PRISON HEALTH IS PUBLIC HEALTH HIV / AIDS and the case for prison reform

23 probably does, take place, it still does not fully illustrate the grave consequences of failing to appropriately address HIV/AIDS in South African prisons. The larger crisis relates to the high proportion of prisoners who will arrive at the prison already infected with HIV. It is highly likely that their health will deteriorate as a result of prison conditions, they will eventually leave the prison sicker, and perhaps with additional illnesses that will then be transmitted through the same high-risk behaviour practiced prior to and during incarceration.

probably does, take place, it still does not fully illustrate the grave consequences of failing to appropriately address HIV/AIDS in South African prisons.The larger crisis relates to the high proportion of prisoners who will arrive at the prison already infected with HIV.It is highly likely that their health will deteriorate as a result of prison conditions, they will eventually leave the prison sicker, and perhaps with additional illnesses that will then be transmitted through the same high-risk behaviour practiced prior to and during incarceration.

Spreading the risk beyond the prison walls
Approximately 175,000 people are currently incarcerated in South African prisons.However, this does not mean that 175,000 criminals are locked away, isolated from the public, and unable to impact on the lives of those in the general community.Over 40% of prisoners are incarcerated for less than one year; only two per cent are serving life sentences.On average, 25,000 people are W hen discussing HIV/AIDS in prison, most people will conjure up the horrific scenario of a young man arrested for a minor infraction.Because he is unable to pay bail, or perhaps due to some unfortunate bureaucratic delay, he spends a night in jail and is raped by another prisoner.He thus contracts HIV and, in effect, has received a death sentence for his alleged crime.This could be construed not just as cruel and unusual punishment, but even extra-judicial execution, as the accused person has suffered his fate before being convicted, or even charged.This situation is horrifying and makes for exciting and inciting media fodder.The drama lies in the possibility that a person from the general community -someone who is not a hardened criminal but was perhaps simply in the wrong place at the wrong time -will be exposed to the dark underworld of prison and all its terrifying evils.As a result he is inadvertently condemned to an early death.However, while such an incident can, and KC Goyer, research consultant for the Institute for Security Studies kcgoyer@yahoo.comreleased from South Africa's prisons and jails each month.This translates into 300,000 former prisoners returning to the community each year, bringing their illnesses, infections, and diseases with them.Concern should therefore not only be directed at the risk of HIV transmission in prisons, but also at the potential impact of prisoners on HIV transmission outside of prison.

Prison: conducive to high-risk behaviour
This is not to say that HIV transmission inside prison does not exist, or that it is not important.The most common forms of high-risk behaviour in the prison environment include high-risk sex, usually in the form of unprotected anal intercourse, as well as rape and other forms of assault which draw blood, and the use of contaminated needles or other cutting instruments, usually for purposes of tattooing.
In other countries, the sharing of needles for intravenous drug use is the leading cause of transmission of HIV in prisons.In South Africa, gangrelated violence, including sexual violence, is the most common form of high-risk behaviour for the transmission of HIV.Among sexual means of transmission, receptive anal intercourse carries the highest probability of HIV infection.And because sex in prison often takes place in situations of intimidation and violence, there is a greater likelihood of tearing and bleeding, which also increases the likelihood of transmission.
The two most powerful gangs in South African prisons are the 26s and 28s.The 26s are known for their hierarchy based on phakama, or attacking a targeted inmate or guard with a knife or other weapon intended to draw blood.The 28s base their power structure on homosexual partnerships and prostitution of designated male inmates.Both gangs can wield control over all aspects of prison life, including access to food and cell assignments, usually with the assistance of corrupt prison guards or officials.Members of either gang are likely to be tattooed with gang-related symbols, They usually have their tattoos done at the same time as other gang members, sharing the same crude unsterilised implements.
Prevention of high-risk behaviour inside prison can best be achieved through reducing overcrowding, engaging gang leaders and other peer educators in HIV/AIDS programmes, and making condoms, lubricant and bleach discreetly and readily available inside prisons.Currently, condoms are only available upon request from the health staff, but lubricant and bleach are not available at all.Peer education programmes exist in some prisons but are extremely limited, and often lack the resources to continue, let alone expand.Partnering with NGOs alleviate this situation; however, policies to address HIV in prison cannot be effective without addressing prison reform in general -reducing corruption, curbing the power of gangs, and alleviating overcrowding.
A high rate of transmission HIV transmission is affected not just by the incidence of high-risk behaviour, but also by the probability of transmission per exposure.Both the incidence of high-risk behaviour and the probability of transmission per exposure are significantly increased by the prevailing conditions in South African prisons.
The probability of transmission per exposure is affected by viral load, and the presence of other sexual transmitted infections (STIs).The viral load, or the amount of HIV present in the body's fluids, increases as the infection progresses.Thus, the more advanced the HIV infection in a prisoner, the more likely that prisoner is to transmit the virus.The progression of HIV can be reduced by Highly Active Anti-Retroviral Therapy (HAART), which is currently not available either in state health care facilities or in prisons.The progression of HIV is increased by poor nutrition, other opportunistic infections, and by stress and/or poor mental health.These factors are realities of life in impoverished communities, and of life in prison.
Prisoners tend to have a background of poverty and poor health, and the majority of prisoners are young men between the ages of 18 and 35.Prisoners therefore represent a segment of the population that is at high risk of HIV infection even prior to entering prison.Furthermore, the HIV infection of a person in prison is likely to advance more quickly than that of someone who has been living with HIV, but with access to good nutrition, private health care, and a supportive environment.GOYER The probability of transmission per exposure is very high in the prison environment because of the likelihood that at least one of the persons involved in the high-risk behaviour is already HIV-positive.High-risk sex is more risky when the HIV infection rate among available partners is high.It is the equivalent of adding a few more bullets to a game of Russian roulette.

STIs and opportunistic infections
Prisoners are a high-risk population, not just for HIV but also for other STIs, and the two work together in deadly combination.The presence of ulcerous STIs, which can result in sores or other breaks in the skin of the genital area, greatly increases the risk of transmission.Also, STIs increase the concentration of HIV in genital excretions such as semen, as well as advancing the progression of HIV infection in general.
In addition to STIs the presence of opportunistic infections will also speed the progression of HIV and therefore impact on the probability of transmission.The most common opportunistic infection in South Africa is tuberculosis (TB).Pulmonary TB is particularly common in prisons, because it results in coughing and can be transmitted by inhaling infected droplets of the sputum brought up by coughing.When a large number of people are confined in a small space with little or no ventilation, the risk for airborne transmission of pulmonary TB is extremely high.Furthermore, a carrier of latent TB who becomes HIV positive will develop active TB and thus begin to exhibit symptoms and become contagious.Just as the presence of HIV exacerbates TB, the presence of TB speeds up the progression of HIV infection.In South Africa, about half of all new cases of TB are attributable to HIV.In sub-Saharan Africa, it is estimated that one out of every four deaths from TB, among people who are not also infected with HIV, would not have taken place in the absence of the HIV pandemic.

Overcrowding, overcrowding, overcrowding
Addressing HIV transmission in the prison environment entails addressing the needs of inmates who are already HIV positive, including the conditions that lead to increased illness as well as increased prevalence.High-risk behaviour, the prevalence of gang activity, and the impact of prison conditions on general prisoner health are all affected by severe overcrowding.Similarly, the effective implementation of any policy to address high-risk behaviour, including gang activity, will be significantly curtailed by overcrowding.The Department of Correctional Services is struggling to accommodate twice the number of prisoners than prisons currently have the capacity for.
This overcrowding, seeing up to 60 men confined in a cell intended for 18, leads to decreased security and increased violence, as well as making any efforts at rehabilitation all but impossible.The overcrowding problem is primarily the result of the high number of prisoners awaiting trial, currently estimated at one third of the prisoner population.The number of prisoners awaiting trial is affected by the increasing length of time it takes for a case to go to trial, and bail practices that leave many imprisoned for no other crime than being poor.
As more and more people are sent to prison, more and more of them are dying before serving out their sentence.Research into the death records at various prisons throughout South Africa has found that approximately 90% of deaths in prison are the result of HIV/AIDS.In a prison hospital in KwaZulu-Natal, 95% of the deaths during the year 2000 were from TB and/or HIV.The number of natural deaths in South African prisons has increased more than five-fold since 1995, while the number of prisoners has increased 38% over the same period.
The bulk of the increase in the prisoner population is made up of prisoners awaiting trial, which means that an increasing number of unsentenced prisoners are also dying before their release.Whether sentenced or not, reintegration is not likely for anyone who has endured the brutalisation and violence which is endemic in South African prisons.Recidivism rates, or the likelihood that a prisoner will re-offend upon release, are estimated to be as high as 94% in South Africa.Rehabilitation cannot take place without first providing prisoners with conditions of detention that are consistent with human dignity -a constitutional right.This includes addressing concerns about health, which both worsen, and are worsened by, the impact of HIV/AIDS.

Conclusion
The current policies to address HIV in prison include a deeply flawed condom distribution policy, a weakly implemented HIV testing policy, and inconsistent, if not entirely inadequate, treatment and health care.Education opportunities in general, as well as those related to HIV/AIDS, are limited for most sentenced prisoners and are all but non-existent for prisoners still awaiting trial.Efforts by NGOs have proven successful in some locations, usually with the assistance and co-operation of DCS officials.However, this kind of leadership and compassion is not common in the culture of antagonism and neglect that pervades the Department of Correctional Services at all levels.
The challenge presented by HIV in prison has as much to do with improving prison conditions as with specifically addressing HIV and its attendant health concerns.In order to improve prison conditions, overcrowding must be reduced.This cannot be achieved by building more prisons, but only by reducing the size of the prison population.Sentencing and bail practices must be reviewed, and the practical use of prisons in the development context must be critically evaluated.Prison rape, assault and violence is horrific even without the added trauma of the risk of HIV infection.A just and humane society must either reject the premise that prisons are necessarily dangerous and brutal environments, or reject the modern prison institution altogether.In either instance, the appropriate response must include systemic prison reform.

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South African sentenced to prison is at high risk of contracting HIV before he even arrives at prison for the first time.Prisoners are primarily young, black men from impoverished communities already hardest hit by HIV/AIDS.Much of their behaviour prior to incarceration is high risk for contracting HIV, and is likely to continue upon their release.Conditions in South African prisons also contribute to increased HIV prevalence due to gang violence, poor nutrition, and inadequate health care.If these issues are not addressed, the consequences will be dire, not only for the prison population, but for the broader society into which prisoners are released upon completion of their sentences.The overcrowding of prisons is one of the most important factors affecting prisoner health; reducing the size of the prison population is essential to prison reform.