Image Source: New York Times
September 2016
REGION: Sub-Saharan Africa

The article “HIV and Tuberculosis in Prisons in Sub-Saharan Africa” discusses the epidemiology of HIV and tuberculosis (TB) among prisoners in Sub-Saharan African prisons; identifies available services, highlighting successes and challenges arising from the current criminal justice and health care systems; and provides relevant recommendations.

Prison conditions are argued to play a large role in the pervasiveness of HIV and TB; however, the authors were only able to find data on prisons in 24 of the 49 countries in the region. Further, available data was often of poor quality, and there was a serious shortage of information on both women and children. Reported prevalence of HIV infection ranged up to 34.9% and TB up to 16.3%, with rates among detainees almost always greater than among the general population. During the study period, approximately 600,000 detainees were held in Sub-Saharan African prisons on an average day, and in 40% of the countries sampled, pre-trial detainees composed at least half of the prison population. Twenty-three countries reported occupancy rates of over 150%, and several were operating at over 300% capacity.

Access to health care and treatment of prisoners varies greatly among groups in the prisons, with women and juveniles typically receiving poorer care than others. Some juveniles reported extended pre-trial detention or long waits between trial and judgment, and many had no access to counsel. Further, one young prisoner who was interviewed expressed that nearly all juveniles will face sexual violence, are highly likely to leave with a disease, and face great difficulty seeing a health care professional while in prison.

Interventions to curb HIV and TB often face barriers including financial limitations, inadequate infrastructure, unlawfulness of sex between men, lack of health-information management systems, inadequate infection-control procedures, inaccessibility of off-site clinics, scarce human resources, overcrowding, and discontinuity of care. For example, studies suggest that roughly half of detainees who began treatment for TB were transferred to a different facility before treatment was complete or were otherwise lost to follow-up. This breakdown of continuity of care comes with drastic consequences, including the development of drug-resistance. Additional challenges to HIV and TB prevention, treatment, and care problem often stem from detainee substance use and mental health problems. While both these issues are more prevalent among prison populations, only one mental health treatment and one drug harm-reduction program were found in the data studied. Further, the large majority of Sub-Saharan African prisons does not have comprehensive policies regarding HIV and TB prevention, care, and treatment in prisons, but rather depends on guidelines developed for the general community. Finally, estimation of funding for HIV and TB services within prisons is an additional challenge, due to dispersed funding sources and a “frequent lack of transparency in the reporting of funding.” Although several international donors have programs aimed at reducing HIV and TB, very few include prison-related HIV or TB initiatives, and often less than 5% of funding for HIV and TB programs is allocated to prison programs.

Several countries, however, have had varying degrees of success in addressing health service challenges through policy reform. For example, South Africa decreased its prison population by nearly 30,000 by developing policy that included alternatives to detention for pre-trial detainees unable to post bail. Another South African prison experienced decreases in TB rates and overall mortality after a policy change increased food rations. While condom provision is illegal in prisons in many countries, facilities in Burundi, Lesotho, and South Africa are now making condoms available, but data on the uptake and effectiveness of this reform are unavailable. Further, several countries now offer voluntary HIV testing and counseling on-site at many prisons, which has been reported to have been well-received and utilized by detainees. Antiretroviral therapy is not widely available in most Sub-Saharan African prisons, but where it is available, health outcomes have been quite good among detainees who remain in the prison long-term. With adequate support and funding, mass testing of TB was also found to be feasible, well-accepted, and highly utilized across prisons in Zambia, and resulted in high volumes of detainees being tested, diagnosed, and treated, all of which drastically reduce potential for disease transmission.

The report recommends the development and implementation of prison-specific service-delivery policies, and greater funding transparency and accountability among government and donors alike. Specific reform recommendations include an intersectoral collaborative approach to the management of prison health professionals, and the inclusion of prisons in community HIV and TB program reviews. These actions could result in the implementation of comprehensive screening, diagnosis, and treatment services for HIV and TB, as well as services aimed at addressing issues of nutrition, substance use, and mental health in a prison context. Criminal justice reforms should aim to lower the prison population by decreasing lengthy trial delays, limiting arbitrary and pre-trial detention, promoting the release of those detained for minor offences, expanding community correction programs, and increasing access to legal representation. To enable implementation of these crucial reforms, “political will, leadership, operationally relevant research, and long-term funding” are all equally necessary.

NOTE: This summary is produced by the Rule of Law Collaborative, not by the original author(s).

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