Concerns raised about treatment of Michigan’s HIV-positive prisoners

The Michigan Department of Corrections says it is reviewing its records to determine how an HIV-positive inmate was placed on a treatment regimen that does not meet state, federal or international treatment protocols.

The inmate, a 28-year-old who served time for technical parole violations, was diagnosed when he went into prison to serve his time. Shortly after being told of his HIV positive status he was transferred to another facility, where he was treated by a physician who placed him on the HIV drug Combovir. Messenger is not identifying the prisoner or the facility in which the inmate was placed to protect the person’s identity.

It is routine to offer HIV testing to incoming prisoners at MDOC, and testing is required for parole or release.

Officials for the Michigan Department of Corrections say their records show there was not a prescription for Combovir, or the two drugs that make up the drug, in the last two years. All prescriptions are supposed to be logged into a pharmacy computer system operated by contractor PharmaCorr. PharmaCorr, in turn, fills those prescriptions or rejects them based on current policy.

PharmaCorr is a part of Correctional Medical Services (CMS), which in turn is the MDOC medical care provider by contract.

“I’m concerned,” said Dr. Craig Hutchinson, MDOC’s infectious disease consultant. He called the situation out of the ordinary, noting that he is the only doctor who is supposed to see the 254 HIV-positive prisoners. “I’m the only one writing or changing meds.”

“Those two drugs are not an appropriate regime. They will not suppress the virus,” Hutchinson said. He said it was possible that a physician without expertise in HIV was “freelancing” HIV care in this situation. “We are confident it’s not a typical event. We have all kinds of questions.”

Regardless of how atypical the scenario is, the reality is the prescription treatment used in this case could pose a threat not only to the inmate, but to others.

Combovir is a combination of two medications from the same class of drugs and treatment with drugs from only one class of medications is considered monotherapy. Montherapy is not recommended for treatment of HIV as the virus quickly mutates a resistance to the specific drugs being used, which can then lead to resistance to an entire class of medications. The resistant virus can be transmitted, making it more difficult to treat both the original infected person and any subsequent new infections.

During the late 80s and early 90s, when doctors only had access to the drug AZT as a weapon against the virus, researchers discovered that the drug had a limited effectiveness life because the virus mutated resistance to the drug — particularly if a patient failed to follow the complex treatment regimens required. With the advent of protease inhibitors in 1995, researchers found that using a combination of AZT and other classes of drugs as well as the protease inhibitors reduced viral resistance development. Researchers found that adherence to the complicated pill-taking was a key in preventing resistance.

Each class of drug attacks the virus at a different point in its reproduction — some prevent the virus from entering the immune cells used to replicate, while others gum up the complex process of creating a new virus. By hitting the virus at multiple points along the reproduction line, researchers discovered the virus was unable to mutate enough to battle on multiple fronts.

There are only seven classes of drugs approved to treat HIV. While Michigan’s AIDS Drug Assistance Program (ADAP) covers 29 individual drugs in all seven classes, a March report from the Auditor General reported that eight of the top 40 medications prescribed by MDOC physicians are HIV anti-retroviral medications. Those drugs are found in only two of the seven classes of drugs.

ADAP is a federally supported program that provides access to anti-retrovirals as well as a host of medications to treat opportunistic infections of people living with HIV in the state. Sixty-one percent of the program spending is collected via rebates from drug companies.

Angela Minicuci, spokesperson for the Michigan Department of Community Health, says the department is unaware of how many cases of resistant virus have been transmitted from prisoners. However, in an email statement, she said the state is currently crunching the numbers on how many resistant virus infections are known in Michigan.

“Genotype tests are considered by law to be diagnostic of HIV infection and therefore are required to be reported to the health department.

Since 2006, electronic genotype sequences from private and commercial labs nationwide that test Michigan residents have reported their results to the health department. Therefore, we do have a way to measure rates of viral resistance among HIV positive Michigan residents; however this data is still in the process of being analyzed at the Centers for Disease Control and Prevention.

At this point, what I can tell you is that preliminary results are available for a representative subset of people diagnosed from 2006-2008. During this period, out of a total of 782 diagnosed Michigan residents, 14.7 percent had some form of Transmitted Drug Resistance Mutation (TDRM). Rates are currently being calculated by gender, age at diagnosis, race/ethnicity, transmission category, and facility of diagnosis.”

Keith Barber, ombudsman for the Legislative Corrections Ombudsman Office, said his office had not recently dealt with questions and concerns related to HIV treatment of prisoners. The office investigates complaints by prisoners and staff of the MDOC about the corrections system. Barber said that 85 percent of the investigative work his office conducts relates to medical and mental health care concerns and issues, but that HIV treatment had not been an issue since “the 80s.”

“This has not been a huge issue that I can think of where we have seen this issue raised,” he said in a phone interview with Messenger.

State Sen. John Gleason (D-Flushing) says he is concerned about the situation.

“I think it is a real diminishing of the dignity we ought to be offering human beings. These are not animals down at the local animal shelter,” Gleason said. “I intend to ask that question at the next health policy committee.”