Health-Care In Prisons
In the following article, Dr Sally Ford, Clinical Associate at the HIV/AIDS Clinic at Kingston General Hospital, describes her personal experience as the physician responsible for care of patients with HIV/AIDS in federal prisons in the Kingston area.
Health Care for Prisoners Living with HIV/AIDS
The situation with regard to HIV/AIDS in prisons is changing. Until recently, most prisoners with HIV were in early stages of the disease. Lately we are seeing more and more prisoners – both newly admitted and long-term – with advanced stages of HIV disease.
This reflects the evolution of the HIV/AIDS epidemic in Canada, mirroring the rise of infection rates among intravenous drug users (IVDUs) observed since the mid 1980s: an increasing number of IVDUs, many of whom spend at least part of their lives in prison, are developing AIDS and becoming sicker.
Prisoners in early stages of the disease normally do not require anything other than monitoring of the progression of their disease and psychosocial support. For many, imprisonment has resulted in an improvement of their general health status, due in large part to reduced drug consumption, better nutrition resulting in weight gain, and ready access to medical and dental facilities.
Now, in the mid 1990s, prison health services are increasingly faced with having to deal with further-advanced stages of the disease and their manifestations. While the numbers are rising, they are still relatively small: in the Kingston area, where there are about 4500 prisoners, there are presently less than 10 prisoners with CD4 counts under 200. This means that the prison physicians who provide services for them are still relatively inexperienced. The resulting problems are managed if they recognize that they cannot provide the necessary specialized services and treatment, and refer prisoners early enough to the Kingston General Hospital HIV/AIDS Clinic, which provides HIV-specific care for prisoners with HIV/AIDS.
However, problems are sometimes not recognized. Most prisoners are regarded as relatively fit young persons, with drug dependency as their only health problem. While nurses and doctors who work with prisoners deal well with well-demarcated chronic illnesses such as diabetes, cancer, arthritis, or easily recognized emergencies such as acute myocardial infarction or trauma, the HIV-positive patient with a low CD4 count, who may look well but not be well, is a challenge. For example, it is difficult for health-care staff to appreciate that the headache of a well-looking prisoner, still able to lift weights, is due to a life-threatening cryptococcal meningitis. This difficulty is enhanced by the fact that some prisoners have a tendency to try to manipulate health-care staff, who as a result can be more reluctant to "believe" the inmate and to intervene immediately by, for example, making referrals or prescribing medication. Problems are likely to increase in the years to come because, unfortunately, the rise in the number of seriously ill patients – with other serious infectious diseases and/or with HIV – coincides with cuts to health-care budgets.
There are other serious problems as well:
• Access to Drugs: The Kingston area CSC pharmacy has made it very easy for prisoners to access accepted drugs, even expensive ones not available under the Ontario Drug Benefit Plan. However, it has not been possible to obtain investigational drugs such as 3TC, which is being widely used by persons living with HIV/AIDS outside prisons. It is unclear what would happen if a prisoner on such a drug was admitted to the system. Further, it is almost impossible for prisoners to obtain access to nonconventional therapies.
• Pain Medication: On the outside, it is often difficult for health-care staff to accept that drug users in pain will not automatically abuse narcotics given for pain relief. In prisons it can be even more difficult. It is also hard to convince staff that a patient with no easily demonstrable physical signs may still have excruciating pain. Unless a prisoner is in the regional hospital, there is no mechanism for giving adequate pain relief. But not all who require pain relief also require hospitalization: a patient with chronic meningitis in our clinic needed narcotics for the last 15 months of his life, during which time he led an active life. I am very concerned about how prisoners requiring pain relief are being dealt with.
What can be done to improve the situation? A few suggestions follow:
• education of patients: should be part of the solution, although because of the sometimes adversarial relationship between prisoners and staff, it will be of limited value;
• accelerated parole: because offering patients with advanced disease accommodation in the regional hospital or palliative care unit is not an acceptable alternative for the patient, we spend much time trying to obtain early release for patients with AIDS. However, because of the public's concern over violent crime, and because it is feared that prisoners with AIDS, once released, may spread the disease, this is often difficult. Of five applications concerning my patients, only two have been successful; three applications were turned down because of security concerns and because the prisoners were not terminally ill. So far, three of my patients have died in custody: two died shortly after their admission to prison, and the third committed suicide.
- Sally Ford
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