By Royston King
PRISONS hold perhaps the highest concentrations of persons infected with HIV and those at greatest risk of acquiring HIV by intravenous drug use and sexual contact.

It is not difficult to see that HIV interventions implemented in correctional settings are among those with the greatest potential to have a substantial impact on the epidemic. Incarceration provides a remarkable public health opportunity for screening, counselling, and treating those in captivity at high risk of HIV infection and transmission, many of whom will eventually be released and return to their communities.

It is therefore critical that our own prison system pay attention to those inmates who are infected with the virus. But many of us know precious little of what is really happening in the facilities. The Guyana Prison Service (GPS) is a national prison system. It has five prisons spread out over the northern part of our country. The GPS can best be described as a para-military organisation. It falls under the Ministry of Home Affairs.

I spoke with the Director of the Prisons Service, Mr. Dale Erskine, and two of his senior officers to find out how the authorities are dealing with HIV/AIDS behind these prison bars.

I was particularly intrigued by his knowledge, insight and forthrightness on the issue. He demonstrated a very keen sense of awareness of the need to encourage education and leadership among his staff. He believes that much can be done for inmates living with the virus if ranks show good leadership and commitment to their tasks: “They need to be professional at all times,” he said.

In reality, there are 29 cases of HIV spread across the prisons in Guyana. However, the Ministry of Home Affairs has been very proactive in its involvement in HIV/AIDS in respect of the control and reduction programme in the prison. The service has been encouraging and promoting ongoing training and the appropriate response to HIV/AIDS. Last year, there was the handing over of the High Dependency Unit, which was an area specifically identified and located at the Lusignan Prison.

Funding was provided by the World Bank. Persons who are HIV-positive can be accommodated and receive the appropriate treatment. Presently, there are 14 persons in this unit. But other prisoners who are HIV-positive are getting similar treatment. Some might even be working in the normal way on projects and doing various activities like the other inmates outside of these facilities.

There is no discrimination. So, those who are infected are really integrated into the system. I asked the Medex at the prison, Ms Roxanne Parkinson, what was the reaction of the inmates to those who are infected. Her response was: “They are respected because they have a good interaction among themselves… they are all involved in whatever programmes we have, there is no segregation.” Prison Chaplain, the Reverend Fay Clarke, feels there is something deeper at work here. “I think the lack of discrimination and stigmatisation is also as a result of the extensive work that has been put in by the Ministry of Home Affairs from 2003. We have staff and inmates who are peer educators. We have a number of external facilities and non-governmental organisations and groups who are committed to assisting in training and education,” she said. Getting inmates involved in peer education has been effective because they understand how to communicate the message to their colleagues; they are more receptive to the information because they feel more comfortable listening to their friends and therefore act on the information they receive.

Low rates of treatment acceptance and compliance among HIV-infected prison inmates are common myths, Research has shown that over 80 per cent of prisoners living with HIV will accept counselling and treatment offered in an appropriate setting, and that 85 per cent of them will adhere to rules. This rate of compliance is higher than that typically seen in controlled clinical trials. Factors associated with medication adherence in prison facilities include the health status and beliefs of the prisoner, medication dosing and side effects, and the availability and stability of healthcare services

I asked the Medex whether all the prisoners infected were infected prior to their incarceration. She said yes. How did you know? I asked. Her reply was: “There is a medical admission procedure… persons coming in to the prison for the first time, we ask them certain questions, their answers are documented on their medical sheet and that is used for future reference. Just the medical staff know the details of that information… it is confidential.” The Medex assured me that no inmate got infected inside the prisons; They were all infected before they got in. Many of them were already attending clinic and receiving treatment.

However, maintaining confidentiality is one of the best ways to maximise acceptance of HIV testing and treatment by jail and prison inmates. Breach of confidentiality is uncommon in the correctional setting, but information ‘leaks’ are common, and prisoners are quick to develop mistrust of health services and correctional staff as well as fellow inmates. Notwithstanding official policy, confidentiality of HIV-related information is difficult to maintain in a prison setting, and many officers and inmates gain access to medical records and argue they have a right to know who is HIV-seropositive.

It is interesting that there is no system of mandatory testing in the facilities. Teams from the Ministry of Health and other allied agencies visit and conduct voluntary testing and counselling. Prisoners are not forced; they have to volunteer to be tested. I asked the Medex whether she thinks testing should not be mandatory.

The nature of the prison environment seems to suggest that it should be, but there may be other considerations involved that may not allow such an action by the authorities. Still, it should be given some thought, in the interest of lowering the risk of HIV transmission among inmates.

Whatever happens with prisoners behind bars also affects their home and families, and sometimes even the communities in which they reside. Naturally, those who are infected in jail lean heavily upon their families. The prison authorities must have a system which allows this linkage to facilitate greater attention and care on the part of the relatives of inmates so affected. The Reverend Fay Clarke said that in most cases, there is this relationship. “We have had one case where family members requested early release for a prisoner with AIDS to spend time with him because they felt that he was rapidly approaching the time of death. We have not seen cases where the families abandon inmates who are HIV-positive.” She said that there needs to be a more awareness of other STIs (Sexually Transmitted Infections) because if people can come to understand that they can be infected with an STI, then they would not be in denial that they can actually contract HIV/AIDS. People also need to know of related illnesses like Tuberculosis, and Diabetes Mellitus.

There are about 90 female prisoners in the prison system. They would need a bit more attention. Sometimes they throw hints about the condition of other inmates, the Medex told me. This affects the relational approach used by the authorities to encourage and motivate the prisoners to do better in life. There were cases where female inmates had partners in the Camp Street facility who’d contracted the virus. In one case, the man died and then the woman died. It was very sad. In another, both partners were in prison. He had AIDS and died; the woman was in jail and there was no one to look after the children. So the work of the authorities sometimes spills beyond the bars of jail.

But the way prisoners behave have a lot to do with their culture, though the prison system has a culture of its own. There are certain aspects of individual and community culture that affect a person’s attitude. As the Reverend Clarke observed: “Some men they feel they need to be sexually dominant as a show of their manhood. So there is need to target such men, through moral and other education, to make them aware of their value, responsibility, and how to behave. This should be linked to self esteem. If someone feels that he or she has no self worth or value, then he or she might behave irresponsibly… sometimes you hear them say it. ‘I have been in here for five years; so if anyone offends me, I can hurt them and spend another two years; no big deal.’ Whether it’s HIV/AIDS or any other situation, once the person recognises that there is purpose and reason for living, then he or she is likely to change their behaviour. Some people who have negative or anti-social behaviour hold strong to that culture that says something must kill you. But once you change that mindset, there will be change.”

Interestingly enough, people turn to religion and faith for comfort and help. The Reverend Clarke said that she has seen inmates giving their lives to God and finding help, even with their physical condition. In one case, an HIV-infected prisoner had his skin rash cleared up through prayers. “It was amazing!” she said.

On reflection, Director Erskine said that he is pleased with the programme to deal with the disease in prison. “When you look at where it was to where it is today, I think we have made tremendous efforts… not only our involvement and resources, but by collaboration with the Ministry of Home Affairs and the Ministry of Health. They have helped us with equipment, beds and other things that have enabled us to do a better job,” Erskine said. However, there are other challenges that militate against the efforts of the authorities; challenges such as space, the number of prisoners, and the lack of more

high-tech equipment to conduct a greater range of medical intervention. In many cases, inmates have to be sent to the hospital. Erskine feels that the prison should have the capability to deal with minor medical interventions; that only very serious issues of medical complaints should be sent to the hospital. He believes that trust is crucial to inmates accepting treatment. As a result, whenever they are sent for medical attention, they are supervised by a GMO. However, there is much to be done, because prisoners are entering the facility with a larger range of illnesses, like hypertension and diabetes mellitus. The prison needs the capability to diagnose these at an early stage and treat them in a meaningful way, because the system has the responsibility to protect the lives of the inmates.

According to Mr. Erskine, over the last two years, the institution has expended about $15M. But, he noted that it is policy-driven and managed in a collaborative way by the Ministries of Home Affairs and Health and the Guyana Prison Service.

In all of this, we, sometimes, forget the people who are actually providing the service to the inmate – the Prison Officers. I posed the question of protection of those officers who must face the daily challenges of dealing and caring for all prisoners, including those infected with the virus. Ms Parkinson said: “We have the international safety precaution. Some of them are fearful to deal with them, but they still do their job.” But there may be prisoners suffering with HIV who may use their condition to threaten a staff or influence or manipulate the system. According to The Reverend Clarke, if someone behaves in a threatening manner, or attempts to hurt an officer or inmate, then he or she will be segregated. This is referred to as removing that prisoner “from the general public.”

Director Erskine noted that education is one way of helping officers protect themselves. Also, he holds the view that officers could get inmates to cooperate by their ability to lead.

Stepping back, there appears to be a need for continuous intervention by the authorities, even after prisoners having the virus get out of prison. Ms Parkinson said that before they leave the system, they refer them to the appropriate agency or institution so that they can get help.

Many strategies have been employed in the prison in response to the growing problem of HIV infection among inmates. Some of these strategies have been implemented, while others have been structured to provide HIV education, prevention, and treatment services to inmates prior to, and following, release. The most common HIV intervention strategies employed in correctional settings include HIV serologic testing from the general prison population, establishing special healthcare units for HIV-positive inmates, and providing HIV counselling and risk reduction services.

HIV-infected persons released from correctional institutions typically encounter difficulties gaining the acceptance of people in society. Many of them are turned away because of their history. People reject them and leave them on their own without support. As a result, quite a few end up right back in prison. The Reverend Clarke believes that it has a lot to do with the economic circumstances of these prisoners. Poor economics result in bad nutrition, hunger and desperation. The need to have even the basic things in life, like a proper place to live and good clothing remain unfulfilled because of a negative economic situation and rejection.

Clearly, prisons and other such facilities have a moral and legal responsibility to prevent the spread of HIVAIDS and other infectious diseases among inmates, and to staff and to the public, and to provide a level of care for inmates living with HIV comparable to that available in the local community. Whether HIV testing should be mandatory or voluntary is seriously contested by administrative and advocacy groups.