The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 15: Special Populations• The Immigration and Refugee Services of America (IRSA) Medical CaseManagement Program provides technical assistance to organizations that areresettling refugees with special healthcare needs. In the current phase of the26program,picasIRSA is working with national and community based resettlementagencies to enhance organizational capacity to provide care for HIV-positiveclients and to create partnerships with AIDS service providers. Call (202) 797-2105 or contact irsa@irsa-uscr.orgPEOPLE WHO ARE INCARCERATED OR NEWLY RELEASEDBackgroundMore than two million people are currently incarcerated in jails and prisons in the U.S. AfricanAmericans and Hispanics constitute an overwhelming 75% of all new admissions. In 1997, anestimated 8,900 inmates had AIDS and 35,000 to 40,000 inmates were living with HIV, representinga prevalence of infection and disease five times higher than that of the overall population.The HIV rate among inmates is disproportionately high for racial and ethnic minorities: ratesare as high as 11.3% and 11.1% among Hispanic and African American inmates, respectively,compared to 3.7% among white inmates. 5 The proportion of inmates living with HIV varies byregion as well as by institution.As the management of HIV has improved with antiretroviral therapy, HIV has become a chronicas well as terminal illness; in either case, palliative care is an important aspect of care. Providingpalliative care within correctional institutions poses unique challenges. The concern forsecurity in jails and prisons determines how medical care is provided in those settings. Palliativecare, with the goals of preventing further deterioration and maximizing the patient’s comfortand function rather than curing disease, is less readily adapted than primary medical careto the rigid hierarchical structure and culture of a corrections environment. 6 For example, forsecurity reasons it may be appropriate for most inmates to be transported in shackles. Whileputting a dying inmate in shackles would be unnecessary and unreasonable from a health carestandpoint, corrections protocols may require such treatment.In 1976 the U.S. Supreme Court ruled that prison and jail inmates have a right to health carewhile incarcerated. 7 However, palliative care is difficult to provide behind bars in a manner thatmeets both the individual’s need for symptom relief and the institution’s need for security andcontrol.By definition, compassionate care requires deviation from the correctional norm whose goalsare segregation, stigmatization, and punishment. Dying inmates need increased medical attention,expanded visiting hours with family and clergy, access to special foods, and relaxation ofroutine restrictions. 8Jails and prisons differ in both structure and motivation in terms of how they provide medicalcare to inmates. Jails are temporary quarters for persons who have been arrested and are awaitingtrial, and turnover is generally fairly rapid. Therefore, with nonacute medical problems,cost-shifting can occur; if a medical problem is not immediately addressed, the inmate may bedischarged without the jail having expended resources. Prisons, on the other hand, are permanentquarters to which people are sentenced for long periods of time. The prison assumes re-XVU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 323