The benefits of combination therapy may quickly vanish if you don’t or can’t take it on the correct schedule and in the right relation to meals. Why? The virus easily develops resistance to a whole class of drugs. POZ has received some 200 letters from HIV positive prisoners describing inappropriate practices in administering medications. Below are a few of the most commonly asked questions, answered by Frederick L. Altice, MD, director of the HIV in Prisons Program at Yale University.

What should I do if I get my meds at the wrong times?

Make sure all medications are administered as ordered—taking less than three drugs will promote resistance. Increased viral replication begins only after missing a few doses of the meds. Such drugs as ddI (Videx), 3TC (Epivir) and nevirapine (Viramune) may be doubled if the previous dose was missed, but others should not be. The dose of nelfinavir (Viracept) can be increased and given twice daily. Medications like ddI and indinavir (Crixivan) must be taken on an empty stomach, but not at the same time. If the dose is available at a later-than-scheduled time, take it anyway. The longer the lapse in therapy, the more likely it is that the virus will become active. Try to negotiate with staff for corrections in timing of your doses.

What if my meds are delayed by days or weeks, or changed completely, either because of a transfer or a shortage?

If one of the anti-HIV drugs is due in a day or two, continue taking the others. If the delay is expected to be longer, anti-HIV (but not prophylactic) meds should be stopped until all the drugs are available. Sometimes, substitutions may be considered, but that requires expert advice. Medications should only be changed permanently if the previous combo has failed (that is, your viral load is detectable or has increased). If this happens, a replacement regimen should include a minimum of two new medications that you have never taken before.

If my institution takes a long time to refill meds, is it best to postpone starting anti-HIV treatment until the situation improves?

That’s a very individual decision. Those with high CD4 counts or low viral loads may choose to delay therapy. For others with a long prison sentence, this may not be a viable option.

What if my doctor threatens punishment for my refusal to start treatment?

Prisoners have a right to the community standard of care, but medical staff are not supposed to threaten punishment for your declining to take prescribed medical therapy, except perhaps in the case of tuberculosis treatment.

What can I do to avoid problems with medical care for me and other prisoners?

Always address medication issues with medical staff first. If that doesn’t work, you may need to write a medical grievance or contact an outside advocacy group (see “Resources,” p. 94). Among the suggestions you may want to make: 1) more flexible hours for getting meds; 2) early renewal of medications; 3) training of medical and correctional staff about HIV drug adherence and side effects; 4) confidential administration of pills with voluntary options for “on-person” meds or “med window” access; 5) pre-transfer medical review and transfer of meds along with you; and 6) consulting an HIV specialist for potential med substitutions or double doses.