NCCC Warmline: Consultations with Correctional Facilities Providers
May 15, 2013
Nearly 1.4% of the country's incarcerated population -- or about 20,500 state prisoners and 1,500 federal prisoners -- is known to be HIV-positive, according to the most currently available data from the U.S. Department of Justice's Bureau of Justice Statistics. Most of this population contracted HIV prior to incarceration, and some may be engaged in continuous care for the first time upon entering the correctional system. The National HIV/AIDS Clinicians' Consultation Center (NCCC) provides hundreds of clinical consultations each year for healthcare providers working with incarcerated populations in federal, state, and local prisons and jails. In 2012, the NCCC answered 235 calls on the Warmline, 248 on the PEPline, and 7 on the Perinatal HIV Hotlinefrom providers working with incarcerated persons who are HIV-infected, or who may have sustained an exposure to HIV. The Center also works specifically with a team of pharmacist and physician providers for the Federal Bureau of Prisons, providing monthly distance-based consultations and management recommendations for complex or ongoing cases.
Correctional institution consultations, particularly those provided over the Warmline regarding issues of ongoing management, are among the most complicated that NCCC clinicians provide for a number of reasons including: 1) providers often have incomplete medical histories for patients, missing information prior to incarceration or from periods of previous incarceration in different systems; 2) patients often have co-infections and whole person healthcare issues; 3) patients often develop resistance from periodic non-adherence to medication regimens; 4) antiretroviral selection for patients can be limited to what institutions are capable of stocking in their formularies; and 5) information shared between different components of the care team, such as patient consultants and pharmacists, can be incomplete.
NCCC consultants note that one of the most important aspects of advising on a call about any patient with a complex history that may include co-infections, fluctuating CD4 counts and viral loads, and periods of non-adherence, is to assemble as complete a medical history as is possible. In cases involving incarcerated HIV-infected persons, gaps in medical history may indicate that records were irretrievable from other institutions, or indicate periods of fragmented care when patients were released, but did not maintain a treatment and care regimen. Released patients are often provided a month's worth of medication and assistance in coordinating care, and then transition to coordinating their own care thereafter. Gaps in treatment and corresponding history are thus common, as indicated by this recent call to the Warmline:
Sample Call: A provider called about a 29-year-old male patient who was diagnosed with HIV in 2005 and was currently presenting a high viral load and low CD4 count. The available treatment history begins in 2008, and the patient is not clear which antiretroviral medications he took prior to that time. A large portion of the patient's medical history is derived from clinics outside the correctional system and sometimes refers to test results without including lab reports. While the patient’s viral mutations are included, they are likely incomplete. Consultants must attempt to reconstruct the history and address the mutation and resistance concerns based on available information.
Since the patient's CD4 count is dangerously low, a history of poor adherence is suspected, and his future antiretroviral options are therefore limited. The consultant advises directly observed therapy and provides three treatment options based on what she can infer from the history, including the inferred likelihood of residual activity from regimens presumed based on given information. She recommends a combination of at least two NRTIs and a fully active protease inhibitor; a combination of tenofivir/ emtricitabine, ritonavir, darunavir, and raltegravir is likely to achieve full viral suppression.
This is a common situation. A training opportunity here may focus on helping providers determine what pieces of information are important in reconstructing a history. Consultants have found that with some assistance, providers can often assemble a more thorough history, including full laboratory results and other important components. Another training opportunity may focus on how to problem-solve around issues of comprehensive treatment, including co-morbidities, which present both symptomatic and drug-drug interaction challenges that must be considered along with HIV treatment. Common co-infections among incarcerated HIV-infected persons include hepatitis B and C. HIV-specific co-morbidities such as peripheral neuropathy and psychiatric presentations and common medical conditions such as hyperlipidemia and hypertension must also be taken into account for various treatment reasons, including those of drug-drug interactions as indicated by the following call to the NCCC Warmline from a correctional facility:
Sample Call: A pharmacist called about a patient in his early 60s with a high CD4 count and low viral load, who had been diagnosed with HIV in 1998 and was currently on a zidovudine/lamivudine plus efavirenz regimen. The patient has a history of diabetes mellitus, hyperlipidemia, hypertension, and chronic renal failure. He is taking a number of other medications including fluvastatin and metformin. The NCCC Warmline consultant advises the pharmacist to consider stopping the fluvastatin if the patient has increased creatine phosphokinase (CK) levels.
If this change does not fully address the increased CK, the consultant advises reviewing the HIV drug regimen, since zidovudine can cause increased CK levels. The consultant recommends replacing the zidovudine if the patient remains symptomatic after dropping the statin; abacavir is recommended in this case because raltegravir has been indicated in CK level elevations. The consultant additionally advises that the patient should be monitored for lactic acidosis since patients with chronic renal failure on metformin have a higher risk for development and since NRTIs have been associated with lactic acidosis.
Finally, consultants giving clinical advice to providers in correctional facilities must themselves be mindful of the sometimes limited formularies available at institutions. Since formularies are stocked based partially on what makes the most sense within a strictly defined budget and since available drugs must be backed with compelling evidence toward their efficacy, some of the newest or less frequently used HIV medications may not be available. Communicating clearly about the possible treatment options can save time for both the provider and the consultant. Conversely, some pharmacists working in correctional settings may benefit from additional training on current available medications in order to advocate for the availability of newer, and potentially, more effective drugs.
As educators who work directly with these providers, we would love to hear what training opportunities you explore with healthcare workers in correctional institutions. How might consultation be even more effective in aiding these providers in giving optimal care?