AIDS epidemic raging behind bars:  Newark AIDS specialist calls care of inmates 'a disgrace'

Bernard Coston was taken to prison in March 2002 on charges he stole a $50 jacket from an elderly woman. Coston was released from prison 18 months later on a slab. Dirt and feces covered his body. Insects had been gnawing on his corpse.

Diagnosed with AIDS before he went to prison, Coston spent his last four months in the infirmary of Wilmington's Gander Hill prison -- at least that's what is written on a state medical examiner's autopsy report.

But Coston's sister, Victoria Trice, said she was told by a prison counselor that her brother wasn't in the infirmary, that he withered away, alone in a cell with no food or medical attention. He was too weak to bathe.

"They are more humane to an animal than to my brother or anyone else who died in there," Trice said.

Coston died in what the U.S. Centers for Disease Control and Prevention labels the third decade of the HIV epidemic. Prisoners call it "the bug." And nowhere is that epidemic more clear than behind bars.

More prisoners in the United States die of AIDS than any cause other than a natural death. Nearly one in four inmates who died in a Delaware prison since 2000 died of AIDS-related causes. In two of the past four years, Delaware's rate of prisoners dying of AIDS was the highest in the country.

AIDS is Delaware's secret death sentence -- an epidemic former prison medical staff say that the governor, key lawmakers and the correction commissioner are not motivated to address.

"It's a disgrace," said Dr. David M. Cohen, an AIDS specialist with the Christiana Care HIV Wellness Clinic. "Because they're prisoners, the government has the right to take away their liberty. But they do not have the right to take away their health."

Those who are released expose their families and others to more virulent strains of HIV. Cohen said he sees AIDS patients in his Newark practice who've spent time in prison, and many have told him that doses of their antiviral medication routinely were not administered.

That's dangerous for the community, Cohen said. "Compliance with the dosing schedule is critically important with these medications, because missing even one dose, the virus has a chance to over-grow and mutate, creating a public health problem."

Delaware now ranks seventh nationally for all residents infected with the AIDS virus. And many of those patients live in the tough neighborhoods of east Wilmington.

African-American men here are more likely to be infected and more likely to be imprisoned than other residents. African-Americans represent 19 percent of Delaware's population, but make up 63 percent of its prison inmates -- one of the worst disparities in the nation.

According to a News Journal review of 22 medical examiner reports of inmates who died of AIDS-related causes since 2000, the average age at the time of death was 42. The youngest was 31, the oldest 55. Sixteen of the inmates were African-American, six were white. All were men.

Coston's death certificate states simply that he died of AIDS. The external examination from the autopsy paints a more gruesome picture:

•"The scalp is dirty"

•"Examination of the skin on the back reveals a layer of dirt"

•"Dirt is noted under the fingernails"

•"Fecal material is smeared on the buttocks."

"It's obvious he got poor, poor, poor medical care," said Lynda R. Kopishke, a forensic nurse and branch director of Interim Health Care in Newark.

At the request of The News Journal, Kopishke agreed to review Coston's autopsy report, prepared by Dr. Adrienne Sekula-Perlman, Delaware's deputy chief medical examiner. Kopishke found it hard to believe that Coston had been treated for four months in a prison infirmary.

"I struggle to understand the inconsistencies surrounding these findings," Kopishke said. "If I did not know this individual was in the infirmary, I would wonder if he had been buried under dirt at some point in time."

Treatable infections

Since 1991, the national infection rate of HIV/AIDS inside prisons has been three times that of the U.S. population, according to the Bureau of Justice Statistics. Delaware's AIDS rate inside its prisons is 10 times that of the general population, an analysis of Delaware Division of Public Health statistics shows.

Many deaths were attributed to treatable infections, including wasting syndrome, pneumocystis carinii pneumonia and cryptococcal meningitis, a brain infection caused by a fungus found mainly in dirt and bird droppings.

Most medical professionals are aware of the symptoms associated with cryptococcal meningitis, such as headaches, fevers and confusion, said Dr. Donna Sweet, who chairs the American College of Physicians board of regents. "If you are doing general medicine ... you need to be aware," she said. "In this day and age, especially in a prison setting, one has to assume the worst could be there."

If the infections are caught early, death can be prevented. But in Delaware, at least three of the 22 inmates who died of AIDS-related causes over the past five years died of pneumocystis carinii pneumonia.

"It's very rare to see patients with [pneumocystis carinii pneumonia] nowadays," said Dr. Robert L. Cohen, a prison medical expert and former director in the New York City jail system. "You have to have AIDS experts seeing all patients with HIV infections."

The last AIDS doctor employed in the state's prisons -- Dr. Ramesh Vemulapalli of Dover, an infectious disease specialist -- quit in 2003. The state's current private medical provider, St. Louis-based Correctional Medical Services, employs an infection-control nurse.

A headache is misdiagnosed

Louis W. Chance Jr. died in 2003 -- seven days short of freedom.

Chance, 37, was serving a six-month DUI sentence at the Webb Center, a work-release facility in Prices Corner, when he developed a severe headache. At his first medical visit, Chance told nurse Beverly Anderson that he had had a headache for three days, according to a medical malpractice lawsuit filed against the state and First Correctional Medical, Delaware's medical provider at the time, in U.S. District Court in Wilmington.

Anderson gave him six Excedrin and sent him back to his cell.

The next day, Chance reported no relief and was prescribed Motrin.

After three more days, a correctional officer reported Chance was confused and had possibly "overdosed." Chance was transferred to Gander Hill prison in Wilmington, where, his attorney says, the pressure inside his head from cryptococcal meningitis affected his hearing.

Unable to respond to nurses, Chance was reported to be disoriented, uncooperative and hostile. Officers subdued him, put him in a straitjacket and left him in a cell under suicide watch. Chance, who had not yet been examined by a doctor, was prescribed Ativan, Benadryl and Haldol. The drugs are used to treat panic attacks, allergies and psychosis, respectively. Together, they can calm a person.

About three days later, Dr. Niranjana Shah, a contract physician with First Correctional Medical working at Gander Hill, prescribed Tylenol and a daily cup of coffee because, Chance's medical records state, caffeine helps combat headaches. On Sept. 18, 2003, Chance was sent back to the work-release facility at Prices Corner.

Five days later, Chance died.

Had Shah and Dr. Jose A. Aramburo followed protocol for a patient with HIV, Chance could have lived, claims Ken Richmond, a Philadelphia attorney representing the Chance family in the lawsuit against FCM and the two doctors.

"It appears to be a concerted effort to avoid treating someone who was HIV-positive," Richmond charged. "This is gross negligence."

Months before Chance got sick with cryptococcal meningitis, FCM employees performed a blood test on him, Chance's medical records say. He tested positive for hepatitis C and was given brochures on hepatitis and HIV, according to the lawsuit.

About a quarter of people in the United States who have HIV also have hepatitis C, according to the CDC. Because HIV patients are especially susceptible to cryptococcal meningitis, Richmond said, FCM should have tried to rule out the condition before trying other treatments.

"That's the sad part about this," he said.

FCM's owner and founder, Dr. Tammy Kastre, did not respond to repeated calls and e-mails requesting comment.

No mandatory testing

Nineteen states mandate HIV testing for prisoners -- some before they enter the institution, some before they get out, others coming and going. Twenty-four states have laws obliging sex offenders to be tested at the request of the victim, prosecutor or court, according to the National Conference of State Legislatures.

The New York Department of Health draws blood from every inmate entering the prison system to test for diseases other than HIV. Every couple of years, blood is drawn from a few thousand inmates to conduct a random test for HIV.

Delaware has mostly ignored preventive measures. Delaware does not conduct mandatory testing, except for sex offenders. Condoms behind bars are forbidden. AIDS patients aren't segregated. Inmates who ask, exhibit obvious symptoms or those who need serious medical care can be tested for HIV.

Armando Gonzalez, an HIV/AIDS educator with the Latin American Community Center in Wilmington, believes HIV testing in prison should be mandatory. "If you are HIV-positive, then maybe someone can help you," he said.

Gonzalez has been working with a former inmate who was unaware he was infected until he was released from prison. Now his wife is pregnant. The couple are not sure if the wife or fetus is infected.

Mandatory testing would help get inmates treatment faster. It also will encourage inmates to become educated and avoid passing the virus, Gonzalez said.

Dr. Theodore M. Hammett, who conducted an infectious disease study in the late 1990s at the request of the CDC, opposes mandatory testing for AIDS. While testing would identify infected inmates and most likely lead to earlier treatment, Hammett said identifying the virus can stigmatize an inmate and subject him to ridicule and abuse.

Robert Saunders, who in 1975 was sentenced to life in prison for murder, said some inmates were afraid of breathing the same air or bumping into infected prisoners.

"It was sheer ignorance," said Saunders, who used to counsel inmates about AIDS at Sussex Correctional Institution in Georgetown.

Saunders, who goes by the name Shamsidin Ali, said inmates facing rejection and isolation are less willing to fight the virus. "They basically don't believe there is a light at the end of the tunnel."

California, which has the nation's largest penal system, is considering legislation that would allow the distribution of condoms, already a practice in prisons in New York and Philadelphia.

The idea has never gained traction in Delaware.

"The fear is that handing out condoms would actually promote more [sex], not less," said Stan Taylor, Department of Correction commissioner.

Sex behind bars in Delaware, including consensual, is a felony punishable by up to two years in prison. Other risky behavior, such as tattooing, which could pass along the virus, is prohibited indirectly by laws against contraband.

More effective drugs

In the mid-1990s, people infected with HIV lived an average of nine years before developing AIDS. Once the virus took hold, their average life expectancy was 18 months, according to the CDC. But better drug therapies have stretched the average period between a diagnosis of HIV and the onset of AIDS to 11 years. The life expectancy of someone living with AIDS, as of 2000, was about six years.

"We expect the life expectancy to continue to increase over time," said Jennifer L. Ruth, a CDC spokeswoman.

While there is no cure, new drugs slow the rate at which HIV destroys the body's immune system. "We also know that people who live the longest are those who know about their HIV infection the earliest, which is why it is so important that people seek out early HIV counseling and testing to learn their status and protect their health," Ruth said.

All four classes of antiviral treatments are available in Delaware prisons, said Dr. Vemulapalli, an infectious disease specialist who worked a little more than a year at the Delaware Correctional Center near Smyrna. But inmates, he said, did not always receive them.

"Most patients who come to the hospital from the Department of Corrections are generally far too advanced," said Vemulapalli, who is now in private practice in Dover. "I've seen several cases from the prison -- all patients who have died -- that didn't get referred to the hospital at the appropriate time. They're not providing adequate care."

Vemulapalli, who worked for Tucson-based FCM, claims company owner Kastre ordered him to treat AIDS or hepatitis C -- but not both, even though many patients have both. The reason, Vemulapalli said he was told, is that "it was too expensive to treat both."

Kastre would not comment.

"If there's a death, and it's an explicit result of this policy, go ask your attorney general why this isn't manslaughter," said Jules Epstein, a professor at Widener University law school, whose private law firm has successfully battled to improve conditions in Philadelphia lockups.

Attorney General M. Jane Brady said she had never heard of such an order.

If there is, or was, such a practice at the prisons, the attorney general said, "I would certainly want to know about it. And I will contact the Department of Correction to determine if that's an accurate statement."

Brady's spokeswoman, Lori Sitler, said the attorney general is still waiting for a response from Commissioner Taylor.

In the Smyrna prison, which houses about 2,400 inmates, orders for medical tests on inmates were sometimes ignored, said Vemulapalli, who said he treated 100 AIDS-positive inmates there. He had to get permission for testing from Kastre.

"I had to clear everything through her," he said.

Autopsies are rare

Francine Wright's final memories of her son, Darnell L. Anderson, are from a room at St. Francis Hospital.

Anderson, 35, who was serving a four-year drug sentence, was handcuffed to the hospital bed. She remembers that the tracheotomy tube in his throat made it almost impossible for him to speak. She also remembers how skinny he was.

"He was smaller than me," she said. "That was scary."

Anderson died earlier this year of pneumocystis carinii pneumonia as a result of AIDS. This form of pneumonia, commonly known as PCP, is one of the most common opportunistic infections in people with HIV.

Most people who get PCP die if not treated, but PCP is preventable and treatable with common antibiotics.

Anderson suspected he had AIDS. And in his final letter to his mother, he said he had asked to be tested, but said prison officials denied the request. Anderson's medical file, examined by The News Journal, shows that when he was transferred to St. Francis, doctors did not know he had HIV.

Wright blames prison officials for letting her son die, and she contends the state medical examiner's report is a farce. After complaining of "shortness of breath" Anderson's condition "deteriorated," the medical examiner's report states, and "he expired." No autopsy was done.

Autopsies show two important things: cause of death and manner of death. When it comes to deaths of inmates with AIDS, the state does not normally perform an autopsy, unless there is some sign of foul play, said Chief Medical Examiner Richard Callery.

"It doesn't make a lot of sense" to do the autopsies on inmates with AIDS, Callery said, because in most cases the person has been under the supervision of a doctor who knows the cause of death.

It's common for medical examiners not to conduct autopsies on AIDS patients, said Fred Jordan, president of the National Association of Medical Examiners. But, Jordan said, "most people feel that a complete autopsy ... should be done on any person in a prison. I'm one of those who believes that."

Jordan estimates that an autopsy done by a public medical examiner costs between $1,200 to $1,500. An autopsy performed by a private doctor would run about $3,000.

A News Journal review of 22 medical examiner reports on inmates who died of AIDS shows that autopsies were performed on only four.

Wright said her son was so thin before he died that when she wrapped her hand around his forearm she was able to touch her thumb and middle finger.

But in Assistant Medical Examiner Jennie Vershvovsky's autopsy report, Anderson is described as well-developed and well-nourished. Anderson, who was 5 feet 5 inches tall, weighed 155 pounds at the time of death, Vershvovsky wrote.

According to court records, Anderson also weighed 155 pounds when he was arrested in April 2002, about 32 months before he died of AIDS.

"Someone is lying," Wright said. "I am angry. Yes, I am very angry."