Peer support has been pivotal to inmates taking responsibility for their health
When Mazvita Ruwambara, 28, tested positive for HIV in 2015, his reaction was disbelief, even though he knew this could happen in his line of work, which occasionally involved having unprotected sex.
At the time, he worked as an actor in pornographic videos, a job he had settled for after a desperate search for “decent” work proved fruitless in South Africa. He had migrated from his hometown, Rusape, in Eastern Zimbabwe, to the neighbouring country in search of greener pastures.
The job paid comparatively well, initially earning him more than R3 000 a month — until he started experiencing sexually transmitted diseases (STDs) that sometimes affected his work.
On visiting a clinic for treatment in 2015, Mazvita tested positive for HIV and was told that he would need to take antiretroviral therapy (ART), a treatment he would need to continue for the rest of his life.
Despite the diagnosis, Mazvita ignored the results of his HIV test and the medical advice. He continued to frequent clinics to get treated for other STDs but would evade HIV testing and change clinics whenever the subject was raised.
“I found it hard to accept that I was HIV positive. It just felt so unreal to me. I was in denial and decided to ignore that I needed antiretroviral treatment. I was not ready to deal with the shame and the stigma from my family and society.”
In 2021 he was convicted of theft in Zimbabwe and was placed in Rusape Remand Prison.
While in prison, he saw several inmate peer educators disclosing their HIV status and urging others to get tested and seek treatment early. He noticed the peer educators appeared healthier than he was. His health had seriously deteriorated.
“I became serious about my health in prison after I developed herpes. Fellow HIV-positive inmates who were peer educators looked healthier than l was and always preached that it was because they were taking medication. It was then that l decided to kick the shame away and seek treatment,” Mazvita admits.
In Zimbabwean prisons, HIV prevalence rates are almost double the national rates. For example, In 2018, there was a 28% HIV prevalence rate in all 47 prisons, while nationally, the rate was about 14%. Female prisoners had a 39% rate.
It is not known whether higher prevalence rates in the prisons are a result of new HIV infections occurring in prison facilities or a disproportionate number of HIV-positive people being jailed.
Prison authorities maintain that inmates are not at risk of new infections while incarcerated.
Whatever the causes, there has been a progressive decline in HIV prevalence in prisons. A 2005 Independent Institute of Correctional and Security Studies report estimated a 51.4% HIV prevalence in prisons. Today, this number has dropped by almost half.
Nationally, the Zimbabwean government has joined the efforts of The Joint United Nations Programme on HIV and Aids toward the 95-95-95 target, ensuring that by 2025 a total of 95% of people living with HIV know their status, 95% of those who know their status are on treatment and 95% of those receiving treatment have had their viral load suppressed.
Today, Zimbabwe has reached 86.8%, 97%, and 90.3%, respectively, according to a 2020 Zimbabwe Population-based HIV Impact Assessment.
Prisoners are a key population for meeting these national and global targets. Under guiding principle 33 of the 1999 National Policy on HIV/Aids for Zimbabwe, prisoners have basic rights that must be respected and protected, including the right to information on HIV/AIDS and sexually transmitted infections, counselling and care.
Zimbabwe Prisons and Correctional Services (ZPCS) has been striving to uphold this principle.
“From a holistic point of view, the health delivery system in prison should not differ from the one in the community. Being an inmate does not mean that you no longer have health rights; thus, from a human rights point of view; an inmate must access all HIV services that are accessed by those outside for the sake of continuity while in prison, as well as when they are reintegrated back onto society,” said the ZPCS Manicaland provincial nursing officer, Superintendent Lebson Mudyano.
Just as in a society, where people are not always willing to get tested for HIV and seek treatment, prisoners also show a similar reluctance. Prisons try to counter this through periodic educational talks promoting physical and mental well-being.
“That is how we have managed to increase the number of prisoners coming forward for testing,” said Mudyano. “We also identify prisoners who show symptoms that are HIV related and urge them to get tested. After diagnosis, we offer antiretroviral treatment so that we suppress their viral load.
“For prisoners who are already on medication, we continue to offer treatment. Our educational health talks are crucial in instigating inmates’ health-seeking behaviours and promoting treatment adherence and mental wellness.
“We realised that some inmates would have defaulted on medication as they lived on the run outside and feared being caught while collecting medication at clinics, so we also tried to put them back on treatment. In Manicaland province, we currently have about 1 965 male and 31 female inmates. Of these, 273 males and eight females are on antiretroviral treatment,” Mudyano added.
Educational health talks encourage inmates to develop a sense of urgency towards their health and adhere to treatment.
“Some years ago, I was behaving irresponsibly, disregarding my health. I now have a better understanding and responsibility for my sexual and reproductive health from the educational health talks we have in prison, and l take my medication daily,” said Mazvita.
A female prisoner at Mutare Remand Prison, Chikomborero (a pseudonym), said she had learned from the educational health talks. As an HIV-positive mother, she understands the role she has to play in preventing the transmission of the virus to her child.
Chikomborero entered the prison pregnant last year and has continued receiving maternal and postnatal care under the gender responsive approach in prison. With the medication administered to her, she will be able to breastfeed her five-week-old infant for up to six months.
She is determined to take her medication to protect her child.
“I am glad that though l am in prison, I am able to receive medication that will allow me to keep my baby safe from HIV infection. Adherence to my medication is important to me because the prison nurses told me that if l don’t, l risk infecting my baby, and l don’t want my child to contract the infection because of me. My baby is too innocent to experience the physical and emotional pain that l face with this infection,” Chikomborero said.
Despite receiving medication that prevents perinatal transmission,Chikomborero could still transmit the virus to her baby through breast milk.
“I was told l had more chances of not transmitting the virus to my baby if l stopped breastfeeding and gave baby formula instead. There is no provision for baby formula in prison, and I cannot afford to buy it. I can only adhere to medication. So I breastfeed and hope for the best,” she explained.
Although antiretrovirals and other drugs are available at prisons, the major setback in ensuring good health for inmates is poor diet and a shortage of warm clothing, according to Mudyano.
“While we do not have challenges in terms of medication provision, we still have resource challenges that inhibit the provision of foodstuffs that ensure a more balanced diet, as well as clothing and blankets that protect the prisoners from cold weather. HIV-positive inmates require a variety of nutritious foods and to keep warm all the time to maintain good health. Without a sufficient supply of these resources, their health remains compromised,” Mudyano said.
To address food shortages, most prisons across Zimbabwe have gardens that help improve inmates’ dietary needs but these are not enough to ensure a balanced diet.
The ZPCS works with partners such as the United Methodist Church, which occasionally donates foodstuffs; Voluntary Service Overseas (VSO), which offers health interventions; the National Aids Council of Zimbabwe and Zimbabwe Network of People Living with HIV to ensure that inmates’ needs are met.
Esnath Ndazonakei Manhiri, project officer for the Southern Africa Network of Prisons under VSO, says there has been progressive HIV-related health development from its partnership with the ZPCS and the prisoners.
“Over the years, we have seen an increase in the uptake of health-related services like HIV testing, HIV counselling, and HIV treatment, tuberculosis and Covid-19 screening, among other services, by inmates. There has also been a reduction of stigma and discrimination associated with HIV-positive status, while support groups and peer-to-peer counselling enhance ART adherence,” said Manhiri.
To a great extent, the progressive development is owed to VSO’s development of a peer education manual used for training prison officers and inmates on how to run a sustainable peer educator-support group model. The VSO has used this manual in 13 prisons and trained 452 inmates and 91 prison officers since 2014.
“Trained inmate peer educators act as the bridge between fellow inmates and nurses in prison institutions by referring their peers for HIV services, closely monitoring their peers who receive any HIV service from the clinic, and providing cell-based care to chronically ill inmates. As a result, there are very rare cases of bedridden inmates because peer educators play a critical role in encouraging inmates to present themselves to their clinics. Hence, they receive early treatment,” added Manhiri.
Peer educators went a step further in 2018 at Chikurubi Maximum Prison in Harare. They created a makeshift recuperating space known as “Ward 4” after volunteers realised a need for a more comfortable place for bedridden inmates to recuperate after receiving initial treatment.
The VSO highlights improved treatment adherence from 50% to 100% at Chikurubi during this period after the introduction of the peer support scheme.
The manual includes vocational skills training to allow inmates to sustain themselves and their families through honest work on release.
These initiatives have not been without difficulties. In the past two years, the emergency of Covid-19 slowed progress and interrupted the implementation of planned activities in prisons because of lockdown measures to reduce the spread of the pandemic. In addition, limited financial resources also affected the VSO’s ability to extend programmes to all prisons in Zimbabwe.
The programme is for all prisoners where volunteers work, but some foreign inmates are left behind because of language barriers.
According to the National Aids Council of Zimbabwe’s provincial key population coordinator Farai Zihute, some services that promote HIV prevention in prison facilities are still absent.
“In prisons, we are supporting by merely offering information on HIV prevention. We can’t offer PrEP [Pre-Exposure Prophylaxis] and condom programming because prison authorities deem prisoners not at risk. Prison authorities deny that prisoners engage in sex,” said Zihute.
In addition, the ZNNP+ Manicaland coordinator, Moses Chananauka, said disregarding sexual orientation by prisons leaves inmates open to sexual abuse and at risk of contracting HIV.
“Our prisons do not consider issues of sexual orientation sufficiently. LGBTQI issues must be considered so that proper screening and separate facilities are erected. As it stands, officials just look at the outward appearance and throw the prisoner where they feel they fit.
“There they may get abused by other prisoners. Even now, there is no separate facility for juveniles. This has caused older prisoners to lure juveniles into exchanging sex for food and other basic needs that are scarce in prison. With that, there is potential HIV infection in prisons,” said Chananauka.
Taking a leaf from the current HIV interventions in prison, Taurai Bieni, a volunteer peer educator at Mutare Remand Prison since 2015, is looking forward to using the knowledge he gained in prison to start a peer support scheme in his rural village in Buhera district when he is released.
“With the training l received as a peer educator, I have benefited from a lot of knowledge on HIV management and the importance of supporting each other as people living with HIV in this prison. I realised that this is a model that has the potential to improve the lives of those with HIV in my rural home, Buhera. l plan to use the knowledge to help my community when l get released,” Bieni said.
Mazvita, on the other hand, hopes to encourage others to make wiser health decisions. Today he is healthy, living positively and uses his story to inspire others in prison to be open to testing for HIV and start treatment. Mazvita is scheduled to be released from prison in November and has pledged that on his release, he will continue adhering to medication and practice safe sex.
“I am HIV positive today because l decided not to practice safe sex. When l get out of prison, l will teach others that prevention is always the best decision. And for those facing the same fear l faced, I will advise them to ignore the stigma and seek treatment early. I wish I had been well informed to seek treatment early, too.” — bird story agency