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The HIV and TB Prison Crisis in Southern Africa

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In 1988, while Nelson Mandela was in prison, he contracted tuberculosis (TB). TB is common in prisons, with overcrowded cells and poor ventilation facilitating transmission. Mandela is now long free, but TB remains a threat to all prisoners - and to all South Africans.

South Africa has one of the worst TB rates in the world, and in 2008 reported over 6,000 cases of multi-drug-resistant TB. Prevalence of TB in overcrowded prisons mirrors that of overcrowded communities and the failure to address TB in one setting jeopardizes efforts to combat TB in the other. The maxim, "good prison health is good community health" highlights the fact that prisoners - and prison officials - return to their communities daily, making the idea of a separation of prison and public health concerns a myth.

In April, Human Rights Watch, the AIDS and Rights Alliance for Southern Africa, and the Prisons Care and Counselling Association released a report detailing prison health conditions in Zambia. Even more than in South Africa, Zambian prisons are facing a crisis of overcrowding and poor health conditions. In compiling our report, we spoke with almost 250 prisoners. They described to us the terrible conditions in which they live: Prisons are so overcrowded that inmates sometimes sleep in shifts, or seated. Corporal punishment is common. Food is inadequate, and prisoners with HIV and TB have difficulty taking medications because of their hunger. In many prisons, prisoners are given no soap to wash themselves, nor clothes to wear.

The threat of TB and drug-resistant TB are all the more crucial given the high HIV prevalence in southern African prisons, and in the general population. HIV prevalence in the region's prisons has been estimated to be between 2 and 50 times that outside of prisons. In Zambia, it was last measured at 27 percent, almost double the prevalence of adults in Zambia overall. The combination of high HIV and TB prevalence in prisons can be deadly: Worldwide, TB is responsible for nearly one in four deaths from AIDS.

In South Africa, the recently announced national voluntary HIV counseling, testing and treatment campaign should support expanded HIV/TB testing and treatment in prisons. But HIV and TB in South Africa's prisons cannot be tackled only by improved HIV and TB programs. Prison overcrowding must be addressed by greater financial investment and by reforming the criminal justice system. The frequent use of pretrial detention and lack of affordable bail contribute to overcrowding and its negative effect on prison health.

At the 15th International AIDS Conference in Bangkok in 2004, Mandela urged the world to extend the fight against HIV to include efforts against tuberculosis. "We cannot win the battle against AIDS if we do not also fight TB." The 18th International AIDS Conference ends today, yet we still are not doing enough to address HIV or TB in prisons - or the criminal justice system failures that exacerbate the spread of both diseases. For South Africa to succeed in the fight against HIV and TB, improving prison programs and ensuring access to justice, is critical.