Are prisons the missing link to ending the spread of HIV?
The situation in prisons across Southern Africa has been described as ‘dire’. Overcrowding, lack of resources and challenges providing decent nutrition and rehabilitation make them ‘incubators’ for HIV and tuberculosis (TB), with infection rates twice as high as in the general population.
We cannot hope to end high levels of these diseases across the region without addressing prison health. Research reveals the extent of the threats we face – and informs our vital work addressing them.
Improving prison health vital to protecting public health
Each year over 30 million men and women spend time in prisons and other closed settings. The prevalence of HIV, sexually transmitted infections, hepatitis B and C and TB in prison populations is 2 to 10 times as high, and in some cases up to 50 times as high, as in the general population.
Virtually all prisoners will return to their communities, many within a few months to a year – so it is vital to see prison health as a public health issue.
We will restore health and dignity of prison populations in Southern Africa over a period of nine years. This is happening through a joint programme between VSO’s Regional HIV and AIDS Initiative in Southern Africa (RHAISA) and the UN Office on Drugs and Crime (UNODC) - with the engagement of stakeholders. By working together, we can resolve some of the most pressing health challenges.
A perfect storm for poor health
VSO’s research report into the status quo in prisons across Malawi, Zambia and Zimbabwe was concluded in June this year. It reveals prisons to be ‘breeding grounds’ for infection and provides a baseline against which we will measure the impact of our programme.
It shows that challenges faced by incarcerated people include:
Malnutrition impairs the immune system, speeding up the progression of HIV to AIDS. So it is of grave importance that people living with HIV, and receiving antiretroviral therapy (ART) in prison have access to an adequate, healthy diet.
However, research shows that the majority of prisoners do not have adequate access to food of good nutritional value. Resource challenges in delivering nutritious meals mean that it is not unusual for prisoners to receive just one meal per day. Food is sometimes traded for sexual favours. Meals lack the variety needed to promote good health – with no additional provision for prisoners using ART.
"The radio says we need different types of nutritious foods but we don't get them in here!"
Prisoner living openly with HIV, Malawi
Overcrowding & hygiene
The number of people in prisons worldwide has increased by 10% since 2004. Our research found some prisons struggling to cope with populations up to nine times their designed capacity. Prisoners may have to sleep seated or in shifts. These conditions could lead to increased levels of stress, which compromises the immune system. It also improves the ease with which infections can spread.
Overcrowding coupled with resource scarcity leads to grave challenges delivering access to safe drinking water and toilet facilities. In Malawi and Zambia, only three in ten people have access to a clean and functioning toilet. Prisons may have to resort to providing buckets to make up for the shortfall that are a health hazard and afford no privacy for the people having to use them.
Risky behaviours including unprotected sex (including rape) and illicit drug use further the spread of HIV and other infections. Only two countries in Southern Africa currently distribute condoms to prisoners.
The struggle of reintegrating into society
Many people returning to their communities at the end of their sentences find it severely challenging to reintegrate. They face stigma from the community, and barriers to employment that contribute to pre-existing poverty. Food security is among the biggest fears prisoners have about life after release (47% of prisoners surveyed in Malawi fear this).
Hope for the future
Countries across Southern Africa are addressing these challenges head-on, including through the “Promoting human rights and access to health services in prisons in Southern Africa” project.
The first three-year phase, which began in 2015, is being implemented in Malawi, Zambia and Zimbabwe. The Swiss Agency for Development and Cooperation (SDC) provided the grant for this project.
VSO RHAISA is working jointly with UNODC to:
- Improve co-ordination between the various stakeholders working to improve the outlook for prisons and correctional services
- Form improved networks of ex-prisoner associations
- Improve nutrition, rehabilitation and reintegration through enhanced skills-training in prisons, including a focus on addressing malnutrition and income generation through prison farms
- Improve access to quality health services in prisons, and access to information
- Advocate for policy reform to promote health and dignity in prisons
Volunteers from across Southern Africa are building the capacity of prisons and correctional facilities, and of partner organisations.
For example, volunteers are working on a peer education initiative with Harare Remand Prison, supported with the Big Lottery Fund. In Zimbabwe, the prevalance of HIV in prisons not far from one in three (28% of prisoners).
Volunteers are using a peer education strategy here to spread information about HIV care and prevention, and to provide support to prisoners. To date, 36 inmates have been trained as peer educators and two support groups have been formed. One HIV positive prisoner attests to the impact on his life:
"For a long time, I had chests pains and each time I went to seek medical attention, I insisted that I wanted to only get tested for TB - not HIV. However, the counsellor encouraged me for a long time to agree to the HIV test, which I did. It came out positive. This was six months ago.
"I commenced ART immediately and linked with peer educators in the prison who took it upon themselves to ensure that I adhered to medication, they always escorted me to get my dose from the dispensary and ensured that I received counselling. I am happy that I got tested in the prison where there are peer educators who have continued to support me. I am certain that if they were not there, I could have died. I did not believe I could test positive because of my religious beliefs.
"The peer educators supported me to join a support group, where I am getting information on positive living. I thought testing HIV positive was a death sentence. The support group has helped me accept my status and am now looking forward to living for many years to come. the testimonies of others in the support group who have lived for more than 21 years with HIV have given me hope for living longer."
 As defined by prison guidelines: Having a three well balanced meals per day