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When Linda Rose Frank, PhD, MSN, ACRN, FAAN, helped start the University of Pittsburgh's Pennsylvania/Mid Atlantic AIDS Education and Training Center in 1988, clinicians and patients viewed HIV infection as a death sentence.
Within the somber confines of prisons and jails across the country, pessimism reigned much as it did on the outside.
Most prisoners did not want to know their status, instead opting for blissful ignorance, Franks says.
"Inmates at correctional facilities would say, 'Why should I get tested? There is nothing you can do for me anyway,'" said Frank, an associate professor in the Graduate School of Public Health, University of Pittsburgh.
"Now we can give medicine that prolongs life and prevents opportunistic diseases," she said. "We have some people now who have been living with HIV for 25 years."
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Educating Inmates
In the early days and beyond, Frank worked to develop prevention programs, eventually heading a peer-education program for inmates. Wardens/superintendents identified prisoners who they believed would be effective educators, while Frank and her staff trained them.
"We developed a peer-education curriculum approved by the department of corrections," said Frank, who worked in psychiatry for 15 years prior to her involvement with corrections. "We trained teams of peer educators who would ultimately be supervised by nurses in those facilities to do peer education classes for other inmates."
Peer-education training typically took about a week, and prisoners demonstrated competency by teaching the standardized curriculum back to educators. "They loved having me come and teach them," Frank said. "The program changed the prisoners' way of thinking about HIV prevention. Prisoners wanted to become peer educators, and there was even a waiting list, primarily because it allowed them to engage in institutional life in a positive way."
Bringing awareness about HIV transmission is one way to spark a sense of personal responsibility that Frank believes can cross over into life after incarceration. "Taking away their freedom is the punishment," she said. "About 90 percent of the people incarcerated today will be released, so inmates should be given many more opportunities for education, learning and jobs. An HIV-prevention curriculum is one of those positive outlets, and they take it to heart, even relaying it to their family members."
Frank estimates the vast majority (more than 95 percent) of HIV-positive inmates are already infected when they get to jail or prison. Once in the prison, the goal is stop the spread through a message of abstinence and risk reduction.
"There are some county prisons that give out condoms, but most state prisons do not," she said. "In the best of all possible worlds, it would be a good idea to give out condoms. We know condoms help prevent HIV infections. From the perspective of a public health professional, it makes sense."
 Chronic Disease Model
Eric Fenkl, PhD, RN, CNE, estimates the mortality landscape for HIV began to change dramatically right around 1996. Treatment protocols such as highly active anti-retroviral therapy (HAART) became widespread nationwide, and eventually filtered into the nation's prisons and jails.
As a nurse educator in correctional facilities from 1993-2002, Fenkl witnessed the transformation firsthand as he trained nurses to work with HIV-positive inmates. Now, the assistant professor at the Miami-based Florida International University College of Nursing and Health Sciences still has a research interest in the long-term effects of HIV medications.
The implications of lengthy HAART protocols, for example, are largely unknown, particularly in the area of cardiovascular risk. Time will tell, but in the meantime Fenkl hopes the clinical focus will remain on education and consistency.
The problem is stays are short and medication compliance is a huge problem, particularly among jail inmates (as opposed to prison inmates who have longer sentences to serve in most cases). "I always told nurses who were going to work in corrections that the toughest work is often done in jails, because jails are a revolving door," Fenkl said. "With the county jail situation, there is a big onus on nurses and medical staff to not send contagious people right back into the community. You must have compliance, and that is difficult in the revolving door jail. When inmates leave, they inevitably go off the meds."
As lifespans change dramatically, clinicians have fundamentally changed the way they view "AIDS" and "HIV," opting for the chronic disease model of management. In the old days, the formal diagnosis of "AIDS" usually kicked in when a patient's T-cells dropped below a certain threshold, but these instances are increasingly rare.
"As HAART came along, it became more common to test for viral load," explained Fenkl, a member of the Association of Nurses in AIDS Care. "Viral loads would come down with treatment. Some patients now have zero viral load, T-cells are up, and viral loads are undetectable."
Mandatory HIV Testing
From the standpoint of pure research and information gathering, Fenkl agrees testing all inmates for HIV upon entry and exit from correctional facilities would be "a good idea."
However, should that testing be mandatory? On that question, he is conflicted.
"From a medical perspective, you want to test and treat," Fenkl said. "According to the National Commission on Correctional Health Care standards, inmates always get a full physical. Should they have a choice about HIV testing? I don't know. Having worked with inmates for many years, I have always tended to promote inmate advocacy amongst nurses, and I believe in free choice to a degree. While it is beneficial to the inmate to be tested and receive treatment, mandatory testing harkens back to the notion of medical paternalism."
Frank insists HIV testing should always be voluntary, believing a prisoner's freedom-deprived state should not extend to health matters.
"It's a whole different dynamic if you require HIV testing," she explained. "When you make it mandatory, you don't engage inmates in the process. The whole goal around risk assessment and getting people tested is engagement in learning about their own health - and then being able to change behavior. That is the whole goal."
Vastly Different Setting
Success in changing behavior among inmates, whether it is medication compliance or prevention, is one reason many nurses seek the challenge of correctional work. It's not easy, but the vastly different work environment can be a welcome change.
The "alternative" setting usually means a younger patient population with different medical needs that encompass HIV care to injuries that require emergency treatment.
"It's not your bed-pan type of environment," Fenkl said. "In my case, I wanted a community health environment, and that is basically what corrections is. It's not a tertiary-care environment with patients hooked up to tubes and laying in beds. The draw is the alternative population that you may find interesting."
For nurses who desire more autonomy, correctional work can also be a big attraction. Clinical judgment calls within the proper framework are common. This so-called "task shifting" is increasingly called for both in and out of the corrections environment, and Fenkl believes that trend will only continue.
"There are an ever-increasing amount of people who require healthcare, and not a lot of MDs are going into primary care," he said. "You are seeing NPs trying to fill that void; and they are happy to fill that void."
With all the HIV prevention and treatment challenges in the correctional setting, Fenkl said fear is usually the last of a nurse's concerns, despite the presence of multiple convicted felons. "When I quit working in prisons, I realized that here at a large university, there are no locks on these doors," he lamented. "Anyone can walk in here with a gun. In a prison, you are going through metal detectors and pat downs. It feels like the safest place in the world when you get used to it."
"The nurses and other health professionals working in prison and jails are providing care for a population that in many cases had limited access to comprehensive healthcare prior to incarceration," Frank added. "These health professionals are dedicated and able to offer such care in a setting that many others would not want to work. They need to be recognized and acknowledged for this dedication."
Greg Thompson is a frequent contributor to ADVANCE.
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