ASSESSMENT OF HIV PREVALENCE AND RISK BEHAVIOURS AMONG THE PRISON POPULATION IN ZIMBABWE; Adoption of the UNODC situation and needs assessment toolkit for the Zimbabwe situation Dr. P. D. Parirenyatwa Executive Director Centre for Health Strategies 11a Lincoln Rd, Avondale Harare, Zimbabwe. E-mail; chest@zol.co.zw

Study Objectives To estimate the prevalence of HIV among prison inmates and define risk behaviors associated with HIV transmission To provide baseline information to inform policy, advocacy and refinement to national strategies as well as program planning for the prison population To determine availability and accessibility of services for HIV and AIDS prevention, care and treatment in prison settings and document service delivery gaps for comprehensive HIV and AIDS prevention, care and treatment To make recommendations for a comprehensive action plan on HIV and AIDS prevention, care and treatment in the prison settings

Step 1:Multi-sectoral Approach UNODC Toolkit Establish a national steering committee P.I. To recruit research team ZIM Situation Multi-disciplinary steering committee ; Zimbabwe Republic Police; Drug unit Zimbabwe Prison Service Ministry of Health and Child Welfare: AIDS and TB Unit National AIDS Council W.H.O UNFPA UNODC Thorough selection and vetting of research assistants

Step 2:Development of Protocol UNODC Toolkit Consult W.H.O, National Ethics body, Prison Ethics body on ethical considerations. Obtain approval of protocol from steering committee ZIM Situation Consulted W. H. O ethical requirements and more importantly Zimbabwean National Ethics guidelines. Presented protocol to steering committee through a consultative full day workshop.

Step 3: National Ethics Committee Approval UNODC Toolkit Apply to national ethics committee ZIM Situation Obtained approval from Medical Research Council of Zimbabwe (MRCZ) and the Zimbabwe Prison Service Ethics Board (ZPSEB)

Train assessment team on Step 4: Train Assessment Team, collect and analyse available information (secondary data) UNODC Toolkit Train assessment team on Overview of objectives Interviewing techniques Field procedures Questionnaire description Confidentiality agreement forms Collect secondary data ZIM Situation Four day training session of research assistants; Logistician Field supervisors Interviewers Laboratory technicians Training content; Administering interviewer guided questionnaires Conducting FGDs Questionnaire description Ethical conduct Serial HIV testing using Rapid HIV test Kits Confidentiality agreement forms Mainly primary data as there is lack of secondary data

Obtained secondary information from Step 5: Collect and analyse the national framework and prison conditions UNODC Toolkit Data collection and analysis of the national framework and prison conditions from ZPS and relevant ministries ZIM Situation Obtained secondary information from ZPS; data paucity Ministry of Justice and Legal Affairs however it was not comprehensive. Ministry of Health and Child Welfare did not have anything.

Step 6: Qualitative data collection; Interview staff and prisoners UNODC Toolkit Interview prison staff and prison inmates Conduct FGDs Key Informant Interviews ZIM Situation Interviewer administered questionnaires for both staff and inmates; Administered staff questionnaires to all seven levels of prison staff including health personnel All inmates who responded to questionnaires were also tested so as to link results with responses (Anonymous testing) FGDs conducted to inmates in groups of 15 to 20 (at least two discussions at each sampled prison site) Key Informant Interviews; Permanent Secretary of Ministry of Justice and Legal Affairs Director Ministry of Health and Child Welfare; AIDS and TB unit NAC Chief Executive Officer, etc

Step 7 a): Cross sectional anonymous survey on risk behaviour ZIM Situation Field preparation; Sensitised ZPS and respective sampled prison sites through letters and visits. Adapted questionnaires Administration of all questionnaires was interviewer guided-for completion and to cater for illiterate inmates Used common prison language and terminology. Translated questionnaires from English to Shona and Ndebele. Pre-testing was done at a selected prison site; Kadoma prison UNODC Toolkit Field preparation Questionnaires; Should be self administered or face to face interviews in the case of illiterate inmates Localised languages Frequently used prison terminology Pre-testing

Step 7 a): Cross sectional anonymous survey on risk behaviour (2) UNODC Toolkit Sampling; Sample should be sufficiently large to yield an acceptable degree of precision (confidence interval of 95%) and sample should represent the full study population. ZIM Situation Sampling; sampling frame used was a list (obtained from ZPS headquarters) of all prisons and numbers of inmates (both sexes) nationwide. Cochrane formulae used to calculate sample size. Employed multistage sampling with the following characteristics; Stratified by males and females and collected adequate samples to ensure at least 5% margin of error and 95% confidence level for both Clustered by prisons and visited all four regions Calculated samples for males and females independently using probability proportional to sample size (PPS) for each prison site. Ensured that each inmate had equal probability of being selected; Simple random sampling used to select participants; picked numbers from a hat and then they were called out until sample target was achieved.

Step 7 a): Cross sectional anonymous survey on risk behaviour (2) ZIM Situation Inclusion criteria Inmates > 3 months stay in prison > 18 years of age All 46 prisons in the country Recruitment of prisoners: All inmates assembled at one place and informed of the study aims and benefits. All willing participants had further explanations of the study and signed informed consent forms. No incentives as this is against national rules and regulations. Keeping data anonymous; No names were used at any point, instead numbers were used. UNODC Toolkit Inclusion criteria Recruitment of prisoners Keeping data anonymous; Barcode labelling Simple numbering system

Step 7 b): Cross sectional anonymous survey on risk behaviour UNODC Toolkit HIV testing methodology; ELISA Western Blot Rapid Test Kits ZIM Situation HIV testing methodology; Used rapid test kits in accordance with the national serial HIV testing protocols. First used Determine Then used SD Bioline to confirm any HIV positive results Used Insti to decide if the two above did not agree.

Step 8: Analyse and interpret data UNODC Toolkit Understand the trend and impact of HIV and AIDS in the prison system Determine the characteristics of HIV-infected persons and persons engaged in high risk behaviours ZIM Situation Analysis was done using the Statistical Package for Social Sciences (SPSS version 17.0) Relationships between variables were identified using cross tabulations, frequencies and Chi Square Tests e.g. Length of stay of prisoners and risk behaviours Risk behaviour versus HIV positive inmates

Step 9: Prepare final report UNODC Toolkit Should answer the objectives ZIM Situation Deliverables include Estimated HIV prevalence Findings regarding availability and accessibility of HIV services in prison, as well as common risk behaviors. Recommendations Proposed action plan

Step 10: Focus Interventions UNODC Toolkit Results of the assessment should allow for tailoring the response to the situation and needs. ZIM Situation It is our hope that this needs assessment will indeed guide future interventions regarding HIV and AIDS in prison Zimbabwean settings.

NDATENDA!