Dear Correctional Colleagues:

In the early days of the AIDS epidemic, much of the basic pathogenesis and epidemiology of HIV had not yet been clarified. Not enough was known about how the virus was transmitted, how it could be prevented, how it caused immune deterioration, what infections and cancers infected persons were at risk for, and how these opportunistic infections could be prevented. As a result, the management of those with HIV infection was relegated to infectious disease specialists and to a small cadre of dedicated pioneers drawn from a variety of medical fields.

By the end of the 1980s, much of the basic details concerning HIV had been elucidated. Soon, the number of cases of HIV in this country overwhelmed the available specialists. Because of the simplicity of the limited treatment options (essentially PCP prophylaxis and AZT) most primary care clinicians were able to manage the treatment of those infected with HIV.

The 1990s witnessed a dramatic increase in treatment options for HIV and related illnesses. Along with these new treatments have come severe, potentially fatal side effects and a myriad of complex pharmacokinetic interactions. Outcome based studies have demonstrated that patients who do not receive care from clinicians who specialize in the management of HIV are at a greater risk for HIV related morbidity. Furthermore, the life expectancy of those who are HIV-infected is directly related to the experience of their physician. Clearly, we have come full circle, in that only those clinicians who make it a priority are able to master the complexities of the care of the HIV-infected. We can all hope that in the future the HIV specialist will be obsolete ... until that time, we have a responsibility to ensure that those inmates entrusted to our care have access to clinicians who specialize in the management of HIV.

This month, Dr. David Paar provides an update on guidelines for the treatment of HIV. Dr. Bethany Weaver presents a case that discusses some of the challenges of using efavirenz in those who have a major mental illness, and our HIV 101 details some of the pharmacokinetic interactions that can occur between antiretroviral agents and psychotropics. At the conclusion of this issue, readers will be more familiar with the new HIV treatment guidelines, be aware of potential for drug interactions between HAART and psychotropics, and know more about the potential side effects of efavirenz.

Beginning next month, Dr. David Thomas will assume the role of co-chief editor managing content for IDCR. We welcome Dr. Thomas to this new role, and we also welcome three new members to our editorial board: Dr. William Cassidy, Associate Professor of Medicine at Louisiana State University Health Sciences Center, Dr. Neil Fisher, Medical Director and Chief Health Officer of Martin Correctional Institute; and Barry Zack, M.P.H., Executive Director of Centerforce. Thank you for your continued readership of IDCR, and we encourage your suggestions concerning future topics.

Sincerely,
Joseph Bick, M.D.
Co-Chief Editor, IDCR