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

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.

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

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

Prevalence among inmates-Gender HIV prevalence was significantly different between male and female prisoners. 32.34% 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

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

Disease prevalence and incidence among inmates according to Age

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

Prevalence among Officers in Correctional Institution

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.

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.

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

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

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 15 - 20 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.

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

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

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 !!!!