HIV/AIDS in prisons: facing the challenges
The first of December marks World AIDS Day. In recognition of this important date, Raed Aburabi, ICRC's coordinator for health in detention, describes the organization's work to fight HIV/AIDS in prisons. He highlights the seriousness of the problem and the challenges of providing treatment for prisoners with the disease.
Is HIV/AIDS a major problem in prisons?
In many prisons around the world, especially in conflict areas, there is a high rate of infection by the human immunodeficiency virus (HIV) – the virus that attacks the body's immune system, rendering the patient vulnerable to a whole range of diseases and ultimately causes acquired immunodeficiency syndrome (AIDS). At the same time, prisons also have high rates of tuberculosis (TB), syphilis, various strains of viral hepatitis and other contagious diseases. In fact, HIV and TB are known as the " twin diseases, " since the two fuel each other.
In most countries the level of HIV infection tends to be significantly higher in prisons than among the general population, though the prevalence varies considerably around the world. Several countries have reported a rate in the range of 10 to 20 per cent among the prison population. However, the full extent of the epidemic in prisons in low-income countries is not known.
Several factors, including overcrowding, tattooing and drug use, make prisons ideal breeding grounds for onward transmission of TB/HIV infection. Drug injection with shared, non-sterile needles probably accounts for most new HIV cases in prisons around the world. Unprotected sex between men (sometimes rape) is another important factor in HIV transmission among prison inmates.
So HIV/AIDS is definitely a major problem in prisons.
What is the ICRC doing to address this problem?
The ICRC is at the forefront of efforts to address this problem. The organization's delegates visit detainees in almost 80 countries around the world with the aim of ensuring that their treatment and conditions of detention are acceptable. ICRC medical staff identify, assess and prioritize public health problems, including especially TB and HIV/AIDS, in the prisons they visit.
The ICRC actively participated in HIV/AIDS programmes in various prisons around the world, including in Armenia, Azerbaijan, Georgia and Kyrgyzstan. In Africa it is carrying out programmes in countries such as Burundi, Côte d'Ivoire, Rwanda, Lesotho and Uganda.
The ICRC raises awareness of the issue and seeks to ensure that the parties that can make an impact, such as States, international organizations, National Red Cross and Red Crescent Societies and the medical community, assume their responsibilities.
The ICRC does not itself treat prisoners infected with HIV/AIDS with anti-retroviral drugs, but seeks instead to lay the groundwork for successful care. For example, in Uganda the ICRC launched a pilot project in three prisons aiming to improve detainee health by strengthening the capacity of Uganda Prison Medical Services to provide treatment for HIV/AIDS, TB and malaria equivalent to that available outside prison walls. The ICRC also provided Prison Medical Services and the Ministry of Health with a tested and cost-effective model for improving HIV, TB and malaria prevention and treatment that can be implemented across the prison system with the resources available. Similar projects will now be carried out in other prisons by the authorities.
What is the ICRC's approach?
The ICRC works in partnership with a variety of interested parties. First and foremost, it works with governments to ensure that there is a political commitment to address the problem. As HIV/AIDS has social, health, and economic implications, it is important that the various governmental bodies work together to implement a coherent programme. The ICRC also works with local authorities, health ministries and the international community, to name but a few of its partners.
Before the ICRC launches an HIV/AIDS programme in a prison, it seeks to determine how the virus is contracted or spread there. This knowledge, together with an understanding of how the prison is run, enables the ICRC to develop strategies.
In Azerbaijani prisons, for example, the ICRC conducted an assessment of HIV/AIDS " knowledge, attitude and practice " together with government officials to see how the ICRC can help to put HIV at the top of the agenda.
For any programme designed to fight HIV/AIDS in prisons to succeed, it is essential that the treatment involved is similar to that provided in the outside community which prisoners are likely to return to. Because HIV/AIDS requires treatment over a patient's entire lifetime, the outside community must be able to carry on any treatment already begun after prisoners are released. The ICRC therefore works hand-in-hand with National Societies to ensure proper treatment and follow-up.
What are the challenges involved in providing treatment for prisoners with HIV/AIDS?
HIV/AIDS differs from other illnesses because of various societal, cultural, medical and ethical considerations. Some countries deny that the problem exists, others consider the topic taboo.
It is a challenge to persuade countries that the issue should be a priority. Prisons are usually low on the list for government funding. It's necessary to convince political authorities that prisoners are members of the community who are temporarily confined but will sooner or later rejoin the outside world.
In addition, the pressures on patients and staff are extreme. Because medical services in prisons often do not meet the same standard as those provided for the general population, prisoners may not be willing to be treated. Moreover, HIV/AIDS is perceived to be a private matter, and people are reluctant to be tested because of the stigma attached to the illness or because they do not trust the health-care system.
Then there is the cost. Living conditions in prisons depend on the level of economic development in the countries where they are situated. The quality of medical services available is similarly linked to economic development. While the cost of treating HIV/AIDS has come down over the years, some developing countries still cannot afford it. In addition, medical staff must be trained and laboratory testing needs to be performed. These further costs have to be borne by an already overstretched system.