HIV Treatment in Prison: Vacaville Update

HIV-positive prisoners last month protested deteriorating
conditions at Vacaville, California's main prison hospital for
men, by refusing to take their medications. As many as 150 of
the 330 inmates living in the facility's separate HIV unit
participated. An exceptional number of fatalities sparked the
action. These included two men whose failing physical condition
was ignored for several weeks. They were finally removed from
their cells at the point of death.

In May 1991, AIDS TREATMENT NEWS interviewed the three
doctors who then cared for Vacaville's known HIV-infected inmates
[see AIDS TREATMENT NEWS #126]. At that time, we were impressed
by the level of professional care for the inmates and by the
personal concern these physicians felt for their patients.

It was also clear that the doctors were continually
frustrated by the the prison bureaucracy's indifference to
patients' needs. All three practitioners (Jessica Clarke, M. D.,
Jan Diamond, M. D., and HIV Director German Maisonet, M. D.)
left Vacaville last spring. Dr. Clarke now heads the HIV program
at a private San Francisco hospital. Dr. Maisonet is an
infection control specialist at the minimum security federal
prison in Pleasanton, CA. Dr. Diamond first went on maternity
leave and then was transferred to the state prison in San
Quentin. Her new role, to enhance the state of medical care in
San Quentin, results from a lawsuit against conditions there.

Dr. Maisonet said of his decision to resign, "It hurt a lot
to leave, but we were faced with an increasing number of patients
and a decreasing amount of resources. I would have had to
practice medicine at a level below the standard of care, and I
wouldn't have been satisfied."

To get a sense of the underlying problems, we talked with a
number of ex-inmates and Vacaville staff members. The picture
that emerges is one of poor management and lack of planning
compounded by AIDS phobia. Prisons have a custodial mentality;
"people can wait" is their attitude even when confronted with
acute disease.

The average age of prison doctors is 62. Many are ex-
military officers in the prison system to collect a second
pension.

"How will they come up to speed on AIDS care?" asked one
staffer. Free AIDS training is available for the few with the
energy and the interest, but there is little incentive.
Physicians are so poorly supervised that no one checks up on
whether they actually see patients or how well they do.
Monitoring for toxic reactions has been a particular weakness.

This year, Vacaville received extra money from the state
budget to hire three new AIDS doctors. In the meantime, Dr.
Diamond is temporarily moving back to Vacaville. We talked to
her about the general measures needed to improve HIV care at
Vacaville and other California prisons.

According to Dr. Diamond, "The key to improving health care
is more oversight. Patients' records should be regularly
reviewed by a second physician. Providing good HIV care is quite
possible in the prisons. Any drug you want is available, and if
you just stick to medical care, it isn't that busy."

Asked about Vacaville's attempt to hire new HIV specialists,
Dr. Diamond commented, "With the ever-growing health crisis and
insurance mess, a lot of doctors in private practice are looking
for other work. We should be able to hire physicians who are
motivated to learn about AIDS and sensitive to treating inmates
like people."

The chief hurdle to the conscientious physician is the
absence of support services. "German would spend 20 hours a week
doing what a social worker should do," Dr. Diamond noted.

In the past, no one did discharge planning for inmates with
health problems. Released patients faced a bleak future unless
their doctors shouldered the responsibility for finding them
shelter and financial support such as disability payments.
Partly due to the efforts of Drs. Maisonet and Clarke, the parole
division of the Department of Corrections this year started a
pilot discharge planning program for inmates from the Los Angeles
and San Francisco regions.

Getting help for patients with psychiatric problems has been
another trying experience. HIV-positive inmates reside in
separate housing units without access to the standard mental
health department. They get only intermittent assistance for
mental problems, even though HIV disease creates its own
psychiatric problems and aggravates new ones.

Those with advanced HIV dementia are generally warehoused in
isolated cells known as "psychiatric management units." A
violent prisoner affected by dementia is considered merely a
disciplinary problem. Just breaking a window or throwing food at
a guard can get someone placed in solitary confinement, which
"can end up being quite damaging, quite inhumane," Dr. Diamond
observed.

An inability to hire more nurses further increases doctors'
burdens. The nursing shortage restricts the size of Vacaville's
acute care unit, meaning that severely ill inmates have to be
sent at enormous expense to outside hospitals, interrupting the
consistency of care. Meanwhile, the absence of an out-patient
infusion center keeps prisoners with CMV retinitis in the acute
care unit indefinitely so that they can receive their daily
maintenance infusion of ganciclovir. If it weren't for these
one-hour infusions, they could return to the residence units

Inadequate support staff makes it hard to monitor for side
effects. The number of treatments needed to manage AIDS- related
conditions can multiply into the dozens, and many of these
substances themselves require careful management based on
frequent lab tests.

"There is not enough appreciation of AIDS drugs' toxicity,"
Dr. Diamond noted.

One area where she thinks too many drugs are given is in
prophylaxis for candidiasis and cryptococcal meningitis. She
feels that Pfizer Laboratories has promoted its product
Fluconazole too aggressively for this use. Fluconazole costs $7
per day, and using it excessively might create resistant fungal
strains.

The Vacaville HIV service tends to give fluconazole to
everyone with T-helper counts less than 200. Dr. Diamond instead
recommends frequent screening for cryptococcus until a patient's
T-helper count falls under 50. Prophylaxis with fluconazole
should begin only at this point, unless the patient is already
taking the drug for recurrent esophageal candidiasis or other
reasons. Of course, this approach depends on timely lab testing.

One way to overcome the lapses in staff support is to teach
prisoners to recognize the symptoms of cryptococcal meningitis
and other diseases so they can report them immediately.
Prisoners could also learn to watch for signs of drug toxicities.

A special aspect of self-help has been Vacaville's Pastoral
Care Service. Sponsored by a prison chaplain, PCS is run by
inmate volunteers who provide comfort to terminally ill
prisoners. Without PCS, sick inmates in the hospital unit would
be alone almost all day. The volunteers help the sick with basic
physical functions, keep them company and intercede with the
nurses to obtain needed care. Members of PCS sit constant vigil
with inmates in the final days of their lives.

"It's little short of a miracle that Father Leslie [the
chaplain] got this done," Dr. Diamond commented.

But Michael Haggerty, an inmate who coordinated Pastoral
Care until his release last May, complains that Vacaville's new
chief and associate wardens are much less supportive of PCS than
the previous administration. PCS activities became sporadic, as
approval and training of new volunteers were stalled and access
to clients' living quarters denied.

"It's hard for officials to see that inmates really want to
help. It will be an ongoing proposition to get PCS entrenched,"
said Haggerty.

All these comments apply only to the identified HIV-positive
inmates. The unknown ones receive no HIV care at all.

Surveys indicate that the total number of California
prisoners with HIV is five to ten times the number known to be
positive. Inmates avoid HIV testing because those found to be
infected with HIV suffer from a variety of restrictions. The
segregated housing units, bans on conjugal visits, and bans on
working in food and medical department jobs discourage California
inmates from obtaining what limited help there is for HIV-related
conditions.

Vacaville Prison Seeks HIV Physician

The California Medical Facility in Vacaville seeks a
physician with "good working knowledge of internal medicine and
infectious disease in the HIV-infected patient. The physician
will be administering health care to all categories of patient
care from outpatient clinics, inpatient care, emergency services
and screening examination of the HIV+ inmate."

The position includes liability coverage. "Additionally,
there is no office overhead, malpractice insurance or salaries to
pay, and no billing or collection problems."

For more information, contact Raymond L. Andreasen, M. D.,
Chief Deputy Warden(A), Clinical Services, P. O. Box 2000,
Vacaville, CA 95696-2000. Or call Karen Huston, Examination
Coordinator -- Personnel, 707/449-6532.

AmFAR Announces Community-Based Research Grants: Letters Due
November 5

The American Foundation for AIDS Research plans to award up
to nine Operating Grants of up to $50,000 each, and up to six
Project Grants of up to $100,000 each, to community-based
clinical trials organizations within the United States and its
territories, or (exceptionally) in other areas. Letters of
intent (which must follow a specified form, including cover page,
abstract, biographical sketch, and list of participating
physicians -- with ten copies in addition to the original) must
be received by 5:00 Eastern Standard Time on Thursday, November
5. Those whose letters are accepted will be given about six
weeks to submit a grant application.

For complete instructions on submitting the letter of
intent, call the Community-Based Clinical Trials Program,
American Foundation for AIDS Research, 212/682-7440.