Submission on HIV/AIDS in Prison: Treatment, Intervention, and Reform
In prison, HIV/AIDS exacerbates existing problems and also creates new ones, yet the potential for far-reaching positive impact remains. Prisons are an intervention opportunity to reach a segment of the population, which is most likely to need government services related to HIV/AIDS and is also least likely to receive them through any other channel. Most people who end up in prison come from marginalised communities with limited access to health, education, and/or other sources of social welfare. For many of these people, their interaction with the criminal justice system will be their most extensive exposure to public services of any kind. Without an appropriate response to HIV/AIDS in prisons, the potential consequences will be increasingly tragic for both prisoners and the communities they represent.
The people who are most likely to be in prison are also amongst the most likely to contract HIV: young, unemployed, un- or under-educated, black men. Many of the socio-economic factors that place an individual at high risk for contracting HIV, are the same factors which lead to criminal activity and incarceration. Thus, a substantial portion of prisoners will have HIV prior to entering prison. Inside prison, high-risk behaviours for transmitting HIV include sexual assault, high-risk sexual encounters, same sex intercourse, tattooing, and the use of contaminated cutting instruments. Conditions of overcrowding, stress, and malnutrition compromise health and safety and have the effect of worsening the overall health of all inmates, and particularly those living with HIV or AIDS. The institutionalised victimisation of younger, weaker prisoners appears to be a direct result of the relatively unobstructed power of gangs, facilitated by corruption within the Department. Gang activity also increases the incidence of tattooing and violence between prisoners, both of which can create the risk of HIV transmission.
The challenge of treating HIV in the prison environment is related to limited resources and problems with ensuring the crucially important level of adherence to treatment programmes. International guidelines advocate the ‘equivalence principle’, or the idea that the same care should be provided in prisons that is available to the general public. Many of the public health issues surrounding HIV/AIDS in the general community will be present, and in some cases, magnified in prisons. Specific health concerns related to HIV/AIDS outside of prison, such as TB and other STIs, are of particular importance inside prison. Given that the burden of disease amongst the prisoner population is consistently greater than that of the outside community, the government should make the provision of health services in prisons the responsibility of the Department of Health, rather than Correctional Services.
The Department of Correctional Services in South Africa has introduced policies to address HIV/AIDS in prison, which have some good features that are implemented extremely well, some excellent features that are not appropriately implemented, and some features that are neither correctly designed nor implemented. Correct implementation of the HIV testing policy as it is written will improve adherence to the international standard of the equivalence principle. The condom distribution policy would be considerably improved if it were made more discreet, rather than requiring prisoners to access condoms in plain view in common areas. Furthermore, the provision of water-based lubricant in a similarly private manner would reduce the probability of condom breakage and/or rectal tearing, both of which contribute to the risk of HIV transmission.
For prisoners in the late stages of AIDS, the early release policy must be updated and streamlined. Additional assistance for this, and other much needed HIV-related initiatives, can be provided by various NGOs and funding organisations. The Department would do well to encourage and facilitate partnerships with NGOs, including academic and research institutions, in order to understand and provide better solutions to the challenges of the prison environment. Given the very real budget constraints faced by DCS, consolidation and re-allocation of resources will help make sure that more is achieved for each rand spent.
Recommended HIV/AIDS policies will accomplish little in the absence of basic prison reforms. Overcrowding has adversely affected prison conditions to the point that they are inhuman and may be unconstitutional. Anyone who visits a prison or otherwise knows of this situation has the right to be outraged, but the demand for action must be correctly directed, as the Department does not determine the size of the prisoner population. Reforms in the Department of Justice are necessary to reduce prison overcrowding, including addressing the problem of prisoners awaiting trial. An endemic problem over which DCS has exclusive control is the lack of proper nutrition provided for prisoners. Outsourcing options should be explored, both to provide a higher quality of service at a lower price but also to reduce corruption and smuggling.
In 2001, a study on HIV prevalence, and the relationship with STIs and other factors, was conducted by the Health Economics & HIV/AIDS Research Division (HEARD) at the University of Natal, Durban, in conjunction with the Medical Research Council. The results of this study were presented to the Department of Correctional Services in May 2002, but the National Commissioner has prohibited the public release of the findings. To date, this study represents the only prevalence data from a prison in South Africa. However, both the general public and even other relevant decision-makers in the criminal justice system have been denied access to the report.
All but a small percentage of prisoners return to the community. Hundreds of thousands of prisoners, mostly young, black men are released from prison each year. Many of these former prisoners are drawn from, and will return to, those communities that are hardest hit by public health issues, including HIV. The impact of this marginalised segment on the rest of the South African population can either be that of positive change or of further hardship. The determining factor will be the appropriate design and implementation of the government’s response to the challenge of HIV/AIDS in prison.