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HIV/Aids in Prison: Problems, Policies and Potential
Zimbabwe Monograph - Institute for Security Studies
by KC Goyer
February 2003

Any attempt to address HIV/AIDS in prison in South Africa will be affected, if not entirely thwarted, by the problems with prisons in general which are in desperate need of reform. For this reason, the following recommendations cover issues of prison reform in general, as well as those which specifically pertain to the issue of HIV/AIDS.

Overcrowding
The primary challenge facing the Department of Correctional Services is overcrowding. Reducing overcrowding will accomplish a great deal in the interest of general prison health as well as a number of other conditions which impact on the nature and extent of HIV infection in the prisons. The rights of prisoners to conditions of humane detention are guaranteed in the South African Constitution’s Bill of Rights, article 35(2)(e):

Everyone who is detained, including every sentenced prisoner, has the right to conditions of detention that are consistent with human dignity, including at least exercise and the provision, at state expense, of adequate accommodation, nutrition, reading material, and medical treatment.

Any prisoner, former prisoner, prison employee or anyone that has ever visited a prison in South Africa will agree that not a single one of these constitutional rights is respected in South African prisons. Overcrowding is the primary culprit. The solution to overcrowding is not to build more prisons, however, but to reduce the prison population.

The prison population consists of a significant number of people who simply should not be there at all. These include not just prisoners who are awaiting trial, but also prisoners who have been convicted of petty theft or non-violent crimes of a strictly economic nature. These are crimes born of poverty and unemployment; factors which are not alleviated by a prison sentence.

Legislators and policy makers involved in sentencing laws and decisions should be made aware of exactly what prison can and cannot achieve and the appropriate instances for which incarceration is warranted. If an arrested person is not considered a threat to society and likely to appear on his or her court date, then the person should be released on bail. If the person cannot afford bail, then the amount should be suspended or reduced. Additional measures to reduce the prisoner population include pre-trial diversion, admission of guilt and payment of fine without a court appearance, release on warning, correctional supervision, electronic monitoring, and use of non-custodial sentences.218

While the overcrowding issue is largely beyond DCS’ control, there are some aspects which the Department is able to address. Most notably, the inadequate accommodation provided by outdated prison facilities. First and foremost, the use of communal cells should be discontinued. Warehousing prisoners in large cells with minimal space and privacy is inconsistent with human dignity even in the absence of overcrowding.

Many prisons in South Africa were designed with communal cells and to abandon this practice would require significant structural changes to the prison buildings themselves. A better solution is to knock them down entirely and build a new prison which will be designed for both better security and better conditions, including cells which contain a maximum of four prisoners.

One means of financing such a large-scale initiative is to identify prisons which were originally built on the outskirts of urban centres but now find themselves taking up prime suburban real estate. These prisons should be knocked down and the land sold, and newer better prisons should be built and located elsewhere. The location of Pollsmoor Prison, for example, is amongst golf courses, housing developments and a brand new business complex. The profits from the sale of this enormously valuable stretch of land alone could probably fund new prisons for the entire Western Cape.219

Prison health care
One of the first reforms to improve prison health care attempted in other countries is to discontinue the separation of prison health services from the general public health agency. As discussed previously, all but a small fraction of prisoners return to the community. Therefore, issues of prison health are issues of public health. Providing suggestions for UNAIDS, Professor Tim Harding was emphatic about this first step in appropriately addressing HIV/AIDS in prison:

If there is one thing, more than anything else, which should be done, it is that health in prisons must come under the responsibility of the public health authorities. The link between health in the community and health in prisons must be made as strong as possible.220

Prison health care facilities were never designed nor intended to care for such a large proportion of chronically or critically ill patients. The prison hospital should be run and funded as a public hospital, the budget for prison health should come from the DOH, and the staff and management should be the realm of public health, not correctional, services. Expanding the responsibilities of the DOH to include the prisons would reduce funds wasted on the duplication of efforts and amend the disparities in the quality of health care provided in prison.

Sexually transmitted infections (STIs)
Over the last few years, the DOH has made the detection and treatment of STIs a top national priority mainly because these infections increase the chances of an individual transmitting and acquiring HIV. For the same reasons it is recommended that the DOH in conjunction with DCS develop a comprehensive programme to reduce the incidence and prevalence of STIs in prisons. In line with WHO recommendations, the DOH has adopted the strategy of ‘syndromic’ treatment of STIs and has issued national guidelines to assist clinicians in managing a patient who presents with an STI. It is strongly recommended that the same guidelines be adopted by the DCS and the DOH doctors who work in the prisons.

Because of the limited access that prisoners have to the broader community, the possibility exists that curable STIs may be completely eradicated within prisons. This may be done by screening for STIs on admission to prison using a combination of history taking, examination and laboratory testing. Because of the high cost of laboratory testing and the fact that many STIs do not produce symptoms in everyone, consideration should be given to presumptive treatment on admission. In other words, all prisoners are given antibiotics aimed at eradicating STIs upon arrival at the prison.

Many of the symptoms of STIs can be embarrassing to discuss, and lack of knowledge about the treatment available can prevent people from seeking appropriate care. Through presumptive treatment upon admission, combined with information about the symptoms and treatments for STIs, a prisoner may become more likely to seek treatment for an STI both during his incarceration and upon his release. The incidence of STIs could thus not only be eradicated in the prison environment, but could also be reduced in the greater community.

Tuberculosis (TB)
Prison conditions are conducive to the spread of TB. The current ad hoc approach to health care in prisons in general will not control the spread of this epidemic and places both prisoners and staff at risk. The lack of a comprehensive response also carries with it the added danger of multiple drug resistant TB (MDRTB).

The World Health Organisation (WHO) has published guidelines for the effective treatment of TB, referred to as Directly Observed Therapy (DOT). The term ‘Directly Observed Therapy’ stems from the requirement that the patient is directly observed taking the medication. Direct observation is emphasised because, much like ARV treatment, poor adherence can result in decreased cure rates and drug resistant strains of the disease. DOT is a six to eight month programme, during which time the patient must take a combination of five different drugs. The cure rate for DOT averages around 90%, and can cost as little as US$11 for the duration of treatment. While DOT has become widely practised in developing countries, treatment for multiple drug resistant tuberculosis (MDRTB) is usually not available because it is much more expensive.221

Nutrition
The nutrition in prisons is abysmal to the point that the food provided can scarcely be considered adequate sustenance for a normal healthy adult. The solution to this problem is not for the Department to spend more money and buy more and better food, as internal corruption will prevent additional food from actually reaching the bulk of the prisoner population. Prisoners often work in the prison kitchens although they are usually not paid for their work. Instead, they take their compensation in the form of smuggling. What was originally intended to be distributed equitably and free of charge is then sold to the highest bidder. As is the case outside the prison, those who control the market have the greatest power to benefit—as the prison meals get worse, the profit incentive to smuggle food increases.

Food service is an entirely separate industry and a well-developed one in South Africa. As food service is not a core function of the prison system, it is advisable that DCS outsource this component to a national food service provider. This could not only generate savings to the government but, if implemented conscientiously, would result in improved nutrition and decreased smuggling and other instances of corruption associated with the currently prison-run kitchens. A contract to provide food services to the entire prison system would be an attractive opportunity for any catering company. The sheer scale of operations combined with assured future cash flows should be used as leverage in negotiating a financially advantageous outsourcing contract for the Department.

Furthermore, the private catering firm should be permitted to hire prisoners, provided they are trained and paid a normal wage. This will create an incentive on the part of kitchen staff to keep their jobs, which carries along with it an incentive not to steal. In the current situation, prisoners have little to lose if their smuggling is discovered, and the ubiquitous nature of such activities make them seem more or less acceptable. In a situation of employment, the environment will change considerably and it can only be hoped that this change would be for the better as it could scarcely get any worse.

Testing
Prisoners should receive HIV testing upon request. A prisoner has the right to receive the same standard of care as the general community. HIV testing is available free of charge in the general community and as such it should be provided without exception inside prison. The prisoners at Westville Medium B have demonstrated their interest in knowing their HIV status, an encouraging start for any intervention programme. The pre- and post-test counselling procedure should continue, as well as the commendable emphasis on confidentiality and prisoner’s mental health.

Condoms, lubricant and bleach
Condoms and lubricants must be made available in latrines, showers, the cafeteria and any other common area to which the prisoners have access. Prisoners should no longer be required to personally request condoms, although the required HIV and STI counselling should remain available. This counselling should not, however, be a prerequisite for obtaining condoms. Condoms should rather be available in a manner that they can be obtained discreetly and without requiring face-to-face interaction.

Water-based lubricant should be provided in a similar manner as condoms in order to prevent condom breakage and reduce rectal tearing. The use of water-based lubricants can help prevent condom breakage during anal intercourse, thus making the condoms currently available more useful in the prison context. Also, because lubrication reduces tearing of the rectum as a result of anal intercourse, the risk of transmission is further reduced.

In order to foster increased condom usage for the purposes of reducing HIV transmission, both within the prison and also upon release, the appropriate gang leaders should be engaged. Knowing that the 28s, and to a lesser extent the 26s, regularly participate in high risk sex as part of their gang’s entrenched tradition and activities, the leaders of these gangs should be incorporated into any strategy to increase condom use in the prison. One approach could be identifying gang leaders for peer intervention programmes, and harnessing their demonstrated leadership skills to effect positive change.

To the same extent that condoms and lubricants are made available, bleach tablets should be distributed so that prisoners can sterilise implements used for tattooing. Although IV drug use has not yet presented a problem in South African prisons, laying the groundwork now to introduce bleach and to educate prisoners about the need to sterilise cutting or piercing instruments will prove a useful preventative measure against HIV transmission should IV drug use increase. The involvement of gang leaders to promote this initiative should also be explored, as prison tattooing is directly related to gang membership.

Education
Education is one of the most important ingredients of an effective HIV intervention programme. However, HIV/AIDS education in the prison environment presents specific challenges which are unlike those in the general population. The personality profile of many prisoners often includes a deep-seated suspicion of anything ‘official’ or government related, which can negate the efforts of programmes which have enjoyed significant success in the general community.222

In addition, mass education programmes have not proven effective at changing behaviour because they are not presented in the context of specific lifestyles. The prisoners perceive them as irrelevant and will not relate the information to their own lives.223 Scare tactics have also proven ineffective, and may possibly be counterproductive to the extent that they elicit a denial response.224 Not just the content, but also the medium of education materials must be tailored to the prison environment. Written materials must cater to the wide diversity of languages spoken in prisons, and need also to take into account the low literacy rate of the prison population.

The unfortunate truth is that an increase in HIV/AIDS-related knowledge is not always translated into altering or reducing high risk behaviour.225 HIV/AIDS information needs to be specifically targeted, and must consider the common characteristics or lifestyles that put prisoners at risk for HIV. The influence of peers is essential in any successful intervention strategy as the credibility of the communicator has a significant impact on the capacity of the message to engender behavioural change. This credibility should be determined within the context of the prison population, because what might be valued by the average citizen outside of the prison is not the same as that appreciated by the average prisoner.226

The general consensus regarding peer education is that, “accepted norms of the target group play a larger part in influencing behaviour than does outside intervention by authorities or health educators.”227

Suggested means of education and intervention programmes for prisoners include drama and video presentations followed by small group discussions. The most effective intervention programmes are those which utilise a small group format and encourage prisoner participation.

In spite of the resource limitations which constrict the efforts of staff at Westville Medium B, several such programmes have been implemented including an HIV support group and a peer education programme. These efforts should be encouraged and continued, with the assistance of appropriate staff and resources. The potential exists for tremendous return on investment if programmes which affect the awareness and behaviour of this high risk target group are adequately funded and expanded.

Early release
The decision for early release should involve the input of the nurses who care for the prisoner on a day to day basis, perhaps confirmed by a visiting specialist. The application should be sent to one correctional services official who is responsible for making sure that the prisoner in the application is the same one as the prisoner in the hospital. This same official should be the only signatory required to approve the early release of the prisoner.

The social worker assigned to contact the family and ensure that appropriate care is available upon release should be notified as soon as possible, perhaps when the patient is admitted for AIDS-related illness rather than waiting until the prisoner is near death. In this way, the social worker will have more time to contact the family, and can also provide assurances to the prisoner that may encourage him to hang on to life a little longer so that he may be rejoined with his family before dying.

Partnership
DCS has recognised the importance of intervention programmes for HIV/AIDS in prison by appointing a Provincial HIV/AIDS Co-ordinator (PHC) in each province. However, the effectiveness of this position is severely hindered by the lack of funds available. As the PHC is appointed from the existing nursing staff, he or she must perform all the duties of co-ordinating HIV/AIDS programmes in an entire province in addition to his or her regular duties as a member of the prison health staff.

In order for the PHC to be effective, he or she must be relieved of at least a portion if not all of his or her nursing duties. It will remain important that the PHC has first hand experience with providing health care in the prison environment, and thus it is recommended that the PHC still be appointed from a member of the nursing staff. However, appointment as PHC should be constituted as a new and separate position, rather than the assignment of additional responsibilities for an already over-worked individual.

The social workers, psychologists, and health staff who have set up the existing HIV/AIDS intervention programmes have an extremely valuable depth of knowledge. However, the staff in each province operate in near isolation without the benefit of sharing experiences and information with their counterparts in other prisons. There does not even appear to be a phone list distributed.

The achievements of each PHC should be shared with other DCS and DOH staff in order that the entire prison system can benefit. Inter-provincial and even inter-prison co-ordination and communication will be critical if the DCS is to address HIV/AIDS in the country’s prisons in a meaningful way.

The not-for-profit sector, in the form of NGO’s and donor agencies, could provide capacity for complementing and supplementing current DCS efforts. International donor agencies are increasingly taking notice of the HIV/AIDS pandemic in the southern African region, and are willing to make funds available for effective intervention programmes.

The Center for Disease Control (CDC) in the United States has set up offices in several African countries, and has demonstrated a commitment to prison health initiatives. South African NGO’s, in partnership with the Department of Correctional Services, could tap into these funding sources and provide education and other intervention programmes in the prison system. Voluntary HIV testing and counselling, peer education, workshops and training for both prisoners and staff could be implemented with the assistance of local organisations.

The Department must invite proposals and express a willingness to meet and work with outside organisations to assist in developing successful intervention strategies for addressing HIV/AIDS as well as other public health issues in South African prisons.

DCS culture
The first policy to address HIV/AIDS in the South African prison system was formulated in 1992 and, according to Achmat and Heywood, was based on “fear, lack of knowledge, and prejudice”.228 In early 1995, a pluralist approach to prison policy making was attempted for the first time. Then deputy president, Thabo Mbeki, called together the relevant interest groups and decision makers, and the Transformation Forum on Correctional Services was formed.

The Transformation Forum consisted of representatives from the Department of Correctional Services (DCS), the Parliamentary Portfolio Committee, the Police and Prisons Civil Rights Union (POPCRU), Public Servant’s Association (PSA), Correctional Officers’ Union of South Africa (COUSA), South African Prisoner’s Organisation for Human Rights (SAPOHR), the Minister’s National Advisory Council, Lawyers for Human Rights, National Institute for Crime Prevention and the Rehabilitation of Offenders (NICRO), the Centre for the Study of Violence and Reconciliation (CSVR), and the Penal Reform Lobby Group (PRLG).The forum first identified and prioritised several areas for transformation, which included demilitarisation, health care, independent inspection, human resource management, and the establishment of a change management team.229

Despite high aspirations in the beginning, the forum soon fell apart with the failure of the Minister, or any of his representatives, to attend any of the meetings. Within a few months, Minister Mzimela officially withdrew the Department’s participation in the forum until the then President Mandela instructed him to return. In spite of renewed promises of Ministry involvement, again the Minister remained absent and un-represented at the forum’s meetings. The Minister’s example was for the most part followed by the Department as well, which seemed to resent the “interference” of the forum.230 Thus, although the Department appeared to achieve legitimacy, through an attempt at co-operative involvement with the community, it remained a closed, highly centralised authoritarian institution reminiscent of the apartheid era.

Developments such as those outlined above have created the impression of a hierarchical and dogmatic approach to policy making in the Department of Correctional Services. The apparent view of other stakeholders as impediments is reinforced by the Department’s continued insistence on secrecy, and the difficulties encountered for anyone who attempts to gain access to prisons for the purposes of either journalistic investigation or academic research.

Further research
The Department should encourage further research in the prisons, and should attempt to streamline the process through which permission is obtained to conduct such research. Currently, various members of the Department at various levels seem to have conflicting information about the appropriate person responsible for co-ordinating research and the appropriate processes which must be adhered to for gaining access to conduct research at a prison.

Given the sensitive nature of prison research, and the propensity for media distortion, there is a need for a co-ordinating body to facilitate co-operative and constructive relations between researchers and DCS officials. Previous research findings and general statistical information, both internal and external, should be accessible to policy makers and researchers alike. In this way, specific information which legislators and DCS officials require in order to inform their policy decisions would be more readily available.

The information available on HIV/AIDS in South African prisons is very limited. Currently, the Department has prohibited the release of the only prevalence study ever conducted in a South African prison. Not only should this study be released to the public, but additional studies should be encouraged and proposals seriously and expeditiously considered. Research should be conducted at minimum and medium security prisons where inmates serve much shorter sentences, as the turnover at these facilities, and thus the access for intervention programmes, will be much greater.

Further research should be conducted at facilities for women and juveniles, as these groups make up 3% and 16% of the prison population respectively.231 Both women and juvenile populations have specific characteristics and needs which must be better understood in order to inform appropriate policies and intervention programs.

Juveniles as a target group for intervention programmes are particularly important as they represent a significant opportunity to prevent future HIV infection. Juveniles, defined as prisoners under the age of 21, are just beginning to engage in high risk behavior and also represent a group which may not be reached by more conventional programmes, such as those which are administered in schools. Research into the knowledge, attitudes and practices regarding HIV in juvenile correctional facilities would yield extremely valuable information for health, education, and DCS policy makers.

One third of the prison population is made up of awaiting trial prisoners. These unsentenced prisoners are usually held separately from sentenced prisoners, and facilities for unsentenced prisoners are among the most severely overcrowded in the country. For example, awaiting trial prisoners in Johannesburg are held in a prison which is currently at 393% capacity. The circumstances of awaiting trial prisoners vary considerably from those who participated in this study, and thus this is a segment of the prisoner population which merits further research.

Addressing HIV/AIDS in prison effectively also means addressing other public health concerns, such as TB and STIs. The prison provides an opportunity to obtain valuable data on the interaction between HIV/AIDS and TB. In addition, the controlled environment afforded by prison can assist with STI control, if not eradication, in the South African prison population. Further research should be encouraged in order to realistically pursue the goal of eradicating STIs in the prisons, as the positive impact both within the prison and in the general community would be enormous.

The optimal course of action would be to conduct a national study of health issues in the various types of prisons, in each of the nine provinces, in both men’s and women’s prisons, and also in juvenile correctional facilities. This national study should incorporate the incidence and prevalence of TB and STIs as well as HIV/AIDS in order to better understand the broader concerns of general public health in the prison environment. Only when this kind of comprehensive data is obtained will the most effective policies and successful intervention programmes become possible. Although the nature and extent of HIV will vary, there is no reason to believe that a single prison in South Africa has escaped the impact of HIV/AIDS. It is a nationwide problem that can only be solved with a nationwide response.

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