Alternatives to current HIV/AIDS policies and practices in South African prisons

Journal of Public Health Policy,  2002  by Goyer, K C,  Gow, Jeff

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STATEMENT issued by the Joint United Nations Programme on HIV/AIDS to the United Nations Commission on Human Rights in April 1996:

"[By] entering prisons, prisoners are condemned to imprisonment for their crimes; they should not be condemned to HIV and AIDS. There is no doubt that governments have a moral and legal responsibility to prevent the spread of HIV among prisoners and prison staff and to care for those infected. They also have a responsibility to prevent the spread of HIV among communities. Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities."

INTRODUCTION

The official reported levels of HIV/AIDS illness and deaths in the South African prison system is small, around z% of prisoners being identified as HIV+; and approximately 20% of prisoners who die each year, die of AIDS-related illnesses. It is strongly suspected that these levels may be large underestimates. Given the situation more generally in South African society, it is unlikely that the situation within the prison system will not be as serious, with prevalence rates as high as 36% in KwaZulu-Natal province and zo% in the broader South African adult population (I). In all likelihood it is probably much worse, for reasons briefly outlined in this paper.

South African Correctional Services Commissioner, Mbete, when talking about the numbers of prisoners who are HIV+, said, "Now we don't know how many fish are in this sea. If we did screening, at least we would know the extent of the problem and could begin to deal with it. We cannot continue saying we don't know" (2.).

FACTORS CONTRIBUTING TO INCREASED LEVELS OF HIV INFECTION

Prison Health Care

The recommended treatment for HIV+ individuals is "symptomatic management" of the disease (3). This usually requires treating and preventing the more common opportunistic infections associated with HIV, namely pneumonia and TB. Both of these illnesses can be prevented and cost-effectively treated. Prison hospitals normally administer INH and Bactrim for HIV+ patients, but their supplies are disrupted as a result of unreliable distribution services.

The quality of prison health care, compared to that available to the general public, is deplorable, and there is little reason to assume that the care specifically for those who are HIV+ is an exception. The epidemic results in prison health care facilities faced with the care of much higher numbers of chronically or critically ill patients than these facilities were intended or designed for. A proposed solution is to send prisoners with HIV/AIDS to public health facilities. This alternative is not recommended in South Africa, as state hospitals are already dealing with a high number of HIV/AIDS patients, and their resources are equally scarce. Added to the reality of limited resources is the reluctance of public health workers to deal with prisoners, particularly when their presence requires the presence of armed guards and other security precautions.

Poor Nutrition

The most common health problem within prisons affects seropositive and seronegative prisoners alike: poor nutrition. The major complaint from both prisoners and health care staff is the lack of a balanced diet. More than one staff member at the Westville Medium B prison cited the prevalence of smuggling and theft in the prison kitchen, by both prisoners and staff alike, as a primary cause for the lack of decent meals. The problem is not alleviated for those prisoners who receive visitors who bring them food. Many of these items are confiscated or disallowed because of the risk of their containing contraband. Even fresh fruit and vegetables are not permitted, as these could potentially be injected with drugs. In turn, the limited access to such things as vegetables or other desired foods serves to increase the price at which prisoners or staff can sell these items inside the prison. Whatever the cause, the impact of poor nutrition on prisoners is exacerbated for those with HIV. Unfortunately, the provision of adequate nutrition is a problem that can only be solved by serious reforms on the part of the correctional services structure and bureaucracy.

Condom Provision

If prison officials are willing to admit that sex takes place in prison, they must then address the increased risk of HIV transmission created by the unprotected sexual activities of inmates. In 1996, a South African Court decision found in favour of a gay male incarcerated at Pollsmoor Prison who tested negative for HIV prior to entering prison. While incarcerated, the prisoner repeatedly requested condoms for more than a year. He continued to be tested every three months, and after a year, tested HIV+. The Supreme Court decision ordered that the Department of Correctional Services (DCS) provide condoms to inmates, on a similar basis to that by which they are available outside the prison (4).

The current policy in South African prisons is that condoms are distributed only as part of counselling and education programmes, and only by nurses who are trained as AIDS counsellors. In France, condoms and lubricant are available, and are placed "in open containers in reception, the health care centre, and other locations where potential users . . . have the opportunity to take them unobserved" (5). The problem with the current South African policy is that the available condoms are not strong enough for anal sex, no lubricants are issued, and the means of accessing them is limited and potentially embarrassing for the prisoner requesting them. Interviews with prison and health staff at Westville Medium B confirmed that inmates almost never request condoms. Those who argue against condom availability maintain that sodomy in prison is at a minimum, coerced under threat when it is not forcible rape, and that the perpetrators would not agree to using a condom anyway. Proponents of the condom distribution policy argue that the condoms would be used if they were the correct kind and were more easily and discreetly accessible to inmates. Further study of the situation requires interviews with prison inmates and such assessment hinges on the permission of officials in the Department of Correctional Services.