IPT for ex-inmates? Only if you target
Otherwise, costs will outstrip returns
The news is mostly bad when it comes to programs that try to get inmates released from prisons and jails to complete their isoniazid prophylactic therapy (IPT). There’s probably a simple explanation, say some experts: namely, that people who don’t feel sick aren’t motivated to take medicine. With newly released inmates, that truism seems to be doubly applicable.If there’s a lesson to be learned, it’s that such programs should be carefully targeted; otherwise, "resources can be terribly wasted," says Eran Y. Bellin, MD, program director of Montefiore Rikers Island Health Service in New York. "Very few people, including doctors, complete their prophylactic regimens," Bellin says. "If you’re going to have any program at all, it should be very tightly targeted at those with a high likelihood of reactivation — namely, those who are HIV positive, and of those, the ones in the more advanced stages of HIV positivity, with low CD4 counts."
Identify at-risk groups
Such targeting requires that correctional systems have a way of identifying prisoners with HIV infection, Bellin says. Success also depends on whether providers are prepared to expend substantial resources on the at-risk populations identified, Bellin adds.Sometimes, even that may not be enough. For example, a study of compliance among prison inmates receiving IPT found that the more the inmates understood the reason for taking isoniazid — to prevent infection from becoming disease — the less likely they were to take their medicine.1
In New York City, a small pilot program designed to provide IPT to released prisoners appears to deliberately keep its sites aimed low. Prisoners due to be released on prophylaxis get a pair of vouchers in jail, each worth about $20 in tokens. They redeem the first voucher the day they show up at a community clinic to start their program and the second when they complete their course of therapy.
The program doesn’t distinguish between prisoners who are HIV positive and those who aren’t. "We believe all prisoners are equally at risk," says Sonal Munsiff, MD, director of medical affairs at the department of TB control. "I don’t think the program’s going to be terribly successful," she adds. "People on treatment for active disease are followed much more aggressively, and with them, we have a much better outcome."
A multi-layered intervention falls flat
In Baltimore, a program that lavished attention and education on prisoners in pre-release facilities failed to make any appreciable difference in their rate of completion of IPT, says Matthew Rodieck, research coordinator for the Robert Woods Johnson Foundation TB Project.Rodieck’s program consisted of "layers" of interventions applied at different points in time, including both before and after prisoners were released into the community. Outreach workers (all of them "culturally competent," Rodieck says, with a good understanding of prisoners’ lives) performed needs assessments, provided education, and made referrals while prisoners were still behind bars. Then, on the outside, more peer counselors did their best to track down ex-prisoners, provide them with more education and counseling, and help them find jobs and manage their finances. "They did everything you could think of to help stabilize these peoples’ lives," says Rodieck.
A slow process
It was to no avail, however. Inside the prison, correctional staff were slow to implement a new streamlined system of getting paperwork from the prison out to the community clinics; and a computerized data bank where medical records could be stored never really got on line. Of 80 people eligible for IPT, only a quarter showed up at the community clinic where they’d been told to go. Of that number, less than half finished their course of INH. A comic book Rodieck conceived, featuring artwork by inmates that emphasized the importance of completing chemophylaxis, got held up in production and was never distributed to the test subjects."It’s a very at-risk, vulnerable population and very difficulty to intervene upon," says Rodieck. He is preparing to publish a report on qualitative research — consisting of in-depth interviews with released inmates — that explored why the completion rate was so poor.
One particular obstacle to ex-cons’ compliance appears to be a sort of guilt-by-association. "Usually, the prison forces them to take the medicine," Rodieck says. "They get out, and the first thing they want to do is whatever the prison doesn’t want them to. They run from those restrictive behavioral things."
Bellin is skeptical of this analysis. At Rikers Island, "we’ve done supervised therapy on folks taking multiple medications and achieved compliance rates of 85% to 90% in the community," he says.
Education only goes so far
But that’s because working with people with active disease is "a very different entity," he adds. "Therapy is an altogether different animal from prophylaxis. With prophylaxis, you don’t have people who were sick to begin with, so health education doesn’t happen; people don’t pay attention unless they’re sick."Rodieck agrees. Among other things, he concludes, his project shows that education can only go so far in persuading people to do something they have little interest in doing in the first place, he says.
"In prison, TB isn’t exactly a salient issue. People aren’t sitting around talking about it in the first place," he says. "If they’re not at a teachable moment, it doesn’t really matter what you say."
Reference
1. Alcabes P, Vossenas P, Cohen R, et al. Compliance with isoniazid prophylaxis in jail. Am Rev Respir Dis 1989; 140:1,194-1,197.
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