HEPP News, Vol. 3 No. 10 HIV Education Prison Project

University of Rhode Island DigitalCommons@URI

Infectious Diseases in Corrections Report (IDCR)

2000 HEPP News, Vol. 3 No. 10 HIV Education Prison Project

Follow this and additional works at: http://digitalcommons.uri.edu/idcr

Recommended Citation HIV Education Prison Project, "HEPP News, Vol. 3 No. 10" (2000). Infectious Diseases in Corrections Report (IDCR). Paper 19. http://digitalcommons.uri.edu/idcr/19

This Article is brought to you for free and open access by DigitalCommons@URI. It has been accepted for inclusion in Infectious Diseases in Corrections Report (IDCR) by an authorized administrator of DigitalCommons@URI. For more information, please contact [email protected]. HIV EDUCATION HEPP PRISON October 2000 Vol. 3, Issue 10 news PROJECT Sponsored by the Brown University School of Medicine Office of Continuing Medical Education and the Brown University AIDS Program. ABOUT HEPP Corrections on the National Conference HEPP News, a forum for Agenda: Update from the 24th NCCHC correctional problem solving, targets correctional administrators Anne De Groot, M.D.*, Brown Univ. School of Medicine and HIV/AIDS care providers including HIV in correctional settings is beginning to infil- Figure 1. Cost Effectiveness of physicians, nurses, outreach workers, trate our nation's political theater. In response Medical Interventions and case managers. Published monthly 120 and distributed by fax, HEPP News to this new development, the National provides up-to-the-moment informa- Commission on Correctional Health chose 100 tion on HIV treatment, efficient prominent political leader Reverend Jesse 80 approaches to administering HIV treat- Jackson Sr. to open this year's National ment in the correctional environment, Conference on Correctional Healthcare 60 national and international news related (NCCHC), held September 9-13 in St Louis, 40 to HIV in prisons and jails, and changes Missouri. in correctional care that impact 20 HIV treatment. Continuing Medical NCCHC is the largest nationwide educational Education credits are provided by the 0 gathering of physicians, nurses, dentists, psy- Brown University Office of Continuing cost/year of lives saved (thousands) Medical Education to physicians who chiatrists, psychologists, other health care pro- Renal Enalapril Dialysis CoronaryBypass accurately respond to the questions on fessionals, administrators, attorneys, and oth- ComboTherapy AR for CHS the last page of the newsletter. ers working in prisons, jails, juvenile confine- Mammography ment, and detention facilities. Participants had Cost effectiveness of HAART, compared to other EDITORS an opportunity to meet and network with experts medical interventions for other chronic diseases. as they discussed current correctional health Anne S. De Groot, M.D. Groot at the 4th annual symposium (Ft Director, TB/HIV Research Lab, issues. Recent developments in the manage- Lauderdale, 1999), correctional providers who Brown University School of Medicine ment and treatment of HIV were featured in a had performed an HIV management interven- special track of programs throughout the con- Frederick L. Altice, M.D. tion in a correctional setting and had measured Director, HIV in Prisons Program, ference. Yale University AIDS Program the impact of that intervention were invited to present their results. Joseph Bick, M.D. Illustrating correctional health care's most pop- Chief Medical Officer, ular issues, the pre-conference seminars fea- Outcomes Research Studies HIV Treatment Services tured NCCHC's standards and mental health What are outcomes studies? In the HIV/AIDS California Department of Corrections care guidelines, an introduction and an California Medical Facility, Vacaville arena, outcomes research attempts to measure advanced look at quality assessment, practical the impact of HIV management interventions on preparations for NCCHC accreditation, and clinical and economic outcomes. Clinical out- Faculty Disclosure measuring outcomes of HIV interventions. In accordance with the Accreditation comes are the clinical events and progression Council for Continuing Medical Education HEPP Symposium on Outcomes of HIV disease that occur in clinical practice, Standards for Commercial Support, and economic outcomes are the economic One way of measuring the potential success, or the faculty for this activity have been events and progression of resource use in HIV outcome, of an intervention is to count the num- asked to complete Conflict of Interest disease that occur in clinical practice.1 Disclosure forms. Disclosures are listed ber of individuals who volunteer to participate. at the end of articles. All of the individual Based on that measure, the HIV Behind Bars Outside corrections, researchers have asked medications discussed in this newsletter 2000 was a success: attendance at the annual some hard questions about HIV treatment and are approved for treatment of HIV unless symposium increased this year to more than otherwise indicated. For the treatment of 140 individuals, most of whom stayed for the Continued on page 2 HIV infection, many physicians opt to use combination antiretroviral therapy which entire 4 1/2 hour session. is not addressed by the FDA. WHATS INSIDE The focus of the symposium was on "measuring HIV 101 pg 5 HEPP News is grateful for the primary outcomes." Previous "HIV/AIDS Behind Bars" HEPPigram pg 6 support of Agouron Pharmaceuticals and sessions have described components of HIV Spotlight pg 7 the additional support of Roche Pharmaceuticals, management (from intake to discharge plan- Save The Dates pg 8 Merck & Co., Roxane Laboratories, Dupont, Abbott ning) and models of care. This year, following Self-Assessment Test pg 9 Laboratories, Glaxo Wellcome and Bristol-Myers up on a challenge issued by organizer Anne De Squibb through unrestricted educational grants.

Brown University School of Medicine Providence, RI 02906 401.863.2180 fax: 401.863.1243 www.hivcorrections.org If you have any problems with this fax transmission please call 877.896.7636 or e-mail us at [email protected] October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 2

Update from the Table 1. Correctional Outcomes Studies 24th NCCHC... CLINICAL ECONOMIC BEHAVIORAL CORRECTIONAL (continued from page 1) OUTCOMES OUTCOMES OUTCOMES OUTCOMES outcomes. For example, given that the life- time cost of HIV treatment averages Directly Observed Telemedicine Pre-release Peer Discharge planning Therapy (DOT) vs $149,000 (starting at a count of 500 CD4 T Education with careful linkage Self-administered to community health cells2) or from $10,000 to $20,000 per year Therapy (SAT) centers

of life gained, researchers have compared Intervention this investment to other healthcare invest- % with Viral Loads Cost per encounter Adherence to Recidivism ments. As it turns out, HAART is less below 400 medication expensive, per year of life gained, than mammography ($40,0000) and much less Measures expensive than coronary artery bypass (see Fig 1.) In fact, one notable (but less # of patients Patient Satisfaction Medication Viral load on return widely disseminated) outcome of HAART developing acceptance to prison medication appears to be that the predicted lifespan of

Measure side effects an individual on HAART with CD4 T cells > Additional 100 is on par with the lifespan of an age- Florida Texas California North Carolina matched peer who is HIV-seronegative!3 Ex. Thus HAART lengthens lifespan more than Directly observed 95% of telemedicine California peer Patients returning to most other medical interventions. therapy resulted in encounters pre- educated patients prison after a period better reductions empted an onsite were more likely to of release have Budgetary Outcomes of (DOT 85% below 5 visit, reducing costs; "report" condom use poorly controlled HIV Care copies; SAT only 69% of inmates pre- (38% vs 20%, p = HIV. 50% below 50 fer telemedicine to 0.05). Other outcomes research has evaluated Results copies) in viral the impact of HAART and/or skilled HIV travel. loads and fewer toxi- care on hospitalizations and the incidence cities (15% vs 35%). of opportunistic infections, which is more in line with correctional budgetary concerns. Fischl, M., D. Paar, Grinstead O, Zack Stevenson B, Wohl HAART has clearly been shown in a num- Rodriguez, A, Telemedicine in B. Collaborative D. et al. Release ber of studies to reduce the development of Serpella, E. Practice; HEPP research to prevent from prison is asso- opportunistic infections4 and reduce costs Monroig, R, News Vol 3 (5). May HIV among male ciated with associated with treating these infections. Thompson, D, 2000. RM Brecht, prison inmates and increased HIV RNA Therefore, most economic outcomes evalu- Rechtine, D., Impact CL Gray, C their female part- at a time of reincar- ations of HAART have reported that the of DOT on outcomes Peterson, B ners. Health ceration. XIII in HIV clinical trials. increased cost of treatment was balanced Youngblood, UTMB- Education and International AIDS 7th Conference on Texas DOC Tele- Behavior, 1999; 26: Conference 2000, by a reduction in expenses associated with References Retroviruses and medicine Project, 225-257. Durban, South hospitalizations and specialty consultations Opportunistic findings from the Africa.Abstract for opportunistic infections. Furthermore, Infection, Chicago, first year of opera- TuOrD323 care by experienced HIV/AIDS physicians IL, February 2000, tion, Telemedicine has been shown to result in two thirds Abstract 71. Journal Vol 2. no 1. fewer hospital bed days and fewer special- 1996. ty consultations than care by control (non- experienced) providers. This is most likely Outcomes in Corrections A number of the HIV "stars" of correctional due to the specialists' ability to prevent ill- However, as we're well aware, studies con- medicine spoke at the HEPP symposium. nesses and toxicities in their patients. ducted in community settings are only an Dr. David Thomas, Medical Director of the Outcomes studies have also reported on approximation of conditions for HIV-infect- Florida Department of Corrections, Dr. Joe the cost-effectiveness of interventions for ed patients behind bars. What information Bick, Medical Director of the HIV/AIDS opportunistic infections in HIV/AIDS is available for correctional settings, where facility at Vacaville, California, Dr. David patients. For example, treatment of PPD the distribution of costs may be significant- Paar of Texas Department of Criminal positive, HIV-infected individuals is an ly different from the outlay that communities Justice, and Dr. Lou Tripoli, Medical extremely cost-effective intervention. By experience in providing HIV care? Director for Correctional Medical Services, providing $36 of medication per patient all presented information on HIV-related (INH, 300 mg PO QD for one year) TB The good news is that outcomes studies interventions in their systems. Dr. Joseph cases can be reduced to neglible propor- are being funded and performed in correc- Paris, Medical Director of the Georgia tions (36% reduction).5 tional settings and there is a new recogni- Department of Corrections moderated the tion of the importance of measuring the symposium with characteristic tact and Other researchers have queried whether impact of an intervention (See Spotlight, diplomacy, provided expert audiovisual HAART prevents other budgetary outlays, Page 7). The bad news is that few out- support, and reported on outcomes mea- such as hospitalization costs and treatment comes studies have been performed and sures for his state. of opportunistic infection costs. Indeed, results are, as yet, unavailable for the Continued on page 4 HAART results in a net savings, especially largest of these studies. The HIV Behind in terms of hospitalization costs, in studies Bars 2000 symposium featured presenta- conducted outside corrections.6 tions by a few "interventionists" who reported their results. October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 3

Senior Advisors Theodore M. Hammett, Ph.D. Letter from the Editor Abt Associates Ned E. Heltzer, R.Ph., M.S. Dear Colleagues, Prison Health Services, Inc. The 24th NCCHC in St. Louis had so much for everyone in the field it is difficult to pinpoint Ralf Jürgens Canadian AIDS Law Legal Network any one salient feature. Yet...a special moment is indelibly etched in my mind. At the open- David P. Paar, M.D. ing ceremony, a number of correctional physicians grilled Reverend Jessie Jackson with University of Texas Medical Branch pointed medico-social questions. The Reverend did not miss a beat, but some of his Joseph Paris, Ph.D., M.D. answers did not convey the flavor of staff research. It seemed that he had not previously CCHP Georgia Dept. of Corrections heard some of the novel questions posed by a few well meaning, corrections-savvy NCCHC Khurram Rana, Pharm. D. attendees. University of RI College of Pharmacy David Thomas, J.D., M.D. After the HEPP Seminar, SCP Meeting and full-length NCCHC proceedings, I had the Florida Dept. of Corrections impression that the near 2,000 attendees had satisfied (and then some) their thirst for cor- Lester Wright, M.D. New York State Dept. of Corrections rectional health care knowledge. With so much on everyone's plate, we were fast approach- Associate Editors ing the point of correctional health care information overload. However, one cannot have too Betty Rider, M.A., M.S. much of a good thing. I just hope the next joint meeting duplicates or enhances the St. Louis North Carolina Division of Prisons performance. Anne C. Spaulding, M.D. Brown University School of Medicine This issue of HEPP News features a report on the HEPP-run "Outcomes" symposium at the Stephen Tabet, M.D., M.P.H. NCCHC conference. Information on research studies preformed in correctional settings is Univ. of Washington Division of Infectious provided in the main article, and an update on the CDC/HRSA research initiative is featured Disease Seattle HIVNET in our spotlight. We've also provide you with a few websites that may assist you with obtain- David A. Wohl, M.D. ing and planning your own outcome studies. In addition, our HEPPigram this month University of North Carolina addresses differential diagnosis of skin rashes, and our HIV 101 reminds you of effective Managers Dennis Thomas prophylactic interventions for Opportunistic Infections. HIV Education Prison Project After reviewing this issue, readers should be able to diagnose different presentations of Michelle Gaseau The Corrections Connection rashes, identify which preventative treatment is appropriate for opportunistic infections in Layout HIV infected patients, and identify the benefits of HIV interventions outcomes research. Kimberly Backlund-Lewis In the next issue of HEPP, Mary Sylla will review legal issues in corrections and we'll pro- The Corrections Connection vide an update on what has happened with clinical trials in corrections since our conference Promotion and Distribution one year ago. As usual, we welcome any feedback or written contributions! Amanda Butler Cimon Consulting Group Managing Editor Elizabeth Stubblefield Sincerely, HIV Education Prison Project The editorial board and contributors to HEPP News include national and regional correctional Joseph Paris, M.D., Ph.D., C.C.H.P. professionals, selected on the basis of their Guest Editor experience with HIV care in the correctional setting and their familiarity with current HIV treatment. We encourage submissions, feed-back, and correspondence from our readership. Subscribe to HEPP News and/or HIV Inside Fax to 401.863.1243 for any of the following: (please print clearly or type)

____ Yes, I would like to add/update/correct (circle one) my contact information for my complimentary subscription of HEPP News fax newsletter. ____ Yes, I would like to sign up the following colleague to receive a complimentary subscription of HEPP News fax newsletter. ____ Yes, I would like to order the following back issues (please include volume/issue/date). ____ Yes, I would like my HEPP News to be delivered in the future as an attached PDF file in an e-mail (rather than have a fax). ____ Yes, I would like to add my contact information for my complimentary subscription of HIV Inside.

NAME:

FACILITY: (Optional) # of HIV Infected Inmates: Physician Physician Assistant Nurse Practitioner Nurse/Nurse Administrator CHECK ONE: Pharmacist Medical Director/Administrator HIV Case Worker/Counselor Other

ADDRESS:

CITY: STATE: ZIP:

FAX: PHONE: E-MAIL:

SIGNATURE: DATE: October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 4

Update from the tend. Spencer sees an overall change in the She asked the probing question, are these 24th NCCHC... trends of correctional research from measur- barriers or excuses? ing prevalence of certain conditions to actu- (continued from page 2) Summary ally measuring outcomes of corrections- There is much to do in the field of outcomes based interventions. measures in correctional settings. As Jaye Highlighting the Need for Anno, Spencer, and Paris urged corrections Anno noted, we as correctional healthcare Research physicians to conduct research concerning: providers know very little about our patients In keeping with the theme of the HEPP sym- inmate co-pay systems, obesity, dietary as a whole. We have seen, however, many posium, many other speakers at NCCHC management (heart-healthy diet versus nor- promising HIV care interventions, and are addressed research in correctional settings. mal diet), conditions of confinement (such as learning which ones work best. Steven Spencer, Jaye Anno, and Joseph the impact of having athletic facilities), the Furthermore, judging by the number of par- Paris presented on "Emerging Research health needs of women, the impact of men- ticipants at our NCCHC meeting, outcomes Topics/Issues in Correctional Health Care." tal health problems on healthcare, dental research is of increasing interest to our col- Anno noted that correctional healthcare needs, women's use of health services, par- leagues. For more information on grants for providers are 20 years behind other medical enting issues, and lastly, data management. outcomes research, see our resources on groups in terms of knowledge of our Anno closed by addressing the fact that page 8. patients. Paris noted that there are unique many correctional physicians claim that For a complete listing of the sessions or medical issues in corrections with which obstacles to care include insufficient staff, more information, contact the NCCHC at community clinicians do not have to con- time, money, and commitment. [email protected].

Table 2. Other NCCHC Highlights Joseph E. Paris, M.D., Medical Director, Georgia Department of Corrections

Meeting of SCP The annual meeting of the Society of Correctional Physicians (SCP) was its most successful ever and it preceded and enhanced the NCCHC Meeting. Many correctional physicians joined the SCP in St. Louis. SCP President Dr. Joseph Paris from the Georgia DOC introduced Dr. Jennifer Clarke from the RI DOC, who presented an Overview of Women's Wellness, Dr. Norman Johnson of Health Professionals, who reviewed Geriatric Issues of Incarcerated Females, Dr. Rosemary Jackson, Ms. Jennie Lancaster, and Ms. Betty Rider, of the North Carolina DOC, who addressed the Difficulties of Health Services and Custody Working Together, and Dr. Kathryn Anastos, of the Albert Einstein College of Medicine, who discussed Gender and Ethnic Differences in HIV Patients. The meeting closed with an open forum on Women's Health Issues.

Among the many NCCHC Concurrent Sessions, the following sessions stand out: G Staff from the Hampden County Correctional Center presented a successful public health model of health care for corrections consisting of a three-year evaluation and research of the measurable benefit and favorable outcomes of their model. G Another seminar addressed the rights of medical professionals facing the option of settling a civil lawsuit. Robert Vogt analyzed insurance policies, consent issues, impact of the settlement on regulatory and reporting agencies and confidentiality. G Drs. Spaulding and Clarke, and staff from the RI DOC had sessions on "Developing an Algorithm for Testing Jail Entrants for Sexually Transmitted Diseases" and related topics. G "Domestic Violence Issues for Correctional Health Care Professionals" were explored by Dr. Diane Rechtine and others from the Florida Department of Corrections. G William Rold, JD, CCHP, noted correctional attorney, described the latest developments in the laws effecting the provision of health care to incarcerated individuals. G A dental presentation by Thomas Shields II, DDS, CCHP, and Gregory Becker, DM, of the Florida Department of Corrections, dealt with periodontal disease and associated bacteria and their link to numerous systemic diseases including infective endocarditis, cardiovascular disease, atherosclerosis, respiratory disease, and diabetes, as well as various bacteremias in correctional facilities. G Richard Novack presented the latest concerning nelfinavir dosing. Although pharmacokinetics of nelfinvavir might predict that TID dosing would be superior to BID dosing, the improvement in adherence that occurs from switching to BID actually results in better treatment outcomes. G The geriatric inmate was covered by Norman Johnson, MD, Health Professionals LTD, Karen Stocke, RN, Stephen Cullinan, MD, and Adrian Feinerman, MD. G Dr. Joseph Paris presented the HIV + Inmate Post Release Program of the Georgia Department of Corrections, aimed to ensure continuity of HAART after release to society.

References: * Consultant: Agouron Pharmaceuticals, Bristol-Myers Squibb Speakers Bureau: Agouron Pharmaceuticals, Bristol-Myers Squibb, Glaxo Wellcome 1. Moore R. Cost-Benefits of Antiretroviral Therapy. The Brazil/Johns Hopkins University HIV/AIDS Conference October 20, 21 and 22, 1999, Rio de Janeiro. http://www.hopkins-aids.edu. 2. Moore, RD, Chaisson, RE, JAIDS 1997; 14: 223-231. 3. Justice A. CHORUS HIV Cohort. 39th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco September 25- 29, 1999. Abstract 1158. 4. Gallant, J., and Moore, R., et al., The impact of prophylaxis on outcome and resource utilization in pneumocystis Chest 107 1995, k1018-1023. 5. Moore R. Cost-Benefits of Antiretroviral Therapy. 6. Gebo KA, Chaisson RE, Folkemer,JG, Bartlett JG, and Moore RD. Costs of HIV medical care in the era of highly active antiretroviral therapy. AIDS 1999; 963-969. October 2000Volume 3,Issue10 III: B: A: Rating systemsforstrengthofrecommendation II: I: Categories ReflectingQuality ofEvidenceSupportingtheRecommendation C: *Bactrim ispreferablebecauseitprevents twoillnesses:Pneumocystiscariniiand Toxoplasma gondi. Adapted fromBartlettJGandGallantJE.2000-2001MedicalManagement ofHIVInfection.JohnsHopkinsUniversity, Baltimore, Evidence fromatleastoneproperly randomized,controlledtrial. (preferably from morethanonecenter),orfrom multipletimeseriesstudies ordramaticresults fromuncontrolled experiments. Evidence fromatleastonewell-designed clinicaltrialswithoutrandomization,fromcohort or case-controlledanalyticstudies Both strongevidenceforefficacy andsubstantial clinicalbenefitsupportrecommendationforuse.Shouldalwaysbeoffered. Evidence from opinions ofrespectedauthorities basedonclinicalexperience, descriptivestudies,orreports of expert committ adverse consequences(e.g.toxicity, druginteractions,orcostofthechemoprophylaxis alternativeapproaches).Optional. Should generallybeoffered. Moderate evidenceforefficacy-or strongevidenceforefficacy, butonlylimitedclinicalbenefit-supports recommendationforu Evidence forefficacy isinsufficient tosupportarecommendationfororagainst use,orevidenceforefficacy maynotoutweigh HIV 101 Prevention ofOpportunisticInfections. M. avium Varicella Toxoplasma M. Tuberculosis Pneumocystis complex gondii carinii secondary VZV primary or no historyof for VAV orhave seronegative are either shingles who chickenpox or exposure to Significant mm CD4 count<50 gondii serology for positive IgG <100/ mm CD4 count II) (A TB thathealed quately treated tory ofinade- II)orhis- tact (A con- recent TB I), treatment (A tion) withprior (>5 mmindura- Positive PPD II)* 2wks (A thrush orFUOx HIV-associated or prior PCP <200/ mm CD4 count RISK 3 3 3 , plus T. doxine 50mg/day G I)* SS/day (A TMP-SMX 1DS/dayor PREFERRED PREVENTION or AIII) hours (A sure, preferablywithin48 within 96hoursofexpo- VZIG 5vials(6.25mL)IM 1200mg poweekly(A1) I)orazithromycin (A Clarithromycin 500mgorbid II)* TMP-SMX 1DS/day(A I) mos. withinterruptions(A doses x2mos.orupto3 20mg/kg/day with>60 600mg/day +pyrazinamide or NNRTI: Rifampin G mos. withinterruptions(BI) doses, 9mos.orupto12 observed therapy, >76 100mg 2x/wkwithdirectly G II) mos. withinterruptions.(A doses, 9mos.orupto12 INH 300mg/day+pyri- Patient notreceivingPI INH 900mg+pyridoxine ii EPNewsonlineat visit HEPP > 270 dence ofefficacy. but wasdeletedfromthe1999versionduetolackofsupportingclinicalevi- Guidelines, Prophylactic acyclovirwasincludedinthe1995USPHS/IDSA NNRTIs) 300mg qd(CI)(checkrifabutindoseadjustmentforusewithPIsor Rifabutin 300mgpoqd(BI)orazithromycin1200mg/wkplusrifabutin G G G TMP-SMX 1SS/day(BIII) Pregnancy: INHregimens anticipated activity-ethambutol/pyrazinamideorlevofloxacin/pyrazinamide Contact withstrainresistant toINHandrifamycin: 300mg poqdx4mo.(CIII) Alternative: Rifabutin/pyrazinamide(abovedosesx2mo.)(BIII);Rifabutin I) (Above doses)(A Contact withINHresistant strain: Rifampin 600mgqdx4mos.(BIII) interruptions (BIII) pyrazinamide 20mg/kg/daywith>60dosesx2mos.orupto3 ules arenotavailableforFortovase.Rifabutinshouldbecombinedwith Note: Rifabutinshouldnotbecombinedwithdelavirdineanddosesched- G G G G G namide 20mg/kganddoseadjustmentoftheantiretroviralagent(BIII). Patients receivingaPIorNNRTI needrifabutininplaceofrifampin/pyrazi- G G G G G G ALTERNATIVES The followingarerecommendedasstandard ofcare. 10mg qd(CIII). leukovorin 25mgpo/wk leukovorin 25mgpo/wk(BI) 25mg/wk (BI) 25mg/wk (BI) Atovaquone 1500mgqd±pyrimethamine25mg+leukovorin Dapsone 200mgpo/wkpluspyrimethamine75mg Dapsone 50mgpoqdpluspyrimethamine50mg/wk Ritonavir --standard dose;rifabutin--150mgqod Nelfinavir --1000mgtid;rifabutin150mg/d Indinavir --1200mgq8h;rifabutin150mg/d Efavirenz-standard; rifabutin-450mg/d Amprenavir-standard; rifabutin-150mg/d Atovaquone 750mgpobidwithmeals(NEJM1998;2\339:1889)(BI) Aerosolized pentamidine 300mgqmo Dapsone 200mg/wkpluspyrimethamine75mg/wkleukovorin Dapsone 50mgqdpluspyrimethamine50mg/wkleukovorin Dapsone 100mgqdor50mgpobid(BI) TMP-SMX 1DS3x/wk(BI) www.hivcorrections.org Rifampin pluspyrazinamidex2mos. use 2agentwith MD. 2000.

se. ees.

5 October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 6 HEPPigram Differential Diagnosis of Rashes in HIV-Infected Patients

DIFFUSE LOCALIZED

Scaling, patches and Bacillary Lobulated nodules, Erythematous Psoriasis plaques on elbows, angiomatosis any place on skin. knees, scalp, lum- bosacral area, ± nail changes and arthritis. Scaling, patches and plaques on Seborrhea scalp, central face, ears, chest, Erythmatous macules and papules Syphilis upper back, axillae, and groin. involving trunk, extremities, palms and soles (Secondary syphilis); chancre (primary syphilis). Scaly, annular plaques with active Dermatophytes borders and central clearing lesions involving skin or nails. Sun-exposed areas- hyperpigmen- Photosensitivity tation, eczematization, may blister.

Kaposis's Firm, dark colored, slightly Papules sarcoma Large, beefy red lesions Candidiasis raised macules, papules, w/satellite papules on plaques and nodules. groin area, under breasts, and axillae.

Prurigo nodularis Hyperpigmented, hyperkeratotic, often excoriated, associated White or flesh-colored papules Molluscum w/ other signs of chronic w/central umbilication, present on contagiosum pruritis/excoration. face (beard area), neck, genital region (can be diffuse).

Scabies Excoriated, crusted pinhead-sized papules; burrows; intense general- Blisters perioral "Fever blisters" ized pruritis that is worse at night. Herpes simplex I (May be localized but often disseminated in HIV-infected patients). Perianal and/or genital. Herpes simplex

Unilateral dermatomal Herpes zoster distribution associated with neuralgia and crusting in later stages. HIV-Associated W/out cutaneous lesions Pruritis Pruritis except excoration. Folliculitis (S. aureas, Pityrosporum Drug reaction Morbilliform exanthum ± pruritis; Pruritic follicular papules and ovale, Demodex less common-urticaria, erythema pustules, face, trunk, extremities. folliculorum, multiforme, TEN, pityriasis (If localized on web of hands and eosinophilic rosea-like eruption. feet, see scabies). inflammation)

Asteototic Patches and plaques with Scales Polygonal shaped Icthyosis vulgaris eczema varying degrees of erythemia, scales on extensor scaling, crusting, and l surfaces of arms ichenification. Diffuse dry skin and legs. is always present.

For treatment of rashes, see the reference for this flowchart, Table 7-10: Dermatologic Complications in Patients with AIDS in Bartlett JG and Gallant JE. 2000-2001 Medical Management of HIV Infection. Johns Hopkins University, Baltimore, MD. 2000. October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 7

Spotlight: Federal Funding For HIV in Corrections: One Year Later by HEPP Staff

A year ago, departments of corrections in seven states received a mil- plan and perform a medical record abstraction. Even more importantly, lion dollars each in CDC/HRSA grant money. California, Florida, Illinois, during Post-Release Services, staff will report at 30-day intervals on Georgia, Massachusetts, New Jersey, and New York are using the medical & mental health care, treatment, housing, benefits, and funding to create stronger ties and linkages between HIV-infected employment (see Table 1). inmates and community health care providers with an eye toward In addition, the researchers will conduct offender interviews as they go improving continuity of medical care after release. One year later, CDC through the discharge process. "We will be doing a baseline and a fol- officials are beginning to evaluate the progress of these grantees and low-up interview with participants either three months post the last con- their programs with the hope of eventually identifying a model for com- tact with the intervention in the community or 6 months past release, munity linkages for other corrections jurisdictions. whichever come first," said Ted Hammett of Abt Associates. The goal of the CDC/HRSA initiative was to target African Americans According to Hammett, the follow-up interview with clients will be a self and other racial minorities, increase access to HIV/AIDS primary health report where investigators will look at whether linkages were made and care and prevention, improve transition between correctional facilities if the clients were able to access them. and the community for HIV positive offenders and develop support in the community for HIV health and social services. "The emphasis is to Table 1. Aggregate Data focus on folks who are HIV positive and those who have been dispro- portionately impacted as well as those with any other behavioral risks, Treatment/Case G Started on HAART TB, hepatitis-and we can't ignore substance abuse. They all roll into Management G Are receiving Case management or one," said John Miles, of the Centers for Disease. discharge planning M/DP G Released with referrals/appointments Dr. Kimberly Arriola, a member of the Evaluation & Program Support G Released with HIV medications Center (EPSC) team at Emory University in Atlanta, summarized the HIV Prevention G Single sessions or series of sessions current status of the projects at the HIV/AIDS Behind Bars 2000 Pre- G Unduplicated number of participants Conference Symposium, National Commission on Correctional Health G Demographics (series participants) Care Conference, St. Louis, MO. Other members of the EPSC team G Percentage completing every session in series include Ronald Braithwaite, Ph.D. (project principal investigator), and G Spanish-language sessions Alyssa Robillard, Ph.D. Additional members include Theodore G Sessions conducted by peer educators G Length of sessions Hammett, Ph.D. (Co-Principal Investigator) and Sofia Kennedy, MPH of Abt Associates (Cambridge, MA). Peer Educator G Number of peers recruited Training G Number of recruits who completed training Dr. Arriola emphasized that correctional settings are ideal for preven- G Demographic characteristics of peer tion and treatment interventions, and that HIV treatment, management, educators and prevention interventions to date appear to have been inadequate. Disease G Disease Screening (by disease entity) Therefore, the goal was not to fund improved HIV care, but rather to Screening & G Tests· positive tests model how linkages to the community can address the problem of HIV Staff Training G Results not received management in corrections. G Partner notification/contact tracing G Treated/started on treatment Evaluation Objectives G Staff Training The objectives of the evaluation are to document the process of pro- G Single session/series of sessions gram implementation, and to describe the challenges & strategies, and G Number eligible/attending determine whether the interventions are building on existing programs or forging new collaborations. The grantees were to demonstrate the Expected Challenges range & volume of services provided and examine client-level out- CDC officials are well aware that corrections and public partnerships comes for selected intervention components. Furthermore, they were can be challenging to develop depending on the jurisdiction. to show linkage with key services in the community; utilization of care; "We're very fortunate in the states that competed [for the grants]. They and the impact of their interventions on HIV risk reduction. are all states with major problems with the burden of disease [and the "We are looking at which [program style] is better. Giving someone a community was open to partnerships]," Miles said. "In general there's a referral card is nice, but a phone call, appointment and a face-to-face real recognition that keeping the inmate population healthy is part of hand-off is even better. Hopefully in the long run, if we do all of this well, improving the safety and well being of the institution. It also bodes well we will see if it has an impact in recidivism and reducing [disease] with the community trying to build the collaboration; that needs to be transmission," said Miles. there." The program features a "constellation" of interventions (HIV treatment, In January, CDC officials and grantees will meet to discuss any hurdles Case Management, Discharge Planning, Prevention Case experienced along the way to creating the community linkages for HIV- Management) along with HIV prevention (Educational sessions, peer- positive offenders. based programs), disease screening, and staff training in a range of Conclusion settings in prisons, jails, and juvenile facilities. Evaluation of the outcome of this CDC/HRSA Initiative is likely to offer Evaluation Activities insight on what factors influence engagement & maintenance in post- During year one, the evaluators learned about the grantees via site vis- release medical care. Although the researchers have encountered sev- its and meetings (obtaining buy-in was important!). According to eral obstacles and experienced delays in data gathering, the initiative grantees, one of the major impediments to the development of pro- has potential to make a major impact on public health policy and estab- grams was the lack of existing research and programmatic infrastruc- lish models for implementation elsewhere. ture, such as experience with IRB approval of projects to be carried out At the HEPP symposium, audience participants were informed that the CDC in correctional settings, (see main article). study forms would be available to other individuals interested in collecting Some of the information that will soon be available includes information data. Contact Dr. Arriola at Emory University or Dr. John Miles at the CDC gathered during intake (jail or prison) such as discharge planning for additional information. Although no additional states or sites will receive needs, health status, health care utilization, alcohol and drug use and funding through this initiative, HEPP readers may find it useful to adapt the treatment, and client demographics. In addition, information will be CDC/HRSA forms to their own projects. Information about other potential gathered from the medical record such as the client's HIV status, sources of funding for HIV intervention projects is available from the web- whether the client was tested during that incarceration, and mental ill- sites sited in the resource section of this issue. ness diagnoses. At release, the staff will evaluate the final discharge October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 8

Save the News Flashes Dates New Complication of HIV: 800 to 1,000 inmates who have the viral infec- Osteonecrosis of the Hip tion, a leading cause of liver disease, to see Management of HIV/ AIDS in the who will qualify for the expensive drug therapy. Correctional Setting: A Live Investigators at the National Institutes of Health The Correction Department's new plan provides Satellite Videoconference Series, (NIH) have demonstrated that a disabling bone Antiretroviral Update 2000 disorder, osteonecrosis of the hip, is surprisingly treatment to inmates with liver disease who Available for online viewing at common among patients with HIV infection. meet all of eight qualifications, including the your convenience after October 16 Concern that the disorder might be a new and willingness to undergo random drug tests. at the HEPP News Website: unrecognized complication of HIV infection Prisoners are excluded for any of 17 reasons, http://www.hivcorrecttions.org prompted the investigation, a collaboration including "high-risk behavior" after their diagno- 2.5 CME credits available between the NIH Clinical Center and the sis, such as "sexual behavior, body piercing from Albany Medical College National Institute of Allergy and Infectious and tattoos." Patients also are excluded if they Corrections to Community: Disease (NIAID). Magnetic resonance imaging are scheduled to meet the parole board within Continuity of Care was used to evaluate 339 study volunteers, all 18 months so that treatment does not have to A one-day discharge planning training patients with HIV. While none of the study par- be terminated if an inmate is released (Wolfson, presented by SEATEC. ticipants had the hip pain typically associated A. The Courier-Journal, September 21, 2000). November 9, 2000, Gainsville, GA with osteonecrosis, 15 (4.4%) were found to December 7, 2000, Forsyth, GA "Liver Failure Common in HIV- have the disorder. One concern is that the January 10, 2001, Tifton GA Infected Patients" All trainings are free, provide lunch, lesions will lead to clinical symptoms that ultimately require total hip replacements. The rea- A report in the September issue of the Journal and run from 9am to 4pm. of Acquired Immune Deficiency Syndrome Contact: Marjorie Dunne at son for this unexpected complication of shows that HIV-infected individuals often die [email protected] osteonecrosis (bone death) is unclear. A longitu- Call: 404.712.9687 dinal study is under way to determine how from liver failure. Italian researchers studied Visit: http://www.seatec.emory.edu many patients will develop these lesions and 1,900 HIV-infected patients for eight years, during which time there were 467 deaths. Among American Public Health how many will ultimately need hip replacement. (NIH News Release, Clinical Center the 308 in-hospital deaths, AIDS was a key fac- Association Annual Conference tor in 89% of the deaths, while liver failure was November 13-16, 2000, Boston, MA Communications). the primary cause of death for 5% of the A number of correctional healthcare topics will be featured. Kentucky Inmates to receive medical patients and a concurrent cause of death in an To register, Call: 514.847.2293 care for hepatitis C additional 6%. Dr. Massimo Puoti-who also Email: [email protected]. A few months after a federal magistrate con- found that 80% of the patients who died in the Visit: www.apha.org demned the Kentucky Corrections Department hospital tested positive for antibodies to hepatitis C-said that key strategies to prevent liver Request for Proposals (RFP): for denying medical treatment to a prisoner with failure among HIV-infected individuals include Equal Access Initiative- Computer life-threatening hepatitis C, the agency adopted Grants Program 2000/2001. a new plan that could mean up to 1,000 working to prevent hepatitis B, treating existing Due Date: December 1, 2000 inmates will get the care, at a cost of $25,000 hepatitis B infections, and reducing alcohol use. 100 minority community-based per patient. The department currently is testing (Puoti et al. JAIDS, Sept 18 2000;24:211-217.) HIV/AIDS organizations will lreceive access to the Internet through a unique in-kind computer grants program. Resources & Opportunities Contact: National Minority AIDS Council (NMAC) at 202.483.6622 A corrections edition of Bartlett and Grant and Funding Websites or [email protected] Gallant's 2000-2001 Medical NIH Grants and Funding Opportunities Visit: www.nmac.org/pubs/ Management of HIV Infection is now http://grants.nih.gov/grants/index.cfm RFP2000-2001.htm available. The only difference between the CDC's Procurement and Grants Office National STD Prevention Conference corrections edition and the regular edition is the http://www.cdc.gov/od/pgo/funding/ December 4-7, 2000 first chapter. The HIV Management Guidelines grantmain.htm Milwaukee, WI are outlined in this book and updated every Contact: Glenda Vaughn, Centers for week on the web at http://www.hopkins- Guide to Winning Grants Disease Control and Prevention aids.edu. http://www.grantstech.com/ Call: 404.639.1806 E-mail: [email protected] HRSA's HIV/AIDS Bureau has recently Grantspring http://www.grantspring.com/research.htm Medical Management of AIDS: A published A Guide to the Clinical Comprehensive Review of HIV Care of Women with HIV. This 2000 HIV Treatment Websites Preliminary Edition is available at no cost and Management - Winter Symposium AIDSline will be updated at http://www.hrsa.gov/hab. December 7-9, 2000 http://www.igm.gov San Francisco, CA Contact: Cliff Brock Expert Perspectives: Department of Medicine UCSF Strategies for the Management National Institute on AIDS Call: 415.476.5208 of HIV/HCV Co-infection http://www.niaid.nih.gov Fax: 415.476.3542 Dr. Douglas Dieterich of Cabrini Medical Center Virology on the Web Email: [email protected] and Drs. John Bartlett and Mark Sulkowski of http://www.virology.net Web: http://medicine.ucsf.edu/ Johns Hopkins University School of Medicine programs/cme recently co-chaired a meeting of researchers Health Resources and Services 2001 ACA Winter Conference and experts on HIV and hepatitis to assemble Administrations HIV/AIDS Bureau January 22-24, 2001 guidelines for the treatment of HIV and hepatitis http://www.hrsa.gov/hab Nashville, Tennessee C co-infected patients. The guidelines appear Call 1-800-222-5646, ext. 1922 online in a continuing medical education National Commission on Fax: 1-301-918-1900 monograph at http://www.projectsin Correctional Health Care Visit: www.corrections.com/aca knowledge.com/hiv-hcv/index.html http://www.ncchc.org October 2000 Volume 3, Issue 10 visit HEPP News online at www.hivcorrections.org 9 Self-Assessment Test for Continuing Medical Education Credit Brown University School of Medicine designates this educational activity for 1 hour in category 1 credit toward the AMA Physicians Recognition Award. To be eligible for CME credit, answer the questions below by circling the letter next to the correct answer to each of the questions. A minimum of 70% of the questions must be answered correctly. This activity is eligible for CME credit through Nov. 30, 2000. The estimated time for completion of this activity is one hour and there is no fee for participation.

1. A patient presenting scaling, patches, and plaques with active 6. An HIV infected patient currently on protease inhibitors, was borders and central clearing lesions involving skin or nails may recently exposed to an INH resistant strain of TB, and is now have: PPD-positive. The appropriate treatment for latent TB infection in a) Psoriasis this case could be: b) Candidiasis a) Rifampin 600mg/day + pyrazinamide 20mg/kg/day c) Icthyosis vulgaris with > 60 doses x 2 mos or up to 3 mos with interruptions. d) Scabies b) INH 300mg/day + pyridoxine 50mg/day > 270 doses, e) Dermatophytes 9 mos. or up to 12 mos with interruptions c) Rifampin + pyrazinamide 20mg/kg x 2 mos 2. A patient presenting with pruritic papules and pustules on web d) Rifabutin.pyrazinamide 20mg/kg/day of hands and feet may have: with = 60 dose x 2 mos. or up to 3 mos with interruptions; a) Drug reaction e) Rifabutin 300mg po qd x 4 mo. b) Psoriasis f) a and c c) Folliculitis g) d and e d) Scabies h) All of the above e) Dermatophytes HEPP News Evaluation 3. The preferred prevention for Toxoplasma gondii is: a) Dapsone 100mg qd 5 Excellent 4 Very Good 3 Fair 2 Poor 1 Very Poor b) Dapsone 50mg po qd plus pyrimethamine 50mg/wk plus 1. Please evaluate the following sections with respect to: leukovorin 25mg po/wk educational value clarity c) TMP-SMX 1 DS/day Main Article 5 4 3 2 1 5 4 3 2 1 d) Clarithromycin 500mg HEPPigram 5 4 3 2 1 5 4 3 2 1 4. Indicate which of the following statements is true: HIV 101 5 4 3 2 1 5 4 3 2 1 a) The lifespan of an HIV-infected person on HAART with Spotlight 5 4 3 2 1 5 4 3 2 1 CD4<100 is close to that of someone who is Save the HIV-seronegative. Dates 5 4 3 2 1 5 4 3 2 1 b) HIV drug resistance is less common in inmate populations than in the general population. 2. Do you feel that HEPP News helps you in your work? c) HAART is a less expensive intervention per year of life Why or why not? saved than mammography or coronary artery bypass.

5. Strategies for preventing liver failure in HIV infected patients 3. What future topics should HEPP News address? include: a) Strategic treatment interruptions b) Using enteric coated ddI (Videx) instead of the 4. How can HEPP News be made more useful to you? buffered ddI. c) preventing Hepatitis B by vaccinating d) a and b e) All of the above 5. Do you have specific comments on this issue?

BROWN UNIVERSITY SCHOOL OF MEDICINE OFFICE OF CONTINUING MEDICAL EDUCATION BOX G-A2 PROVIDENCE, RI 02912 The Brown University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education activities for physicians.

The use of the Brown University School of Medicine name implies review of the educational format and material only. The opinions, recommendations and editorial positions expressed by those whose input is included in this bulletin are their own. They do not represent or speak for the Brown University School of Medicine.

For Continuing Medical Education credit please complete the following and mail or fax to 401.863.2660 Be sure to print clearly so that we have the correct information for you.

Name ______Degree ______

Address ______

______

City ______State ______Zip ______

Telephone ______Fax ______