Tuberculosis and HIV within prisons skyrocketing, a public health threat

Overcrowding, low access to health care, lack of political will and the prominence of high-risk populations among prisoners all contribute to a “perfect storm” for HIV and TB infection among prison populations worldwide, researchers announced at the 40th Union World Conference on Lung Health this Saturday in Cancun, Mexico.

Dr. Fabienne Hariga of the UN Office on Drugs and Crime and UNAIDS’ Dr. Alasdair Reid both highlighted dismal health statistics for those behind bars. According to Hariga, up to 65% of some prison populations are infected with HIV.

Adding to this, says Reid, TB rates in prisons are up to fifty times higher than in the general population. Increased rates are found in prisoners who have served longer sentences, tying TB acquisition with prison time. Prisoners are also more likely to die from TB and/or default from treatment than non-incarcerated populations.

Dr. Hariga insists that such poor indicators not only pose a threat to prisoners’ health, but the health of the general public as well. Given the high rate of return to society, prisoners’ HIV and TB are easily spread to communities.

Prison staff are also affected by the high incidence of HIV and TB. Dr. Salome Charalambous of South Africa, speaking about HIV and TB prison projects sponsored by the country’s Department of Corrections and the Aurum Institute, notes that many prison staff supported greater testing, treatment and infection control because of concerns over their own health.

“Prisons are not isolated from the community,” says Hariga. “You have people working in [them], you have prisoners moving in and out very often.”

But despite dismal health statistics, effective penal reform that includes increasing health services for prisoners is far from a reality. Dr. Hariga claims that “there is a lack of interest” among policy makers, resulting in a shortage of funds to address health problems for prisoners. “In many places in the world, there is no health-in-prison programme,” she states.

The difficult nature of prison populations also contributes to the low number of programmes. Dr. Charalambous cited logistical concerns that hampered the testing and treatment of prisoners in the South Africa study, who are often moved from prison to prison or released, interrupting HIV and TB follow-up and treatment.

In large part due to this mobility, 21% of patients initiated onto ART within one of the study’s programmes were lost. In another prison, seven of the 22 prisoners who were called for follow-up had been transferred prior to undergoing review.

In order to combat low programme retention, the ongoing study only enrolls prisoners with a sentence of four months or longer. Researchers also “tag” those enrolled, alerting prison authorities not to transfer them unless essential for trial purposes.

Additionally, using symptom-based diagnosis to identify possible TB patients is difficult among prison populations. In the South Africa study, 46% of patients demonstrated any symptom for TB, while 37% displayed a trio of symptoms.

However, Charalambous surmises that some of these can be attributed to the prison environment in general rather than TB infection specifically, and therefore states, “symptom screening might not be as effective in this environment.”

Despite these challenges, Dr. Charalambous is hopeful that prisoners present a captive audience for TB and HIV testing and treatment. Her study suggests that prisoners may be responsive to such programmes: in one site, 98% of prisoners agreed to join. Dr. Reid agrees, claiming that prisons offer unique opportunities for treating marginalised populations.

In order to encourage more prison health programmes, Dr. Reid calls for further research that assesses the rate of acquiring HIV and TB behind prison bars: while data that demonstrates the high rate of both infections among prison populations is readily available, numbers that point to prisons as conducive to their spread is harder to find.

In order to fuel political will, Reid condones the “advocacy, naming and shaming” of countries who boost some of the worst indicators for prisons with regards to overcrowding, HIV and TB, and human rights violations. “Global reporting is essential to get countries to take this seriously,” he says.