I remember 30+ years ago when “rumors” started about a new disease that was primarily attacking gay males and IV drug users and sex workers. A little later, it was disclosed that individuals like Ryan White and Robin Glaser contracted this new disease through blood transfusions. I remember in those early years people who came to the Emergency Department in which I worked and were infected with the Human Immunodeficiency Virus (HIV) did not live long after diagnosis. There were few drugs to combat the virus, and the drugs themselves had severe side effects. Often, multiple pills had to be ingested multiple times each day, and they had to be administered exactly as prescribed. Any fluctuation in the administration schedule meant that the therapeutic levels in the blood could drop, rendering the drug less effective against the virus. Fluctuations in drug blood levels also meant tolerance could occur. In the correctional environment, this schedule was doubly problematic, as every incarcerated person in the jail or prison knew that if someone was getting awakened at 2:00 am for medication, most likely they had HIV. Sadly, there were many incarcerated patients who refused the care because of this stigma and potential for harm from others. I remember one patient distinctly from whom I was getting an informed refusal for all HIV treatment who looked me in the eye and said, “I have to be in here for a while, and then I have to see a lot of these guys on the street. I would rather die from the disease than get the crap (paraphrased) beat out of me here every day.”

Today, the picture is much different. HIV is considered a chronic disease. There are antiretroviral medications (ART) that are administered once a day, and there are combination medications so that multiple tablets do not have to be taken at a time. According to the Antiretroviral Therapy Cohort Collaboration (Lancet HIV, 2017) an individual diagnosed at 20 years old now has an expected life span of greater than 70 years. There are currently six drug classes and over 20 antiretrovirals approved for use against HIV by the Federal Drug Administration. Over time there have also been varying opinions as to when ART should begin, with the most current treatment recommendation being “rapid start” – the initiation of ART when first diagnosed, regardless of CD4 count. Patients with HIV are now getting older, and so they are suffering from age-related conditions that typically were not seen in the HIV population because of their life-expectancy. It is theorized that these conditions are seen in greater frequency in the HIV+ population than would be expected due to the effects of long-term ART, erratic immune system regulation, and systemic inflammation. These conditions include Type II Diabetes; cardiovascular disease; malignancies such as Karposi sarcoma, non-Hodgkin lymphoma, liver cancer and lung cancer; chronic kidney disease; and HIV-associated neurocognitive disorder. At a past conference I attended, I heard about clinical trials that were being conducted for a new combination drug that may be administered monthly via injection and is long acting. I understand this drug is now available, and there is hope that it will greatly enhance adherence! In addition to changes in the treatment of HIV, today there is also PrEP, prophylactic medication for individuals at risk of contracting HIV. PrEP can be administered orally (every day) or by injection (monthly and then every other month).

What does this mean for nurses in corrections? Our role continues to be central to case identification, administration of treatment and patient education. Through our intake process, we identify individuals with HIV and make provisions for the continuation of that treatment. We screen for risk factors for HIV infection. In some facilities, rapid HIV testing is done for persons entering the system, with nurses conducting pre-test counseling, doing the test itself, and providing the test results and patient education. We administer medication as ordered by the provider and we monitor patients for side effects with every administration. We counsel patients who are non-adherent, and per facility policy, we refer those who continue non-adherent to the ordering provider for further counseling and treatment plan review.

How has your treatment of HIV patients changed over the years? Have you encountered patients admitted to your facility who are not HIV positive, but are prescribed PrEP? Is the medication continued, or is it discontinued because there is no disease diagnosis? Please share your experiences!