Initiatives in the past four years have greatly increased inmates’ access to healthcare.
The article titled “Prisoners’ health rights routinely violated in SA’s jails” in the Mail & Guardian of April 24 raised issues related to tuberculosis (TB) in prisons and gave the impression that not much has been done by the government to protect inmates from contracting and developing TB. This is not accurate, however.
Protecting inmates from infectious diseases such as TB is important not only for their health; it also makes good public health sense. For most inmates, incarceration is temporary: about 25 000 of the 160 000 inmates in prisons are released annually. Protecting them from TB and HIV is therefore not only good for them, but also for the population at large.
In 2011, the departments of health and correctional services launched a joint response to TB in prisons. In 2012, the health department developed guidelines that currently inform the management of inmates with TB or HIV.
The Global Fund to Fight Aids, TB and Malaria made available R500-million to South Africa to address HIV and TB in prisons, including multiple-drug resistant TB. About R150-million has been spent on strengthening the HIV and TB programmes in correctional centres since 2013 and to improve health services in such facilities. Health worker capacity, for instance, has been bolstered and equipment has been improved to provide better quality HIV and TB services. The systems have been redesigned to routinely screen, counsel and test inmates for TB and HIV. Correctional services facilities are also being assessed from an environmental perspective so that disease infection control and prevention can be improved.
Screening and diagnostic interventions
There has been a deployment of 164 counsellors and 36 data capturers to the correctional centres. Specific TB diagnostic machines called GeneXpert, which can diagnose all forms of TB within two hours instead of sending samples to a laboratory, have been installed in seven management areas that collectively house about one-third of all inmates. The remaining correctional centres are linked to GeneXpert machines in the nationwide laboratory system run by the National Health Laboratory Services. In addition, three mobile digital x-ray machines, each costing R1.5-million, have been bought to screen inmates for TB.
By February, 167 462 inmates were routinely screened for TB – something that didn’t happen prior to 2013. Of these, 66 862 inmates were tested for TB using the GeneXpert (fewer than 6 000 were tested this way prior to 2013) and, of these, 3 887 inmates with drug-susceptible TB and 176 inmates with multidrug-resistant TB were diagnosed and initiated on treatment.
It is acknowledged that the spread of TB in correctional centres must be improved and this requires better air-borne diseases infection control. The majority of correctional services facilities have been built with only security considerations in mind and with little or no emphasis on the basic standards for infection control.
Using resources from the Global Fund, the health department, working with the Centre for Scientific and Industrial Research, is undertaking infection control risk assessments. These assessments will inform corrective plans that will guide infrastructure adjustments to minimise cross-infection among inmates.
Part of broader strategy against TB
The enhanced response to the TB epidemic in correctional services facilities is not being done in isolation. It is part of a larger effort to turn the tide against South Africa’s TB epidemic. Health Minister Aaron Motsoaledi has, over the past few years, advocated for radical interventions in dealing with the TB epidemic, with the same vigour that he brought to South Africa’s world-renowned fight against HIV.
The initial steps included a fast-tracked roll-out of the GeneXpert that has enabled South Africa to be the only country in the world that provides access to such testing to all its citizens. South Africa now has the largest number of GeneXpert machines of any country globally and all citizens have access to this technology.
In October 2014, during the international Lung Health Conference in Barcelona, Motsoaledi challenged the world to adopt bold targets against TB. Based on similar HIV targets, he called for the 90,90,90 targets to deal with TB globally, with particular focus on people with an elevated risk of TB infection (including inmates) by committing to:
- Screen at least 90% of people for TB;
- Initiate treatment for at least 90% of those with TB; and
- Successfully treat at least 90% of those with TB by getting them to complete their drug courses.
These targets have been adopted by Brazil, Russia, India, China and South Africa. The Stop TB Partnership, a global TB advocacy agency, will use these bold targets in its new Global TB Strategy to be launched in November.
Rates will probably reduce
As the world adopts these targets, South Africa has moved rapidly to give practical meaning to how these goals can be met. On World TB Day on March 24, Deputy President Cyril Ramaphosa launched a massive TB screening campaign that will run over the next three years. This campaign, which will initially focus on inmates, miners and mining communities, seeks to reach at least 135 000 inmates, 459 088 miners and 4 597 342 residents in six districts.
It is more than probable that these interventions will see the rate of new TB infections reducing in the country generally and specifically in correctional services facilities. In fact, over the past three years the numbers of deaths from TB have decreased by more than 25%, from 55 102 in 2011 to 40 542 in 2013.
TB is a disease of poverty – poor housing, unemployment and food insecurity fuels its spread. The response therefore cannot only be medical, but should be part of a broader socioeconomic intervention.
But simple infection control methods, such as covering one’s mouth when coughing, keeping windows open, identifying TB symptoms – coughing for more than two weeks, night sweats, chest pains, unintentional weight loss – and seeking treatment early are all things that every South African can do to help end the TB epidemic.
Yogan Pillay is the director for HIV and TB delivery at the Bill & Melinda Gates Foundation. Prior to this he was the South Africa country director of the Clinton Health Access Initiative before which he spent more than 20 years in the national health department in various management positions.