In Swaziland, where 35 percent of the prison population is HIV-positive and the incidence of tuberculosis is twice that of the general population, TB/HIV services in correctional facilities is a critical public health intervention.
In 2009, with funding from PEPFAR through the CDC, ICAP began partnering with the Ministry of Health to scale-up HIV care and treatment by expanding services from hospitals and health centers to clinics and local facilities. As part of these efforts, ICAP revised the Royal Swaziland Police’s policies and strategies, expanding HIV care and treatment to all three branches of the Uniformed Services, a special population comprised of the military, the defense force, and officers and inmates of correctional facilities.
In Swaziland’s prisons, HIV prevalence among men is more than 10 percent higher than the national average. Through ICAP’s partnership with the Uniformed Services, ICAP now works in 13 correctional facilities in all four districts in Swaziland, introducing the first on-site HIV care and treatment services for inmates. Out of 13 of the correctional facilities, eight currently provide antiretroviral treatment (ART). Prior to ICAP’s intervention, the lack of on-site services impeded care. HIV-positive inmates had to be transported off site for care, a process which often disclosed their status and discouraged inmates from seeking care or adhering to treatment.
To increase on-site availability of TB and HIV services, ICAP worked with Uniformed Services to renovate health centers at correctional facilities, providing essential supplies and equipment. ICAP’s multidisciplinary team of senior nurse advisors, clinical advisors, and adherence and psychosocial advisors worked with eight of the 13 correctional facilities to become designated ART facilities and supplied medicines to support continuous treatment to inmates.
ICAP bolstered these efforts by recruiting over 40 HIV-positive inmates as expert clients. ICAP trained them in health promotion, treatment support, and adherence counseling and provides a stipend for their support. Since expert clients live in the general inmate population, they serve as role models to other inmates, they reduce stigma through leadership, and they also offer informal opportunities for inmates to learn about TB and HIV care and treatment options.
As part of the standard operating procedures developed by ICAP and the Ministry of Health, inmates receive transition assistance to guide care and treatment after they are discharged from prison. Newly-released inmates must be linked to local facilities and receive care within four days of release, ensuring they receive support for a healthy transition back into the general population.
As of September 2014, ICAP had supported HIV testing for over 3,500 inmates and ART for over 410 inmates in prison facilities. Of the 114 patients newly-enrolled on ART in 2013, 89 percent were still in treatment after 12 months.
“ICAP’s partnership with Uniformed Services, specifically in the correctional facilities, represents and incredible opportunity to provide direct, high-quality HIV services to one of Swaziland’s most vulnerable groups,” said Wafaa El-Sadr, MD, MPH, director of ICAP and Mailman School professor of Epidemiology and Medicine.