TB controllers scalded as HIV prison debate begins to boil over

TB docs ponder coercing inmates to take INH

In recent months, jails and prisons that don’t have all the elements of TB control tightly in place have been finding themselves caught uncomfortably in the spotlight. In most cases, it’s not even TB outbreaks that trigger the initial scrutiny.

What seems to be going on instead is that as the debate over health care for HIV-infected inmates heats up, those charged with controlling TB are getting caught in the backsplash.

In Atlanta, for example, two overcrowded jails that serve adjoining counties are both under court orders to clean up their TB control acts. What launched the first of two class action lawsuits (filed by the Atlanta-based Southern Center for Human Rights) were complaints about medical care being withheld from HIV-infected inmates in Fulton County jail. Fulton County includes much of Atlanta. That lawsuit eventually expanded to address shortcomings in TB care as well.

In the second investigation, TB care at neighboring Dekalb County jail has come under considerably heavier fire, with the judge presiding over the case ordering a long list of TB-related improvements.

County TB controllers complain off the record that they’ve been desperately short-handed, and that the jail’s private health care subcontractor hasn’t wanted any TB-related advice. They also seem to have developed terrible cases of phone-call phobia.

"I’m familiar with lots of jails around the country, and what surprised me here in Atlanta was the absolute paucity of attention to all matters of public health - including HIV, TB, and sexually transmitted diseases," says Robert Griefinger, MD, court-appointed monitor for the two cases, and chief of the New York City-based Bromeen Group.

Griefinger’s comments underscore the subtext of both investigations: the growing national debate over how much health care jails and prisons owe their inmates.

The premise that inmates of correctional facilities are at increased risk for infectious diseases of all sorts isn’t news. In the wake of court rulings that mandated increased screenings, Atlanta’s Fulton County jail began doing syphilis testing; fully 7% of the jail’s inmates were found to be positive.

Prevalence of other infectious diseases in jails and prisons is equally breathtaking. Nationwide, for example, about 25% of HIV-positive people pass through jails and prisons, as do 30% of the country’s hepatitis C cases, says Anne De Groot, MD, co-chair of the HIV Education prison project at Brown University School of Medicine in Providence, RI.

Getting attention with drug-resistant HIV

What is new is how human-rights advocates such as De Groot and the Southern Center for Human Rights have begun using the specter of the spread of infectious disease — especially drug-resistant HIV — to force correctional systems’ hands. "There’s every reason to expect that the spread of HIV-resistant strains will become more commonplace, given the concentration of HIV-infected individuals in settings where HIV care is substandard," De Groot says. She adds that the current situation "closely resembles" the point at which multidrug-resistant TB began to spread beyond the correctional setting in New York State.

In TB control circles, the debate over jailhouse health care has taken an interesting twist of its own. Because so many inmates in correctional settings are TB-infected, the argument goes, why not work harder at getting preventive treatment into them?

Indeed, the Institute of Medicine’s report on TB elimination released last year breaks with tradition and recommends a new, strong-armed approach to jailhouse prophylaxis, suggesting that prisons begin using measures such as a "tuberculin hold" status to lock down inmates who refuse preventive medicine. (See: Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, DC: National Academy Press; p. 101.)

For the last four years, that’s exactly what New York State prisons have been doing, says Lester Wright, MD, MPH, chief medical officer for the state’s prisons. So far, courts that have heard cases related to the policy have ruled in favor of the state prison system.

Is this a good thing? Several experts interviewed by TB Monitor answered with an emphatic "no."

"The idea of forcing people to take prophylaxis for TB infection is based on ignorance," says Ronald Shansky, MD, a Chicago-based correctional health care consultant and a board member of the Chicago-based National Commission on Correctional Healthcare (NCCH). "The overwhelming majority of inmates identified as having TB infection will take the medicine voluntarily if you give them proper counseling." Besides, he adds, in most places, TB control in jails and prisons is working well; falling TB rates in the community reflect that fact. "So why," he asks, "do we need to add compulsion?"

Edward Harrison, president of NCCH, agrees. "Coercive practices can result in an adversarial relationship between inmates and health care providers, and that’s not something you want," he warns. "What’s much better is to develop a relationship of trust. Inmates in some places are used to having stuff shoved down their throats, but that can be very bad for patients. It’s also bad for the community once the patient gets released."

Wright says he worried about that when he first came up with the idea of tuberculin hold, which is based on the premise that an inmate is most likely to come down with TB in the first year after infection and that infected inmates have been recently infected. "So far it hasn’t been a problem, though," he says.

Plus, Wright adds, most inmates don’t need a lot of coercing — just a good explanation of the risks and benefits. "Most people understand and accept that taking [treatment for latent TB infection] is for their own good, and for the good of the community," he says.

Moreover, Wright believes the opportunity to give such treatment in the prison setting is simply too good to pass up. "The correctional setting is truly an excellent place to do public health," he says. From TB control’s new emphasis on identifying and treating infection, it follows that jails and prisons have a mandate to do what they can. Where else in America, he asks, can someone be supervised so easily through an entire course of preventive therapy?

"Here, it’s manageable," he concludes. "Anywhere else, people get tired of it, and they quit before they’re finished. If this country really wants to focus on latent infection, correctional settings are the logical place to do it."