HIV/AIDS Comprehensive Care Program: Provider Perspective
Dr. Frank Graziano (pictured) is the director of the UW Health HIV/AIDS Comprehensive Care Program at UW Hospital and Clinics, where he is active in both clinical care and research.
The UW Health HIV/AIDS Comprehensive Care Program does extensive work with the state's HIV-positive prison population. We interviewed Dr. Graziano to learn about his perspective on the challenges of treating prisoners infected with HIV.
How long have you been practicing HIV medicine?
More than twenty years.
How long have you been caring for inmates with HIV? About 19 years. I'm not entirely sure.
How did your relationship with the Department of Corrections (DOC) start? All the inmates come to UW for health care. HIV is one of the specialty clinics so they come here for that, too. When they first started coming to our clinic, the correctional officers would come in full surgical garb — masks, hats, gloves — to escort prisoners to this clinic. There was so much fear. The policy was for them to be in the exam room and I would always throw them out of the room. I got into many arguments. Everyone should have privacy, of course, but especially with HIV. Eventually I stopped seeing prisoners. If I don't have full confidentiality, I won't see them. I didn't see any prisoners for six months. The chancellor of the university even called me to say how wrong it was that I wouldn't see patients. We had a meeting with the prison warden, hospital administration, our clinic manager, some DOC staff. It was not a nice meeting — we were at odds about how to reconcile patient confidentiality with the safety concerns. At some point our clinic manager said, "Why not have cameras in the exam rooms?" So that's what we did. Now the guard is outside the closed door and can see — but not hear — what's going on in the room.
For you, what are the biggest challenges to providing care to inmates with HIV?
The biggest problem we've had is making sure patients get their meds on time. You can miss a few pills for a lot of diseases but HIV ain't the same. In some cases, like with the NNRTIs, you can lose all activity to a drug if you miss a few weeks, or even days. Our next biggest problem is follow-up with prisoners once they get out. That's why we have the prison case manager process here in clinic. We can treat them all we want; if they get out and don't get care then they're not going to do well. We try to work within the rules of the DOC. I want prisoners to get the same care than anyone in the clinic gets. You can't be confronting all the time and expect that kind of care from the DOC so we try to follow their rules. Generally, we've been able to work together.
What do inmates say are the challenges?
Confidentiality is a huge problem. They get very concerned that if someone finds out they have HIV then it goes through the prison and then they will have big problems.
What's your sense of the level of understanding about HIV basics, like transmission routes, both with inmates and DOC staff? HIV is a big problem for us but it's not a huge problem in the prison system so it's difficult for staff to get a handle on it. It's not as common as diabetes or heart disease. Sometimes the prisoners nod their heads, but I don't know how many really understand. Some inmates come to us newly diagnosed and really don't have a clue. There are also so many stereotypes in prison, which can be hard to get beyond.
What's your feeling about TeleMed?
When I use TeleMed, I don't get the feel that I get when I see the prisoner in person and it feels less private to me. However, some of the prisoners like it because they don't like coming down here in shackles, and I understand that. Telemed can help me work with patients that I otherwise might never see because they don't want to come here.
Where do we have the most work to do when it comes to HIV/AIDS in the prison setting?
We have a lot of work to do in terms of education with the staff and the prisoners. I'm not sure people accurately understand transmission or how HIV is treated and managed. I think the challenges are the same as out in the community — confronting the stigma of HIV/AIDS, improving the understanding of this disease and making sure that people get tested and have available to them affordable treatment and care.