In 2000, when former South Africa President Nelson Mandela spoke at the International AIDS Conference in Durban, the former prisoner awakened the world’s conscience. It was not until the AIDS conference returned to Durban this year, however, that health access in prisons took center stage. In the meantime, an effort sparked by a session at that earlier conference introduced HIV and TB testing and treatment to prisons in the Caribbean . . .
DURBAN, South Africa – It was 16 years ago at the 2000 International AIDS Conference here that Dr. John May, an American correctional physician, attended a presentation on the infectious disease-fueling conditions of prisons in the Dominican Republic. Overcrowding there, as well as grossly inadequate sanitation and nutrition exacerbated risks among inmates already greatly more vulnerable to infectious diseases than the general population. In addition, twice weekly visiting days, when facility gates were opened to wives, girlfriends, commercial sex workers and family members, exposed surrounding communities to another cycle of risk. It was a cycle that Dr. May had begun seizing opportunities to break in Cook County, Ill. jails at the start of his career, and had continued since, in Washington, DC, and across the United States. He saw opportunities in correctional settings — both for infectious diseases to spread, and opportunities to counter them by offering the kind of health care services too often out of reach for incarcerated people.
Based in South Florida, he also knew, as health officials are seeing once again this year during the spread of Zika virus, how outbreaks that have flourished in the neighboring Caribbean can make landfall in U.S. communities among tourists, immigrants, and other travelers. So he went to the island of Hispaniola, shared by the Dominican Republic and Haiti to see what could be done.
Dr. May returned to Durban this year to an International AIDS Conference where the theme of “Access equity rights now” encompassed responses to infectious diseases in prisons and jails where tuberculosis rates are estimated to be as much a 100 times higher than those among the general population, and HIV rates are estimated to be from two to 50 times that of the general populations of their settings.
Early on July 20, when, later in the day, a panel would discuss the broad issues highlighted in the Lancet issue on HIV and related infections in prisoners, Dr. May discussed the impacts of collaborative work, and the introduction of health systems in prisons. In the year following the 2000 conference, he had visited prisons in Haiti and the Dominican Republic where deaths from HIV-tuberculosis co-infection were common, and he had worked with a handful of volunteers to launch Health through Walls. A nonprofit organization based in Miami, it had been started by him bringing surplus supplies and equipment to prisons, predominately in the Caribbean, from U.S. prisons, including tests for HIV. The organization had introduced screening for infectious diseases to correctional settings in resource-limited countries. It had built systems to provide care and treatment to prisoners with HIV and TB in Haiti’s Prison Civile, and the Dominican Republic’s La Victoria prison. Health through Walls had received grants that allowed it to hire local physicians and form partnerships with local organizations, including the Haitian GHESKIO to offer specialty training, laboratory support, access to antiretroviral medications, and treatment linkages for released prisoners and it had worked to establish foundations for sustainable systems of continued care, treatment and prevention.
In 2009, Health through Walls had received the first USAID grant to be awarded to a prison health program, allowing the organization to coordinate and conduct large-scale voluntary medical screenings and examinations for each of the more than 4,000 prisoners at Haiti’s national prison then (more than five times the capacity it had been built to house), creating a medical record for each prisoner, established systems of intake screening, chronic care clinics, and discharge planning. At the same time, through the partnerships it had formed it began to train prison officers and staff about HIV, tuberculosis, sexually transmitted diseases and cholera. In the years since, the organization has addressed the overcrowding that exacerbated disease spread at the Prison Civile by partnering with the Vermont-based Rural Justice Center to accompany medical screenings with a legal component. That effort, with attorneys and law students interviewing and assisting prisoners, led to the release of some prisoners.
In 2014, the organization reported that despite rising prison populations and overcrowding levels among the highest in the world, death rates in Haitian prisons had been reduced more than three-fold in the last three years. From 2014 to 2015, 303 prisoners were identified with TB, 42 of whom were co-infected with HIV. Of 1002 patients with HIV, 488 received antiretroviral treatment that year.
“The Haitian Ministry of Health is embracing test-and-treat guidelines,” Dr. May said, “so soon we will be able to make an even bigger impact, and not have to wait.”
In a year when the focus of responses spurred by talk at the 2000 conference is fixed on those left behind, Health through Walls also is expanding its reach. This year, it has begun work to provide health screening and links to those visitors, lined up outside the prison in the Dominican Republic whom Dr. May first learned about in a session here 16 years ago.