Services and Gaps in the prevention and treatment of HIV/AIDS for South African prisoners

1. Services and Gaps in the prevention and treatment of HIV/AIDS for South African prisoners Centre for the Study of Violence and Reconciliation 11 March 2009 Sasha Gear

2. HIV/AIDS Policies & Services in SA Prisons Difficult to give a general sense of what the status of services is on the ground: • Relatively new policy that not close to fully implemented or monitored or evaluated • “Framework for the Implementation of Comprehensive HIV & AIDS Programmes and Services for Offenders and Personnel 2007 – 2011” (2007) • Department of Correctional Services (DCS) Minimum Service Level Standards for HIV &AIDS Programmes for Offenders. (n.d) • At the same time: • it’s under review & about to be changed • bits been over-ridden by other decisions. • Vague : actual implementation requires much fleshing out Overall, uneven and intermittent services and capabilities at different prisons – hard to generalise

3. Hindering Service Delivery What we know : • many of the services that are supposed to be available to inmates are not / not consistently, • &/ inmates up against substantial obstacles to access those that are. DCS faces severe staff shortages & overcrowding, lacks capacity to implement the policy and make required services available in an ongoing way – or at all. On the other hand – while the policy does seem to cover many key issues, there are important gaps & silences in policy, procedures and attention.

4. Lack of capacity, human resources numbers • 35 % of professional nurse posts are vacant (DCS 2007-2008) • unable to retain health professionals (social workers, psychologists). “healthcare in crisis” (JIOP 2007) skills, perceptions, will & support structures (critical gaps) • No HIV/AIDS training for correctional officers (who mediate inmate’s access to all health services, information, - just about everyone & everything…& are face of DCS for inmates.) • HIV/AIDS denial and fear of stigma particularly powerful amongst staff:

5. staff skills, perceptions, will & support structures (cont) “The stigma attached to the disease is of such gravity that the majority of officials would rather die than risk disclosure…. Where officials were clearly suffering from the disease, they refused to access available ART because this would provide concrete evidence to others that they were suffering from AIDS” (Tapscott 2008). • Beyond devastating effects of these attitudes and fears for individuals and DCS staffing, how can they then support inmates re HIV/AIDS? • Reports of serious malpractice and derelection of duties as well (part of broader context of widespread corruption, smuggling etc.) eg. bribery, refusing access, giving wrong medication (?)

6. GAPS and LACKS Policies and trainings ignore prison context: No recognition that it’s a mobile population • Nothing specific in “Framework” re continuity of care (health care management for released or about-to be released prisoners) – only vague note on referral (Muntingh and Tapscott, 2009) • Actual practice regarding this is unknown but DCS doesn’t regard as responsibility (PMG minutes) – initial ivestigations suggest often falling through cracks.

7. The un-named elephant in the prison - • Widespread male on malesexual intercourse and sexual violence (key forms of transmission in prison) unacknowledged in policy or trainings. – • There is certainly talk of “Sodomy” but in ways that reflect confusion about what it means. • Same-sex Male rape often gets conflated with “homosexuality” (Both subj of big taboo) = lumping together of practices as different as sex and violence is destructive: • contributes to homophobia, • to continued risky sex practices & • invisibility of male rape. Staff are divided and confused about just what is and what is not allowed in prison – often don’t seem to be distinguishing abuse from sex. No policies or trainings to assist, give guidance promoting healthy sex practices, preventing / responding to sexual violence.

8. Prevention: elephant contin… Lack of acknowledgement of the fact that men are having sex with men is reflected in the inadequate provision of protection. • Condoms are supposed to be freely and confidentially available – and although adhoc & varied, has been improvement in access. • BUT no water-based lubricant provided • Coexists with absence of prison relevant information re transmission – eg. vaseline – Boksburg survey points to dangerous misinformation amongst inmates.

9. Existing services, related lacks Certainly there are some efforts being made to combat HIV / AIDS in prisons, but long way to go: VCT supposed to be offered at all sites but obstacles to accessing & uptake low (Sifunda, Muntingh & Tapscott, 2009) Extent seems to depend on availability of outside service providers (welcomed on ground, but not supported in policy). • Power of correctional staff over movement and information – existing services often inaccessible. Inmates need to negotiate every movement (general problem beyond VCT) • VCT supposed to be gateway to treatment, diet and support – but inmates not seeing the benefits. - underscored by inmates having recently resorted to litigation in attempt to get their ARVs & numerous other reports of inability to access medical care

10. PEP –kits & guidelines supposed to be available at all centres but depending on available staff, may be referred outside (huge problem of reporting in context of silence of sex & sexual violence) • MTCT – pregnant women referred outside for all ante-natal care. Treatment ARVs • After much wrangling DCS had by 2008 set up 12 ART centres at prisons • But access remains difficult (logistics – may need to be referred outside) • Re CD4 count: again, lack of cognisance of prison context (tends to rapid deteriortation in health status). Inappropriate to apply same count measures as outside.

11. More gaps & lacks No recognition in policies & procedures of a range of disclosure-related issues re prison context: • difficulties maintaining discretion in prison (and role of officers in this) • widened & complexified disclosure decisions are likely by virtue of being in prison • families - tensions & logistics • fellow inmates. • Silence re most common means of modes of transmission - sex and sexual violence (above)

12. More gaps & lackscontin Initial Health Assessment on Arrival Great opportunity for: prevention (estab support, promote testg) & treatment (quickly identify what’s needd) • But superficial & wanting – if not uniformly so (Muntingh & Tapscott 2009). • JIOP (2008) finding that 37% “natural deaths” in prison within 1st year of incarceration suggests the same and attributed to inadequate health care, superficial health status examinations, unhealthy detention conditions. - rapid deterioration and development of AIDS

13. Finally, • With some exceptions, centre managers unwilling to take lead & set example re HIV/AIDS programmes rather showing little interest in the programmes. (Tapscott 2009) • This is a subject of complaint amongst those staff trying to implement the programmes, • But without the commitment of DCS leadership the impact of HIV/AIDS programmes is severly undermined, by inter alia perpetuating the hold of stigma amongst officials, which in turn impacts on their dealings with inmates. THANK YOU sgear@csvr.org.za www.csvr.org.za