IV. MethodologyThis investigation began in early 2007 with a review of complaints received by Human Rights Watch from detained immigrants and their advocates regarding medical care for detainees with HIV/AIDS. Human Rights Watch first examined the policies and procedures of the Department of Homeland Security (DHS) and its sub-agencies (ICE and DIHS) relating to HIV-positive immigration detainees. We examined how these policies and procedures compared to national and international standards and ensured quality care for all HIV positive detainees, including those held in the hundreds of local and county jails to which ICE outsources its immigration detention. The policies and procedures of DHS, ICE, and DIHS relating to HIV-positive detainees are discussed in section VI below. Also discussed are the results of a Freedom of Information Act (FOIA) request to DHS requesting data concerning the detention, testing, treatment and services provided for immigrants with HIV/AIDS in all facilities supervised by, or contracting with, ICE. Human Rights Watch next interviewed twelve current and former immigrant detainees living with HIV/AIDS about medical care and services for HIV infection provided in detention. The immigrants were referred to Human Rights Watch by their attorneys or, in some cases, local community advocates. They were interviewed in English, under conditions that ensured privacy and confidentiality. Detainees were interviewed at detention facilities in California, Alabama, New Jersey and Virginia. These facilities included one Service Processing Center, one corporate-owned facility, and four county jails. Ex-detainees described their experiences at detention facilities in Pennsylvania, Texas, Louisiana, Illinois, Wisconsin, and Virginia. Regarding the death of Victoria Arellano, Human Rights Watch interviewed one current and one former detainee and reviewed the testimony submitted to civil rights attorneys by dozens of detainees from her housing unit. Human Rights Watch attempted to interview her cellmates but more than 20 key witnesses to her death were transferred days before the arrival of Human Rights Watch at the San Pedro Service Processing Center (see text box below). Human Rights Watch has requested a copy of the coroner’s report as the investigation of her death continues. Human Rights Watch also interviewed wardens at a privately owned prison in Alabama and a county jail in Virginia, and a medical liaison officer at a county jail in New Jersey. On October 25, 2007 Human Rights Watch attended a meeting with ICE officials, including Gary Mead, Asst. Director for Detention and Removal, US Immigration and Customs Enforcement. With the consent of the interviewees, Human Rights Watch engaged the services of a medical expert to review detainee medical records and provide an independent opinion concerning compliance of the medical care with community standards. Dr. Jaswinder Legha is board-certified in Internal Medicine and received her medical and Master’s degree in public health from Columbia University. Dr. Legha completed her residency training in Internal Medicine at Bellevue/NYU Medical Center, an institution which serves a significant population of individuals living with HIV. Her review was necessarily limited to the records received by Human Rights Watch from the various facilities, which in some cases were incomplete or partially legible. Highlights of the medical review appear below following the testimony of the detainees. Because the Division of Immigration Health Services does not monitor the number of detainees living with HIV/AIDS, it is impossible to determine the scope and representativeness of the medical care provided to detainees interviewed for this report. Although the number of detainees interviewed is limited, the methodology supports generalized conclusions regarding the quality of medical services provided to detainees living with HIV/AIDS. The testimony provides geographical coverage (9 states), covers the three major types of facilities utilized by ICE (Service Processing Centers, corporate-owned, and county jails), and is supported by continuing correspondence to Human Rights Watch from additional detainees and their advocates. The independent medical review found a consistent pattern of sub-standard care. HIV/AIDS and Medical Treatment AIDS is caused by the human immunodeficiency virus, or HIV. By killing cells in the immune system called CD4+ T cells (CD4), HIV progressively destroys the body’s ability to fight infections and certain cancers. Regular monitoring of CD4 cells and the amount of HIV in the body, or viral load, is essential to determining appropriate treatment. Antiretroviral therapy, or ART, treats HIV with a combination of medications that each attacks the virus’s life cycle in a different way. Based on laboratory test results, doctors also prescribe different prophylactic drugs to prevent patients from developing opportunistic infections such as PCP (pneumocystis pneumonia). A key aspect to achieving the benefit of ART is full adherence to the therapy regimen. Due to the rapid multiplication and mutation rate of HIV and other factors, very high levels of adherence to antiretroviral schedules are necessary to avoid viral resistance. In comparison with patients who are adherent to ART, non-adherent people have higher mortality rates, less improvement in CD4 cell count and spend more days in the hospital. Viral resistance not only affects the health of the individual, but also that of the community, as resistant strains can be transmitted to others. Sources: Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. United States Department of Health and Human Services. October 10, 2006; 1-113. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 5, 2007); WHO/UNAIDS/UNODC, Effectiveness of interventions to manage HIV in prisons- HIV care, treatment and support (Geneva, WHO,2007).
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