Michelle Teasdale, DNP, APRN, FNP-C

Hello everyone,
I recently attended the National Commission on Correctional Health Care (NCCHC) conference in Las Vegas. One topic of discussion was transgender healthcare and housing recommendations in corrections. After the conference, I talked with medical providers and correctional employees about a few discussion points covered during the presentation. I received a variety of opinions on the topic. I have listed some of those discussion points and would like to know your thoughts.

1- Transgender individuals should be addressed by their chosen names (not their legal names) and correct pronouns. Should staff at the correctional facility be subject to legal or institutional repercussions if they do not comply with the inmate’s request? Why or why not?

2- Transgender inmates should be housed in areas of the same gender they identify without segregation or isolation from other inmates. Do you agree?

3- Suppose an inmate is incarcerated for a long period of time and during the incarceration, now identifies as transgender. Do you believe it should be the correctional facility’s responsibility to diagnose the individual with gender dysphoria, if it applies, and begin treatment? Do you foresee any legal challenges associated with such a change?

4- There have been some correctional facilities that have paid for gender reassignment surgery. Should this treatment be an option for all transgender individuals who meet surgical requirements while incarcerated? Should federal/community funding be used to directly pay for such services?

Michelle Teasdale, DNP, APRN, FNP-C

Background

A 28-year-old male with a history of HIV presented to jail. During the prescreening process, he denied any symptoms of an acute illness or mental health condition and was booked into jail. A comprehensive nursing exam (CNE) was completed and notable for the following:

He was diagnosed with HIV in 2001 and has Bictegravir 50mg/emtricitabine 200mg/tenofovir 25mg once daily (Biktarvy) prescribed. The last dose was taken two weeks prior to presentation. He has no known allergies and no recent travel outside of the United States.

The patient has a 10-pack-years tobacco history. He drinks alcohol socially and has no history of illicit drug use. He has multiple male sexual partners, and his last sexual activity was one month prior to presentation. 

Physical Exam

Temperature, 98° F, Heart rate, 98 beats per minute, Blood pressure, 128/78 mm Hg, Respiratory rate, 16 breaths per minute, Oxygen saturation, 100% while breathing ambient air. He is well-appearing, well-nourished, alert and oriented, and in no acute distress. The review of systems (ROS) are negative per his report. All body systems during the head-to-toe examination are within normal limits. 

CNE Follow Up

An active Biktarvy prescription could not be verified. He was scheduled to follow up in the HIV clinic.

HIV Clinic Visit

The patient was evaluated in the HIV clinic two weeks after being booked into jail. He reported feeling well, without specific medical concerns. He tolerates Biktarvy without side effects. He denies fever, chills, or cough. The remainder of the ROS are negative, and all body systems are within normal limits.

The provider ordered a CD4/CD8 absolute and %, T-Cell Panel, an HIV viral load, and confirmation of prior Biktarvy prescription before starting.

Clinical Course

Biktarvy was initiated after evaluation in the HIV clinic. Eight days later, the patient discontinued Biktarvy due to a new rash. He was scheduled for a follow-up provider visit.

Provider Visit

Chief Complaint

Rash

Subjective

The patient reported five days of a new onset rash involving the entire torso and upper extremities. No fever, chills, or difficulty swallowing. He otherwise feels well.

Objective

Dermatologic exam – Vesicular rash covering the trunk, upper, and lower extremities with sparing of the palms and soles. There was no evidence of mucosal or ocular involvement.

Lab Results

CD4 count 100 cells/µL

HIV RNA Quant 861,000 copies/mL

The provider sent him to the hospital. Do you know why?

Answer: the provider’s impression was disseminated zoster following immune reconstitution inflammatory syndrome in a patient with HIV and a CD4 count of 100. He found this quite concerning due to the possibility of secondary sequelae, including eye involvement and encephalitis. 

What is Immune Reconstitution Inflammatory Syndrome?

Immune Reconstitution Inflammatory Syndrome (IRIS) depicts a group of inflammatory disorders associated with worsening preexisting infectious processes following the initiation of antiretroviral therapy (ART) in patients infected with HIV. Preexisting infections in individuals with IRIS may have been previously identified and treated or could be subclinical and unmasked by the individual’s regained capacity to produce an inflammatory response. If immune function improves rapidly with ART initiation, systemic or local inflammatory reactions may occur at the site of underlying the infection (Wolfe, 2019).

Patient Risk Factors

• Studies have demonstrated that lower CD4 cell counts or high HIV viral load at the time of ART initiation increase the risk of developing IRIS. The patient’s lab results revealed both.

The ER visit

Physical exam

All body systems are within normal limits with the following exception.

Skin – warm and dry. Notable lesions to arms, chest, back, small erythematous raised papular lesions. Some are scabbed and in various stages of healing.

Differential Diagnoses considered by the ER physician included chickenpox, mpox (formerly known as monkeypox), adverse reaction to Biktarvy, and syphilis.

The physician collaborated with an infectious disease specialist and an epidemiologist. It was determined that it was unlikely that Biktarvy caused the rash, and the medication should be continued. Testing for mpox, varicella, and syphilis was obtained.

Mpox

Mpox is a zoonotic viral infection. Most cases have been identified in men who have sex with men. Close contact with an infected skin lesion during sexual contact is the most likely mode of transmission. Person-to-person transmission can also occur through large respiratory droplets. The incubation period is 7-10 days after exposure (Isaacs & Mitja, 2022).

Mpox has traditionally caused a systemic illness during the prodromal or early clinical stage, including fevers, chills, and myalgias. A characteristic rash develops helping, to differentiate it from other vesicular rashes. The rash materializes one to two days before or three to four days after the onset of the systemic symptoms and persists for two to three weeks (Isaacs & Mitja, 2022).

The rash associated with mpox usually begins as 2 to 5mm diameter macules that simultaneously develop on any part of the body. The lesions evolve into papules, vesicles, and then pseudo-pustules. The lesions are well-circumscribed, deep-seated, and often develop umbilication. One to two weeks after the onset of the rash, the lesions crust over, dry, and fall off. The rash is usually described as painful but can be pruritic during the healing phase (Isaacs & Mitja, 2022).

Changes during the Mpox 2022 outbreak

During the 2022 mpox outbreak, some patients presented with a rash but did not have systemic symptoms, and not all lesions were in the same stage of development (Isaacs & Mitja, 2022).

Patient Risk Factors

• The patient reported he has multiple male sexual partners. 
• Vesicular rash in varying stages of development.

Varicella-zoster

Varicella-zoster virus (VZV) causes two recognizable diseases – chickenpox and shingles. Varicella is the primary infection and is known as chickenpox. The rash caused by chickenpox can occur anywhere on the body but is usually concentrated on the face and trunk. Vesicular lesions characterize the rash. The lesions are on an erythematous base and appear in different stages of development (Albrecht & Levin, 2022). 

During varicella, the virus establishes latency in the sensory ganglia and can become reactivated, resulting in herpes zoster, better known as shingles. The shingles rash occurs unilaterally in a single or two bordering dermatomes. The lesions are vesicular and painful. Systemic symptoms, such as fever, fatigue, or malaise, occur in less than twenty percent of patients (Albrecht & Levin, 2022).

Immunocompromised persons are at higher risk than the general population for VZV reactivation and the development of herpes zoster. The rate of complications, including herpes zoster keratitis, herpes zoster ophthalmicus, and encephalitis, are also significantly higher in immunosuppressed patients (Albrecht & Levin, 2022).

Patient Risk Factors

• Immunocompromised
• Biktarvy reinitiated, putting him at risk for IRIS/VZV virus vasculopathy. 
• Vesicular rash in varying stages of development.

Syphilis

Syphilis is transmitted from person to person by direct contact with a sore, known as a chancre. Chancres are lesions that can occur inside or on the penis, vagina, anus, rectum, lips, or mouth and can be transferred during vaginal, anal, or oral sex (Hicks & Clement, 2022).

Primary syphilis: the initial sign of infection is a chancre that can appear 21 days after exposure at the inoculation site. Typically, it appears on the genitals but may develop at other sites, including the posterior pharynx, anus, or vagina (Hicks & Clement,2022). 

The lesion begins as a papule and advances to an ulcer. The 1 to 2cm ulcer has a raised, indurated margin and is painless. Since the sore is painless and may go unnoticed, many patients do not seek medical attention, increasing the risk of transmission. The chancre usually heals within three to six weeks, even without treatment. Primary syphilis can quickly become systemic and is the cause of secondary syphilis (Hicks & Clement, 2022). 

Secondary syphilis: Twenty-five percent of people, mainly patients who have not been treated, develop systemic illness representing secondary syphilis. This can occur within a few weeks to a few months after the development of the chancre (Hicks & Clement, 2022). 

Secondary syphilis may produce various signs and symptoms, such as fever, malaise, sore throat, myalgias, and weight loss. The most characteristic finding is a diffuse rash that can present in any form, although vesicular lesions are uncommon. The rash involves the trunk, extremities, palms, and soles. Involvement of the palms and soles is a crucial finding in diagnosing secondary syphilis; however, localized lesions may also occur. Secondary syphilis symptoms may resolve spontaneously without treatment. (Hicks & Clement, 2022). 

Patient Risk Factors

• Patients with HIV are at higher risk for STIs.
• Immunocompromised 
• Rash

The Diagnosis – with lab results from the ER

Secondary Syphilis

He did not have any memory of a chancre and therefore did not know he had been infected. Although his rash was not characteristic of secondary syphilis, documentation shows that different presentations can be expected. 

Outcome

The recovery of immunological function resulted in unmasking the unknown preexisting syphilis infection. He received the first Bicillin 2.4 million unit injection before he left the hospital. Two more doses were prescribed one week apart. Since ART can predispose patients with IRIS to opportunistic infections, he was also prescribed Bactrim prophylaxis for pneumocystis jirovecii pneumonia.

When he returned to jail, he was placed in isolation until the other test results were available. The results for varicella and mpox were negative. He completed treatment for syphilis and continued on Biktarvy without complications. He was released from jail before follow-up HIV labs could be obtained.

Michelle Teasdale, DNP, APRN, FNP-C

The opioid epidemic is an ongoing crisis in the United States. The epidemic began during the 1990s when the practice of prescribing opioids increased; however, inexpensive heroin and synthetic opioids have prolonged the epidemic. Given this situation, it is no surprise opioids are the most commonly reported drug used by the individuals incarcerated at the correctional facility where I practice.

During the intake process, many individuals will report they swallowed heroin before being arrested. This scenario is problematic for medical staff as they are forced to determine if the heroin was actually ingested, or if the disclosure was a fabrication. This is further complicated by the fact that heroin is generally distributed in a non-opaque container, generally latex or plastic, and is not easily visible by x-ray.

During this scenario, there are only two options, refuse to accept the individual into the jail until they are cleared at the hospital, or accept them with close monitoring. Due to limited resources, the former is often believed to be the safer practice. Of course, we want to provide safe medical care, however, the liability for this decision can be difficult and frustrating. Inmates have admitted to reporting the ingestion, hoping the arresting agency will not take them to jail or will release them from custody because the charges are generally not severe enough to justify the time and expense of a hospital visit. My colleagues and I would like to develop a safe process that can be used to reduce or even eliminate the “get out of jail free card” often employed to avoid incarceration.

Naturally, any drug ingestion can be critical. I have focused on heroin because it is the most reported drug ingestion we have encountered so far. Have you experienced similar reports of drug ingestion to avoid incarceration at your facility? If you have and the individual has been accepted, other than using the Clinical Opiate Withdrawal Scale (COWS), what additional practices, policies, or procedures are used in your facilities to ensure patient safety?