In-depth: HIV in prisons
SOUTH AFRICA: Feeling the impact of HIV/AIDS in prisons
Photo: IRIN
Pretoria Prison Reserve entrance, South Africa
JOHANNESBURG, 11 June 2003 (IRIN In-Depth) - Sentenced and locked away, prisoners are often a forgotten population, with little being done to prevent the spread of HIV/AIDS in an environment where they are at a greater risk of infection.
South African laws protect the rights of prisoners living with HIV/AIDS on paper, and the government has a stated policy on the management of those who are infected. But the reality is that the implementation of these policies is proving an uphill battle.
The Pretoria Prison Reserve, a sprawling mass of buildings known locally as "Pretoria Central", contains four main facilities: Maximum Security; Central, which houses sentenced prisoners; Female; and Local Prison, one of the largest holding areas for awaiting-trial prisoners in the country.
As the heavy steel gate closes behind the Local Prison checkpoint, the noise immediately hits you. Deep male voices singing in the background and voices calling to each other across their cells.
Local Prison was "like a zoo", Nico Baloyi the head of the prison, told PlusNews. This is where juveniles, children, awaiting-trial prisoners, and those awaiting further charges are held. The regional hospital is also situated there.
So far this year, the four gaols have recorded only 354 known cases of prisoners living with HIV/AIDS. But a report by the Institute for Security Studies has found that 45.2 percent of the 17,5000 people in the country's prisons are estimated to be HIV-positive.
Altogether, the prison facilities have a capacity for 4,500 inmates. "At this stage we are overpopulated and have an occupancy level of 169 percent. We have over 8,000 [prisoners]," Area Manager Benny Ndebele noted.
HOSPITAL FEELS IMPACT
Statistics aside, the impact of the disease is becoming evident in the regional hospital. According to Ndebele, the 120-bed hospital is constantly full and "running short" of nurses, as most of the patients are HIV-positive.
HIV testing, along with pre- and post-test counselling, is also conducted at the hospital and in the various prison clinics. Patients receive daily treatment at their local clinics for most opportunistic infections and are referred to the hospital when their condition deteriorates.
A maze of stairs eventually leads you to the hospital, behind another entrance with heavy steel bars.
Ward Two looks like any other state hospital - high metal cots and the regulation government-stamped sheets. The barred windows and nurses in brown prison warder uniforms are the only telltale signs. It is a ward specifically for HIV-positive patients.
A separate ward was "a necessity", as most of the patients were also chronically ill with tuberculosis (TB) and other "contagious infections", Sister Lucia Maako, explained.
All the patients are asleep, emaciated and tired looking; they barely register the stream of visitors. They have just been diagnosed with TB and are undergoing the initial phase of treatment.
TB is the most common opportunistic infection among HIV-positive prisoners. Poor living conditions, including inadequate sanitation and overcrowding, are a major problem, but strict patient observation makes it easier to monitor treatment adherence.
"MDR [multi-drug resistant TB] is not such an issue here because we watch them when they are taking their medicine," Maako said.
Up to six of the hospital's TB patients have been moved upstairs to an extension of Ward Two and are about to complete their treatment.
The ward upstairs is buzzing with activity, "these [patients] are the 'up-and-abouts', they are getting ready to join the rest of the prison population," she added.
HIV-positive patients receive a high-protein diet, "sometimes with extra fruit, raisins and peanut butter", as well as multivitamins to boost their immune systems.
When discharged into prison, they are required to receive the same diet, but whether this actually happened was difficult to determine, Maako admitted.
In line with the national AIDS policy, antiretrovirals are not yet available.
ACCESS TO CONDOMS
Government policy states that condoms are to be distributed to the prisoners "on the same basis as condoms are provided in the community."
But the policy document also adds: "A prisoner may not receive condoms before having undergone education/counselling regarding AIDS, the use of condoms and the dangers of 'high risk behaviour'. The fact that a prisoner has received counselling must be recorded on his/her medical file."
At Local Prison, this meant an inmate had to have a "private discussion" with a medical officer called George, one of the prisoners told PlusNews.
Sello Cornelius, the chairman of the Local HIV/AIDS Counsel - a prisoner-run body conducting awareness and education campaigns, and support groups - admitted that prisoners might find this "uncomfortable".
Consequently, very few prisoners approach the health care workers for condoms. "They are suspicious of the [lack of] privacy," he said.
"We don't condone any vulgar practices, but we have to, of course, advise them where to get them, if necessary," Cornelius told PlusNews.
There were no easily accessible condom dispensers within the prison, "because we are trying to prevent sodomy," he added.
"We are caught in a dilemma. We are saying 'don't do sodomy, but if you're going to do it, use condoms,'" prison head Nico Baloyi commented.
The policy on condom distribution in prisons, however, was applied on an "ad hoc basis", Gloria Lekubu, provincial prisons HIV/AIDS coordinator, pointed out. "In some prisons, there are condom cans [dispensers] which are easily accessible," she added.
Baloyi argued that prisoners would "take advantage" by blowing up condoms and "making a mess".
"But part of the dilemma is that they could mess up their lives, and not just the prison, if they don't receive condoms," Lekubu noted.
VOLUNTARY COUNSELLING AND TESTING
Despite a proliferation of awareness and educational campaigns encouraging voluntary HIV testing, most prisoners are reluctant to come forward.
"We comply with the policy that rules out mandatory testing - we only get to know a prisoner's status when they are sick," Ndebele said.
But Local's HIV/AIDS Counsel feels more can be done.
"When we have awareness functions, the other prisoners tell us they want to go out and say they are HIV-positive. "But first they want to talk to people from outside, like their pastor," Mandla Linda, a member of the group, told PlusNews.
IMPACT ON STAFF
Problems such as these appear not to have evaded prison staff. According to Ramanee Hira, who runs the employee assistance programme, the biggest obstacle in workplace programmes remains stigma and discrimination.
"Its very difficult to introduce VCT, the environment is not geared for it," Hira said. It was also difficult to form support groups and talk openly about the disease. "Everybody wants to keep it secret," she added.
Although the number of AIDS-related illnesses among the workforce was "still very low", Hira raised concerns about how HIV-positive staff would be supported when ill.
She called for "less of a demarcation" between programmes targeting prisoners and staff. "There is still an 'us and them' attitude - people are very nervous about things like this."
"We have to work through all the barriers and create an environment conducive to openness - for ourselves and the prisoners," she added.
EARLY RELEASE
World Health Organisation (WHO) guidelines call for the early release of prisoners in the advanced stages of AIDS, to allow the person to die in dignity. An HIV-positive woman was recently released from the female prison on medical grounds, after her eight-week old baby was taken by her grandmother.
"She was very weak and suffering from diarrhoea, the doctor decided we had to let her go," Sister Maako said.
Last year, eight prisoners from the Pretoria Prison reserve were released on medical grounds.
Addressing HIV/AIDS in prisons effectively was "not easy" provincial AIDS coordinator, Gloria Lekubu noted. A spate of bad publicity surrounding prisons has skewed the public's impression of what is being done in prisons.
The Department of Correctional Services, which oversees all prison facilities in South Africa, introduced their AIDS policy in September 2002. However, there has been little coordination to ensure proper implementation, a prison official said.
Despite the bad press, prisons were upbeat about tackling the disease. "Things are happening. We are lobbying for outside support as a show of our commitment," Lekubu said.