1. HIV and related infections in prisoners

2. HIV and tuberculosis in prisons in sub-Saharan Africa L Telisinghe, S Charalambous, SM Topp, ME Herce, CJ Hoffmann, P Barron, EJ Schouten, A Jahn, R Zachariah, AD Harries, C Beyrer, JJ Amon

3. Prevalence of HIV and TB in sub-Saharan African prisons is very high Backdrop Generalized HIV and TB epidemics in many countries Limited resources To meet international targets for HIV and TB and human rights obligations The needs of detainees must be identified and met Why focus on sub-Saharan African prisons? HIV and related infections in prisoners

4. Objectives and methods Describe Prison populations Epidemiology of HIV and TB Interventions to prevent, screen, diagnose and treat HIV and TB Policies and available services for HIV and TB Funding for HIV and TB programmes Using Literature (grey and peer-reviewed) Key informant interviews Surveys

5. Prison populations Estimated average daily census between 2011-2015 ~600,000 Overall numbers relatively small BUT High proportion of on-remand detainees (≥50% in ~40% countries) High occupancy compared to capacity (>150% in ~half the countries) Reports of: Lack of food, access to health care Physical and psychological abuse Lengthy pre-trial detention

6. Prison populations 1 Total population Detainees/ 100 000 population % pre-trial detainees % occupancy Ethiopia11105012814.0126 Kenya5415411814.4108 Nigeria566203169.3240 Rwanda5427943127.1133 South Africa15916329327.1236 Uganda4509211555.0247 Six countries account for 80% of the prison population 1 Prison studies.org

7. Epidemiology Only 49% of countries had data published between 2011 and 2015 Most showed higher prevalence of HIV and TB among detainees HIV prevalence2.3-34.9% West and Central Africa2.3-10.8% East Africa4.2-23.0% Southern Africa7.2-34.9 TB prevalence0.5-16.3% West and Central Africa1.2-16.3% East Africa0.5-12.1% Southern Africa3.6-7.6%

8. Interventions to prevent, screen, diagnose and treat HIV and TB HIV interventions Known prevention interventions are either illegal or not available in many countries Voluntary HCT and ART are reported in some countries Can result in earlier ART initiation Clinical outcomes comparable to the community Care continuum – service uptake similar to the community TB interventions ACF reported in a few countries Not clear how best to screen prison populations Chest radiographs and newer diagnostics (e.g. nucleic acid amplification) are feasible Treatment outcome data concerning <50% completed treatment/documented cure

9. Policies and services Case studies in 5 purposively selected countries Prison-specific HIV/TB policies Lacking except in South Africa & Malawi (for TB only) Service provision Can occur despite lack of policies – but sustainability/impact limited Does not always occur even when policies in place – on-going systems barriers include Inadequate / poor integrated health care staff Transfers/releases and admissions that disrupt care continuity Inadequate infrastructure and financial resources

10. Funding Domestic funding Limited data → Not presented International donor funding Four donors: all provided some funding to prison programmes/research Difficulties obtaining detailed information The Global Fund and PEPFAR Unable to extract specific information on prison related projects Information based on planned interventions → no data on if activities were conducted Detainees included as part of most at-risk population (PEPFAR)

11. Summary of findings Limited and poor quality epidemiological data Hinders planning and financing appropriate services Reports suggest inadequate health services Limited operational data weakens our ability to know what works Prison specific polices guiding service implementation often missing Unable to gain a comprehensive picture on funding for prison HIV/TB programmes Evidence suggests funding is inadequate

12. BUT – promising practices Examples of innovative programmes across the region Often involving multilateral collaborations Criminal justice system reforms to decrease overcrowding South Africa Routine voluntary HIV and TB entry screening Zambia and South Africa Integrating mental health services into a health package Malawi Task sharing to include detainees in care provision Rwanda, Zimbabwe, Zambia and South Africa

13. Recommendations Health systems strengthening approach Political commitment and prioritisation of detainees for HIV/TB and health care Prison specific policies Funding: adequate and sustained with transparent reporting Intersectoral approach to health care in prison Prison programmes part of national HIV/AIDS and TB programmes Care provision and supervision consistent with community programmes Criminal justice reforms to decrease prison population size Reforms to improve conditions within prisons Regularly updated epidemiological, programmatic and research data To guide prevention, treatment and care strategies Transparency of data to share best practice and knowledge across the region

14. “It is said that no one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones.” Nelson Mandela Thank you HIV and related infections in prisoners