Initiation of Antiretroviral therapy for newly diagnosed HIV patients in the NYC Correctional system

The New York City correctional system consists of eleven separate jails with an approximate daily census of 13,000 and 90,000 admissions annually. Approximately 5% of the patients report being HIV+ on arrival; however a smaller number are identified as being HIV positive through testing in jail. Unlike already diagnosed patients, who generally require continuation of prior care, newly diagnosed patients require many services including assessment for possible anti-retroviral initiation. All the newly identified HIV+ patients are immediately evaluated by a physician or physician assistant, HIV health educator within 48 hours and by an HIV Specialist (physician) within 2 weeks. The initial medical visit involves post-test counseling, ordering of tests and assessment of the patient's emotional status. Initiation of ARV's, which is difficult in the jail setting, is generally done at the HIV Specialist visit when all the laboratory test results are available. Analysis of this patient cohort for 2009 and 2010 revealed 244 newly diagnosed HIV patients. Among these patients, 41 % had CD 4 counts above 500 and 22 % had CD 4 counts below 200. The majority of the newly diagnosed patients (25%) had viral loads between 25k and 100K, but among those initiated on ARV's, most (60%) had viral loads between 110K and 300K. Overall, 17 % were started on ARV before discharge and over 50% were discharged within 2 weeks not allowing enough time for necessary testing and follow up with the HIV Specialist. About 35 % of these patients had Mental Health diagnosis which is similar to the overall population in the NYC jail system. Appointments for care in the community were made for 66 % of these patients, with 80% of appointments kept. This analysis reveals a population of newly identified HIV+ patients that is small in number when compared to the known HIV+ population (roughly 9,000) during the 2 year period. The devotion of significant resources for this cohort is crucial in determining who merits ARV initiation while in jail, and importantly, continuity of care in the community. The most common reasons for not initiating ARV therapy were lack of clinical indication and departure of patients before their visit with the HIV Specialist. Recent changes to guidelines for ARV initiation have not significantly increased the percentage of newly identified patients who are initiated on ARV's because significant challenges exist for ARV initiation in jail, including short stay, HIV stigmatization and concerns about adherence.