Adherence Strategies: Inmates don't view DOT favorably
Adherence Strategies
Inmates don't view DOT favorably
Privacy is biggest concern
Concerns about privacy and medication distribution staff have resulted in a majority of North Carolina inmates who are HIV positive to say they would rather keep their antiretroviral drugs in their own lockers than receive the medications via directly observed therapy (DOT), a new study says.1
"Inmates have a lot of concerns about confidentiality, and there is a lot of suspicion about whether they're getting the right medications or whether prison guards are trained to give out medications," says Andrew Kaplan, MD, professor in the department of medicine and microbiology at the University of North Carolina, Chapel Hill.
A pilot study that looked at the health beliefs and attitudes concerning antiretroviral adherence among prisoners receiving DOT found that 72% of the inmates surveyed believed they would be hassled in prison if other inmates found out they were HIV infected.1
"Most people prefer to take the medications on their own," Kaplan says.
UNC's division of infectious diseases provides HIV care for the North Carolina Department of Correction (NCDOC), Kaplan says.
From July 1, 1999, to April 1, 2000, when the study was conducted, the NCDOC state prison system had 83 prisons with a 32,000 daily census. About 2% of the men and 4% of the women incarcerated were HIV infected.
Medical care and medications are free to inmates for all conditions, and one of the critical issues is getting people to take their medicines as prescribed, Kaplan notes. "So prison seems like an ideal place to do directly observed therapy," he says.
For example, prisoners who are on narcotic pain medication, drugs for tuberculosis infection, and psychiatric medication already receive their pills via DOT, Kaplan says. "So they had this DOT program in place when protease inhibitors first came along in the 1990s, and they started putting PIs on the formulary," Kaplan explains.
The PIs were very expensive, and the DOC wanted to make sure drugs were used properly and not wasted, so they had PIs included in the drugs distributed through DOT, Kaplan adds.
Inmates received their PIs through DOT, but the nucleoside and non-nucleoside reverse transcriptase inhibitors were dispensed as a 30-day supply that inmates could self-administer.
"We came along and provided HIV care for prisoners, and we started to hear concerns about how well the system worked, so we decided to study it," Kaplan says.
Investigators found that prisoners' chief concern was confidentiality. The DOT system required inmates to stand in a line outside along with other inmates, including those with TB and psychiatric disorders, he says.
"And sometimes corrections officers are the ones who are dispensing the medications, and there's an adversarial relationship between guards and inmates," Kaplan says.
"We would hear from nurses that certain inmates wouldn't go to the DOT line to get their medications," he says. "So we decided to look into some of these issues."
The study about inmates' attitudes found that 16% of those participating reported they would miss their medications rather than wait in the DOT medication line.1
A sample of 65 HIV-infected participants, recruited from a convenience sample of people attending the HIV clinics at the Central Prison, were included in the study.
Another finding was that inmates who had positive attitudes about PIs had higher levels of adherence, although the same association could not be made with beliefs about reverse transcriptase inhibitors and adherence.
DOT has drawbacks, including its high cost, so investigators also decided to study whether it worked. One pilot study suggests that antiretroviral adherence among inmates receiving DOT was the same as adherence among inmates who took their antiretroviral drugs on their own, Kaplan says.
As a result of these findings, investigators decided to study adherence among inmates receiving DOT in a larger, randomized, controlled study, and the data are still being analyzed, he adds.
Investigators also are enrolling volunteers as part of a large, randomized, controlled trial to address the question of bridging HIV treatment from prison to the community, Kaplan notes.
HIV inmates are randomized to the standard of care in prison or to a bridging case manager. The standard of care includes 30 days of medication when they leave, and a nurse helps them connect with a doctor, Kaplan says.
Reference:
- White BL, Wohl DA, Hays RD, et al. A pilot study of health beliefs and attitudes concerning measures of antiretroviral adherence among prisoners receiving directly observed antiretroviral therapy. AIDS Patient Care STDS. 2006;20(6):408-417.
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