Thai programme demonstrates HIV services can be successfully delivered in prison

An HIV intervention programme in Thailand shows that satisfactory outcomes can be achieved in under-resourced prison settings and could be implemented by any government providing treatment in the general population, according to a June report from the medical charity Médecins sans Frontières (MSF). It notes that prison services represent an opportunity to reach people from marginalised groups who would not usually seek or be given care.

With the global scale-up of antiretroviral therapy, services for marginalised groups, such as prisoners, is of increasing concern. In 2006, South African civil-society groups took the government to court over prisoners’ rights to treatment.

“While there is an emerging consensus that prevention and treatment is feasible and effective in prisons, experience of implementing comprehensive HIV/AIDS programmes that include antiretroviral therapy in resource-limited countries is limited”, write Daniel Wilson and colleagues from MSF. The team from Bangkok, Thailand, report their experiences of providing HIV prevention and treatment in two prisons (PLoS Med 4(6): e204. Doi: 10.1371/journal.pmed.0040204).

168, 264 people are incarcerated in Thailand, exceeding prison capacity by 50%. Despite the country's overall success in tackling HIV, one study found that 25% of prisoners tested were HIV-positive compared with a national average of 1.5%.

Many of the prison population are foreign nationals or unregistered Thais, who are not eligible for national health insurance. Risk behaviours related to HIV infection in prisons include unprotected consensual or non-consensual sex, injecting drug use and tattooing. Condoms are allowed in Thai prisons but various factors, including the attitudes of guards, mean they are often not distributed or used.

In 2003, MSF initiated treatment services in two sites, a medium-security prison and a maximum-security prison. Subsequently, activities expanded to included prevention, such as educational interventions for prisoners and guards, training of prisoner representatives to distribute condoms, and HIV counselling and testing. “Confidentiality is a major challenge”, the authors note, “and we have attempted to address this issue during workshops for both staff and prisoners.”

Of 165 HIV-positive patients, 112 were diagnosed in prison, most often after an opportunistic infection, commonly tuberculosis. 122 people had advanced disease (WHO stages 3 or 4) and 88 started an antiretroviral treatment programme, with first-line therapy of stavudine, lamivudine, and nevirapine.

“CD4 cell gain is comparable with treatment programmes in other settings”, the team reports. After a median follow-up of 18 months, 72% remain on treatment, 20% have been released, 5% have been transferred, and 2% have died. For those released, support is available from a social worker, and three months' medication is given on discharge to allow time for enrolment in a community treatment programme. Despite these measures, five prisoners have been lost to follow-up.

Treatment adherence in prison is promoted by peer-group support and a buddy scheme. “Prisons have been said to be the ideal environment for ensuring high compliance to treatment,” the authors note, “but in our experience there are many important barriers to overcome that require constant re-evaluation.”

These include fear of stigma, which discourages prisoners from taking medicines in a crowded environment, mistrust of staff, transfer to another facility, and poor social support on release. Prison healthcare staff have been very supportive of prevention and treatment efforts.

“The fact that none have questioned that three prisoners facing the death sentence receive antiretroviral treatment is a clear indication of the staff’s commitment to treatment as a basic human right.”

The authors conclude that the programme efforts will have a sustained impact, with local medical staff now managing most issues and medication supplied by government. The Department of Corrections has asked MSF to develop training curricula for education in other prisons. “Ultimately”, the team conclude, “barriers that prevent the provision of treatment in prisons when it is available outside are not technical or financial, but political”.