In-depth: HIV in prisons
SOUTH AFRICA: Introduction
Watchtower at South Africa's Pretoria prison
JOHANNESBURG, 11 June 2003 (IRIN) - The jail doors that slam behind a newly arrived inmate are likely to open again at some point in the future and release the ex-convict back into society. The problem of HIV/AIDS in prison, and the wider issue of penal reform, are therefore questions that should concern us all.
Prison conditions in most countries of the world are ideal for the transmission of HIV. "They are frequently overcrowded. They commonly operate in an atmosphere of violence and fear. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex," a UNAIDS "Best Practice" report noted.
These are conditions that some people face more than once during the course of their lives, entering and leaving prison repeatedly. In South Africa, over 40 percent of prisoners are incarcerated for less than a year, with only two percent serving life sentences, according to a study by the Pretoria-based Institute for Security Studies (ISS). On average, 25,000 people are released from South African prisons and jails each month.
HIGH RATES OF HIV
HIV prevalence in prisons is usually higher than in the population at large. As a result of the poverty and deprivation that helps drive criminality and HIV/AIDS, many of those inmates who are HIV-positive in prison were already infected on the outside.
"Poverty is a defining characteristic of both prisoner and HIV-positive populations alike," the ISS report, "HIV/AIDS in Prison: Problems, Policies and Potential", points out. But rather than acceptance of the problem, measures can be taken to reduce the transmission of HIV, and help delay the emergence of AIDS-related illnesses.
"Policies to address HIV transmission in prison cannot be effective without immediate and urgent prison reforms," the report stressed. "Overcrowding, corruption and gangs are the primary culprits behind rape, assault and violence in prisons, and this environment is horrifying, even without the risk of HIV infection."
HIGH RISK BEHAVIOUR
The main types of high-risk behaviour in prisons are contaminated needles used by injecting drug users - which is not a major problem in African countries - and/or instruments used for tattooing. Unprotected sex between men is another important factor.
"The extent of sexual activity in prisons is difficult to determine because studies must rely on self-reporting, which is distorted by embarrassment or fear of reprisal. Sex is prohibited in most prison systems, leading inmates to deny their involvement in sexual activity. Sex in prison usually takes place in situations of violence or intimidation, thus both perpetrators and victims are disinclined to discuss its occurrence," the ISS study noted.
In women's prisons where there are male prison staff, sex between men and women may also take place, UNAIDS pointed out, creating a risk of HIV transmission.
Homosexual activity is illegal in every southern African country with the exception of South Africa. However, according to UNAIDS, 8.4 percent of men in the Zambian prison of Kamfinsa reported anal sex in a study in 1995, with the true figure likely to be higher. A 1999 Penal Reform International study of Zomba prison in Malawi reported respondents as estimating that between 10 to 60 percent of prisoners had participated in homosexual activity at least once.
Three aspects of man-to-man sexual activity in prison make it a high risk for HIV transmission: anal intercourse, rape and the presence of sexually transmitted infections (STIs). Related problems in prisons across Southern Africa include overcrowding, shortages, corruption, and the presence of juveniles alongside adult prisoners.
The Zomba study noted that those who served as the "receptive partner" were usually: "recently detained, either juveniles or young adults, who have no blanket, soap, plates or food. They have no relatives from the outside to help them and care for them, they are in physical need and confused by their recent detention, and they turn to somebody to care for them. The ones they usually turn to are those who have outside supplies. The relationship between them was described as similar to that between a poor prostitute and a rich client."
The report also noted the existence of "prostitution rings", in which guards were involved in smuggling juveniles into the adult blocks, sometimes for as little as 30 US cents. The practice was assisted by inadequate supervision and segregation of juveniles from adult inmates.
The appalling physical conditions of most prisons in Southern Africa, along with inadequate nutrition and health services, exacerbates the incidence of AIDS. Particularly serious is tuberculosis (TB), which can easily spread in overcrowded prison conditions. People with HIV are especially vulnerable to TB, and HIV-positive people can transmit the disease to those not infected with HIV, the UNAIDS report warned.
The potential for the spread of HIV is also increased by a lack of information and education, and a lack of proper medical care. STIs, if left untreated, can greatly increase a person's vulnerability to HIV through sexual contact, UNAIDS noted.
WHAT TO DO?
Rather than accepting the reality of sexual activity and the attendant risks, most prison authorities in Southern Africa refuse to provide condoms for inmates in the belief that it will encourage homosexuality. Attitudes of denial will have to change if societies want to see the rate of HIV infection - inside prison and outside - decrease.
The UNAIDS position is clear. "Recognising the fact that sexual contact does occur and cannot be stopped in prison settings, and given the high risk of disease transmission that it carries, UNAIDS believes that it is vital that condoms, together with lubricant, should be readily available to prisoners. This should be done either using dispensing machines, or supplies in the prison medical service."
Even in South Africa where the provision of condoms is policy, in the prisons themselves, access is still circumscribed by issues of shame and censure.
"The impact of HIV/AIDS on prisoners is most visible in the rising number of deaths in prison each year," the ISS report cautioned. "What must be envisioned is the positive impact prisoners can have on HIV/AIDS."
The study recommends aggressive behavioural change interventions, transforming cells into classrooms, in which gang leaders are co-opted as peer educators. It also calls for better health education and health services, enabling the prison authorities to make "significant contributions towards an AIDS-free generation in South Africa".