Innovative twinning programme in prison setting

Arnaud LAURENT, Programme Manager, ESTHER France Innovative twinning programme in prison setting Access to HIV prevention and care in prisons of Cote d’Ivoire ESTHER initiative in MACA prison (Maison d’Arrêt et de Correction d’Abidjan)

ESTHER in Côte d’Ivoire
Since 2005
7 hospital twinnings ( 1 with ESTHER Germany in Bouaké )
3 projects with civil society organisations

Background
National HIV prevalence: 3.9% (UNAIDS, 2008)
No data available about HIV and TB prevalence among prisoners
In November 2008, the MACA medical Center and Bordeaux Hospitals (CHU/UCSA), under the ESTHER twinning program, started a prevention and care program at the main civilian prison in Abidjan (Maison d’Arrêt et de Correction d’Abidjan)
The main objectives were:
to provide HIV and TB prevention and care to prisoners, guards and their families,
to promote health policy changes for prisons in Côte d’Ivoire.

Brief MACA presentation
Location: Yopougon, Abidjan
Population:
5400 prisoners for 1 500 places (+ 300%)
around 50% of total prisoner population of Côte d’Ivoire (12 135 on the 31/12/09)
97% males, 2% females and 1% minors
Monthly flow : 600 prisoners (in/out)
150 guards and penitentiary personnel
MACA

« Cité MACA » Females block Minors block Medical Center Social & Medical Center Administration « Disciplinary » block A et B blocks « VIP » block

Health situation
Common pathologies : respiratory infectious diseases/TB/malaria/diarrhea/ skin diseases/ … and HIV/AIDS
Poor hygienic conditions (promiscuity, water access, sanitarians, … cholera epidemic recently)
Insufficient daily food ration : once a day (1000 Kcal/day), poor quality and poor quantity, family support if any, … malnutrition cases and beriberi outbreak

MACA Medical centers
Medical care services in and « out of the walls » : around 10 000 persons (prisoners, guards and their family members, and local population from « cité MACA »)
Medical facilities : 120 beds with 60 dedicated to TB, specific nursing center for females, mortuary, basic laboratory, pharmacy, …
Personnel : 2 doctors, 4 nurses, 1 midwife, 4 medical assistants, 2 pharmacist assistants, 1 laboratory technician, and … 50 prisoner volunteers
Organisational issues: Open 5 days/week + on-call duty for emergencies, « free » medical care, 1 800 in out-patients clinic/month

ESTHER Intervention Modalities (capacity building)
At MACA level:
Prevention + testing activities
Peer educators are making regular IEC sessions and promoting HIV testing among prisoners.
Counselors are offering HIV testing (rapid tests) and TB screening to all new prisoners
Care and Treatment activities
A team of national and international experts providing technical assistance and trainings .
OPD and IPD Rehabilitation + procurement of small medical equipment
=> A medical team of 2 doctors and 4 nurses delivered care and treatment, including ARVs, to HIV patients.

ESTHER Interventions Modalities
At Institutional level :
ESTHER has supported Ministry of Health and Ministry of Justice with:
a health situation analysis in 9 prisons,
national workshop about health in prisons
the development of a National Joint Committee “Health-Justice” with the objective of defining a national plan on health in prisons
Integration of prisoners among beneficiaries of Global Fund (Round 9)

Main results in 16 months (november 2008 - march 2010)

Counselling and HIV testing in MACA (from nov.08 to march 10) Nb of prisoners counseled Nb of tested prisoners Nb of prisoners HIV+ Nov. 08 Jan. 09 Mar. 09 Jul. 09 May 09 Sep. 09 Nov. 09 Jan. 10 Mar. 10 0 200 400 600 800 1000 1200 1400 1600

HIV Testing results ( from nov. 08 to march 10)
Total prisoner population for the period: 15 355 prisoners ( 52% tested )
HIV test acceptance rate: 74%
HIV prevalence rate among prisoners: 5.65%
Male prisoners HIV prevalence: 5.1% (2 x general male pop.)
Female prisoners HIV prevalence: 17.15% (3 x general female pop.)

Capacity building

HIV care and treatment for PLWHIV
All released prisoners under ART are lost to follow-up (n=15)
14,3% are eligible for ARV treatment according to national criteria (<200 CD4)
All patients are on 1st line treatment
ARV : TDF-FTC-NVP: 45% (female)
D4T-3TC-NVP: 35,6% (male)
NB: Viral Load testing in process will give us a better view about prisoners adherence
Prisoners Guards and others Total Nb. of blood tests (CD4) 425 21 446 CD4< 200 54 10 64 CD4 between 200 et 350 71 3 74 CD4 > 350 300 8 308 Nb. of patients put on ART 76 10 86 15 released Death under ART 6 0 6

TB and co-infection HIV/TB
HIV prevalence rate among TB patients: 22.7%
No chest x-ray and no access to culture for Drug Sensitivity Test => low diagnosis for TB/MDR TB
Prisoners Guards and others Total Number of TB cases 172 0 172 Nb. of TB/VIH+ cases 39 0 39 (13 ARV+) (22.7%)

How the Health Policy has changed In order to promote health improvement in prisons ESTHER has supported a political and institutional process as below. The 2 main acheivements are the official adoption of a national policy for health in prisons and the integration of prisoners among beneficiaries of the Global Fund .

Conclusion/Recommandation
HIV infection and TB are both public health priorities among prisoners in Africa. Prevention and care programs in prisons are still few. It is urgent to scale-up these programs in prison settings.
We show that such programs are feasible if accompanied by national mobilization and political will.
Twinning is at the center of the program and networking is important to involve local, national and international stakeholders to insure ownership and sustainability.

Innovative twinning programme in prison setting

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