Researchers and advocates have singled out South Africa’s under-staffed and overcrowded prisons as hotbeds for the transmission of HIV and TB, which fuel the country’s already rampant epidemics.
At the 40th Union World Conference on Lung Health in Cancun, Mexico, earlier this month, a panel of international experts on prison healthcare highlighted the dismal health indicators that incarcerated populations face worldwide.
The World Health Organisation estimates that, globally, TB rates are up to 100 times higher in prisons than in the general population, with prisoners more likely to die from TB or default from treatment than those who are not in jail. Fabienne Hariga of the United Nations Office on Drugs and Crime (Undoc) said that up to 65% of some prison populations are infected with HIV.
According to UNAids official Alisdair Reid, poor ventilation, little personal space and limited access to both testing and treatment, coupled with the intensity of high-risk behaviour such as unprotected sex and needle sharing, contribute to a ”perfect storm” for the transmission of TB and HIV.
South Africa’s prisoners are especially prone to contracting both illnesses, given the country’s high disease burden and prison overcrowding. According to 2009 figures, the country’s prisons are at more than 40% over capacity. In the country as a whole about 460 000 new TB cases were diagnosed in 2007, with 73% being co-infected with HIV.
Undoc’s Hariga insisted that prisoners’ poor health indicators also pose a threat to public health, with HIV and TB contracted behind prison walls spreading to the general population.
”Prisons are not isolated from the community,” said Hariga. ”You have people working in [them] and prisoners move in and out very often.”
Poor healthcare for South African prisoners was highlighted earlier this year when the Treatment Action Campaign (TAC) took the department of correctional services to court over the death of an HIV-infected prisoner, known as MM.
The TAC contended that antiÂÂretroviral treatment for MM was stalled by prison authorities, resulting in early death.
Department documents revealed that the prisoner began receiving treatment weeks before dying, when he had a CD4 count of 100, well below the level prescribed for drug treatment by national guidelines.
The TAC says hundreds of other prisoners have died unnecessarily because of delayed treatment.
However, Dave Clark of the Aurum Institute, an NGO that is in partnership with correctional services in improving and monitoring health services for prisoners, said HIV and TB are of ”grave concern” to the department.
Although Aurum is still in its infancy its researchers are optimistic about the potential effect of its work, with 98% of prisoners in one prison agreeing to enrol and many prison staff being supportive.
But prisoners frequently move from prison to prison and from prison to the outside community, hampering follow-up care.
Interrupted treatment not only threatens the health of infected people, but can result in increased drug-resistant strains of both HIV and TB.
In Aurum’s HIV study 21% of prisoners defaulted from treatment. With regard to TB, 18% of those who needed additional care had been transferred to another prison before being seen by the Aurum team.
Jurisdictional disputes have hindered efforts to care for prisoners, with the health department and correctional services claiming the other is responsible for providing care.
As a result, accessing testing diagnostics and the ”procurement of drugs [has] been difficult due to lack of clarity”, said Salome Charalambous, the project’s lead researcher.
Clark said the problem was being addressed.
Charalambous said correctional services was planning to open more prisons throughout the country.
But panellists at the World TB conference called for penal reform. ‘We need to look at more than just opening new prisons,” said Reid, who noted that South Africa has the eighth-highest incarceration rate in the world.
”This cant just be addressed with ‘build more’,” said Hariga. ”We need to look at the justice systems.”