In 2010 a Human Rights Watch report charged the Zambian prison system with severe overcrowding, gross human rights violations and conditions that perpetuate infectious diseases, notably tuberculosis.
The report led to a partnership between the Centre for Infectious Disease Research in Zambia with funding from the President’s Emergency Plan For AIDS Relief, and Zambia’s Ministry of Health to pilot TB control program in three of the nation’s prisons.
In Kabwe, Lusaka Central and Livingstone, the pilot program included TB screening of inmates, reducing the numbers of inmates in cells, creating/HIV isolation cells, training of prison officers in TB control and prevention, and training inmates to serve as peer educators. TB drugs were provided and nutrition improved. Facilities were renovated to improve infection control.
Over the course of the pilot, 366 inmates were diagnosed with TB with 83.8 percent accepting HIV testing. Thirteen percent of the confirmed cases had a prior history of TB and of the TB patients who agreed to HIV testing, 33 percent were co-infected. Of those diagnosed with TB, 90 initiated treatment and 56 percent were cured or completed treatment. Forty percent of the inmates diagnosed with TB were lost to follow-up.
Unexpected release and the frequent transfer of inmates to other facilities were major challenges to the program’s success. In addition, the lack of diagnostic technology within prison walls and the inherent delay in getting results from TB culture contributed to many patients not receiving treatment. Facility overcrowding, in addition, continues to be a significant issue.
Those challenges to the pilot activities helped generate recommendations, including that rapid TB diagnostic tools, including GeneXpert be made available in prison contexts. In addition the pilot pointed to the need for links between national TB programs, prisons and community health clinics. The pilot also led to the recommendation that prison health management teams be developed, and that an electronic prisoner management and tracking system be created to reduce loss to follow up and promote continuity of care.
Some changes and responses to the pilot are already occurring. A prison service medical directorate has been established and the government is opening more open air prisons to ensure infection control. The health ministry and its partners continue to do TB assessments in other prisons and have recommended the acquisition of GeneXpert.
With HIV prevalence of 15 percent — 1.2million people living with HIV – 75 percent of adults with TB are co-infected with HIV, a representative of Zimbabwe’s Ministry of Health said. And while 86 percent of the general HIV-infected population eligible for antiretroviral treatment is getting it, that rate drops to 60 percent among those who are coinfected with TB.
The government offers TB services in all 1560 health facilities, and has 980 HIV treatment sites.
To respond to the need to scale up ART access for TB patients, the country is piloting a one-stop shop for coinfected patients where antiretroviral treatment and TB treatment are provided by the same nurse in the same day. Community health care workers provide daily directly observed therapy and also support isoniazid preventive therapy. Supporting health care workers in recording and reporting each of their encounters, it was noted, is essential for the success of this data-driven supervision.