" refers strictly to being in prison. There are 33 prisons in California alone.

Guy Vandenberg, R.N., M.S.W. reviewed some of the risk behaviors among inmates that promote the spread of both HIV and HCV. Tattooing with reused equipment is a common phenomenon. Body piercing is also performed with shared instruments and is becoming increasingly more common among heterosexual males. Needle-sharing and unprotected sexual intercourse of course are problematic. Inmates often are involved in fights or bonding rituals which involve sharing of bodily fluids. "Keistering" is the transporting of contraband in body cavities which also presents a risk. In one study, 22% of the men and 7.7% of the women reported having had non-consensual sexual intercourse while incarcerated.

There are a number of dis-incentives for inmates to access primary care while in prison. Whether or not to disclose pre-existing health status is an issue for most inmates. They fear stigma and segregation as well as loss of privileges. On the other hand, for many prisoners incarceration provides them with their first entry to the health care system. A number of prisons have medical facilities. Health care professionals are often part of the correctional staff and not an independent medical staff. Where medical services are available, there are increased opportunities for prisoners to obtain prevention education, general health education as well as access to health care. Prison offers the opportunity to commence antiretroviral therapy in a very closely monitored setting. However, for the prisoner who chooses to access a primary provider, visits to the clinic take away from work time. In many prisons, the inmates make money and credit time against their sentences by working and work time is sacrificed if they are seeking medical care.

Guy went on to describe the situation in some of the California prisons. The California Medical Facility (CMF) at Vacaville houses the largest population of men with HIV and HCV. Segregated housing units as well as hospice care are available at both the CMF as well as the Central California Women's Facility (CCWF) in Chowchilla. A question that he has been interested in is why prisoners with HIV do not continue to seek health care upon release. He described the concept of re-entry programs that have been designed to provide inmates with some structured options for transition back into the community. However, he remarked that many prefer no structure upon release. In San Francisco, most released inmates wind up in the Tenderloin. People get kicked out of Tenderloin hotels after 28 days -- otherwise they would become legal residents- so homelessness is fostered. People used to get re-arrested just for "being" in the Tenderloin, charged by the police with associating with felons because that's where all the felons hang out.

The Springboard Program has been effective in getting released prisoners into primary care programs, obtaining ADAP services, etc. post release. Mr. Vandenberg described the results of analysis of outcomes in 71 HIV+ Springboard clients. The goal of the program is to provide transitional case management for people of color with HIV/AIDS released from the CMF, the CCWF and San Quentin. Services are extended to parolees who have been paroled to San Francisco, San Mateo and Marin County and are offered for 6 months pre-release to 2 months post-release. (Contact Helen Lin, 415-437-2900, Helen@continuumhiv.org) Of the 71 HIV+ clients, 31 are alive and out of custody, 21 have been re-arrested, and 15 are awaiting release. Two have died and two are lost to follow-up. All clients were housed immediately upon release. All living, non-fugitive, non-reincarcerated clients attended at least one primary care visit within the first month of release. All clients were enrolled in the AIDS Drug Assistance Program within two weeks of release. All clients were connected to pharmacy services and received medication refills within two weeks of release. All clients receiving HAART while incarcerated continued treatment upon release. Two more began therapy after connecting with their primary care provider through the Springboard program.

Dr. Estes next gave a brief history of the Forensic AIDS Project of the San Francisco Department of Public Health Jail Medical Services, outlining particularly the changes that have occurred in administration of antiviral therapies. He has now been affiliated with the program for the past six years, commencing just prior to the availability of protease-inhibitor containing regimens. At that time, there was little initiation of therapy in patients in the jails. They continued, for the most part, whatever regimen they had been on in the outside. With the onset of the HAART era, the Forensic AIDS Project became more proactive about discussing HIV infection with the clients, educating them about the virus and its treatment and beginning antiretroviral therapy.

Initially very involved with the question of treatment for tuberculosis and adherence issues, Dr. Tulsky has become quite interested in the question of what happens to those individuals who have begun HAART while in jail once they are released. She opened her comments with praise of Sherriff Hennesey for his openness and concern around these issues. She reviewed some data from the National Clinician's Consultation AIDS "warm line" phone calls. Looking at 1205 phone calls from incarceration sites received from 1991-1999, 66% of all calls came from just 5 states. Thirty-seven percent of the calls came from rural areas. Of the providers calling for information, 28% cared for less than 10 patients with HIV. The mean age of the patients being called about was 37 years. Two-thirds were people of color and a similar percentage had bona fide AIDS diagnoses. CD4+ cell counts were <200/mm³ in 52% and < 100/mm³ in 36%.

Dr. Tulsky then reviewed information from 77 inmates released after being cared for by the Forensic AIDS Project since 1997 to assess the level of care provided to patients in the jails. The clients were predominantly African American (52%) men (91%) with a mean age of 38 years who had spent an average of 3 months in jail. Seventy-eight percent had had a CD4+ or HIV RNA level drawn. The mean CD4+ cell count was 335/mm³, with 22% under 200 cells/mm³. The mean HIV RNA level was 20,000 copies/mL with a median of 3200 copies. One-quarter had undetectable HIV RNA. All patients with CD4+ cell counts < 200/mm³ were receiving prophylaxis for Pneumocystis carinii pneumonia. She concluded that the patients care in the San Francisco jail was "right up to par with high-end private practice care ... Inmates may be the only group in the county where health care is a right!"

In this cohort, using the 1996 treatment guidelines, all patients eligible for antiretroviral therapy had been offered treatment. Of these, 72% accepted treatment. Seventy-one percent picked up their prescriptions upon release. Of the 15 eligible patients not on therapy, 8 refused treatment, 3 were released prior to picking up their medications and the issue in the remaining 4 was unclear. Now Dr. Tulsky is involved in a project to describe a cohort of patients in real time. Her goals are to assess indicators of disease state and examine the prevalence of genotypic resistance mutations working in collaboration with Robert Grant, M.D., Ph.D., of the Gladstone Institute of Virology and Immunology. All eligible inmates seen by Forensic AIDS Project physicians are eligible for enrollment. Subjects are receiving financial reimbursement for their participation, just as they would if they were "on the outside" and taking part in a trial. She presented information on 53 participants evaluated to date. In the cohort, the mean age is again 38 years with a predominance of African American (55%) males (85%). Forty percent are on SSI/SSD or VA benefits. The majority (83%) have been homeless at some time and 77% have a history of injection drug use while 41% report problem drinking in the past. The mean duration of HIV infection is 7 years. CD4+ count averages 315/mm³ with 28% less than 200/mm³. HIV RNA is undetectable in 36% of the cohort and < 1000 copies/mL (the lower limit of detection for a genotypic resistance assay) in 66%. Only one of the 16 specimens tested demonstrated evidence of resistance mutations. After 6 months of follow-up, over 80% have been located for repeat testing. Fifty percent are still in jail, 17% are back in jail and 7% are in prison. She concludes that it is possible to identify and follow a cohort of HIV-infected people in county jail. In addition, it is possible to achieve successful suppression of HIV while being treated in the jail setting. Dr. Tulsky believes this is all the more remarkable when one considers that the correctional facilities have become the de facto mental health facilities in this country.

The issue of the care of the incarcerated patient with HIV will only become larger with time. The panelists were thanked not only for their outstanding informative presentation but also for the work that they are doing in serving this unique patient population.