Human immunodeficiency virus care and management in incarcerated populations in Sub-Saharan Africa between 2010 and 2022: A narrative review

Abstract

Background

Different countries in sub-Saharan Africa (SSA) have established guidelines to reduce HIV transmission and improve its management in prisons. This narrative review aimed to examine established literature on HIV care and management among incarcerated persons in SSA to identify successful interventions that could inform improved guidelines, policies, and practices related to the clinical care of this population.

Methods

We searched PubMed, Scopus, Web of Science, Embase, and TRIP Medical Databases in August 2022 for articles published between 1st January 2010 and 30th June 2022. We identified 27 eligible articles based on the Population/Concept/Context framework.

Results

HIV screening primarily involved mass campaigns rather than formal prison programmes, with limited implementation of universal testing and treatment. Although a few studies reported on access to antiretrovirals (ARVs), prisoners in urban areas and females had disproportionate access. Barriers identified include poor living conditions, high levels of stigma, and resource constraints. Inter-prison transfers, release from prison, and lack of established programmes hindered follow-up and linkage to care.

Conclusions

The implementation of strategies such as universal testing and treatment, human resource strengthening, financing plans for testing, ARV care, and frequent assessment of risk could improve HIV care and management in prisons in SSA.

Keywords

Human immunodeficiency virus Prisoners sub-Saharan Africa antiretroviral therapy narrative review

Background

In many countries, the prevalence of HIV in prisons is reported to be several times greater than in the general population.^1,2 Compared to other regions of the world, sub-Saharan Africa (SSA) has the highest proportion of incarcerated people living with HIV.² A meta-analysis of the prevalence of HIV in prisons reported a pooled prevalence rate of 6% for Africa.² Mirroring global trends, the prevalence rates of HIV are higher in female prisoners than in their male counterparts.^2,3 The high prevalence of HIV in prison populations in SSA has been attributed to factors such as prison overcrowding, risky sexual behaviour before and during incarceration, drug injection, weak infection control, limited access to HIV services, and recidivism.^4,5

While HIV poses a significant physical health and psychological burden on individuals, its effects in incarcerated populations are more severe. For instance, the incidence of tuberculosis (TB), a major cause of mortality among people living with HIV (PLHIV), is considerably higher in correctional settings.⁶ For instance, Edge et al. reported that co-infection of HIV and TB among prisoners ranged from 2.4 to 74.3%.⁷ Other comorbid conditions such as liver fibrosis are higher among prisoners living with HIV.⁸ Also, the double stigma of being incarcerated and living with HIV has significant mental health implications.^9,10

Incarcerated persons often receive insufficient attention in their HIV care compared to PLHIV in the general population in Africa.³ Additionally, guidelines and policies on HIV care are not routinely followed in prisons in Africa.^11,12 The WHO consolidated guidelines for key populations focus on specific areas including “HIV prevention, harm reduction, HIV testing and counselling, HIV treatment and care, sexual and reproductive health, and the prevention and management of co-infections and co-morbidities”.¹² However, policy implementation varies significantly across countries, with some countries such as South Africa, having made more progress in translating policy into action, compared with other SSA counterparts.³ Furthermore, even in countries where guidelines have been adopted, their degree of efficacy has not been fully elucidated.¹³ The overall impact of HIV policies in prisons in SSA requires evaluation to determine their efficacy, progress made, and limitations to their implementation.

Numerous barriers may prevent adequate, sustainable, and effective care of incarcerated persons. These include limited human resource capacity, poor financing, HIV-related stigma and lack of understanding, weak referral systems or linkage to care, and inadequate health and prison infrastructure.^3,14 Furthermore, stigma by prison staff affects management and follow-up as well as trust between inmates and their service providers.¹⁵ Individual-level factors such as mental health, risky behaviours (e.g., substance abuse and unprotected sex), and violence also contribute to challenges in management among incarcerated persons.¹⁴ Timely reviews of progress made and persisting barriers in care are useful and necessary to direct interventions to improve care and management and thereby reduce the disease burden in this vulnerable population. This narrative review aimed to examine established literature on HIV care and management among incarcerated persons in SSA to identify successful interventions that could inform improved guidelines, policies, and practices related to the clinical care of this population.

Methods

We performed a comprehensive literature search from multiple data sources including PubMed, Scopus, Web of Science, Embase and the Trip medical database in August 2022, to identify original research articles on HIV care and management among incarcerated persons in SSA. Search terms used to identify literature included ‘incarcerated’, ‘prison*’, ‘inmate*, ‘convict*', ‘jail*’, ‘HIV’, ‘Human Immunodeficiency Virus’, ‘Persons living with HIV’, ‘PLHIV’, ‘AIDS’, ‘acquired immunodeficiency syndrome’, ‘ART’, ‘ARV’, ‘Retrovir*’, ‘sub-Saharan Africa’, ‘Africa’, and ‘Africa South of the Sahara’. The Boolean terms ‘AND’ and ‘OR’ were used for the final search results. The search terms were formed using the ‘Population (or participants)/Concept/Context’ (PCC) framework. Eligible materials were original research articles including cross-sectional studies, cohort studies, case-control studies, and systematic reviews published between 1st January 2010 and 30th June 2022. Both qualitative and quantitative studies were included with no language restrictions. For articles written in French, the English version of the article was obtained from the publisher. Where this was not possible, Google Translate was used for translation, with corroboration by a French-speaking researcher for any unclear translation.

The title and abstract of each article were independently reviewed by three reviewers for inclusion. The inclusion criteria were 1) Original research articles on HIV care and management in incarcerated persons in SSA; 2) Review articles on HIV care and management in incarcerated persons in SSA; and 3) Articles published between 1st January 2010 and 30th June 2022. Disagreements were resolved by consensus. Themes that guided the review process on which reviewers built a consensus included: 1) Testing interventions (including screening and diagnostic testing); 2) Therapeutic interventions (including ART and non-ART related therapy, and counselling); and 3) Interventions related to linkage to care and follow-up. Our initial literature search identified 349 potential articles, which were imported into the Rayyan software, after which 68 duplicates were removed. We screened 281 abstracts and excluded 235 due to reasons such as studying the wrong population, being unrelated to HIV, occurring outside of sub-Saharan Africa, and the study setting being outside of the prison. Forty-six abstracts were selected for full-text review, after which 27 were identified as suitable for inclusion in relation to this narrative review (see Figure 1). The other 19 papers were excluded because they did not have any data to extract, did not focus on the key themes to be discussed, or could not be accessed in full text.

Figure 1.

PRISMA diagram.¹⁶

Results

Characteristics of studies reviewed

Most studies were conducted in Southern Africa, including 14 in South Africa, 9 in Zambia, 2 in Malawi, and 1 in Namibia. Eight studies were conducted in Western African countries including Nigeria, Burkina Faso, Senegal, Benin, and Togo, and only 2 studies were conducted in Eastern Africa (Ethiopia). Two articles were originally written in French.^17,18 We retrieved the English version of one of these articles¹⁷ from the publisher’s Web site and translated the other¹⁸ into English using Google Translate. Most studies were quantitative (18 studies), 6 were qualitative, and 3 studies employed mixed-methods approaches. Only 1 study had an implementation component. A summary of the studies reviewed is presented in Table 1.

Table 1.

Summary of studies included in the review.

Author, year, country	Aim(s) of study	Study design, study population and sample size	Relevant findings	Key recommendations
Fuge, Tsourtos ¹⁹; 2022, Ethiopia	To compare HIV-positive prisoners to non-incarcerated counterparts on “factors affecting optimal adherence to antiretroviral therapy and viral suppression” (p. 2).	• Comparative cross-sectional study • HIV-positive prisoners on ART and non-incarcerated HIV persons on ART• N = 370 (incarcerated = 74; non-incarcerated = 296)	• 94% of prisoners had viral suppression compared to 95.5% suppression for non-incarcerated persons• Pharmacy refill non-adherence was significantly lower among prisoners (10.8%) vs. non-incarcerated persons (25%)• Prisoners reported lower levels of satisfaction with ART services than their non-incarcerated counterparts• No significant difference between prisoners and non-incarcerated persons in viral non-suppression• Good satisfaction with ART service, number of clinic appointments missed, ability to adhere to specific medication schedule• Accessing ART services from hospitals, lacking PLWHA cell-mate, and having non-viral suppression were associated with lower odds of pharmacy refill adherence• Greater risk of non-viral suppression among female prisoners, prisoners aged 31-35, and stigmatised prisoners	• ART services should be decentralized to primary healthcare facilities including prisons• Enhance peer support programs in prisons• Educational intervention to reduce health-related social stigma
Mukora, Smith ²⁰; 2022, South Africa and Zambia	To describe resources for UTT implementation and provide costing guide for scaling up UTT	• Cross-sectional descriptive design• Study participants included staff in Johannesburg Correctional Facility and Brandvlei both in South Africa and Lusaka Central Prison in Zambia	• The unit costs for HIV Testing Services (HTS): Lusaka Central ($65.15); Johannesburg Correctional Facility ($73.82); Brandvlei ($92.12)• Authors suggested the estimated costs of UTT in prisons are higher than previously reported for HIV care in communities• Substantial variations in estimated costs of ART services across correctional facilities. ($2,640.6 for Brandvlei, $710 for Johannesburg, and $385.5 for Lusaka)• Estimates are higher for correctional facilities than in the community• Authors linked variations to differences in inmate-to-health staff ratio across facilities, differences in staff salary between the two countries, and differences in security requirements across correctional facilities
Naidoo, Subramaney ¹⁰; 2022, South Africa	To assess the prevalence of mental illnesses, personality disorders, and HIV among female prisoners in South Africa	• Cross-sectional study• Study was done in a correctional centre in Durban, KwaZulu-Natal• Sample size: 126 female inmates• Measured mental illness and personality disorders with the SCID-15	• High prevalence of mental illness• Most inmates with mental illness were previously undiagnosed• Lifetime psychiatric disorder in 90.4% of inmates• High lifetime prevalence rates for most mental illnesses and personality disorders: depressive disorder (70.6%), alcohol use disorder (48.4%) PTSD (46.8%), substance use disorder (31.7%), antisocial personality (15.1%), adult ADHD (9.5%), and psychosis (4.8%)• High suicidal behaviour: Past suicidal ideation (64.3%), suicidal attempt (39%)	• Integrate mental health services into prison health care• Need for continuous surveillance and monitoring
Fernando, Woznica ²¹; 2022, South Africa	To assess “the effect of pre-release HIV-related, peer-based rehabilitation programmes on post-release linkage to community-based HIV care” (p. 474)	• Cross-sectional study• Study was done in the Gauteng Province, South Africa• Participants (N = 351; 301 males and 50 females) included HIV+ persons who were on ART at the time of release	• Participation in peer-based rehabilitation was not significantly associated with linkage to post-release care.• Inmates at long-term sites were not likely to be linked to care post-release	• Incorporate peer-based elements into pre- and post-release programs to facilitate linkage to care during re-entry
Chimoyi, Hoffmann ²²; 2021, South Africa	To assess the prevalence and experience of stigma among prisoners living with HIV	• Study was conducted in three correctional facilities in Johannesburg, Brandvlei, and Worcester• Adopted a mixed-method approach• Total sample was 219 (156 males and 63 females)• Interviews (with 39 participants) explored experiences of HIV stigma in HIV-positive inmates	• High uptake of antiretroviral treatment (92%)• Positive self-coping mechanisms and supportive relationships with staff facilitate engagement in HIV care• High level of HIV stigma among incarcerated persons• Concerns about inadvertent disclosure of HIV status and associated stigma adversely affect sustained HIV care• Privacy concerns associated with HIV care in correctional settings• Incarcerated people not living with HIV expressed anticipated HIV stigma due to concerns about involuntary disclosure when accessing HIV care	• Implement measures that ensure privacy in HIV care delivery• Encourage supportive relationships with correctional staff• Promote social interactions among prisoners
Gondwe, Amberbir ⁴; 2021, Malawi	To explore challenges with accessing HIV essential services and prevalence of HIV risk behaviours among prisons in southern Malawi	• Study adopted a mixed methods approach• Quantitative study involved 412 inmates (93.2% males; systematically sampled from six prisons)• Qualitative data based on in-depth interviews with 39 prisoners who were HIV-positive	• Prisoners demonstrated adequate knowledge about HIV and HIV services in the prisons• Generally low prevalence of HIV risk behaviour (e.g., paying for sex); prevalence rate higher in urban than rural prisons; sharing of tools (e.g., razor blades) more common in rural than urban prisons• Prisoners in urban prisons reported more access to HV services and TB screening; however, none of the prisons had PEP• Female prisoners had less access to HIV services and general medical care compared to men• Presence of on-site clinics linked to higher access to HIV services
Fuge, Tsourtos ²³; 2021, Ethiopia	To explore facilitators and barriers to early ART initiation among inmates in South Ethiopia	• Phenomenological approach with in-depth interviewing• 18 participants: 7 HIV+ prisoners on ART (5 males, 2 females); 2 prison officers; 2 prison health care staff; 3 ART service providers; 2 prison administrators; 2 health agents	Barriers to early ART initiation• Lack of resources and testing facilities in prisons• Opt-in approach to HIV testing (test at prisoners’ requests)• Delayed linkage of HIV-positive inmates to ART service providers after testing due to inadequate training of prison health staff• Inflexibility in prison security systems delays ART initiation e.g., prison officers not cooperating with prisoners’ requests to attend external health services• Concerns about privacy during initiation at external health centres.Facilitators of early ART initiation• Access to information through peer education and support	• Improve access to opt-out-based HIV services• Incorporate peer education and support into HIV care• Train healthcare providers and correctional staff involved in HIV care
Kagujje, Somwe ²⁴; 2021, Zambia	To examine prevalence of all forms of HIV and TB in correctional facilities in Zambia	• Cross-sectional data from the Elton John Juvenile Officers’ Health (EJJOH) project• Analysis based on data from 13 correctional facilities• Screen 8160 inmates for HIV and 8267 inmates for TB	• Overall prevalence (14.3%); Prevalence among males (14.3%)• Prevalence among females (25.8%); Prevalence among adults (15%)• Prevalence among juveniles (3.9%)• No significant between residents and entrants in HIV prevalence rates	• Include juvenile-specific TB programming in prison healthcare• HIV programmes in prisons should be gender-responsive HIV• Need for holistic healthcare service delivery in prisons
Naidoo, Ferreira ²⁵; 2021, South Africa	To explore “experiences of contracting and living with or being affected by HIV among female inmates with a lifetime history of mental illness in a South African setting” (p. 1)	• Qualitative approach• Study done in a correctional facility in Durban, KwaZulu-Natal• Participants were 14 adult female inmates with a history of mental illness, and trauma, and lived with or were affected by HIV	• Women mostly accused their husbands of infecting them with HIV, which underpinned their expressions of anger, disappointment, and felt injustice• Women pointed to cultural norms that endorsed multiple sexual partners among men as part of the problem with HIV transmission• Participants expressed fears about their physical health and contracting HIV in prison• Women were less willing to disclose their HIV status due to fear misconceptions of HIV, misconceptions, prejudices, stigma, and discrimination related to HIV• Women felt disclosure was relatively easier in the prison setting than in the home environment
Stevenson, Podewils ²⁶; 2020, South Africa	To estimate “the prevalence of people living with HIV and identify initiation and retention in the HIV cascade of care across five correctional facilities” (p.1)	• Cross-sectional retrospective analysis• Participants were 30,571 adult inmates involved in TB screening and HIV counselling and testing campaign	• 13.0% of those who consented to screening tested HIV+• Total HIV prevalence was 17.7% (95% CI: 17.2 - 18.3%)• 48% of HIV-positive inmates initiated care• 45% of those who started care qualified for ART initial treatment• Women, those over 35 years, and inmates incarcerated less than 1 year had a greater risk of HIV infection	• Strengthen linkage to care especially for new inmates• Strengthen screening upon entry
Mabuto, Woznica ²⁷; 2020, South Africa	To examine “linkage to care, ART continuity, and factors associated with linkage to care among people with HIV following release from prison in South Africa” (p. 324)	• Observational study• Conducted in the Gauteng Region of South Africa• Participants were 351 (301 males; 50 females) prisoners receiving ART at the time of release	• 65% of participants self-reported linkage to HIV care• No post-release relapse in 47% of participants• Older age, initiation of ART during index incarceration and longer duration of incarceration were associated with a higher likelihood of self-reported linkage to care	• Provide individual-level services to address barriers at the individual level• Enhance communication and monitoring of patients between prison health services and community clinics
Herce, Hoffmann ²⁸; 2020, Zambia and South Africa	To examine “clinical outcomes for a prospective cohort of incarcerated people with HIV who were offered a UTT intervention and followed up during the TasP study” (p. 807)	• Prospective cohort study - South Africa and Zambia• 3 correctional complexes (Johannesburg & Breede River - South Africa; Lusaka - Zambia)• Cohort included 822 HIV+ inmates (84% men)• Follow-up at 6 months and 12 months	• 835 (86%) of participants had started ART at follow-up• Median baseline CD4 count for 835 participants who initiated ART is 329 cells per uL; median time of ART initiation across all sites was 0 days• 262 (97%) of participants had achieved viral suppression (<1000 copies per mL) at 6-month follow-up.• 149 of the 835 who started ART remained incarcerated at 12 months○ 114 (77%) of these were retained in care on the on-site programme○ All 149 eligible for follow-up at 12 months had achieved viral suppression	• Transfer between facilities, release from prison, and re-incarceration undermine the continuity of HIV care• Need to link care facilities in correctional settings with ART clinics in communities
Topp, Chetty-Makkan ²⁹; 2019, Zambia and South Africa	To explore “the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa” (p.189)	• Adopted a case-comparison design• Study setting: 4 correctional facilities (1 in Zambia and 3 in South Africa)• In-depth interviews with inmates ²⁵ and 21 stakeholders (correctional managers, health care providers, and policymakers)• Analysis of policy and programme documents	ZambiaUTT implementation at the Zambian study site was highly feasible. Three factors contributed to success:• Alignment with national policy• Openness to different partners for support• Attitudes and environment that encourage HIV care and treatmentImplementation of UTT as a government-led program did not seem sustainable. Factors undermining sustainability included:• Weak funding and resourcing of health activities for the Zambia Correctional Service (ZCS)• Capacity limitation of the ZCS health system• Lack of clarity on the need for UTT in prisonsSouth Africa2 factors contributed to the feasibility of UTT in the South African study sites• Alignment between National UTT policy and study resourcing• Strong internal capacity of the correctional health system and the pre-existing relationship between correctional health officials and NGO implementing partners.Strong prospects for sustainability in South African correctional facilities. 4 major factors affected sustainability:• Strong policy backdrop and political support (facilitator)• Funding and resourcing (barrier)• Organisational capacity and organisational culture (facilitator)• Stressful prison environment and stigma undermine service demand (barrier)	• Feasibility and sustainability of UTT in correctional settings is strongly influenced by national HIV treatment policies• Improve human resource capacity in correctional settings.• Improve ARV stocks in prisons to facilitate testing and treatment
Kumwenda, Nzala ³⁰; 2017, Zambia	To assess “health care needs among adolescents at the Nakambala Correctional Institution in Zambia, using the Beauchamp and Childress ethics framework” (p. 582)	• Qualitative study (in-depth interviews and focus group discussions)• N = 35 (juveniles 13-19 years) and n = 6 staff	• Respondents characterised the prison health care system as inadequate• Adolescent centres receive inconsistent funding and little priority from the stakeholders• Inadequate medical and pharmaceutical supplies, lack of healthcare personnel at the neighbouring facilities, and weak referral systems• Lack of adolescent-friendly health services creates an ethical dilemma for juveniles with regard to health services	• Needs assessment must be conducted from an ethics framework to understand moral dilemmas associated with health needs
Hessou, Dougnon ³¹; 2017, Benin	“To help develop better decision-making tools by determining which behavioral and serological factors influence the likelihood of HIV infection among prisoners” (p. 83)	• Cross-sectional• N = 496 Inmates	• No prisoner indicated using a condom during their most recent sexual intercourse• 65.5% of surveyed inmates received information about HIV/AIDS and 50.6% were given information about condoms• 14.6% of inmates had blood exposure and 1.4% of inmates had HIV• Male inmates and those serving sentences longer than 1 year had higher rates of HIV• HIV prevalence among prisoners was not associated with age, education, nationality and HIV awareness	• Development of tailed communication strategies for HIV/AIDs prevention in correctional facilities• Education on condom use for the prevention of STDs• Male condoms should be distributed freely in prisons
Telisinghe, Hippner ³²; 2016, South Africa	To evaluate “a novel on-site antiretroviral therapy programme in a South African correctional facility using routinely collected programme data” (p. 1153)	• Retrospective cohort study• N = 409 HIV-positive adults initiated on ART	• Information on previous ART use was available for 404 out of 409 inmates• Increased death hazard for inmates with CD4 counts ≤100 over the total duration of follow-up (hazard ratio [HR] 1.82)• 144 of 404 (35.6%) inmates remained in the same prison; 136/144 (94.4%) remained in care• Of those who were imitated into ART, 59.7% and 33.9% were in follow-up at 6 months and 12 months, respectively, after ART initiation• 191/299 (63.9%) ART-naive patients were followed up for at least six months after ART initiation; viral load measurements were taken at six months for 131/191 (68.6%); 94.7% (124/131) had viral suppression	• Identify HIV-positive inmates as soon as they enter the facility and provide special care to patients who are at high risk of dying• “High losses from the programme reflect the mobility of inmates emphasising the need for systems of continuity of care in resource-limited settings” (1159)
Stephens, Gardner ³³; 2016, South Africa	“To identify the extent to which self-reported Mandrax use impacts condom-use beliefs amongst South African prison inmates” (p. 142)	• Cross-sectional study• n = 121 inmates aged 18 years and older	• Negative association between age of inmates and mandrax use• Mandrax use was negatively associated with beliefs about the importance of consistent condom use and beliefs about the efficacy of condoms	• Focus preventive strategies on substance use and STIs on younger inmates• Need for education on the correct use of condoms to promote consistent condom use
Jaquet, Wandeler ⁸; 2016, Togo and Senegal	“To investigate liver fibrosis and associated factors among inmates incarcerated in West Africa” (p. 250)	• Cross-sectional• A random sample of prisoners in Lomé (Togo) and Dakar (Senegal) were screened for liver fibrosis using transient elastography• N = 347 (Lome) and N = 333 (Dakar)	• Inmates with infections: 2.6 % [95 % CI 1.4–3.8]○ 3.5 % [95 % CI 1.5–5.4] in Lome○ 1.8 % [95 % CI 0.4–3.2] in Dakar• 213 (31.3%) reported history of HIV test• Only 1 out of 18 participants identified as HIV-positive had awareness of his status and had been on ART• Multivariate analysis showed a significant association between HIV infection and severe liver fibrosis (OR = 7.6; 95 % CI 1.8–32.1)	• Explore appropriate mechanisms for monitoring liver diseases in vulnerable populations including inmates• Need for improved documentation of etiologic factors associated with liver damage in sub-Saharan Africa
Telisinghe, Charalambous ³; 2016, Zambia, South Africa, Malawi, Nigeria, and Benin	To “investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons” (p. 1216)	• Scoping review	• In comparison to the non-incarcerated population in the same country, detainees almost always had a greater prevalence of both HIV and TB• Human resource limitations, financial constraints, and weak referral systems were identified as major barriers to treatment and care• Examples of promising practices include “routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa” (p. 1215)	• Strengthen care continuity for inmates at entry, during inter-facility transfers, and after release• Tailed services are needed to meet the differing needs of vulnerable groups in prisons
Maggard, Hatwiinda ³⁴; 2015, Zambia	“To improve the Zambia Prisons Service’s implementation of tuberculosis screening and HIV testing”. (p. 93)	• Implementation project• N= 4700 inmates• Training of peer educators to educate and identify new or symptomatic inmates• Mass screening for TB and HIV at 5 prisons	• High acceptance of HIV testing or knowledge of prior HIV status among inmates (74%; 4694/6330) and encampment residents (62%; 810/1308) encampment residents• Newly diagnosed HIV infection in 512 inmates and 52 encampment residents• 625 participants (565 inmates and 60 encampment residents) had previously tested HIV-positive• Overall, 22.9% (1077/4694) of inmates had HIV infection	• Need for more interventions for screening and treating HIV and TB for prisoners in Zambia
Ouédraogo, Garanet ¹⁸; 2015, Burkina Faso	To investigate HIV vulnerability, HIV risk behaviours and access to HIV prevention among male prisoners	• Cross-sectional• N = 165 male prisoners	• Approximately 4% of male inmates reported having had same-sex relations while in prison• There was evidence of denial and underreporting of same-sex practices by inmates• 49% of inmates shared sharp objects (razorblades)• No inmate reported injecting drugs or having tattoos• 84% of inmates had a good knowledge of HIV/AIDs• Screening tests had been done for only 5% of prisoners during incarceration	• Risk of HIV transmission in prisons could be significantly decreased by implementing a preventative program and managing HIV-positive inmates
Shalihu, Pretorius ³⁵; 2014, Namibia	To investigate the challenges associated with adherence to an HIV medication regime among prisoners in a large prison in Namibia	• Qualitative methods• All male maximum security prison• Estimated positive patients: 333 between 2008-2009 and 122 eligible for ART• ART is provided in the prisons• Standard interview questions were used (8 standard questions)• Key inclusion:• HIV-positive inmate who spoke English and had been on ART for at least 6 months	6 themes were identified.• Stigma and privacy: Prisoners hiding their medications, ‘tagged days’ for clinic as AIDS days• Simple supports for adherence: No reminders for taking drugs• Poor access to food in terms of quantity and regularity.• Commodification of ART: drugs being used for smoking. Sex being given in exchange for ARV• Brutality and despair: Negative behaviours staff to PLHIV if they know their HIV status• Poor understanding of the disease: inadequate information about HIV and its transmission	• Ensure privacy and anonymity and provide simple mechanisms for adherence• Provision of adequate food support• Education to prevent commodification• Education about HIV• Reduce violence, brutality and despair in the prison setting
Ekouevi, D'Almeida ¹⁷; 2013, Togo	To assess seroprevalence and predictors of HIV infection prisoners in Togo	• Cross-sectional study in Togo• Total population: 3042• Among ‘accused or convicted’ prisoners• Have been incarcerated not less than 30 days before the study• From November 07 2011 to January 17, 2012• One prison in every administrative region (6 out of 12 prisons)• HIV testing was done	• Prevalence of HIV among 1289 screened = 45, 4.3% 95% CI (3.2-5.4%)• Mean age of the prisoners:• About 4.9% of the prisoners had engaged in sexual intercourse in the last month. Among these only 10.6% used condom• 46 MSM in the last 12 months• HIV infection higher in female prisons• HIV cases that occurred during detention were not determined	• Knowing the prevalence of HIV will facilitate access to HIV-related health services, prevention and treatment in prisons in Togo
Henostroza, Topp ³⁶; 2013, Zambia	To assess TB and HIV prevalence among prisoners entering, residing within and exiting Lusaka Central Prison,To identify and treat undiagnosed cases of TB and HIV within the prison	• Study was done in Lusaka prison• Total number screened 2514, 2323 had complete data• Different screenings conducted: exit screening for those being releasees, mass screening for those currently residing in prison, entry screening for those entering the prison, community screening for the staff and prison camp surrounding• Chest X-ray, SSM, Culture, VCT for HIV using Abott	• 62% had one or more symptoms of TB. Most of them had a cough• HIV screening during mass screening=27.4%, at entry was 20.3%, Exit testing was done in 38/188 (12 positive, 34.3%), community screening - 25% HIV positive• History of incarceration among those screened• HIV prevalence was approximately twice more than the national prevalence (27% vs 13.5%)• Overcrowding and unprotected sex may have contributed to increased transmission among inmates• TB prevalence around the prison was 2000/100 000 population, also twice higher than the national average signifying possible immediate community transmission and the prisons• Transmission of both diseases around the prison ecosystem was high	• Inadequate prisoner health care could jeopardize local attempts to combat HIV infection
Davies and Karstaedt ³⁷; 2012, South Africa	To assess HIV-related health outcomes among inmates on ART in South Africa	• Retrospective cohort analysis• Study conducted in a large public-sector clinic• 148 inmates included (133 males, 90%)• At a tertiary health facility which has a prison in its catchment area• Inmates enrolled on ART at the clinic from April 2004 to February 2008• Enrolled on Stavudine, Lamivudine and Efavirenz• The WHO guideline at the time was used for inclusion	• 108 prisoners retained on treatment through 96 weeks• 26% had a total of 45 admissions, mostly due to TB• 53% experienced 100 different side-effects• ART regimen was changed in 38/143 inmates most commonly due to stavudine-related toxicity• 44 (33%) were on TB treatment at ART initiation• 9 patients had died (6%), 2 deaths were recorded in four months and the rest a year later• 34 (23%) inmates could not be followed up; 14 were lost while in prison, 11 after repeat, and the movement of 9 could not be traced	• Timely referral to ART initiation facilitates positive health outcomes in prisoners with HIV
Motshabi, Pengpid ³⁸, 2011, South Africa	“To determine factors associated with the utilisation of VCT services in the correctional centres in terms of the level of satisfaction, their experiences, and expectations, and motivating factors and barriers for VCT utilisation at Losperfontein Correctional Centre, South Africa” (p. 107)	• Case-control study• 200 male adult inmates servicing medium and maximum sentences enrolled• South Africa (Losperfontein Correctional Centre)• Age ≥ 22 years• Structured questionnaire	• 48% incarcerated for more than 3 years• HIV Testing attitudes• Fears about the desire for a new sexual relationship and a baby• Some were afraid to know their status and were concerned about stigma and discrimination• Others had a lack of trust in healthcare workers,• Accessibility of VCT services• Fear of being discriminated against by colleagues and correctional officials• Determinants of HIV Testing acceptance• Poor/bad attitudes of healthcare workers• Counselling was being offered but satisfaction to the inmates was low• Lack of ongoing counselling• Counsellors were doing a good job with counselling the inmates	• To remove barriers to VCT and improve acceptance of inmates who test positive for HIV
Todrys ³⁹, 2010, Zambia	To understand how prison conditions and criminal justice rights influence HIV and TB prevention, treatment, and care in Zambia	• Mixed methods study conducted in 6 prisons• Surveys and in-depth interviews involving 246 prisoners• Key informant interviews with the Zambian government and NGO officials• Analysis of Zambian laws governing prisons and the criminal justice system	General access to healthcare• Many of the prisons did not have sick bays and those who had lacked trained health professionals• Medical decisions are made by untrained personnel• Lack of sufficiently trained staff• TB screening and care• Females were less likely to be tested for TB• Remandees and immigration detainers were also less likely to be tested• Time interval between symptoms report and testing was long• Many inmates in a small space of TB care prison (10 by 8 foot metre space occupied by 57 inmates)HIV/AIDS prevention, testing and treatment• Only 6 out of 86 prisons offered VCT• Females, juveniles, remandees and immigration detainees were less tested• Larger prisons are more likely to offer treatment than smaller prisons• Many prisoners were not started on Cotrimoxazole prophylaxis• Unprotected sex was common among males in the prisons including rape• Complete unavailability of condoms	• Improve general medical care, HIV and TB prevention and treatment in prisons, and eliminate shortcomings in the criminal justice system that contribute to overcrowding

Screening for HIV

Six studies assessed interventions involving screening campaigns that estimated the prevalence of HIV in prisons across different countries.^{8,17,24,26,34,36} On the one hand, the studies suggest weak HIV infection control practices in SSA prisons in terms of screening at entry, during incarceration, and at exit from prison. This is reflected in the low proportion of inmates who knew their HIV status prior to screening. For example, only 3.2% of 30,571 inmates included in a screening programme at five correctional facilities in South Africa knew their HIV status prior to screening.²⁶ On the other hand, the studies indicated a relatively high uptake of HIV screening among inmates despite the stigma associated with HIV. Maggard et al.,³⁴ found that the involvement of inmates as peer educators encouraged inmates’ participation in HIV and tuberculosis screening programmes in prisons.

The most common approach reported in these studies involved mass screening of inmates, with findings indicating a higher prevalence of HIV in prison settings compared to national estimates.^{17,24,26,34,36} For example, Maggard et al., reported an HIV prevalence of 22.9% during a mass screening of inmates in six prison facilities in Zambia.³⁴ In another screening campaign in five South African correctional facilities, Stevenson et al. found an estimated HIV prevalence of 17.7% with most (73.4%) being previously undiagnosed.²⁶ Prevalence rates of HIV were found to be considerably higher among female prisoners compared to male prisoners.^17,24 Studies that reported on screening of new prison entrants suggest lower HIV prevalence rates in these populations compared to existing inmates and those exiting prison.^24,36

Two studies^34,36 included screening of encampment residents with findings suggesting that prevalence rates among encampment residents are relatively higher compared to the general population. Only one study²⁴ included screening of juveniles, with results showing a considerably lower prevalence of HIV among juveniles (3.9%) compared to adult prisoners (15%).

The only study that focused on comorbidity between HIV and mental health problems¹⁰ showed a high prevalence of mental illnesses among female inmates living with HIV. In particular, most (70.6%) of the female inmates with HIV reported depressive disorder, and nearly half reported alcohol use disorder (48.4%) and post-traumatic stress disorder (46.8%). The results from this study underscore the need for integration of mental health services into prison health care, especially for inmates living with HIV.

Feasibility and sustainability of testing interventions

Three of the studies examined the feasibility and sustainability of HIV-related interventions in correctional settings. Based on three correctional facilities in South Africa and Zambia, Mukora et al. identified resource requirements and provided a costing guide for implementing and scaling up Universal Test and Treat (UTT), a population-based HIV intervention that involves HIV testing services, ART initiation, and ART maintenance, in correctional settings.²⁰ The unit cost of implementing UTT in correctional facilities was observed to be higher than in community settings. Substantial variations were also observed in the estimated cost and cost drivers of implementing UTT across prisons. These variations were linked to differences in staff costs, security requirements, and cost of supplies in the three correctional facilities.

In an earlier qualitative study in the same prisons, Topp et al.,²⁹ highlighted the importance of policy framework, resource adequacy, and efficiency of health service delivery systems in the feasibility and sustainability of quality UTT in correctional facilities. In particular, the existence of national UTT policy and systems for delivering and monitoring HIV care served as a backbone for the successful implementation of UTT and enhanced its sustainability in South African correctional facilities. In contrast, although implementation of the UTT was found to be feasible in Zambian correctional facilities due to alignment with national policy and positive attitudes towards HIV care, lack of resources and weak health delivery systems were found to undermine the programme’s sustainability.

Access to antiretroviral therapy

Generally, only a few studies reported access to ART, other treatment strategies, and supportive treatment. In some jurisdictions, there was reasonable satisfaction with ART services and a high intake of antiretrovirals (ARVs). However, prisoners in urban areas were reported to have more access to ARVs than those in rural areas. Also, females were less likely to have access to ARVs. In the paper by Todrys et al., none of their prisons offered cotrimoxazole prophylaxis in Zambia, and there was no availability of condoms in the prisons assessed.³⁹ Also, Motshabi et al. presented on lack of ongoing counselling.³⁸

Treatment adherence and coverage

Strategies for adherence to ART were diverse. Fuge et al.,¹⁹ in Ethiopia reported good adherence when inmates were offered a medication schedule. However, in Namibia, Shalihu et al.,³⁵ described that there were no reminders for inmates to take their medication. Notably, supportive treatments such as cotrimoxazole use were broadly not reported. The ability to remind the prisoners to take their medications was closely related to the number of prison officers trained and available to dispense medications. The ratio of the healthcare staff to the prison population was linked to delay in linkage to care in Ethiopia.¹⁹

Treatment coverage was generally poor. Jaquet et al. reported that only one of the eighteen inmates surveyed was aware of their status and was started on ARVs.⁸ Common themes that affect treatment coverage include a reduced ratio of health staff to inmate populations, delay in linkage to care and loss of follow-up with the transfer of inmates to other prisons.

Barriers and facilitators

Several barriers were identified in accessing ARVs and other supportive services. Some obstacles included inadvertent disclosure of inmates' HIV status to the rest of the population, high levels of stigma, poor living conditions, limited human resources, and fragmented referral systems. Other factors included inadequate medical and drug supplies and a lack of adolescent-friendly services.^22,32,35

Despite these challenges, a study in Ethiopia found that medication adherence improved with the use of radio and television, as well as social cues such as the sunset. Also, access to information through peer education and support and building organizational capacity and infrastructure were found to facilitate management.¹⁹

Outcomes of care

Several studies assessed the outcomes of care among incarcerated persons. These outcomes include viral load suppression (defined as having less than 1000 copies of HIV per millilitre of blood) whilst on ART, rates of loss to follow-up within the prison, during transfer to another facility or after release, and finally linkage to further care whilst incarcerated or at the time of release.

Viral load suppression

In their study, Fuge et al.,¹⁹ found viral load suppression to be slightly lower for inmates (94%) compared to non-incarcerated persons (95.5%), although the difference was not statistically significant. It was also found that the risk of poorer viral load suppression was associated with female prisoners, those aged 31-35, and those facing stigma. Similar rates of viral load suppression were reported in a retrospective cohort study in South Africa, where among ART-naive patients, viral suppression was achieved in 94.7% of cases.³²

Linkage to care and loss to follow-up

Linkage to care within prisons and after release is also a key component of HIV care and management. Among South African inmates, roughly two-thirds (65%) self-reported linkage to care.²⁷ Fernando et al.,²¹ found that peer-based rehabilitation had no significant association with linkage to care after release; however, being imprisoned at a long-term site was associated with a higher likelihood of post-release linkage to care. Furthermore, Mabuto et al.,²⁷ identified that factors such as older age, initiation of ART during index incarceration and longer duration of incarceration were associated with a higher likelihood of self-reported linkage to care.

In a prospective cohort study conducted in South Africa and Zambia, in which clinical outcomes for incarcerated persons with HIV were examined following a UTT intervention, it was found that 95% of inmates were retained in an onsite ART programme at 6-month follow-up, and that of these, 97% had achieved viral load suppression (<1000 copies per ml).²⁸ However, these high retention rates were not demonstrated in another study conducted in a correctional facility in South Africa, where roughly 59.7% of inmates were in follow-up care 6 months after ART initiation, and only 33.9% at month 12.³²

Discussion

Despite its importance in the management of HIV, we found that routine screening of incarcerated persons for HIV is largely absent in many prisons in SSA. This situation constrains the diagnosis and treatment of inmates who may be living with HIV, and thereby undermine efforts at preventing the transmission of HIV. The absence of routine HIV screening in prisons in SSA could be attributed to resource and capacity limitations for managing infectious diseases, especially HIV, in correctional settings. Nonetheless, our review suggests that prison inmates may be less likely to resist routine screening efforts, which could facilitate efforts towards the management and prevention of HIV. Indeed, it has been suggested that the implementation of HIV-related intervention is relatively easier in prison populations due to the ease of access to the inmates.³⁴

Findings from studies that focused on mass screening as broader HIV-related interventions underscore the high HIV burden among prisoners. The reported prevalence rates are considerably higher than national or regional averages,^26,34 although some of the studies suggest a decline in prevalence rates over time.²⁶ Similar to findings in other reviews,² female inmates were at greater risk of being HIV-positive. It is important to note, however, that the few studies that included screening for HIV in prisons as part of an intervention were done in southern and central Africa. Thus, estimates reported in those studies may not be representative of other regions in Africa.

While individuals with poor health may be more likely to be incarcerated because conditions commonly associated with poor health (e.g., illicit drug use, unemployment, and poverty, etc.) also increase the likelihood of involvement with the criminal justice system,³⁶ findings from the reviews suggest that prison conditions may increase the likelihood of HIV transmission. This is seen not only in the relatively higher prevalence of HIV found among prisoners in exit screenings but also among individuals living around prison encampments compared to the general population. The higher prevalence of HIV among residents in prison encampments has implications for strategies for the management and prevention of HIV infection.

Interventions that focus on testing all inmates followed by treatment of those diagnosed with HIV, such as UTT, have been found to be effective in the management and prevention of HIV in the general population. UTT encompasses a strategy that recommends screening all populations at risk of HIV and initiating therapy for those diagnosed as HIV positive earlier, regardless of their WHO clinical stage or CD4 count. It includes active testing, adherence counseling, improvement in treatment coverage, and outcomes of HIV infection.¹² It is, however, important to note that evidence on the feasibility and sustainability of UTT in prison settings appears inconclusive. Such programmes tend to thrive on dedicated healthcare systems and the availability of resources.²⁸ However, the apparent neglect of healthcare systems in prison settings in many countries in SSA could undermine the feasibility and sustainability of UTT due to the high cost of implementation and resource limitations.

Access to healthcare is a measure of the proportion of a population that gets appropriate health services. It is primarily used to assess the inequities in the reach of healthcare.⁴⁰ Although HIV treatment is widely accessible, we found in this review that the provision of services in different SSA jurisdictions was vastly different. Whereas in parts of Ethiopia and South Africa, they reported reasonable satisfaction with ART services and a high coverage of ARVs for inmates, prisoners in Namibia said that they did not get reminders to take their medication, suggesting a lack of physical accessibility.^19,22,35 With this evidence, it may be reasonable for ART services within correctional centres to provide structured systems or schedules to notify inmates of treatment times and how they may readily access medicines.

Furthermore, even in the same setting, prisoners in urban areas reported having better access to ARVs than their rural counterparts.⁴ Again, female prisoners had disproportionately less access to antiretroviral therapy.^19,23 A recent study by Blue et al.⁴¹ reported that, in North Carolina, apart from the issue of access to medicines while incarcerated, the availability of ARVs was further impacted by inadequate prison resources. The limited health and human resource capacity in African settings has been well elucidated, and such challenges within prison settings pose a significant risk to the adequacy of care received by inmates, as was reported in some of the studies reviewed.

Closely related to access to ARVs is treatment adherence. Adherence can be measured either by a direct method, such as the medication possession ratio or an indirect approach, such as self-reporting.⁴² In Ethiopia, prisoners could adhere to ARVs because they were given specific medication schedules, improving adherence.¹⁹ Some strategies that have been proposed to enhance adherence and promote coverage include structured guidance, care continuation and professional assistance.⁴³ In their 2006 guidance, the WHO also recommends the provision of treatment and support equivalent to what exists in the community.⁴⁴

In providing optimal HIV care and services to this vulnerable population in SSA, several barriers were identified in our review, including non-disclosure and inadequate medical and drug supplies.³⁰ The prison population already faces challenges such as limited resources that result in understaffing. The limited staff also must take care of other healthcare needs of the inmates, making them unable to provide optimal care to prisoners living with HIV.⁴⁵ Additionally, education on risk reduction measures such as teaching condom use and prevention of STIs should form part of HIV care services within prisons.^18,31,33

This review found rates of viral load suppression among inmates, including those who were treatment naïve, of greater than 90%. The high viral load suppression rate suggests that ART regimens are effective among the incarcerated population when they receive the appropriate level of care. Similar findings were reported in a previous systematic review of outcomes of antiretroviral therapy among prisoners.⁴⁶ The major implication is that the care continuum and provision of ART therapy must be appropriately maintained to achieve viral load suppression among prisoners living with HIV.

Self-reported linkage to care following release was found to be higher among older inmates and those who had been incarcerated for a longer period. It may be possible that self-reported rates are higher than actual rates of linkage to care, and therefore the true figure of those receiving continued therapy after release may be lower. Notwithstanding, studies in the USA have found similar trends in factors associated with linkage to care among incarcerated populations,^47,48 albeit with a lower rate of overall continuity of care, estimated at roughly 36% of inmates.²⁷ It has been suggested that higher rates reported in studies from South Africa compared with the United States are related to free HIV care in South Africa compared to the USA and lower rates of illicit drug use. It is, however, important to note that risk-taking behaviours were still highly prevalent among inmates from South Africa, including the use of mandrax.³³ The implications for other African countries would be to ensure that risk reduction measures to reduce HIV spread within prisons and to encourage sustained HIV care post-release.

Furthermore, potential factors related to loss to follow-up or inadequate linkage to care may be related to the movement of inmates.³⁷ For instance, transferring inmates from one correctional institute to another was found as a potential reason for loss to follow up in the paper by Telisinghe, Hippner.³² In the studies reviewed, there was little mention of specific interventions directed at ensuring linkage to care for inmates living with HIV. Without the institution of systems to ensure that therapy is maintained for prisoners in transition (e.g., upon release or from transfer from one site to another), loss to follow-up may continue to be prevalent within this population, reversing gains that have been made with viral load suppression.

Best practices in HIV care and management in prisons

A few measures emerged from our review that could be highlighted as best practices in the management of HIV in correctional settings in SSA. Prominent among these practices is the introduction of UTT in some southern African prisons. UTT seems to offer a more comprehensive approach to the management and prevention of HIV in correctional settings. According to Herce et al., the utility of UTT in prisons lies in its potential to “achieve levels of same-day ART uptake, retention in care, and viral suppression among incarcerated people with HIV that are comparable to those observed in community settings” (32, p. 1).

Additionally, measures such as offering medication schedules, setting reminders, and giving a supportive treatment environment were identified as best practices that can enhance treatment adherence. For instance, in some studies, the provision of extra portions of food to prisoners living with HIV helped alleviate the taxing effect of ART and enhance medication adherence. Access to basic gadgets like clocks also enhanced medication adherence, as they served as reminders for the administration of medication.

The involvement of inmate peer educators as actors in intervention delivery seems to hold promise for the management of HIV in prisoners. In this strategy, incarcerated persons are trained and mentored to provide services including psychosocial support and health education as part of health intervention delivery in prisons.³ This practice can help to increase uptake in HIV interventions, minimise demands on highly trained and scarce professionals, reduce the cost of intervention delivery, and facilitate linkage to care.³⁴

Recommendations

A notable challenge with the implementation of HIV interventions in prison settings in SSA is the lack of access to testing and treatment services and the lack of resources and capacity to provide adequate testing and treatment services to prisoners. Thus, successful implementation of HIV interventions in SSA prisons requires strengthening of human resource capacity for HIV-related interventions including the training of prison healthcare personnel.

Additionally, funding is a likely impediment to the sustainability of interventions involving testing, ART, and continuity of care in prisons, as the cost of implementing HIV interventions seems to be considerably higher in correctional settings than in the general population. This calls for the development of innovative financing plans for HIV-related care in prison. For instance, social impact bonds, a means of attracting private sector capital to address social problems have been suggested as an innovative approach to funding HIV treatment.⁴⁹ This funding model, which has been experimented with in fighting malaria in Mozambique,⁵⁰ may be a useful approach to funding HIV, especially in correctional settings.

Our findings further call for a move away from ad hoc implementation of HIV prevention and treatment measures to more structured and regularized measures. This would involve implementing periodic screening for HIV and comorbidities including TB and mental illness, with subsequent provision of appropriate linkage to care for all conditions identified. This should be supported with structured treatment schedules for inmates, measures to improve adherence, gender-specific programming for HIV management, and structured linkages to care systems for prison-to-prison transfers. Improving the ratio of health care staff to inmates could also enhance linkage to care within prisons.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

ORCID iD

Francis Annor

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