Of the 2.2 million people incarcerated in prisons and jails across the U.S., about 1.5% are living with HIV, meaning HIV is about four times more prevalent in prison than in the general population.
Delivering high-quality health care to people in prison living with HIV is difficult because of the lack of privacy and the strong HIV stigma in prison. Another major hurdle is funding, with some cash-strapped states choosing not to prioritize specialty HIV care.
The end result is that HIV in prison is a major problem. This correlation was no surprise to nurses gathered at a presentation given by pharmacist Melissa Badowski, Pharm.D., BCPS, AAHIVP, a clinical associate professor at the University of Illinois in Chicago, at the annual conference of the Association of Nurses in AIDS Care (ANAC 2018) in Denver.
With a show of hands, the majority of nurses packed into Badowski's crowded session said they've cared for currently or formerly incarcerated HIV-positive patients. These nurses were looking for new strategies to tackle a decades-old problem.
According to Badowski, those new strategies should include telehealth -- the idea of using Skype-like video consultations and remote diagnostics to deliver high-quality health care. Telehealth originally took off as a way to reach patients living in rural areas. Because telehealth is fully remote, transportation costs are slashed to near-zero.
The Illinois Department of Corrections implemented a telehealth program for incarcerated people living with HIV in 2010. Illinois has the sixth highest number of people living with HIV in its correctional setting -- after Florida, Texas, New York, California, and Georgia.
As part of its new telehealth services, incarcerated patients sit alongside nurses based in-house within the correctional facility and connect via video conference to a team of care providers, including Badowski, a pharmacist, an infectious disease physician, and a case manager.
To determine if the telehealth program was, in fact, improving outcomes, Badowski and her colleagues compared viral suppression rates before and after the program was implemented.
The 'before' comparison group was comprised of 514 incarcerated people whose HIV had been managed by the regular on-site physician from July 2009 to June 2010. The 'after' group was made up of 687 incarcerated people who received telehealth services from July 2010 to June 2012.
At baseline, the CD4 counts for these groups were essentially the same (485.4 cells/µL and 502.9 cells/µL, respectively). After six visits, the telemedicine group had an average virologic suppression rate of 91.1%, while the 'before' group who didn't have access to telemedicine had an average virologic suppression rate of only 59.3%.
The positive effect of telemedicine remained even when researchers removed all the patients who had already been suppressed at their first visit from their analysis (75.8% and 23.0%, respectively). The telemedicine group also had better viral suppression rates regardless of their baseline CD4 count. Badowski and her colleagues published their results in 2014 in Clinical Infectious Diseases.
Badowski is calling Illinois' HIV telehealth program a success. She says similar telehealth programs are taking off in other states, such as California and Texas.
While she's not aware of any data demonstrating its cost-effectiveness, Badowski says telehealth is the most affordable way to deliver high-quality HIV care for budget-conscious states.
"We are increasing viral suppression, [and] this has been able to provide some cost savings from the transportations security standpoint," she said. "I think a lot of prisons are looking at doing a telehealth model, because it just provides wonderful care and wonderful access to inmates."
"I don't know why it isn't in more states," she said.
Nationwide, deaths from AIDS have plummeted in prisons since the 1990s, mirroring the decline in AIDS-related deaths in the general population thanks to highly effective antiretrovirals.
For Badowski, the next major hurdle is ensuring that incarcerated people are set up to succeed outside of prison. Too often, people in prison living with HIV see their health plunge when they're released. If they violate parole or commit another crime, they often return to prison with higher viral loads than when they left.
There's certainly a big role to play for case managers, who can help prepare people in prison for the logistics of navigating the parole system and finding stable employment and housing once released.
But ultimately, Badowski says the answer may lie in technology. Specifically, she pointed to a 2017 study on cell phones and recently released, HIV-positive inmates led by HIV researcher David Wohl, M.D., at the University of North Carolina at Chapel Hill.
For that study, Wohl and his colleagues wanted to see which patients would do better -- those who were released with a cell phone, and those who were released with a cell phone plus a comprehensive engagement program to help them maintain viral suppression.
As it turns out, the group of study participants who received a cell phone plus extra services only did slightly better than those who received just a cell phone. That led Badowski to conclude that the most crucial aspect of the study is the cell phone itself. That alone was enough to help people living with HIV do well post-release, regardless of the other interventions.
For Badowski, this research indicates that formerly incarcerated people are relatively adept at navigating complex systems and staying healthy after release -- provided there's an easy way for them to contact their doctors and parole officers, and an easy way to be contacted directly themselves.