1. Government of Swaziland
His Majesty's Correctional Services
A Situational Assessment on TB, HIV, Syphilis, Hepatitis C, and Hepatitis B Infections and Associated Risk Behaviour in Correctional Institutions in Swaziland
Supported by
Ms. Phindile Dlamini
Assistant Commissioner
His Majesty Correctional Services
ICASA , 2011

2. Objective was to determine:
Background
Objective was to determine:
prevalence of HIV, Syphilis, TB and HBV & HBC among prisoners and officers;
knowledge, attitudes, behaviour and practices in relation to drug abuse and communicable diseases;
gaps in Health Care Service provision in prison
Objective of Prison Assessment was to carry out situation and needs assessments on prevalence of HIV and risk behaviour as well as TB in prison settings through development of comprehensive evidence baseline information to inform policy, advocacy, and refinement to national strategies as well as informing program planning for prisoners, prison staff and their families.

3. Survey Methodology
Semi-structured questionnaire adapted from the UNODC HIV Assessment Toolkit( used to capture KAP & risk behaviour):
Sampled using Probability Proportional to Size (PPS).
473 inmates (out of population of 2800)
243 correctional officers (out of a total of 1400)
Samples (same coding with questionnaire):
Blood for testing HIV, Hepatitis (B &C), Syphilis and
Sputum for TB tests
Data processing
Testing for blood borne disease done on Abbot Architecture
TB testing : microscopy & Culture (for HIV+ participants)
Data entered & analyzed using SPSS V.14 and Stata V. 11.
Questionnaires adapted from UNODC Assessment Toolkit.
Sampling was through : Prabability Proportional to Size of the prison. Big prisons had more participants as compared to small prisons.
Blood samples ( drawn from one tube) used to test all blood borne diseases( HCV, HBV, HIV& Syphilis).
Three sputum collected( spot on, following morning spot , and last spot ). All sputum samples from participants who tested positive for HIV were further analyzed using a TB culture. The TB culture is more sensitive and was used to more accurately identify HIV/TB co-infection. The high cost of the TB culture test prevented it from being used to identify TB in all participants

4. Results : Disease prevalence
HIV
prevalence was 34.9% among inmates
HIV prevalence was 26.9% among officers
Hepatitis B
Among officers: 8.1 %
Among inmates : 10.8 %
Hepatitis C
Among officers: 0.4 %
Among inmates: 0.2 %
Syphilis
Among officers: 17.1 %
Among inmates: 11.8 % TB
Among officers: 4 cases (1900/100,000 )
Among inmates : 15 cases (3570/100,000 )
Prevalence among inmates is 34.9 % compared to 26 % of general population ( Demographic Health Surveys results) . All tests for disease are in terms of prevalence except for tuberculosis, which was an incidence test. A participant was marked as “positive” if any one of the three TB smears or the TB culture returned positive results. Incidences are marked here as cases per 100 people per 2 weeks

5. Prevalence among inmates-Gender
HIV prevalence was significantly different between male and female prisoners % of male prisoners tested positive for HIV, whereas 70.59% of female prisoners tested positive. There were no significant differences in hepatitis B prevalence, hepatitis C prevalence, syphilis prevalence, or TB incidence by prisoner gender

6. Results (cont) More inmates tested positive for: HIV, TB & HBV
a larger proportion of officers tested positive for
Syphilis (17.1% of staff compared to 11.8% of inmates).
Only one inmate and one officer tested positive for hepatitis C
The measured incidence of TB : Higher than national:
Among inmates was 3570/100,000;
among staff was 1900/100,000

7. Disease prevalence and incidence among inmates according to Age

8. Prevalence among Inmates in Correctional Institution
The prison with the highest prisoner HIV prevalence was Mawelawela, the women’s prison (72.4% prevalence); the prison with the lowest prevalence was Mankayane (8.3% prevalence). Pigg’s Peak had the highest prisoner prevalence of syphilis (16.7%), and Nhlangano had the lowest prevalence (no prisoners tested positive for syphilis in Nhlangano).
Prisoners who were HIV positive were significantly more likely to be infected with TB (8.39% of HIV-positive patients compared to 1.06% of HIV-negative patients) and syphilis (18.79% of HIV-positive patients compared to 8.12% of HIV-negative patients). Hepatitis B and C were not significantly related to HIV infection in prisoners; and no disease was significantly related to HIV infection in prison staff

9. Prevalence among Officers in Correctional Institution

10. Questionnaire : Health services availability in Correctional Institution
Among inmates :
76.3% know their HIV Status
65.4% had access to ART.
50.9% had access to TB treatment in their prison and
59.8% had access to STI treatment.
Among Staff :
Only 37.9% know their HIV status
Only 7.9% had been tested for TB in the last year
4.6% had been tested for either hepatitis B or C.
35.4% had undergone a routine health check-up in the past year.

11. Questionnaire: Violence in Correctional Institution
Physical Violence
Most inmates (83.7%) had witnessed physical violence in prison
70.29% of staff noted physical violence exist in the prison;
Psychological Violence
88.2% had witnessed psychological violence (gangs)
Sexual Violence
44.1% of inmates had witnessed sexual violence in prison.
5.1% of inmates had been forced into sex before.
only 1.6% of inmates stated that they had been involved in consensual sex with another inmate
70.29% of prison staff said violence in the prison exists and disturbs their work; 49.17% said sexual contacts between prisoners exists and disturbs their work.

12. Prisoner experiences with violence, according to prison
Despite the fact that 1.6% of prisoners reported having consensual sex with other prisoners, 59.8% of prison staff said consensual sex between prisoners occurs in their prison. An additional 35.4% of prison staff reported that prisoners force each other into sex and 60% reported that prisoners have transactional sex in their prison. Only 1.7% of prison staff said that consensual sex between prison staff and prisoners occurs in their prison institution

13. Staff exposure to blood borne diseases
Prison staff were asked about events in which they had been exposed or feared they had been exposed to HIV, TB, hepatitis B, hepatitis B, or syphilis and/or other STIs. 52.9% of prison staff had experienced an event which made them fear they may become infected with HIV; 17.7% experienced an event which made them fear they may become infected with syphilis or another STI; 91.2% experienced an event which made them fear they may become infected with TB; and 8% experience an event which made them fear they may become infected with either hepatitis B or C. The proportion of staff experiencing these events did not differ significantly by prison

14. Limitations of the study
Population :
Of 473 inmates, only 35 were women. The relatively small sample size of women meant that we were less able to find significant differences in disease prevalence, risk behaviours
Pilot Study
Pilot Site had inmates between years old. Since study participants were over 20 yrs old , this may have caused unforeseen problems, especially with regard to disease prevalence and risk behaviour including drug use.

15. Recommendations for HIV
Intensify HTC on admission
improved HIV education,
Improved rollout of ART
improved access to post-exposure prophylaxis,
improved social support, including provision of SRH for women inmates (including PMTCT)
Discourage tattooing and sharing of sharps/ razors
Encourage officers to know their status

16. Recommendation for TB offer HTC & culture tests for TB
Set up a TB surveillance system for correctional officers and prisoners
Screen new prisoners for TB on entry into prisons
Sensitise inmates & officers about TB control
Isolate TB suspect cases
Improve ventilation of the cells
Create isolation cells
Train officers on TB / MDR-TB & provide TB masks ( N95)
Intensify DOT

17. Acknowledgement Thank you Very Much !!!! Prisoners Prison Officers
UNODC
Ministry of Health (TB program)
National Emergency Response Council on HIV and AIDS (NERCHA)
Ms. Maria Sunderan – data Analysis
Thank you Very Much !!!!