By John E. Dannenberg

The Alabama Department of Corrections (ADOC) settled a class action federal civil rights lawsuit brought by Limestone Correctional Facility AIDS-afflicted prisoners who had complained of unconstitutional conditions of medical treatment and confinement that resulted in excessive suffering and a high mortality rate. The settlement implicated performance failure of Limestone’s former contract medical provider, NaphCare, Inc. The instant settlement is in addition to earlier hepatitis-C and working-conditions settlements previously reported in PLN (Oct. 2003, pp.3, 5; Jan. 2003, p.12).

Antonio Leatherwood and four other Limestone prisoners sued Donald Campbell, Commissioner of ADOC, Ronald Cavanaugh, Director of Treatment of ADOC, Billy Mitchem, Limestone’s Warden and David Wise, Deputy Warden in a 42 U.S.C. § 1983 class action suit for injunctive relief for all AIDS-afflicted Limestone prisoners. The impetus of the suit was to end the years of pain and suffering and ensure that medical care would improve. U.S. District Magistrate Judge John Ott (U.S.D.C., N.D. Ala. (Western Div.) had found, “It is evident that lives were lost due to preventable lapses in the medical treatment. HIV prisoners died without necessary intervention by the Limestone medical staff or ADOC.”

Indeed, court-appointed mortality expert Dr. Stephen Tabet found that 42 prisoners had died of AIDS since 1999, a figure he found “remarkably high” compared to other prison systems. Dr. Tabet concluded that “the most egregious failure at Limestone is the number of preventable deaths. ... In almost all instances, the death was preceded by a failure to provide proper medical care or treatment. Consistently, patients died of preventable illness. ... At least one patient had such severe pneumonia that he suffocated in front of the medical staff despite the patient’s request for treatment and hospitalization. Another, critically ill Terrell Grey, was taken in a van for two hours to a Birmingham hospital, instead of to a local facility; he died enroute, “tended” only by two guards. The plaintiffs had testified that many HIV -positive prisoners “housed in dormitory 16, [the] warehouse HIV infirmary, died a horrible death, literally standing on their feet.”

Accordingly, the parties entered into a comprehensive 18-page Settlement Agreement which became the court’s order on June 24, 2004. Although medical care issues were fully settled, an unresolved issue was the desegregation of HIV-positive prisoners from general population prisoners in their “institutional programs” (e.g., education, training, supervised release). The court felt that it was more important to get medical care resolved via a prompt settlement than to delay the entire case for a lengthy trial (and possible appeal) at the peril of continuing constitutional-magnitude healthcare violations. ADOC agreed to look into the desegregation issue. Nonetheless, although the Agreement automatically terminates after two years, the parties agreed that the court shall retain continuing jurisdiction to entertain claims of ongoing constitutional violations, if any, thereafter. Magistrate John E. Ou was appointed Special Master to monitor progress during the two-year remedial phase.

The Settlement Agreement is as profound as it is disturbing, in that its very terms indicate the depraved state of affairs that gave rise to the suit. At the same time, it is comprehensive and serves as a model for other under-served prisons’ HIV medical needs, and is therefore reported in detail here. Renowned HIV consultant Dr. Joseph Bick was hired to evaluate compliance and to suggest any improvements.

The standard of care is to be consistent with that adopted by the National Commission on Correctional Healthcare and the Centers for Disease Control and Prevention. The provisions apply to antiretroviral treatment of HIV infection as well as to the treatment and prevention of opportunistic infections and other illnesses [especially tuberculosis, where the entire 200 HIV-positive population plus staff were exposed when an active TB case went untreated in the HIV dorm]. “Medically necessary” care shall be provided, including alleviation of pain, prevention of diseases, prevention of organ deterioration and reduction of mortality.

Limestone shall employ an HIV specialist/medical doctor for AIDS and HIV prisoners. He shall have more than three years experience in inpatient and outpatient HIV care, and shall devote at least thirty hours per week to HIV prisoner treatment. An additional full-time registered nurse shall be hired at Limestone, who shall serve as the HIV Coordinator and triage person. A registered nurse (RN) - shall be on duty daily 24 hours/day at Limestone. In addition, a licensed practical nurse (LPN) shall be on duty 16 hours per day, every day, in the HIV dorms.

Guards shall not make medical decisions or judgments. RN’s and LPN’s shall not make decisions outside the scope of their licenses. All medical and custody staff shall receive CPR training. If Limestone cannot adequately care for an HIV prisoner, the prisoner must be sent to an outside specialist in a timely manner.

The HIV Specialist shall see every HIV-positive prisoner at least quarterly, to include a history, physical exam and evaluation of current CD4+ levels and viral load. All prisoners with AIDS will be seen at least every 60 days. Liver enzymes shall be monitored for those taking liver-threatening medications.

Protocols shall be adopted to minimize spread of the skin disease MRSA (Methicillin Resistant Staphylococcus Aureus) [see: PLN, Dec. 2003, p.10], including prevention, intake examinations, diagnosis and outbreak/control plans.

All medications shall be provided within 48 hours of being prescribed by the HIV Specialist, in appropriate doses and times. Medications shall be hand- delivered to acutely ill HIV prisoners, and when medically appropriate, a snack shall accompany them. All HIV prisoners shall have fresh water available to them 24 - 7. The pharmacy shall stock all medications typically used in HIV and related infection treatment.

Limestone shall establish a chronic care program for HIV -positive prisoners. It shall dovetail with established treatment criteria for diabetics, per the agreement reached in Gaddis v. Campbell in October 2004 and those co-infected with Hepatitis C, per the agreement reached in Baker v. Campbell in 2004 (see: PLN, Feb. 2005, p.18). HIV patients showing signs of liver dysfunction shall have an HCV PCR test administered.

All HIV-positive prisoners shall have three meals per day, six days per week. On Sundays and holidays, they shall receive two meals plus a medication snack consisting of one sandwich and eight ounces of milk. Meals shall be served after 5 :00 a.m. Those patients prescribed medical diets shall have their individual needs met for calories, carbohydrates and fat. Patients with wasting shall have dietary supplements as medically necessary.

To cover emergencies, a wireless intercom shall be installed in five cells per dorm housing HIV prisoners. It shall be linked to the dormitory guard station, and shall be available for acutely ill HIV patients.

Any HIV -positive prisoner arriving at Limestone shall be examined by a nurse within 24 hours of intake, and within 48 hours, he shall be seen by the HIV Specialist. Any previously prescribed medication shall be immediately provided again at Limestone, without disruption in the treatment.

Appropriate end-of-life care shall be provided, including choice of end-of-life options regarding life-prolonging treatment.

Physically disabled HIV-positive prisoners shall be provided facilities with adequate hand-railing, including in each HIV dorm shower. Any required prostheses shall be fitted within 90 days. HIV-positive prisoners shall have timely dental care, including treatment and fitting of dentures (within 60 days of impressions).

All sick call slips shall be triaged daily. Informal medical grievance forms shall be answered within 72 hours; formal grievance forms shall be handled within five days. Translators shall be made available for non-English speaking HIV--positive prisoners. Co-payments shall not be assessed for chronic care. Emergency care treatment of communicable diseases or upon any follow-up appointment. Housing shall be cleaned daily and disinfected between prisoner placements. All cleaning shall be documented, and dorms inspected weekly. There shall be no open bay housing or triple celling of HIV-positive prisoners. HIV counselors shall be provided for every HIV-positive prisoner, including use of outside agencies, at least once per week. HIV education material shall be provided, including updated medical periodicals. Prior to release, each such prisoner shall be given release counseling and Social Security Administration and planning services,. Upon release from Limestone, all HIV-positive prisoners shall have access to their prison medical records as well as be given a 30-day medication supply. Any mental health evaluations and treatment of HIV-positive prisoners shall conform with the settlement agreement in Bradley v. Haley. ADOC presently employs Tennessee-based Prison Health Services, Inc. as its medical provider.

Plaintiffs were represented by Gretchen Rohr (Atlanta, GA) and Stephen Hanlon (Washington DC) of Holland and Knight, and David Lipman and Francis Amania (Miami, FL), all appearing for the Southern Center for Human Rights, who filed the original lawsuit in November, 2002. See: Leatherwood v. Campbell, U.S.D.C. (N.D. Ala., Western Div.) No. CV-02-BE-2812-W.

Other sources: Huntsville Times, Birmingham News.

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