HIV Prevention in Prisons

Photo of California State Prison Overcrowding

So Truvada, an expensive HIV prevention drug, has been in the news lately. It got me to thinking about our prison population.

I think I know the answer, but I wonder if Truvada will be made available to prisoners. I wonder if it should be.

How do we measure the costs-benefits to something like that?

Those behind bars are part of our community, and the vast majority will be released back into the population at large. It is short-sighted of us to endanger our own health because we fail to reduce the health risk of the incarcerated. 

At the same time, we have limited resources, so is our money best spent on expensive treatments for the "bad guys?" (How about we start with making something cheaper available, like condoms?)

Like usual, the issue is more complicated than that:

• There are other modes of transmission in jail other than unprotected sex. 
• We have to be careful in any drug therapy of fostering drug-resistance.
• Other diseases such as Hepatitis C and Tuberculosis may be even more widespread.

 So, again, how do we measure the costs-benefits?

Prevention, Prevention, Prevention!

This is my oldest daughter on her first trip to Disneyland. She was around 15 months' old. What you don't see in this picture is the nebulizer and other medicines in the storage under her stroller. You also don't see the scars on all four limbs and in her groin left over from her week-long stay in the Pediatric ICU.

She had been hospitalized overnight just before her first birthday for a suspected virus (RSV) and sent home with a nebulizer and albuterol. Despite repeated trips to the doctor's office, within a month she was back in the hospital and intubated for respiratory failure.

I can't even tell you how much the insurance company had to spend on her total care, but I do remember seeing one bill that was for Nursing Services that was over $40,000. There were so many points where the proper intervention would have made all the difference in this outcome. I am also sure that the proper prevention would not have put my baby's life in danger and would have saved the insurance company lots and lots of money. 

There is a current fight in Washington over paying for the extension of lowered student loan rates by getting rid of a preventative health fund provided by the Affordable Care Act

(Student loan bill fails as Senate gears up for protracted battle). There was one female politician -- I wish I could find her name and the quote -- who seemed to dismiss this preventative health fund as unnecessary. I found her stance outrageous.

At the same time, this post is not about ObamaCare, all right?

What this post is about is the importance of preventive care in improving patient outcomes and patient safety. We as a society need to emphasize prevention to optimize the state of our health care.

Of course, not all preventive measures are effective nor cost-efficient as Doctors Cohen, Neumann, and Weinstein point out in the February 2008 New England Journal of Medicine (Does Preventive Care Save Money? Health Economics and the Presidential Candidates). As with all evidence-based practices, we need to evaluate preventive medicine in an on-going fashion to identify what works and what doesn't.

A Food Tale

Just read on NPR's food blog: What Will Make The Food Desert Bloom? 

It reminded me of a guy I used to date (when I was in my early twenties) who lived in what I would call South Central. Really, it reminds me of his mother. They lived together in a small apartment above a garage. He was "on a break" from Oberlin, and I really couldn't tell you how they paid the rent. I do know their daily meals were takeout he brought home from the neighborhood fast food joints. They did not have a refrigerator, and I don't remember ever seeing groceries in the house. He was a big guy, but his mother was immense. It was sad really. She never left the apartment. She looked unkempt and unhealthy. And on her mantle was a picture of her in her youth where she looked like a young Diahann Carroll. It was hard to reconcile that bright-eyed young woman with the woman I saw before me. Of course, we all have agency, but I remember wondering to myself how anyone could expect this immensely obese woman to eat well when there was no fresh food outlets within miles of her...

And did I mention that they didn't even have a fridge?