South Africa had an estimated 500 000 people diagnosed with tuberculosis (TB) in 2011, the third highest number of cases in the world, after India and China. HIV increases the risk of TB by destroying the immune system and making it more likely for a person to get sick with TB after being infected.
There are more people living with HIV in South Africa than in any other country – an estimated 5.6-million people. In 2011, 65% of TB patients in South Africa were also HIV positive.
The good news is that TB can be cured with six months of daily treatment, whether or not a person is infected with HIV. Within days of starting treatment, patients are no longer infectious, so early diagnosis and initiation of treatment are important to prevent the spread of TB. This is particularly relevant in correctional facilities, where prisoners are in cells with up to 60 others for most of the day.
Every day, between 200 and 300 new awaiting-trial prisoners are admitted to the Pollsmoor Correctional Services Centre in the Western Cape. Between 350 and 400 cases go to court each day and about 20 detainees are released or remanded on bail.
Pollsmoor accommodates more than twice the number of prisoners it was designed for. Overcrowding is at 263% – mostly because of awaiting-trial detainees.
TB is an airborne disease, so overcrowding contributes to its spread. And the daily release of prisoners on bail or because they have completed their sentences means that TB does not stay behind bars. The health of the prison population cannot be separated from that of the public and should be of concern to everyone.
The department of correctional services, whose primary mandate has always been to provide security, is collaborating with the health department to bring health policies and procedures in prisons into line with those applied to the general population.
However, there are still significant differences in the way health services are accessed and provided behind bars, and a tailored set of health practices is essential.
In February, the department of health convened a meeting of representatives of correctional services, the National Health Laboratory Service and the TB/HIV Care Association, a non-governmental organisation, to formulate a set of guidelines on how to manage TB and HIV in correctional facilities.
Proposed innovations in prison TB and HIV management
Several innovations have been proposed. These could rapidly improve the way in which TB and HIV are managed in prisons. They include ways of finding new cases early, getting patients started on treatment, and keeping them on treatment while they are in correctional facilities and once they return to society.
One of the most promising developments is the installation of a GeneXpert TB diagnostic instrument at Pollsmoor. This machine can diagnose TB and also detect resistance to Rifampicin (one of the most important anti-TB drugs) in two hours. Traditional methods of diagnosis would take up to two days, and pinpointing drug-resistant TB through cultures and susceptibility testing could take up to six weeks.
Time delays in diagnosis have a significant negative knock-on effect in correctional facilities. Any prisoner awaiting trial who is sent to court could be released or remanded on bail and not return to prison. This means that if there is a delay between TB screening, diagnosis and starting treatment, there is a real possibility the detainee could leave the correctional system untreated and still infectious. If the inmate does return, the close confines of the prison mean that any delay in diagnosis or treatment carries a very high risk that other detainees will be infected.
A TB diagnosis within a few hours of being screened enables an inmate to be started on treatment the same day. After two to 14 days on effective treatment, most detainees will not be infectious.
The GeneXpert was installed by the TB/HIV Care Association. The project is funded by a grant from the Global Fund Against Aids, TB and Malaria. In a community setting, each person with TB typically infects 10 to 15 other people, so early diagnosis and treatment can prevent many TB infections in prisons. The health department is funding a massive roll-out of GeneXpert machines as the first diagnostic test for TB in National Health Laboratory Service facilities throughout the country by the end of this year.
The new guidelines recommend HIV counselling and testing with screening for symptoms of TB (cough, fever, nights sweats or weight loss) for all those admitted to correctional facilities, biannual or annual TB screening for people already incarcerated and screening of all contacts of detainees diagnosed with TB. The guidelines also focus on continuity of care by ensuring that detainees already on TB or antiretroviral treatment for HIV continue treatment when they are admitted and that released detainees continue to take their pills in state clinics in their communities.
However, these guidelines require additional human resources.
At Pollsmoor, the care association has made 10 lay counsellors available to provide HIV counselling and testing with TB screening, a lab technician to operate the GeneXpert, and a professional nurse to help prison staff to diagnose TB and to start detainees on appropriate treatment. A data capturer will assist in ensuring that relevant data is collected to ensure proper patient management and to monitor the service.
This additional manpower is also necessary because of some of the idiosyncrasies in the way prisoners access health services. Detainees may give a false name to police when apprehended to avoid being charged with crimes associated with their real name. This makes it difficult to trace health files to find out what treatment regimen a patient is on.
Similarly, if a detainee needs to start treatment and is called by facility officials, they may fear that they are being summoned for additional charges and “hide” by not responding. Inmates may also falsely claim to be on either TB treatment or antiretrovirals in order to access what they perceive to be preferential treatment in correctional facilities. Extensive verification is therefore necessary. Additional time and communication resources are critical to tracing health records and inmates.
Once a patient has started treatment, it is important that he or she completes the full course of medication and that anyone who starts taking antiretrovirals continues for the rest of their life. Patients should take responsibility for their own health by taking their medication as prescribed.
The new guidelines suggest that a detainee attending a court date should therefore have at least seven days' medication on their person in case they are released. After release, or if bail is granted, the guidelines recommend that the person be linked with a health facility outside the prison that can continue to provide medication and support.
A steering committee has been formed at Pollsmoor with correctional services, the health department, the association and National Health Laboratory Services to monitor implementation of the new national guidelines and ensure continuity of care.
It is the right of every detainee to access health services. This does not infringe on the rights of the general public, but is advantageous to everyone. Ensuring that detainees have access to rapid, state-of-the-art diagnosis and effective treatment will contribute to controlling TB in South Africa.
Harry Hausler is the chief executive of the TB-HIV Care Association in Cape Town