Criminal Justice Reform as HIV and TB Prevention in African Prisons

HIV prevalence in sub-Saharan African prisons has been estimated at two to 50 times that of non-prison populations [1], while average tuberculosis (TB) incidence in prisons worldwide has been estimated at more than 20 times higher than in the general population [2]. Overcrowding— resulting in and exacerbating food shortages, poor sanitation, and inadequate health care—contributes to the spread and development of disease [3,4]. Minimal ventilation, poor isolation practices, and a significant immune-compromised population also facilitate the transmission of TB and the development of TB disease [5]. Prison health care in Africa is underresourced, and increased funding is needed to ensure adequate treatment is available, including antitretroviral (ART) therapy as treatment for HIV, and for HIV and TB prevention [6,7]. However, even when ART is available, certain classes of prisoners such as foreign nationals may not be receiving treatment [8]. In addition, structural barriers, such as laws criminalizing ‘‘sodomy,’’ policies or practices limiting bail, and justice system problems resulting in long delays in accessing courts, impede prevention efforts and complicate the provision of care. Prisons throughout sub-Saharan Africa are often filled far beyond their capacity. The prison populations in Burundi, Cote d’Ivoire, Kenya, Mali, Uganda, and Zambia are over 200% of capacity; in Benin, it is over three times design capacity (Table 1). Overcrowding can be so severe that inmates may be forced to sleep seated, standing, or in shifts, in cells with little ventilation. These conditions violate international standards [9] and may rise to the level of cruel, inhuman, or degrading treatment [10]. One reason for overcrowding is extended pretrial detention. Half or more of the prison population consists of remanded prisoners (who have not been convicted) in Angola, Benin, Burundi, Cameroon, Chad, Comoros, Congo, Liberia, Mali, Niger, Nigeria, Togo, Uganda, and Tanzania (Table 1). Lengthy pretrial detention can also violate international human rights obligations, including prohibitions on mixing remanded prisoners with convicted prisoners [10], and have serious health consequences [11]. This policy proposal discusses how criminal justice system failures and limited financial resources present barriers to reducing HIV and TB transmission in prisons and how ‘‘structural rights’’ interventions focused upon criminal justice system reform are needed to guarantee detainees’ human rights and health. To better understand structural barriers to HIV and TB prevention in African prisons, we conducted a survey of prison commissioners and medical directors in East and Southern African countries with high HIV and TB rates. Written surveys were sent via email, fax, or post to prison authorities in the 18 states that are members of the Southern African Development Community (SADC) and East African Community (EAC). Ten surveys were returned (from Burundi, Kenya, Malawi, Mauritius, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe). Topics covered in the survey included size of the prison population; available health services; HIV and tuberculosis prevalence; mortality rates; donor and government funding for health services; and challenges in health care administration. Respondents were informed of the purpose of the survey and that information provided would be publicly reported. Consistent with the US Code of Federal Regulations, which exempts ethics review for surveys of elected or appointed public officials, independent ethics approval was not sought [12]. Our policy recommendations are also informed by in-depth interviews with 246 prisoners and 30 prison officers at six prisons in Zambia and 164 prisoners and 30 prison officers at 16 prisons in Uganda, reported previously [13–15], and a review of relevant literature.