HIV & TB Control in sub-saharan African Prisons: Neglect to Hopeful Future

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1 HIV & TB Control in sub-saharan African Prisons: Neglect to Hopeful Future Stewart Reid MD, MPH University of North Carolina at Chapel Hill Centre for Infectious Disease Research in Zambia (CIDRZ) 1

2 Zambian Vice President, Dr Guy Scott -- April

3 2010 Human Rights Watch Report 3

4 Zambian Prison Conditions No HIV Prevention Poor Linkages to Care Inadequate Clean Water Limited HIV Screening Limited Health Care Facilities Psychological Stress No Infection Control Insensitive TB Diagnostics Sexual Violence Overcrowding Poor Nutrition Few Health Personnel Poor Information Management Limited TB Screening 4

5 Lusaka Central Prison Built in 1923 for 200 inmates; In 2011, houses 1500 Up to 50% are Remandees

6 Photo: Jaoa Silva 6

7 all prisoners have the right to receive health care, including HIV preventive measures, equivalent to that available in the community, Ref: UN Universal Declaration of Human Rights; Ref: UN General Assembly: Basic Principles for the Treatment of Prisoners,

8 African Prisons: TB/HIV Rates National HIV Prev. (%) Prison HIV Prev. (%)* National TB Prev. (/100,000) + Prisons TB Prev. (/100,000) TB/HIV Co-infection (%) Cote d Ivoire Cameroon Tanzania Malawi Zambia South Africa *Modified from Dolan et al, Lancet Infect Dis, Modified from WHO Global TB Report 2012

9 TB/HIV: Prison to Community COMMUNITY Other Prisons Visitors Staff Families of Prison Staff Entry PRISON Exit Revolving Door 9

10 Integrated TB/HIV screening, diagnosis and treatment Integrated prison health care systems 10

11 Zambian Prisons: TB & HIV Prevalence ( ) Screening Total Screened At ENTRY % (33) Direct TB yield: 6.8% (n=535) Culture/Smear Clinically All Forms Confirmed Diagnosed 1.0% (23) 2.5% (56) HIV Infected 16.6% (145/873) MASS % (109) 7.9% (312) 10.7% (421) 24.5% (903/3689) At EXIT % (17) 1.0% (3) 6.7% (20) 31.6% (24/76) REFERRAL % (3) 1.5% (2) 3.7% (5) 13.9% (16/115) TOTAL % (170) 4.6% (365) 6.8% (535) 21.6% (1200/5549) 11

12 Prison Staff & Their Families Direct TB yield: 6.8% (n= 535) HIV Infected Screening Intervention Screened Culture/ Smear Confirmed Clinically Diagnosed All Forms 5 of 6 Prisons % (8) 1.9% (25) 2.6% (33) 14.1% (112/796) Lusaka Central Prison % (8) 4.2% (17) 6.2% (25) 25.9% (58) 12

13 Improving prisoner health care is a public health imperative. 13

14 TB Preventive Therapy Awareness/ Buy-in & Training COMPREHENSIVE TB CARE Diagnostics & Infrastructure Inmate Peer Educators = Implemented in Zambia Info Management Systems/Referral & Linkages 14

15 TB Screening Points COMMUNITY Other Prisons Visitors Staff Families of Prison Staff Entry PRISON Referral screening Exit Revolving Door 15

16 Combination HIV Prevention INTEGRATED CARE & LINKAGES TREATMENT PrEP PEP Early ART Initiation PREVENTION SCREENING TRAINING Condom Provision VCT Test & Treat Prison Officers Voluntary Male Circ Routine HIV Coun. & Testing Inmates Safe Tattooing & Injection TB & STI Screening Inmate Peers 16

17 Programme Challenges Difficult to verify referral & treatment outcomes Inmate Peer Educator attrition Social & cultural restrictions on HIV prevention Lack of prison Information Management System Lack of program ownership among Officers Uncertain funding 17

18 Judicial Reform is Necessary Public Health & Human Rights PRISON HEALTH Judicial Reform 18

19 Zambia: Are We Making Progress? 19

20 The fight against HIV and TB in sub-saharan African prisons cannot be neglected. Prison Health is Public Health 20

21 We cannot win the battle against AIDS if we do not also fight TB. 21

22 IAS Posters THPDE0305 Inmate peer educators are essential to prison-based HIV testing and TB screening in Zambia TUPE765 HIV prevalence in Zambian prisons: need for systematic scale-up of provider initiated testing and counseling 22

23 Acknowledgements Zambian Prison Service -Dr Chileshe Chisela -Percy Chato Zambian National Tuberculosis Program -Dr Nathan Kapata Ministry of Home Affairs ZAMBART - Dr Helen Ayles WHO & TB REACH Centre for Infectious Disease Research in Zambia (CIDRZ) -Sisa Hatwiinda -Katie Maggard -Winifred Phiri -Stephanie Topp -Dr German Henostroza -Jill Morse -Jennifer Harris -Cheri Reid 23

24 Prison Research Needs Document disease burdens, epidemiology and behavior dynamics. Inmate cohorts to determine disease (HIV, TB, HIV, hepatitis etc.) prevalence & incidence Detail on demographic and clinical characteristics as well as risk behaviors and living conditions Fingerprinting techniques to establish TB disease transmission patterns. IPT implementation Guidelines for ethical research in prison populations Prison based TB screening algorithms 24