The lack of a concerted response to the pandemic behind bars is compounded by the belief in many societies that prisoners go to jail to be punished for offending society. Initiatives that appear to help inmates are therefore not readily supported. This is in sharp contrast to interventions that have been developed for other at risk groups like sex workers, truck drivers and uniformed personnel.

We, however, believe that prisons are not closed off worlds. Prisoners and indeed prison staff move in and out of jail each day. Many prisoners are jailed for only a short period of time and return to society after their release. Any infection acquired inside prison can therefore be readily transmitted outside. In the long run, giving protection to inmates is also giving protection to society.

Risk factors

Unprotected sex between men, unprotected sex between male wardens and female inmates, unsafe tattooing, and sharing of syringes and needles have been identified worldwide as the main risk behaviours for HIV transmission in jails. In studies we conducted in three large Zambian prisons, Kamfinsa, Mukobeko and Solwezi, in 1999, 27% of inmates were HIV positive, 15% had antibodies to syphilis and the TB case infection rate was over 5,000/100,000. The main risk behaviours identified were;: 4 –16% of inmates reported sex with other men (reported by 4-16% of inmates),17% of inmates had been tattooing while ed in prison (17% of inmates) and 63% of the prisoners reported sharing razor blades (reported by 63% of prisoners). Less than 2% of inmates had injected drugs in prison. Other concerns were congestion and overcrowding in prisons, poor hygiene and sanitation and lack of HIV/AIDS educational materials relevant to prison life.¹

In But Free

To address these risk factors, the Copperbelt University Health Services Department started its In But Free project together with the Zambia Prisons Service in 1995. The project began at Kamfinsa prison in Kitwe and has since spread to all major prisons in the country. It is open to all inmates and staff; t

he total number of prisoners in the country is 13,000 (including about 500 women), while the number of prison officers is 1800. The project does not discriminate on the basis of religion, ethnic background or gender.

IEC materials that are distributed outside prisons by the Ministry of Health do not touch on the specific problems of HIV/AIDS in prisons. Therefore, the project has begun to produce its own materials specific to the prison environment.

The project promotes better standards of hygiene in prisons, including the distribution of razors and other shaving equipment. For women prisoners, special efforts are made to distribute sanitary pads, and milk supplements for those with babies. and Tthe project has, whenever possible, assisted in the antenatal and post-delivery care of expectant prisoners.

The most common illnesses in the prisons include malaria, STIs, tuberculosis, scabies, diarrhoeal diseases and night blindness. Patients with complaints are seen and treated accordingly, provided that the appropriate drugs have been sourced. Although prison clinics throughout the country have erratic supplies of drugs, treatments for tuberculosis are readily available for inmates through the national TB programme. It is hoped that antiretrovirals will soon be made available through a similar arrangement.

In conjunction with the various district health services, the In But Free project offers voluntary counselling and testing (VCT) to both inmates and staff. Through the data generated by the VCT programme, an HIV/AIDS surveillance system is currently functioning. One of the main concerns of the project is the status of terminally ill inmates. The trained peer educators help in looking after very ill inmates, and provide a type of much-needed ‘home'-based care. As the food situation in prisons is generally poor, very ill inmates receive nutritional support.

Monitoring and evaluation

The project is ongoing but undergoes review every year. The annual review takes the form of a conference held at one of the prisons; participants include the project managers, peer educators and their coordinators, prison staff and inmates invited from the prisons. The audience also includes representatives of the Commissioner of Prisons, prison governors from the region and district health officials.

The project team presents for discussion the reports for the year and the results of HIV testing. Other methods used for monitoring and evaluation include monthly project meetings, in-depth interviews with peer educators and focus group discussions with inmates and staff.

The evaluations confirm that the project largely achieves its objectives: health education takes place regularly, shaving equipment and IEC materials are available, monthly medical examinations take place and VCT services are operational. A follow-up KABP (knowledge, attitude, behaviour and practices) study is planned for later this year to quantify the changes in risk behaviours.

Other concerns are that risk behaviours such as the sharing of shaving equipment and tattooing in prisons continue; levels of STIs and TB are still high; and that there is a lack of therapeutic drugs at prison clinics. There is still poor hygiene and overcrowding in prisons and many prisoners have insufficient food.

Finally, the situation for terminally ill inmates remains a big problem. Under the current law, only the Head of State can discharge an inmate on compassionate grounds. The procedure required for a case to reach this far is lengthy and in many cases it takes months before a decision can be made. We have proposed that the Commissioner of Prisons takes this responsibility.

In But Free is one of the few projects in sub-Saharan Africa that specifically deal with the problem of HIV/AIDS in prisons and that has managed to scale up its services to include all national prisons.  As many prisoners are in jail for a short time only and most return to their families, protecting inmates in the long run equates with protecting society, a sound health promotion goal and a critical approach to the HIV/AIDS problem. Giving protection to prisoners against infectious diseases also demonstrates respect for the fundamental human right to health care – imprisonment should not lead to the denial of basic social needs.

1. Simooya, O., Sanjobo, N., Kaetano, L., et al. Behind walls: A study of HIV risk behaviours and seroprevalence in prisons in Zambia. AIDS, 2001, 15 (13): p. 1741-1744.