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Namibian prisoners describe barriers to HIV antiretroviral therapy adherence a
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Nauyele Shalihu , Louise Pretorius , Agnes van Dyk , Ann Vander Stoep & Amy Hagopian a
Senior Superintendent and Head Nurse with Ministry of Safety and Security, Department of Correctional Service, Windhoek Correctional Facility, Windhoek, Namibia b
School of Nursing and Public Health, University of Namibia, Windhoek, Namibia
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Health Alliance International in the Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA Published online: 06 Feb 2014.
To cite this article: Nauyele Shalihu, Louise Pretorius, Agnes van Dyk, Ann Vander Stoep & Amy Hagopian (2014) Namibian prisoners describe barriers to HIV antiretroviral therapy adherence, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:8, 968-975, DOI: 10.1080/09540121.2014.880398 To link to this article: http://dx.doi.org/10.1080/09540121.2014.880398
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AIDS Care, 2014 Vol. 26, No. 8, 968–975, http://dx.doi.org/10.1080/09540121.2014.880398
Namibian prisoners describe barriers to HIV antiretroviral therapy adherence Nauyele Shalihua, Louise Pretoriusb, Agnes van Dykb, Ann Vander Stoepc and Amy Hagopianc* a
Senior Superintendent and Head Nurse with Ministry of Safety and Security, Department of Correctional Service, Windhoek Correctional Facility, Windhoek, Namibia; bSchool of Nursing and Public Health, University of Namibia, Windhoek, Namibia; cHealth Alliance International in the Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
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(Received 22 January 2013; accepted 25 December 2013) Little is available in scholarly literature about how HIV-positive prisoners, especially in low-income countries, access antiretroviral therapy (ART) medication. We interviewed 18 prisoners at a large prison in Namibia to identify barriers to medication adherence. The lead nurse researcher was a long-standing clinic employee at the prison, which afforded her access to the population. We identified six significant barriers to adherence, including (1) the desire for privacy and anonymity in a setting where HIV is strongly stigmatized; (2) the lack of simple supports for adherence, such as availability of clocks; (3) insufficient access to food to support the toll on the body of ingesting taxing ART medications; (4) commodification of ART medication; (5) the brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health; and (6) the lack of understanding about HIV, how it is transmitted, and how it is best managed. Because most prisoners eventually transition back to communitysettings when their sentences are served, investments in prison health represent important investments in public health. Keywords: Namibia; Africa; prisoners; HIV; medication adherence; antiretroviral therapy
Introduction Southern Africa contains all nine of the world’s countries where the prevalence of HIV among young adults (aged 15–49) exceeds 10% (Ng, 2000; The World Bank, 2009). Highly vulnerable subpopulations have even higher rates within those countries. In Namibia, the vulnerable populations include men who have sex with men (Baral et al., 2009), injection drug users (Degenhardt et al., 2010; Mathers, Cook, & Degenhardt, 2010; Mathers et al., 2010), soldiers (Ba et al., 2008), and prisoners (Angora et al., 2011; Aulagnier et al., 2011; Baral et al., 2009; Dolan, Kite, Black, Aceijas, & Stimson, 2007; Reid et al., 2012). Rates of imprisonment are growing worldwide, with more than one million prisoners in Africa’s 54 subSaharan nations. The majority of prisoners is from poor and marginalized communities with a variety of health problems (Moller, Stover, Jurgens, Gatherer, & Nikogosian, 2007). Namibia has one of the highest incarceration rates in Africa, with more than 200 prisoners per 100,000 population, or 4300 prisoners for the nation’s 2.3 million population (ICPS, 2010) compared, for example, to 31 per 100,000 in Nigeria, or 36 in Sudan (Watson, 2007). Despite the vulnerability of the health of incarcerated populations, very little is published in the scientific literature about HIV and AIDS among prisoners; most reports are from North America (Adams et al., 2011; Baillargeon et al., 2010; Braithwaite & Arriola, 2003; Catz et al., 2012; Hedrich et al., 2012; Huang *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
et al., 2011; Hudson et al., 2011; Johnson et al., 2011; Kinner & Milloy, 2011; Palepu et al., 2004; Pontali, 2005; Report, 2010a, 2010b, 2011, 2012; Watson, 2007; Watson, Stimpson, & Hostick, 2004; Williams et al., 2012; Wohl et al., 2011). A few have addressed HIV among prisoners in Africa (Baral et al., 2009; Baral et al., 2011; Ng, 2000; Reid et al., 2012). In Cote d’Ivoire, prisoners are reported to have twice the HIV prevalence as the general population (Angora et al., 2011), while the prevalence in South African prisons is reported to be a startling 44% (Dolan et al., 2007). Other reports substantiate that HIV prevalence in prisons can be several times that in the general population, largely because of overlapping risk factors (2010; Potts, 2000; Report, 2010c). Prisons have been neglected in the global response to the HIV epidemic, perhaps because of the double stigma and disenfranchisement resulting from both HIV infection and incarceration. A strict daily schedule of antiretroviral medications is the current treatment standard to reduce symptoms and extend survival for persons infected with HIV (WHO, 2010). Interruptions in antiretroviral therapy (ART) are a serious problem in HIV care, both because they threaten the health of the individual patient, and because they can lead to drug resistance, creating a concern in the broader community. A considerable body of work addresses adherence generally, although little research has been conducted in prison settings (Mills, Lester, & Ford, 2012). Three
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AIDS Care studies from Spain (Blanco et al., 2005; Ines, Moralejo, Marcos, Fuertes, & Luna, 2008) found prisons mismanage missed medications and identified inmate characteristics, including having an occupation during imprisonment, having HIV-related symptoms, acceptance of treatment, and higher academic background related to adherence. One study from North Carolina in the USA examined the effects of directly observed ART (DOT) on prisoners, finding it not entirely successful because inmates did not like the stigma associated with DOT (Wohl et al., 2003). A US study from Connecticut among female prisoners determined that adherence was associated with trust in the patient–physician relationship and the presence of emotional supports (Mostashari, Riley, Selwyn, & Altice, 1998). Prison conditions are often described in the literature as “appalling.” Prisons suffer from overcrowding, violence, forced sexual activity, close contact contributing to the spread of disease, insufficient opportunities for rehabilitation, poor quality of health care facilities, and generally poor living conditions (UN Office on Drugs and Crime, 2006b). While prisons are a particularly difficult setting, public health prevention principles still apply (Seal, 2005; Springer & Altice, 2005). The purpose of this research was to explore the challenges facing prisoners in a large prison in Namibia with regard to maintaining adherence to an HIV medication regimen. Methods We used qualitative methods to investigate the barriers to ART adherence in an urban Namibian all-male, maximum security prison. Namibia has 13 prisons; this one is among the largest, housing approximately 1300 inmates in a facility built for 900. Within this population, an estimated 333 inmates tested positive for HIV between 2008 and 2009, and 122 were eligible for ART by World Health Organization (WHO) standards. ART is routinely provided as part of the free prison health service for all ART-eligible inmates (with CD4 counts of 300 or lower, as guided by WHO policy) (Ministry of Prisons and Correctional Services, 2008–2009). From a sampling frame of approximately 120 HIVpositive inmates on ART, we selected the first 20 patients who volunteered, who also met our criteria of being on ART for at least six months, and who spoke English reasonably well. Of these, 18 completed a semi-structured interview in English. The interviewer (S.N.), who had worked at the prison as a nurse for 15 years and was recognized as a trusted clinician, was conducting research for her master’s thesis at the University of Namibia (UNAM) School of Public Health, under the supervision of two UNAM faculty members (A.V.D. and
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L.P.). Two University of Washington faculty members helped to conceive of and carry out the project (A.V.S. and A.H.). Ethical permissions for the project were obtained from the Ministry of Safety and Security, Department of the Prisons and Correctional Services, and the University of Namibia Postgraduate Committee. Potential participants, all of whom were regular patients at the prison clinic, were approached by the interviewer as a part of their normal clinic visits for ART review. They were informed the purpose of the study, the interview procedures that confidentially was ensured, and that participation was entirely voluntary. Patients were given two months to decide whether to participate, and those who did were asked to sign consent forms. Interviews were conducted in the nurse researcher’s private clinical office, where their participation would not be noticed. Participants were aged between mid-20s and mid-60s. Interviews ranged from 60 to 90 minutes. Eight standardized interview questions were asked about supports and barriers for ART adherence in prison. Questions addressed whether inmates in general take ART “on time,” whether they take ART in front of others, what supports they have or need for ART adherence, barriers to ART adherence, what could improve adherence motivation, and general comments. The interviewer kept detailed written notes of the interview. At the end of the interview, the researcher read back each recorded quote and asked the participant to make any corrections. All interviews were conducted in the course of a one-week period in March 2009. Interview notes were typed, and the researcher used a manual approach to reviewing transcripts to identify themes and sub-themes, similar to Tesch’s 8-step method (Tesch, 1990). UNAM faculty supervisors reviewed all coding material to ensure reliability.
Results After analyzing the text of the interviews, we observed six themes that help explain why ART adherence is difficult in a Namibian prison.
Stigma and privacy Prisoners described Wednesdays as “AIDS day,” when a truck arrives to take HIV-positive prisoners to local health providers for their care (a large truck for the public clinic, a smaller vehicle for private clinics). It is clear even to the casual observer that those getting on the bus are being taken for HIV treatment, and prison authorities are aware that many inmates concerned about stigma chose not to get on the bus. While public clinic care is free, private patients must pay (typically in these cases their wives have insurance coverage).
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Once in possession of medications following clinic visits, prisoners said they attempted to hide or disguise their pill vials, in an attempt to shield their HIV status from fellow prisoners and guards. WHO advises prisoners be allowed to keep their medication with them, guidance that it is followed in Namibian prisons (Moller et al., 2007). We were told that HIV medications are dispensed in distinctive dispensers, compared to the more generic sachets for other medications. Prisoners also said they looked for private moments to ingest their pills, to not be observed (Table 1).
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Simple supports for adherence After adherence counseling, inmates chose a dosing time, typically twice per day. Inmates typically keep their medicines in their own locked, unrefrigerated cabinets. No reminders are provided, and few ready cues exist as to time of day other than daylight. Prisoners do not have routine access to clocks, radio, or television. Access to media was reported to be a privilege meted out to prisoners depending on their classifications; for example, only prisoners who have completed one-third of their sentences are allowed to have radios. Meals were reportedly served at irregular times, and therefore were not reliable reference points for medication timing (Table 2). Access to food Prisoners reported the phenomenon of experiencing increased hunger and desire for food while on ART. Because it is known that ART stimulates the appetite (Goyer & Gow, 2002; Wang & Wu, 2007; Weiser et al., 2003; Zulu et al., 2011), prison policy affords extra food
rations to inmates on ART, especially protein. However, prisoners reported they usually receive irregular and inadequate meals, even for the most seriously ill. It is common to see malnourished inmates, both on ART and not. Inmates also reported they sometimes have special food delivered by their families, although this is against prison rules (Table 3).
Commodification of ART Prisoners reported various uses for ART unrelated to the relief of HIV disease, including the smoking of ARTs (thus, creating a market among non-HIV-positive prisoners), the belief that taking a dose of ART prior to a sexual encounter can prevent transmission, and offering sex to obtain medications. As there is a market for ARTs, and because access to money in prisons is limited, sex is sometimes exchanged as a commodity to obtain ARTs. News outlets and other researchers (Njagarah, 2012) have reported a southern African street drug cocktail that includes ART medication, among other ingredients, that can produce a high when smoked. This may explain why those seeking an hallucinogenic effect may purchase ARTs (Table 4).
Brutality and despair Most participants complained about the negative behaviors and attitudes of prison staff toward inmates on ART. Prisoners said the treatment they receive from guards who know their HIV status causes frustration, humiliation, and discouragement. It was unclear whether guards lacked information about the importance of ART adherence, lacked empathy, or lacked both (Table 5).
Table 1. Prisoner comments on Theme 1: The desire for privacy and anonymity in a setting where HIV is strongly stigmatized. “I do take it in front of others, though people used to throw stones because they see me taking ARV.” “Privacy is being violated even at the local hospital whereby the NAMPOL (Namibian police) officials are always present while one is consulted by the doctor.” “Going to the hospital at ARV clinic in a big group in the same car, this has revealed people’s status indirect(ly). This has caused some of my colleagues to stop … taking their ARVs.”
Table 2. Prisoner comments on Theme 2: The lack of simple supports for adherence, such as the availability of clocks. “I used to take my ARV medication after breakfast though the breakfast does not have exact time.” “It is difficult in prison to take ARVs on time, because no watches is allowed in prison, people are taking it on estimation, we are forgetting after you remember it is already two or three hours later, simply due to the reason that there is no watches.” “Myself I am estimating on time because I do not have anywhere to check the time, no watches, no radio, no TV. I always take it morning time and afternoon.”
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Table 3. Prisoner comments on Theme 3: Insufficient access to food to support the toll on the body of ingesting taxing ART medications. “Lack of sufficient food cause dizziness then one will skip some doses.” “The prison should to provide inmates on ARV medications with enough high protein food, the quantity should be increased; this will assist inmates to take their ARVs well if they have enough food to eat.” “Inmates should be allowed to receive food from their families at visiting time.”
Table 4. Prisoner comments on Theme 4: Commodification of ART medication.
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“Selling of ARV drugs in exchange with sex.” “Selling of ARV medications to the drug dealers in prison for smoking it.” “There are those who have permanent sexual partners, in an attempt to try to protect their partners from getting infected with the virus, they buy ARV drugs for them.”
Table 5. Prisoner comments on Theme 5: The brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health. “Oh! Are you also on AIDS treatment?” This was said (mockingly, by a guard) in front or in the presence of other inmates and prison warders (wardens). “Disrespect from prison members (guards) who made statements like, ‘I don’t care if you die or your life is just depends on medication only.’” “Psychological humiliation of inmates on ARV therapy by prison officials.” “Frustration caused by members of prison, can make a person not to take ARV therapy, or it discourages you.”
Table 6. Prisoner comments on Theme 6: The lack of understanding of the disease, how it is transmitted, and how it is best managed. “Negligence and ignorance by the user of ARV medication.” “I know many of those who dropped ARV except one whom I convinced and he went back to ARV again, the rest have thrown them away.” “Denial or don’t mind (resigned) attitude, resulted to inmates skip ARV follow ups.”
Lack of understanding of the disease Many inmates, in Namibia as well as globally, are not well educated (Niveau, 2007). Prisoners with poorer formal education have been found to be less knowledgeable about HIV and how it is transmitted as well (Vaz, Gloyd, & Trindade, 1996). The prisoners in our study demonstrated their own lack of knowledge, as well as ignorance among guards and fellow inmates. This lack of information about basic HIV transmission and disease effects triangulates with other themes in this study to undermine health (Table 6).
Discussion There is broad consensus among human rights and global health organizations that people in prison have a right to a standard of health care equivalent to that available outside prison (Committee of Ministers-
Europe, 1998; Lines, 2006; Niveau, 2007). In the USA, incarceration entitles prisoners to better access to health care than available to the general population (Swendiman, 2012), perhaps explaining why seroprevalence among US prisoners has fallen (Spaulding et al., 2009) and why AIDS mortality among state prison in‐ mates is now lower than for the general population (Maruschak, 2012). HIV-positive prisoners, even in low-income countries where universal access to ART is difficult to achieve, should expect access (Pontali, 2005). WHO has acknowledged that while providing prisoner access to ART is a challenge, it is both necessary and feasible (WHO, UNODC, & UNAIDS, 2007). Indeed, prison may even present unique opportunities for HIV education and prevention because of the ready concentration of at-risk individuals who were likely underserved in their communities (Beckwith, Zaller, Fu, Montague, &
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Rich, 2010; Grinstead, Zack, Faigeles, Grossman, & Blea L, 1999). For many new inmates, prison may be their first opportunity to access proper medical attention for a host of medical problems, including HIV (Sifunda et al., 2006). Further, prisons in Africa have demonstrated success in administering comprehensive ART programs for inmates (Davies & Karstaedt, 2012; Makombe et al., 2007). We observed six distinct barriers to ART adherence among the Namibian prisoners who we interviewed, including insufficient privacy within a stigmatized setting, the lack of simple supports for adherence, insufficient nutritional intake, the market value of ARTs to exchange for money or other benefits, the brutality of the prison setting (which leads to despair), and the lack of good information about HIV transmission and care. Limitations and strengths of study Our study’s strengths and weakness stem from the fact that our lead researcher was a long-time prison nurse serving the population we were studying. She was uniquely positioned with access to an understudied, and vulnerable population, enjoyed good rapport with her patients, and was able to conduct meaningful systematic interviews to elicit candid perspectives. Prisoner patients, however, may have been reluctant to talk candidly to a person who they viewed as having an authority role at the prison or knew their health issues personally. Their reticence to talk openly, however, would likely have been magnified had the researcher been a total stranger. Another limitation is that we conducted a modest number of interviews (18), and our volunteers for the study may represent a unique subset who had experiences or perspectives that did not represent those of the all Namibian prisoners with HIV. Despite limitations, the study offers a unique window into the challenges of maintaining high ART adherence within a prison setting. Recommendations Reduce stigma by ensuring privacy and anonymity Prisoner complaints of ridicule and stigma associated with knowledge of HIV-positive status contributed to problems with adherence. The Wednesday “AIDS day” clinic truck logistics could be restructured to reduce spectacle. In-prison peer solidarity and mutual support programs have been demonstrated to reduce stigma (Goyer & Gow, 2002; Grinstead O et al., 1999). Provide simple supports for adherence, such as clocks, radios, or regular feeding times It is simple enough to provide clocks or otherwise announce the time in prison to allow inmates to keep to their medication schedules. Some prisons have also
found limited success with staff or peer-supported DOT (Kirkland et al., 2002), (Altice, Mostashari, & Friedland, 2001; Babudieri, Aceti, D’Offizi, Carbonara, & Starnini, 2000; Fischl et al., 2001). The two government agencies responsible for prisoner health – the Ministry of Safety and Security and the Ministry of Health – have reportedly failed to cooperate on the responsibility for ART administration to the detriment of prisoners (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008). Provide adequate food support Prisoners reported that poor nutrition can make them too weak to maintain ART regimens. A Namibian Legal Assistance Center study conducted in 2008 (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008) found problems with sufficiency and timing of food distribution resulting in prisoners exchanging sex for food. The need for expanded nutritional support during HIV therapy is well documented, but access to food in prisons is inadequate even as it is in the general HIV-positive population in low-income countries (Coetzee, Kagee, & Vermeulen, 2011; Weiser et al., 2010). We recommend increased nutritive sustenance for all prisoners to avoid selective treatment and its associated stigma. Educate to prevent commodification of ART The sale of ART reflects low knowledge about HIV and its transmission and desperation for mind-altering substances. Changing perceptions requires an education program and a change in culture. Reduce brutality and despair in the prison setting Violence in prisons is a way of life and Namibian prisons are no different (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008). The loss of hope, especially among those serving long sentences, fosters reckless behavior. Reducing violence requires adequate staffing, lower incarceration rates, and opportunities for purposeful activity (UN Office on Drugs and Crime, 2006a). Researchers have demonstrated the success of prisoner-led initiatives to organize educational and decision-making capacity (Godji, Togbe, & Aguirre, 2002). Increase understanding about HIV Namibia’s Legal Assistance Center report (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008) indicates that the seven-month training for prison staff includes some education about HIV, including how to conduct bodily fluid clean up, although older staff may not have gotten it. The same report describes barriers created by the language
AIDS Care differences between staff and inmates, which could be solved by recruiting staff with appropriate language skills. Other Recommendations from reports on HIV in prison have supported a number of other measures (Dolan et al., 2007) such as a reduction in incarceration rates and overcrowding (UN Office on Drugs and Crime, 2006b), improved counseling and testing (Goyer & Gow, 2002), and harm reduction such as the provision of condoms for consensual sex (Sifunda et al., 2006; Simooya et al., 2001) and offering bleach and needle exchange (Braithwaite & Arriola, 2003).
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Conclusion Namibia, one of Africa’s youngest countries with a relatively small population, is well positioned to experiment with humanitarian approaches to incarceration that demonstrate innovative practices. The progressive national constitution, which recognizes “the equal and inalienable rights of all members of the human family are indispensable for freedom, justice and peace,” supports prisoner access to health and human rights. Most prisoners eventually transition back to community settings when their sentences are served, so investments in prison health are truly investments in public health. Acknowledgments We appreciate the inmates who participated in the study. Late Eliakim Inicko Shalihu is also warmly acknowledged.
References Adams, J., Nowels, C., Corsi, K., Long, J., Steiner, J. F., & Binswanger, I. A. (2011). HIV risk after release from prison: A qualitative study of former inmates. Journal of Acquired Immune Deficiency Syndromes, 57, 429–434. doi:10.1097/QAI.0b013e31821e9f41 Altice, F. L., Mostashari, F., & Friedland, G. H. (2001). Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 28(1), 47–58. Angora, B., Assemien, J., Laurent, A., Febro, V., CoulibalyOffia, M., Masumbuko, J. M., … Raguin, G. (2011). HIV in prison in low income countries. AIDS, 25, 1244–1246. doi:10.1097/QAD.0b013e328347c0f1 Aulagnier, M., Janssens, W., De Beer, I., van Rooy, G., Gaeb, E., Hesp, C., … Rinke de Wit, T. F. (2011). Incidence of HIV in Windhoek, Namibia: Demographic and socio-economic associations. PLoS One, 6, e25860. doi:10.1371/journal. pone.0025860 Ba, O., O’Regan, C., Nachega, J., Cooper, C., Anema, A., Rachlis, B., & Mills, E. J. (2008). HIV/AIDS in African militaries: An ecological analysis. Medicine, Conflict and Survival, 24(2), 88–100. doi:10.1080/136236908019 50260 Babudieri, S., Aceti, A., D’Offizi, G. P., Carbonara, S., & Starnini, G. (2000). Directly observed therapy to treat HIV
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infection in prisoners. Journal of the American Medical Association, 284, 179–180. doi:10.1001/jama.284.2.179 Baillargeon, J. G., Giordano, T. P., Harzke, A. J., Baillargeon, G., Rich, J. D., & Paar, D. P. (2010). Enrollment in outpatient care among newly released prison inmates with HIV infection. Public Health Report, 125(Suppl. 1), 64–71. Baral, S., Adams, D., Lebona, J., Kaibe, B., Letsie, P., Tshehlo, R., … Beyrer, C. (2011). A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho. Journal of the International AIDS Society, 14, 36. doi:10.1186/1758-2 652-14-36 Baral, S., Trapence, G., Motimedi, F., Umar, E., Iipinge, S., Dausab, F., & Beyrer, C. (2009). HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One, 4, e4997. doi:10.1371/journal.pone.0004997 Beckwith, C. G., Zaller, N. D., Fu, J. J., Montague, B. T., & Rich, J. D. (2010). Opportunities to diagnose, treat, and prevent HIV in the criminal justice system. Journal of Acquired Immune Deficiency Syndromes, 55(Suppl. 1), S49–S55. doi:10.1097/QAI.0b013e3181f9c0f7 Blanco, J. M., Perez, I. R., De Labry Lima, A. O., Recio, J. M., Lopez, E. G., & Basanta, J. J. (2005). Adherence to antiretroviral treatment in prisons. AIDS Research and Human Retroviruses, 21, 683–688. doi:10.1089/aid.2005. 21.683 Braithwaite, R. L., & Arriola, K. R. (2003). Male prisoners and HIV prevention: A call for action ignored. American Journal of Public Health, 93, 759–763. doi:10.2105/ AJPH.93.5.759 Catz, S. L., Thibodeau, L., BlueSpruce, J., Yard, S. S., Seal, D. W., Amico, K. R., … Sosman, J. M. (2012). Prevention needs of HIV-positive men and women awaiting release from prison. AIDS and Behavior, 16(1), 108–120. doi:10.1007/s10461-011-9962-6 Coetzee, B., Kagee, A., & Vermeulen, N. (2011). Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: The perspectives of health care providers. AIDS Care, 23, 146–151. doi:10.1080/ 09540121.2010.498874 Committee of Ministers-Europe. (1998). Concerning the ethical and organisational aspects of health care in prison adopted by the committee of ministers on 8 April. Retrieved from https://wcd.coe.int/com.instranet.InstraServlet?command=com.instranet.CmdBlobGet&Instranet Image=530914&SecMode=1&DocId=463258&Usage=2 Davies, N. E., & Karstaedt, A. S. (2012). Antiretroviral outcomes in South African prisoners: A retrospective cohort analysis. PLoS One, 7, e33309. doi:10.1371/ journal.pone.0033309 Degenhardt, L., Mathers, B., Vickerman, P., Rhodes, T., Latkin, C., & Hickman, M. (2010). Prevention of HIV infection for people who inject drugs: Why individual, structural, and combination approaches are needed. The Lancet, 376, 285–301. doi:10.1016/S0140-6736(10)60742-8 Dolan, K., Kite, B., Black, E., Aceijas, C., & Stimson, G. V. (2007). HIV in prison in low-income and middle-income countries. Lancet Infectious Diseases, 7(1), 32–41. doi:10.1016/S1473-3099(06)70685-5 Fischl, M., Castro, J., Monroig, R., Scerpella, E., Thompson, L., Rechtine, D., & Thomas, D. (2001, February). Impact of directly observed therapy on long-term outcomes in HIV clinical trials. Paper presented at the 8th conference on retroviruses and opportunistic infections. Chicago, Illinois.
Downloaded by [Colorado College] at 15:42 06 November 2014
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Godji, A., Togbe, T., & Aguirre, M. (2002, July) (Abstract no. ThPeD7766). A capacity building approach in the fight against HIV/AIDS in prisons. Paper presented at the Poster Exhibition at the XIV International AIDS conference. Barcelona, Spain. Goyer, K. C., & Gow, J. (2002). Alternatives to current HIV/AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23, 307–323. doi:10.2307/3343227 Grinstead, O., Zack, B., Faigeles, B., Grossman, N., & Blea, L. (1999). Reducing postrelease HIV risk among male prison inmates. Criminal Justice and Behavior, 26, 453–465. doi:10.1177/0093854899026004003 Hedrich, D., Alves, P., Farrell, M., Stover, H., Moller, L., & Mayet, S. (2012). The effectiveness of opioid maintenance treatment in prison settings: A systematic review. Addiction, 107, 501–517. doi:10.1111/j.1360-0443.2011.03676.x HIV AIDS Policy Law Rev. (2010). HIV prevalence in prison is 15 times greater than in the community as a whole. HIV/ AIDS Policy & Law Review, 15(1), 5–6. Huang, Y. F., Kuo, H. S., Lew-Ting, C. Y., Tian, F., Yang, C. H., Tsai, T. I., … Nelson, K. E. (2011). Mortality among a cohort of drug users after their release from prison: An evaluation of the effectiveness of a harm reduction program in Taiwan. Addiction, 106, 1437–1445. doi:10.1111/j.13600443.2011.03443.x Hudson, A. L., Nyamathi, A., Bhattacharya, D., Marlow, E., Shoptaw, S., Marfisee, M., & Leake, B. (2011). Impact of prison status on HIV-related risk behaviors. AIDS and Behavior, 15, 340–346. doi:10.1007/s10461-009-9570-x ICPS. (2010). International centre for prison studies: World prison brief. Retrieved from http://www.prisonstudies.org/ info/worldbrief/wpb_country.php?country = 36 Ines, S. M., Moralejo, L., Marcos, M., Fuertes, A., & Luna, G. (2008). Adherence to highly active antiretroviral therapy in HIV-infected inmates. Current HIV Research, 6, 164– 170. doi:10.2174/157016208783885047 Johnson, A. P., Macgowan, R. J., Eldridge, G. D., Morrow, K. M., Sosman, J., Zack, B., & Margolis, A. (2011). Cost and threshold analysis of an HIV/STI/Hepatitis prevention intervention for young men leaving prison: Project START. AIDS and Behavior, 17(8), 2676–2684. doi:10.1007/ s10461-011-0096-7 Kinner, S. A., & Milloy, M. J. (2011). Collateral consequences of an ever-expanding prison system. Canadian Medical Association Journal, 183, 632. doi:10.1503/cmaj.101848 Kirkland, L. R., Fischl, M. A., Tashima, K. T., Paar, D., Gensler, T., Graham, N. M., … Hernandez, J. E. (2002). Response to lamivudine-zidovudine plus abacavir twice daily in antiretroviral-naive, incarcerated patients with HIV infection taking directly observed treatment. Clinical Infectious Diseases, 34, 511–518. doi:10.1086/338400 Legal Assistance Center AIDS Law Unit, & University of Wyoming College of Law. (2008). Struggle to survive–A report on HIV/AIDS and prisoners’ rights in Namibia. Wyoming: University of Wyoming College of Law. Lines, R. (2006). From equivalence of standards to equivalence of objectives: The entitlement of prisoners to health care standards higher than those outside prisons. International Journal of Prisoner Health, 2(4), 269–280. doi:10.1080/17449200601069676 Makombe, S. D., Jahn, A., Tweya, H., Thambo, L., Yu, J. K., Hedt, B., … Harries, A. D. (2007). A national survey of prisoners on antiretroviral therapy in Malawi: Access to treatment and outcomes on therapy. Journal of Infection in Developing Countries, 1, 303–307.
Maruschak, L. (2012). HIV in prisons, 2001–2010. U.S. Department of Justice. Retrieved from http://www.bjs.gov/ content/pub/pdf/hivp10.pdf Mathers, B., Cook, C., & Degenhardt, L. (2010). Improving the data to strengthen the global response to HIV among people who inject drugs. International Journal of Drug Policy, 21(2), 100–102. doi:10.1016/j.drugpo.2009.12.007 Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., … Strathdee, S. A. (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. The Lancet, 375, 1014–1028. doi:10.1016/S0140-6736(10)60232-2 Mills, E. J., Lester, R., & Ford, N. (2012). Promoting long term adherence to antiretroviral treatment. British Medical Journal, 344, e4173. doi:10.1136/bmj.e4173 Ministry of Prisons and Correctional Services. (2008–2009). Annual prison statistics. Windhoek, Namibia: Windhoek Central Prison. Moller, L., Stover, H., Jurgens, R., Gatherer, A., Nikogosian, H. (2007). Health in prisons: A WHO guide to the essentials in prison health. Geneva: World Health Organization. Mostashari, F., Riley, E., Selwyn, P. A., & Altice, F. L. (1998). Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 18, 341–348. doi:10.1097/000 42560-199808010-00005 Ng, H. (2000). AIDS in Africa: A regional overview. Harvard AIDS Review, winter, 2–5. Niveau, G. (2007). Relevance and limits of the principle of “equivalence of care” in prison medicine. Journal of Medical Ethics, 33, 610–613. doi:10.1136/jme.2006.018077 Njagarah, H. J. B. (2012). Modelling the role of amelioration and drug lords on drug epidemics and the impact of substance abuse on the dynamics of HIV/AIDS (dissertation). Stellenbosch University, Stellenbosch. Retrieved from http://hdl.handle.net/10019.1/17935. Palepu, A., Tyndall, M. W., Chan, K., Wood, E., Montaner, J. S., & Hogg, R. S. (2004). Initiating highly active antiretroviral therapy and continuity of HIV care: The impact of incarceration and prison release on adherence and HIV treatment outcomes. Antiviral Therapy, 9, 713–719. Pontali, E. (2005). Antiretroviral treatment in correctional facilities. HIV Clinical Trials, 6(1), 25–37. doi:10.1310/ GTQM-QRM1-FDW8-Y2FT Potts, J. (2000). HIV/AIDS in federal prisons. Canada’s response. HIV Previous Plus, 2(2), 1–3. Reid, S. E., Topp, S. M., Turnbull, E. R., Hatwiinda, S., Harris, J. B., Maggard, K. R., … Henostroza, G. (2012). Tuberculosis and HIV control in sub-Saharan African prisons: “thinking outside the prison cell”. Journal of Infectious Diseases, 205 (Suppl. 2), S265–S273. doi:10.1093/infdis/jis029 Report. (2010a). Dramatic results for opt-out HIV testing in prison. Proportion of HIV tests increased quickly. AIDS Alert, 25(7), 76–77. Report. (2010b). Research to focus on HIV within U.S. prison, jail systems. AIDS Policy Law, 25(12), 3. Report. (2010c). Trends. Prison AIDS rate is 2 1/2 times greater than general population. AIDS Policy Law, 25(2), 3. Report. (2011). HIV screening of male inmates during prison intake medical evaluation–Washington, 2006–2010. Morbidity and Mortality Weekly Report, 60, 811–813. Report. (2012). Prison did not discriminate against HIVpositive inmates. AIDS Policy Law, 27(6), 6.
Downloaded by [Colorado College] at 15:42 06 November 2014
AIDS Care Seal, D. W. (2005). HIV-related issues and concerns for imprisoned persons throughout the world. Current Opinion in Psychiatry, 18, 530–535. doi:10.1097/01.yco.000017949 2.08064.de Sifunda, S., Reddy, P. S., Braithwaite, R., Stephens, T., Ruiter, R. A., & van den Borne, B. (2006). Access point analysis on the state of health care services in South African prisons: A qualitative exploration of correctional health care workers’ and inmates’ perspectives in Kwazulu-Natal and Mpumalanga. Social Science & Medicine, 63, 2301–2309. doi:10.1016/j.socscimed.2006.06.010 Simooya, O. O., Sanjobo, N. E., Kaetano, L., Sijumbila, G., Munkonze, F. H., Tailoka, F., & Musonda, R. (2001). ‘Behind walls’: A study of HIV risk behaviours and seroprevalence in prisons in Zambia. AIDS, 15, 1741– 1744. doi:10.1097/00002030-200109070-00023 Spaulding, A. C., Seals, R. M., Page, M. J., Brzozowski, A. K., Rhodes, W., & Hammett, T. M. (2009). HIV/AIDS among inmates of and releases from US correctional facilities, 2006: Declining share of epidemic but persistent public health opportunity. PLoS One, 4, e7558. doi:10.1371/ journal.pone.0007558 Springer, S. A., & Altice, F. L. (2005). Managing HIV/AIDS in correctional settings. Current HIV/AIDS Reports, 2, 165–170. doi:10.1007/s11904-005-0011-9 Swendiman, K. S. (2012). Health care: Constitutional rights and legislative powers (Vol. 7–5700). Washington, DC: Congressional Research Service. Retrieved from http:// www.fas.org/sgp/crs/misc/R40846.pdf Tesch, R. (1990). Qualitative research: Analysis types and software tools. Bristol, PA: Falmer Press. The World Bank. (2009). UNAIDS and the WHO’s report on the Global AIDS epidemic: Prevalence of HIV, total (% of population ages 15–49). Retrieved from http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS UN Office on Drugs and Crime. (2006a). HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings. New York, NY: Co-published with the World Health Organization and the Joint United Nations Programme on HIV/ AIDS. Retrieved from https://www.unodc.org/pdf/HIVAIDS_prisons_July06.pdf UN Office on Drugs and Crime. (2006b). HIV and Prisons in subSaharan Africa: Opportunities for Action. UNAIDS, World Bank. Retrieved from http://www.unodc.org/documents/hivaids/Africa%20HIV_Prison_Paper_Oct-23-07-en.pdf Vaz, R. G., Gloyd, S., & Trindade, R. (1996). The effects of peer education on STD and AIDS knowledge among prisoners in Mozambique. The International Journal of STD & AIDS, 7(1), 51–54. doi:10.1258/0956462961 917069
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Wang, X., & Wu, Z. (2007). Factors associated with adherence to antiretroviral therapy among HIV/AIDS patients in rural China. AIDS, 21(Suppl. 8), S149–S155. doi:10.1097/01. aids.0000304711.87164.99 Watson, R. (2007). Prison health care. Journal of Clinical Nursing, 16, 1195. doi:10.1111/j.1365-2702.2007.01848.x Watson, R., Stimpson, A., & Hostick, T. (2004). Prison health care: A review of the literature. International Journal of Nursing Studies, 41, 119–128. doi:10.1016/S0020-7489 (03)00128-7 Weiser, S. D., Tuller, D. M., Frongillo, E. A., Senkungu, J., Mukiibi, N., & Bangsberg, D. R. (2010). Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS One, 5, e10340. doi:10.1371/journal.pone. 0010340 Weiser, S., Wolfe, W., Bangsberg, D., Thior, I., Gilbert, P., Makhema, J., … Marlink, R. (2003). Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. Journal of Acquired Immune Deficiency syndromes, 34, 281–288. doi:10.1097/0012633 4-200311010-00004 WHO. (2010). Antiretroviral therapy for HIV infection in adults and adolescents–Recommendations for a public health approach: 2010 revision. Geneva: Author. WHO, UNODC, & UNAIDS. (2007). Interventions to address HIV in prisons: HIV care, treatment and support evidence for action technical papers. Geneva: Author. Williams, H., Axten, D., Makia, F., Naylor, E., Leonard, O., Teague, A., … Fox, J. (2012). The prevalence of HIV and hepatitis C in individuals leaving prison and entering drug and alcohol treatment services. Sexually Transmitted Infections, 88(7), 538. doi:10.1136/sextrans-2012-050534 Wohl, D. A., Scheyett, A., Golin, C. E., White, B., Matuszewski, J., Bowling, M., … Earp, J. (2011). Intensive case management before and after prison release is no more effective than comprehensive pre-release discharge planning in linking HIV-infected prisoners to care: A randomized trial. AIDS and Behavior, 15, 356–364. doi:10.1007/s10461010-9843-4 Wohl, D. A., Stephenson, B. L., Golin, C. E., Kiziah, C. N., Rosen, D., Ngo, B., … Kaplan, A. H. (2003). Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clinical Infectious Diseases, 36, 1572–1576. doi:10.1086/375076 Zulu, R. M., Byrne, N. M., Munthali, G. K., Chipeta, J., Handema, R., Musonda, M., & Hills, A. P. (2011). Assessing the impact of a food supplement on the nutritional status and body composition of HIV-infected Zambian women on ARVs. BMC Public Health, 11, 714.
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Namibian prisoners describe barriers to HIV antiretroviral therapy adherence a
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Nauyele Shalihu , Louise Pretorius , Agnes van Dyk , Ann Vander Stoep & Amy Hagopian a
Senior Superintendent and Head Nurse with Ministry of Safety and Security, Department of Correctional Service, Windhoek Correctional Facility, Windhoek, Namibia b
School of Nursing and Public Health, University of Namibia, Windhoek, Namibia
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Health Alliance International in the Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA Published online: 06 Feb 2014.
To cite this article: Nauyele Shalihu, Louise Pretorius, Agnes van Dyk, Ann Vander Stoep & Amy Hagopian (2014) Namibian prisoners describe barriers to HIV antiretroviral therapy adherence, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:8, 968-975, DOI: 10.1080/09540121.2014.880398 To link to this article: http://dx.doi.org/10.1080/09540121.2014.880398
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AIDS Care, 2014 Vol. 26, No. 8, 968–975, http://dx.doi.org/10.1080/09540121.2014.880398
Namibian prisoners describe barriers to HIV antiretroviral therapy adherence Nauyele Shalihua, Louise Pretoriusb, Agnes van Dykb, Ann Vander Stoepc and Amy Hagopianc* a
Senior Superintendent and Head Nurse with Ministry of Safety and Security, Department of Correctional Service, Windhoek Correctional Facility, Windhoek, Namibia; bSchool of Nursing and Public Health, University of Namibia, Windhoek, Namibia; cHealth Alliance International in the Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
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(Received 22 January 2013; accepted 25 December 2013) Little is available in scholarly literature about how HIV-positive prisoners, especially in low-income countries, access antiretroviral therapy (ART) medication. We interviewed 18 prisoners at a large prison in Namibia to identify barriers to medication adherence. The lead nurse researcher was a long-standing clinic employee at the prison, which afforded her access to the population. We identified six significant barriers to adherence, including (1) the desire for privacy and anonymity in a setting where HIV is strongly stigmatized; (2) the lack of simple supports for adherence, such as availability of clocks; (3) insufficient access to food to support the toll on the body of ingesting taxing ART medications; (4) commodification of ART medication; (5) the brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health; and (6) the lack of understanding about HIV, how it is transmitted, and how it is best managed. Because most prisoners eventually transition back to communitysettings when their sentences are served, investments in prison health represent important investments in public health. Keywords: Namibia; Africa; prisoners; HIV; medication adherence; antiretroviral therapy
Introduction Southern Africa contains all nine of the world’s countries where the prevalence of HIV among young adults (aged 15–49) exceeds 10% (Ng, 2000; The World Bank, 2009). Highly vulnerable subpopulations have even higher rates within those countries. In Namibia, the vulnerable populations include men who have sex with men (Baral et al., 2009), injection drug users (Degenhardt et al., 2010; Mathers, Cook, & Degenhardt, 2010; Mathers et al., 2010), soldiers (Ba et al., 2008), and prisoners (Angora et al., 2011; Aulagnier et al., 2011; Baral et al., 2009; Dolan, Kite, Black, Aceijas, & Stimson, 2007; Reid et al., 2012). Rates of imprisonment are growing worldwide, with more than one million prisoners in Africa’s 54 subSaharan nations. The majority of prisoners is from poor and marginalized communities with a variety of health problems (Moller, Stover, Jurgens, Gatherer, & Nikogosian, 2007). Namibia has one of the highest incarceration rates in Africa, with more than 200 prisoners per 100,000 population, or 4300 prisoners for the nation’s 2.3 million population (ICPS, 2010) compared, for example, to 31 per 100,000 in Nigeria, or 36 in Sudan (Watson, 2007). Despite the vulnerability of the health of incarcerated populations, very little is published in the scientific literature about HIV and AIDS among prisoners; most reports are from North America (Adams et al., 2011; Baillargeon et al., 2010; Braithwaite & Arriola, 2003; Catz et al., 2012; Hedrich et al., 2012; Huang *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
et al., 2011; Hudson et al., 2011; Johnson et al., 2011; Kinner & Milloy, 2011; Palepu et al., 2004; Pontali, 2005; Report, 2010a, 2010b, 2011, 2012; Watson, 2007; Watson, Stimpson, & Hostick, 2004; Williams et al., 2012; Wohl et al., 2011). A few have addressed HIV among prisoners in Africa (Baral et al., 2009; Baral et al., 2011; Ng, 2000; Reid et al., 2012). In Cote d’Ivoire, prisoners are reported to have twice the HIV prevalence as the general population (Angora et al., 2011), while the prevalence in South African prisons is reported to be a startling 44% (Dolan et al., 2007). Other reports substantiate that HIV prevalence in prisons can be several times that in the general population, largely because of overlapping risk factors (2010; Potts, 2000; Report, 2010c). Prisons have been neglected in the global response to the HIV epidemic, perhaps because of the double stigma and disenfranchisement resulting from both HIV infection and incarceration. A strict daily schedule of antiretroviral medications is the current treatment standard to reduce symptoms and extend survival for persons infected with HIV (WHO, 2010). Interruptions in antiretroviral therapy (ART) are a serious problem in HIV care, both because they threaten the health of the individual patient, and because they can lead to drug resistance, creating a concern in the broader community. A considerable body of work addresses adherence generally, although little research has been conducted in prison settings (Mills, Lester, & Ford, 2012). Three
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AIDS Care studies from Spain (Blanco et al., 2005; Ines, Moralejo, Marcos, Fuertes, & Luna, 2008) found prisons mismanage missed medications and identified inmate characteristics, including having an occupation during imprisonment, having HIV-related symptoms, acceptance of treatment, and higher academic background related to adherence. One study from North Carolina in the USA examined the effects of directly observed ART (DOT) on prisoners, finding it not entirely successful because inmates did not like the stigma associated with DOT (Wohl et al., 2003). A US study from Connecticut among female prisoners determined that adherence was associated with trust in the patient–physician relationship and the presence of emotional supports (Mostashari, Riley, Selwyn, & Altice, 1998). Prison conditions are often described in the literature as “appalling.” Prisons suffer from overcrowding, violence, forced sexual activity, close contact contributing to the spread of disease, insufficient opportunities for rehabilitation, poor quality of health care facilities, and generally poor living conditions (UN Office on Drugs and Crime, 2006b). While prisons are a particularly difficult setting, public health prevention principles still apply (Seal, 2005; Springer & Altice, 2005). The purpose of this research was to explore the challenges facing prisoners in a large prison in Namibia with regard to maintaining adherence to an HIV medication regimen. Methods We used qualitative methods to investigate the barriers to ART adherence in an urban Namibian all-male, maximum security prison. Namibia has 13 prisons; this one is among the largest, housing approximately 1300 inmates in a facility built for 900. Within this population, an estimated 333 inmates tested positive for HIV between 2008 and 2009, and 122 were eligible for ART by World Health Organization (WHO) standards. ART is routinely provided as part of the free prison health service for all ART-eligible inmates (with CD4 counts of 300 or lower, as guided by WHO policy) (Ministry of Prisons and Correctional Services, 2008–2009). From a sampling frame of approximately 120 HIVpositive inmates on ART, we selected the first 20 patients who volunteered, who also met our criteria of being on ART for at least six months, and who spoke English reasonably well. Of these, 18 completed a semi-structured interview in English. The interviewer (S.N.), who had worked at the prison as a nurse for 15 years and was recognized as a trusted clinician, was conducting research for her master’s thesis at the University of Namibia (UNAM) School of Public Health, under the supervision of two UNAM faculty members (A.V.D. and
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L.P.). Two University of Washington faculty members helped to conceive of and carry out the project (A.V.S. and A.H.). Ethical permissions for the project were obtained from the Ministry of Safety and Security, Department of the Prisons and Correctional Services, and the University of Namibia Postgraduate Committee. Potential participants, all of whom were regular patients at the prison clinic, were approached by the interviewer as a part of their normal clinic visits for ART review. They were informed the purpose of the study, the interview procedures that confidentially was ensured, and that participation was entirely voluntary. Patients were given two months to decide whether to participate, and those who did were asked to sign consent forms. Interviews were conducted in the nurse researcher’s private clinical office, where their participation would not be noticed. Participants were aged between mid-20s and mid-60s. Interviews ranged from 60 to 90 minutes. Eight standardized interview questions were asked about supports and barriers for ART adherence in prison. Questions addressed whether inmates in general take ART “on time,” whether they take ART in front of others, what supports they have or need for ART adherence, barriers to ART adherence, what could improve adherence motivation, and general comments. The interviewer kept detailed written notes of the interview. At the end of the interview, the researcher read back each recorded quote and asked the participant to make any corrections. All interviews were conducted in the course of a one-week period in March 2009. Interview notes were typed, and the researcher used a manual approach to reviewing transcripts to identify themes and sub-themes, similar to Tesch’s 8-step method (Tesch, 1990). UNAM faculty supervisors reviewed all coding material to ensure reliability.
Results After analyzing the text of the interviews, we observed six themes that help explain why ART adherence is difficult in a Namibian prison.
Stigma and privacy Prisoners described Wednesdays as “AIDS day,” when a truck arrives to take HIV-positive prisoners to local health providers for their care (a large truck for the public clinic, a smaller vehicle for private clinics). It is clear even to the casual observer that those getting on the bus are being taken for HIV treatment, and prison authorities are aware that many inmates concerned about stigma chose not to get on the bus. While public clinic care is free, private patients must pay (typically in these cases their wives have insurance coverage).
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Once in possession of medications following clinic visits, prisoners said they attempted to hide or disguise their pill vials, in an attempt to shield their HIV status from fellow prisoners and guards. WHO advises prisoners be allowed to keep their medication with them, guidance that it is followed in Namibian prisons (Moller et al., 2007). We were told that HIV medications are dispensed in distinctive dispensers, compared to the more generic sachets for other medications. Prisoners also said they looked for private moments to ingest their pills, to not be observed (Table 1).
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Simple supports for adherence After adherence counseling, inmates chose a dosing time, typically twice per day. Inmates typically keep their medicines in their own locked, unrefrigerated cabinets. No reminders are provided, and few ready cues exist as to time of day other than daylight. Prisoners do not have routine access to clocks, radio, or television. Access to media was reported to be a privilege meted out to prisoners depending on their classifications; for example, only prisoners who have completed one-third of their sentences are allowed to have radios. Meals were reportedly served at irregular times, and therefore were not reliable reference points for medication timing (Table 2). Access to food Prisoners reported the phenomenon of experiencing increased hunger and desire for food while on ART. Because it is known that ART stimulates the appetite (Goyer & Gow, 2002; Wang & Wu, 2007; Weiser et al., 2003; Zulu et al., 2011), prison policy affords extra food
rations to inmates on ART, especially protein. However, prisoners reported they usually receive irregular and inadequate meals, even for the most seriously ill. It is common to see malnourished inmates, both on ART and not. Inmates also reported they sometimes have special food delivered by their families, although this is against prison rules (Table 3).
Commodification of ART Prisoners reported various uses for ART unrelated to the relief of HIV disease, including the smoking of ARTs (thus, creating a market among non-HIV-positive prisoners), the belief that taking a dose of ART prior to a sexual encounter can prevent transmission, and offering sex to obtain medications. As there is a market for ARTs, and because access to money in prisons is limited, sex is sometimes exchanged as a commodity to obtain ARTs. News outlets and other researchers (Njagarah, 2012) have reported a southern African street drug cocktail that includes ART medication, among other ingredients, that can produce a high when smoked. This may explain why those seeking an hallucinogenic effect may purchase ARTs (Table 4).
Brutality and despair Most participants complained about the negative behaviors and attitudes of prison staff toward inmates on ART. Prisoners said the treatment they receive from guards who know their HIV status causes frustration, humiliation, and discouragement. It was unclear whether guards lacked information about the importance of ART adherence, lacked empathy, or lacked both (Table 5).
Table 1. Prisoner comments on Theme 1: The desire for privacy and anonymity in a setting where HIV is strongly stigmatized. “I do take it in front of others, though people used to throw stones because they see me taking ARV.” “Privacy is being violated even at the local hospital whereby the NAMPOL (Namibian police) officials are always present while one is consulted by the doctor.” “Going to the hospital at ARV clinic in a big group in the same car, this has revealed people’s status indirect(ly). This has caused some of my colleagues to stop … taking their ARVs.”
Table 2. Prisoner comments on Theme 2: The lack of simple supports for adherence, such as the availability of clocks. “I used to take my ARV medication after breakfast though the breakfast does not have exact time.” “It is difficult in prison to take ARVs on time, because no watches is allowed in prison, people are taking it on estimation, we are forgetting after you remember it is already two or three hours later, simply due to the reason that there is no watches.” “Myself I am estimating on time because I do not have anywhere to check the time, no watches, no radio, no TV. I always take it morning time and afternoon.”
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Table 3. Prisoner comments on Theme 3: Insufficient access to food to support the toll on the body of ingesting taxing ART medications. “Lack of sufficient food cause dizziness then one will skip some doses.” “The prison should to provide inmates on ARV medications with enough high protein food, the quantity should be increased; this will assist inmates to take their ARVs well if they have enough food to eat.” “Inmates should be allowed to receive food from their families at visiting time.”
Table 4. Prisoner comments on Theme 4: Commodification of ART medication.
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“Selling of ARV drugs in exchange with sex.” “Selling of ARV medications to the drug dealers in prison for smoking it.” “There are those who have permanent sexual partners, in an attempt to try to protect their partners from getting infected with the virus, they buy ARV drugs for them.”
Table 5. Prisoner comments on Theme 5: The brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health. “Oh! Are you also on AIDS treatment?” This was said (mockingly, by a guard) in front or in the presence of other inmates and prison warders (wardens). “Disrespect from prison members (guards) who made statements like, ‘I don’t care if you die or your life is just depends on medication only.’” “Psychological humiliation of inmates on ARV therapy by prison officials.” “Frustration caused by members of prison, can make a person not to take ARV therapy, or it discourages you.”
Table 6. Prisoner comments on Theme 6: The lack of understanding of the disease, how it is transmitted, and how it is best managed. “Negligence and ignorance by the user of ARV medication.” “I know many of those who dropped ARV except one whom I convinced and he went back to ARV again, the rest have thrown them away.” “Denial or don’t mind (resigned) attitude, resulted to inmates skip ARV follow ups.”
Lack of understanding of the disease Many inmates, in Namibia as well as globally, are not well educated (Niveau, 2007). Prisoners with poorer formal education have been found to be less knowledgeable about HIV and how it is transmitted as well (Vaz, Gloyd, & Trindade, 1996). The prisoners in our study demonstrated their own lack of knowledge, as well as ignorance among guards and fellow inmates. This lack of information about basic HIV transmission and disease effects triangulates with other themes in this study to undermine health (Table 6).
Discussion There is broad consensus among human rights and global health organizations that people in prison have a right to a standard of health care equivalent to that available outside prison (Committee of Ministers-
Europe, 1998; Lines, 2006; Niveau, 2007). In the USA, incarceration entitles prisoners to better access to health care than available to the general population (Swendiman, 2012), perhaps explaining why seroprevalence among US prisoners has fallen (Spaulding et al., 2009) and why AIDS mortality among state prison in‐ mates is now lower than for the general population (Maruschak, 2012). HIV-positive prisoners, even in low-income countries where universal access to ART is difficult to achieve, should expect access (Pontali, 2005). WHO has acknowledged that while providing prisoner access to ART is a challenge, it is both necessary and feasible (WHO, UNODC, & UNAIDS, 2007). Indeed, prison may even present unique opportunities for HIV education and prevention because of the ready concentration of at-risk individuals who were likely underserved in their communities (Beckwith, Zaller, Fu, Montague, &
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Rich, 2010; Grinstead, Zack, Faigeles, Grossman, & Blea L, 1999). For many new inmates, prison may be their first opportunity to access proper medical attention for a host of medical problems, including HIV (Sifunda et al., 2006). Further, prisons in Africa have demonstrated success in administering comprehensive ART programs for inmates (Davies & Karstaedt, 2012; Makombe et al., 2007). We observed six distinct barriers to ART adherence among the Namibian prisoners who we interviewed, including insufficient privacy within a stigmatized setting, the lack of simple supports for adherence, insufficient nutritional intake, the market value of ARTs to exchange for money or other benefits, the brutality of the prison setting (which leads to despair), and the lack of good information about HIV transmission and care. Limitations and strengths of study Our study’s strengths and weakness stem from the fact that our lead researcher was a long-time prison nurse serving the population we were studying. She was uniquely positioned with access to an understudied, and vulnerable population, enjoyed good rapport with her patients, and was able to conduct meaningful systematic interviews to elicit candid perspectives. Prisoner patients, however, may have been reluctant to talk candidly to a person who they viewed as having an authority role at the prison or knew their health issues personally. Their reticence to talk openly, however, would likely have been magnified had the researcher been a total stranger. Another limitation is that we conducted a modest number of interviews (18), and our volunteers for the study may represent a unique subset who had experiences or perspectives that did not represent those of the all Namibian prisoners with HIV. Despite limitations, the study offers a unique window into the challenges of maintaining high ART adherence within a prison setting. Recommendations Reduce stigma by ensuring privacy and anonymity Prisoner complaints of ridicule and stigma associated with knowledge of HIV-positive status contributed to problems with adherence. The Wednesday “AIDS day” clinic truck logistics could be restructured to reduce spectacle. In-prison peer solidarity and mutual support programs have been demonstrated to reduce stigma (Goyer & Gow, 2002; Grinstead O et al., 1999). Provide simple supports for adherence, such as clocks, radios, or regular feeding times It is simple enough to provide clocks or otherwise announce the time in prison to allow inmates to keep to their medication schedules. Some prisons have also
found limited success with staff or peer-supported DOT (Kirkland et al., 2002), (Altice, Mostashari, & Friedland, 2001; Babudieri, Aceti, D’Offizi, Carbonara, & Starnini, 2000; Fischl et al., 2001). The two government agencies responsible for prisoner health – the Ministry of Safety and Security and the Ministry of Health – have reportedly failed to cooperate on the responsibility for ART administration to the detriment of prisoners (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008). Provide adequate food support Prisoners reported that poor nutrition can make them too weak to maintain ART regimens. A Namibian Legal Assistance Center study conducted in 2008 (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008) found problems with sufficiency and timing of food distribution resulting in prisoners exchanging sex for food. The need for expanded nutritional support during HIV therapy is well documented, but access to food in prisons is inadequate even as it is in the general HIV-positive population in low-income countries (Coetzee, Kagee, & Vermeulen, 2011; Weiser et al., 2010). We recommend increased nutritive sustenance for all prisoners to avoid selective treatment and its associated stigma. Educate to prevent commodification of ART The sale of ART reflects low knowledge about HIV and its transmission and desperation for mind-altering substances. Changing perceptions requires an education program and a change in culture. Reduce brutality and despair in the prison setting Violence in prisons is a way of life and Namibian prisons are no different (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008). The loss of hope, especially among those serving long sentences, fosters reckless behavior. Reducing violence requires adequate staffing, lower incarceration rates, and opportunities for purposeful activity (UN Office on Drugs and Crime, 2006a). Researchers have demonstrated the success of prisoner-led initiatives to organize educational and decision-making capacity (Godji, Togbe, & Aguirre, 2002). Increase understanding about HIV Namibia’s Legal Assistance Center report (Legal Assistance Center AIDS Law Unit & University of Wyoming College of Law, 2008) indicates that the seven-month training for prison staff includes some education about HIV, including how to conduct bodily fluid clean up, although older staff may not have gotten it. The same report describes barriers created by the language
AIDS Care differences between staff and inmates, which could be solved by recruiting staff with appropriate language skills. Other Recommendations from reports on HIV in prison have supported a number of other measures (Dolan et al., 2007) such as a reduction in incarceration rates and overcrowding (UN Office on Drugs and Crime, 2006b), improved counseling and testing (Goyer & Gow, 2002), and harm reduction such as the provision of condoms for consensual sex (Sifunda et al., 2006; Simooya et al., 2001) and offering bleach and needle exchange (Braithwaite & Arriola, 2003).
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Conclusion Namibia, one of Africa’s youngest countries with a relatively small population, is well positioned to experiment with humanitarian approaches to incarceration that demonstrate innovative practices. The progressive national constitution, which recognizes “the equal and inalienable rights of all members of the human family are indispensable for freedom, justice and peace,” supports prisoner access to health and human rights. Most prisoners eventually transition back to community settings when their sentences are served, so investments in prison health are truly investments in public health. Acknowledgments We appreciate the inmates who participated in the study. Late Eliakim Inicko Shalihu is also warmly acknowledged.
References Adams, J., Nowels, C., Corsi, K., Long, J., Steiner, J. F., & Binswanger, I. A. (2011). HIV risk after release from prison: A qualitative study of former inmates. Journal of Acquired Immune Deficiency Syndromes, 57, 429–434. doi:10.1097/QAI.0b013e31821e9f41 Altice, F. L., Mostashari, F., & Friedland, G. H. (2001). Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 28(1), 47–58. Angora, B., Assemien, J., Laurent, A., Febro, V., CoulibalyOffia, M., Masumbuko, J. M., … Raguin, G. (2011). HIV in prison in low income countries. AIDS, 25, 1244–1246. doi:10.1097/QAD.0b013e328347c0f1 Aulagnier, M., Janssens, W., De Beer, I., van Rooy, G., Gaeb, E., Hesp, C., … Rinke de Wit, T. F. (2011). Incidence of HIV in Windhoek, Namibia: Demographic and socio-economic associations. PLoS One, 6, e25860. doi:10.1371/journal. pone.0025860 Ba, O., O’Regan, C., Nachega, J., Cooper, C., Anema, A., Rachlis, B., & Mills, E. J. (2008). HIV/AIDS in African militaries: An ecological analysis. Medicine, Conflict and Survival, 24(2), 88–100. doi:10.1080/136236908019 50260 Babudieri, S., Aceti, A., D’Offizi, G. P., Carbonara, S., & Starnini, G. (2000). Directly observed therapy to treat HIV
973
infection in prisoners. Journal of the American Medical Association, 284, 179–180. doi:10.1001/jama.284.2.179 Baillargeon, J. G., Giordano, T. P., Harzke, A. J., Baillargeon, G., Rich, J. D., & Paar, D. P. (2010). Enrollment in outpatient care among newly released prison inmates with HIV infection. Public Health Report, 125(Suppl. 1), 64–71. Baral, S., Adams, D., Lebona, J., Kaibe, B., Letsie, P., Tshehlo, R., … Beyrer, C. (2011). A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho. Journal of the International AIDS Society, 14, 36. doi:10.1186/1758-2 652-14-36 Baral, S., Trapence, G., Motimedi, F., Umar, E., Iipinge, S., Dausab, F., & Beyrer, C. (2009). HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One, 4, e4997. doi:10.1371/journal.pone.0004997 Beckwith, C. G., Zaller, N. D., Fu, J. J., Montague, B. T., & Rich, J. D. (2010). Opportunities to diagnose, treat, and prevent HIV in the criminal justice system. Journal of Acquired Immune Deficiency Syndromes, 55(Suppl. 1), S49–S55. doi:10.1097/QAI.0b013e3181f9c0f7 Blanco, J. M., Perez, I. R., De Labry Lima, A. O., Recio, J. M., Lopez, E. G., & Basanta, J. J. (2005). Adherence to antiretroviral treatment in prisons. AIDS Research and Human Retroviruses, 21, 683–688. doi:10.1089/aid.2005. 21.683 Braithwaite, R. L., & Arriola, K. R. (2003). Male prisoners and HIV prevention: A call for action ignored. American Journal of Public Health, 93, 759–763. doi:10.2105/ AJPH.93.5.759 Catz, S. L., Thibodeau, L., BlueSpruce, J., Yard, S. S., Seal, D. W., Amico, K. R., … Sosman, J. M. (2012). Prevention needs of HIV-positive men and women awaiting release from prison. AIDS and Behavior, 16(1), 108–120. doi:10.1007/s10461-011-9962-6 Coetzee, B., Kagee, A., & Vermeulen, N. (2011). Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: The perspectives of health care providers. AIDS Care, 23, 146–151. doi:10.1080/ 09540121.2010.498874 Committee of Ministers-Europe. (1998). Concerning the ethical and organisational aspects of health care in prison adopted by the committee of ministers on 8 April. Retrieved from https://wcd.coe.int/com.instranet.InstraServlet?command=com.instranet.CmdBlobGet&Instranet Image=530914&SecMode=1&DocId=463258&Usage=2 Davies, N. E., & Karstaedt, A. S. (2012). Antiretroviral outcomes in South African prisoners: A retrospective cohort analysis. PLoS One, 7, e33309. doi:10.1371/ journal.pone.0033309 Degenhardt, L., Mathers, B., Vickerman, P., Rhodes, T., Latkin, C., & Hickman, M. (2010). Prevention of HIV infection for people who inject drugs: Why individual, structural, and combination approaches are needed. The Lancet, 376, 285–301. doi:10.1016/S0140-6736(10)60742-8 Dolan, K., Kite, B., Black, E., Aceijas, C., & Stimson, G. V. (2007). HIV in prison in low-income and middle-income countries. Lancet Infectious Diseases, 7(1), 32–41. doi:10.1016/S1473-3099(06)70685-5 Fischl, M., Castro, J., Monroig, R., Scerpella, E., Thompson, L., Rechtine, D., & Thomas, D. (2001, February). Impact of directly observed therapy on long-term outcomes in HIV clinical trials. Paper presented at the 8th conference on retroviruses and opportunistic infections. Chicago, Illinois.
Downloaded by [Colorado College] at 15:42 06 November 2014
974
N. Shalihu et al.
Godji, A., Togbe, T., & Aguirre, M. (2002, July) (Abstract no. ThPeD7766). A capacity building approach in the fight against HIV/AIDS in prisons. Paper presented at the Poster Exhibition at the XIV International AIDS conference. Barcelona, Spain. Goyer, K. C., & Gow, J. (2002). Alternatives to current HIV/AIDS policies and practices in South African prisons. Journal of Public Health Policy, 23, 307–323. doi:10.2307/3343227 Grinstead, O., Zack, B., Faigeles, B., Grossman, N., & Blea, L. (1999). Reducing postrelease HIV risk among male prison inmates. Criminal Justice and Behavior, 26, 453–465. doi:10.1177/0093854899026004003 Hedrich, D., Alves, P., Farrell, M., Stover, H., Moller, L., & Mayet, S. (2012). The effectiveness of opioid maintenance treatment in prison settings: A systematic review. Addiction, 107, 501–517. doi:10.1111/j.1360-0443.2011.03676.x HIV AIDS Policy Law Rev. (2010). HIV prevalence in prison is 15 times greater than in the community as a whole. HIV/ AIDS Policy & Law Review, 15(1), 5–6. Huang, Y. F., Kuo, H. S., Lew-Ting, C. Y., Tian, F., Yang, C. H., Tsai, T. I., … Nelson, K. E. (2011). Mortality among a cohort of drug users after their release from prison: An evaluation of the effectiveness of a harm reduction program in Taiwan. Addiction, 106, 1437–1445. doi:10.1111/j.13600443.2011.03443.x Hudson, A. L., Nyamathi, A., Bhattacharya, D., Marlow, E., Shoptaw, S., Marfisee, M., & Leake, B. (2011). Impact of prison status on HIV-related risk behaviors. AIDS and Behavior, 15, 340–346. doi:10.1007/s10461-009-9570-x ICPS. (2010). International centre for prison studies: World prison brief. Retrieved from http://www.prisonstudies.org/ info/worldbrief/wpb_country.php?country = 36 Ines, S. M., Moralejo, L., Marcos, M., Fuertes, A., & Luna, G. (2008). Adherence to highly active antiretroviral therapy in HIV-infected inmates. Current HIV Research, 6, 164– 170. doi:10.2174/157016208783885047 Johnson, A. P., Macgowan, R. J., Eldridge, G. D., Morrow, K. M., Sosman, J., Zack, B., & Margolis, A. (2011). Cost and threshold analysis of an HIV/STI/Hepatitis prevention intervention for young men leaving prison: Project START. AIDS and Behavior, 17(8), 2676–2684. doi:10.1007/ s10461-011-0096-7 Kinner, S. A., & Milloy, M. J. (2011). Collateral consequences of an ever-expanding prison system. Canadian Medical Association Journal, 183, 632. doi:10.1503/cmaj.101848 Kirkland, L. R., Fischl, M. A., Tashima, K. T., Paar, D., Gensler, T., Graham, N. M., … Hernandez, J. E. (2002). Response to lamivudine-zidovudine plus abacavir twice daily in antiretroviral-naive, incarcerated patients with HIV infection taking directly observed treatment. Clinical Infectious Diseases, 34, 511–518. doi:10.1086/338400 Legal Assistance Center AIDS Law Unit, & University of Wyoming College of Law. (2008). Struggle to survive–A report on HIV/AIDS and prisoners’ rights in Namibia. Wyoming: University of Wyoming College of Law. Lines, R. (2006). From equivalence of standards to equivalence of objectives: The entitlement of prisoners to health care standards higher than those outside prisons. International Journal of Prisoner Health, 2(4), 269–280. doi:10.1080/17449200601069676 Makombe, S. D., Jahn, A., Tweya, H., Thambo, L., Yu, J. K., Hedt, B., … Harries, A. D. (2007). A national survey of prisoners on antiretroviral therapy in Malawi: Access to treatment and outcomes on therapy. Journal of Infection in Developing Countries, 1, 303–307.
Maruschak, L. (2012). HIV in prisons, 2001–2010. U.S. Department of Justice. Retrieved from http://www.bjs.gov/ content/pub/pdf/hivp10.pdf Mathers, B., Cook, C., & Degenhardt, L. (2010). Improving the data to strengthen the global response to HIV among people who inject drugs. International Journal of Drug Policy, 21(2), 100–102. doi:10.1016/j.drugpo.2009.12.007 Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., … Strathdee, S. A. (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. The Lancet, 375, 1014–1028. doi:10.1016/S0140-6736(10)60232-2 Mills, E. J., Lester, R., & Ford, N. (2012). Promoting long term adherence to antiretroviral treatment. British Medical Journal, 344, e4173. doi:10.1136/bmj.e4173 Ministry of Prisons and Correctional Services. (2008–2009). Annual prison statistics. Windhoek, Namibia: Windhoek Central Prison. Moller, L., Stover, H., Jurgens, R., Gatherer, A., Nikogosian, H. (2007). Health in prisons: A WHO guide to the essentials in prison health. Geneva: World Health Organization. Mostashari, F., Riley, E., Selwyn, P. A., & Altice, F. L. (1998). Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 18, 341–348. doi:10.1097/000 42560-199808010-00005 Ng, H. (2000). AIDS in Africa: A regional overview. Harvard AIDS Review, winter, 2–5. Niveau, G. (2007). Relevance and limits of the principle of “equivalence of care” in prison medicine. Journal of Medical Ethics, 33, 610–613. doi:10.1136/jme.2006.018077 Njagarah, H. J. B. (2012). Modelling the role of amelioration and drug lords on drug epidemics and the impact of substance abuse on the dynamics of HIV/AIDS (dissertation). Stellenbosch University, Stellenbosch. Retrieved from http://hdl.handle.net/10019.1/17935. Palepu, A., Tyndall, M. W., Chan, K., Wood, E., Montaner, J. S., & Hogg, R. S. (2004). Initiating highly active antiretroviral therapy and continuity of HIV care: The impact of incarceration and prison release on adherence and HIV treatment outcomes. Antiviral Therapy, 9, 713–719. Pontali, E. (2005). Antiretroviral treatment in correctional facilities. HIV Clinical Trials, 6(1), 25–37. doi:10.1310/ GTQM-QRM1-FDW8-Y2FT Potts, J. (2000). HIV/AIDS in federal prisons. Canada’s response. HIV Previous Plus, 2(2), 1–3. Reid, S. E., Topp, S. M., Turnbull, E. R., Hatwiinda, S., Harris, J. B., Maggard, K. R., … Henostroza, G. (2012). Tuberculosis and HIV control in sub-Saharan African prisons: “thinking outside the prison cell”. Journal of Infectious Diseases, 205 (Suppl. 2), S265–S273. doi:10.1093/infdis/jis029 Report. (2010a). Dramatic results for opt-out HIV testing in prison. Proportion of HIV tests increased quickly. AIDS Alert, 25(7), 76–77. Report. (2010b). Research to focus on HIV within U.S. prison, jail systems. AIDS Policy Law, 25(12), 3. Report. (2010c). Trends. Prison AIDS rate is 2 1/2 times greater than general population. AIDS Policy Law, 25(2), 3. Report. (2011). HIV screening of male inmates during prison intake medical evaluation–Washington, 2006–2010. Morbidity and Mortality Weekly Report, 60, 811–813. Report. (2012). Prison did not discriminate against HIVpositive inmates. AIDS Policy Law, 27(6), 6.
Downloaded by [Colorado College] at 15:42 06 November 2014
AIDS Care Seal, D. W. (2005). HIV-related issues and concerns for imprisoned persons throughout the world. Current Opinion in Psychiatry, 18, 530–535. doi:10.1097/01.yco.000017949 2.08064.de Sifunda, S., Reddy, P. S., Braithwaite, R., Stephens, T., Ruiter, R. A., & van den Borne, B. (2006). Access point analysis on the state of health care services in South African prisons: A qualitative exploration of correctional health care workers’ and inmates’ perspectives in Kwazulu-Natal and Mpumalanga. Social Science & Medicine, 63, 2301–2309. doi:10.1016/j.socscimed.2006.06.010 Simooya, O. O., Sanjobo, N. E., Kaetano, L., Sijumbila, G., Munkonze, F. H., Tailoka, F., & Musonda, R. (2001). ‘Behind walls’: A study of HIV risk behaviours and seroprevalence in prisons in Zambia. AIDS, 15, 1741– 1744. doi:10.1097/00002030-200109070-00023 Spaulding, A. C., Seals, R. M., Page, M. J., Brzozowski, A. K., Rhodes, W., & Hammett, T. M. (2009). HIV/AIDS among inmates of and releases from US correctional facilities, 2006: Declining share of epidemic but persistent public health opportunity. PLoS One, 4, e7558. doi:10.1371/ journal.pone.0007558 Springer, S. A., & Altice, F. L. (2005). Managing HIV/AIDS in correctional settings. Current HIV/AIDS Reports, 2, 165–170. doi:10.1007/s11904-005-0011-9 Swendiman, K. S. (2012). Health care: Constitutional rights and legislative powers (Vol. 7–5700). Washington, DC: Congressional Research Service. Retrieved from http:// www.fas.org/sgp/crs/misc/R40846.pdf Tesch, R. (1990). Qualitative research: Analysis types and software tools. Bristol, PA: Falmer Press. The World Bank. (2009). UNAIDS and the WHO’s report on the Global AIDS epidemic: Prevalence of HIV, total (% of population ages 15–49). Retrieved from http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS UN Office on Drugs and Crime. (2006a). HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings. New York, NY: Co-published with the World Health Organization and the Joint United Nations Programme on HIV/ AIDS. Retrieved from https://www.unodc.org/pdf/HIVAIDS_prisons_July06.pdf UN Office on Drugs and Crime. (2006b). HIV and Prisons in subSaharan Africa: Opportunities for Action. UNAIDS, World Bank. Retrieved from http://www.unodc.org/documents/hivaids/Africa%20HIV_Prison_Paper_Oct-23-07-en.pdf Vaz, R. G., Gloyd, S., & Trindade, R. (1996). The effects of peer education on STD and AIDS knowledge among prisoners in Mozambique. The International Journal of STD & AIDS, 7(1), 51–54. doi:10.1258/0956462961 917069
975
Wang, X., & Wu, Z. (2007). Factors associated with adherence to antiretroviral therapy among HIV/AIDS patients in rural China. AIDS, 21(Suppl. 8), S149–S155. doi:10.1097/01. aids.0000304711.87164.99 Watson, R. (2007). Prison health care. Journal of Clinical Nursing, 16, 1195. doi:10.1111/j.1365-2702.2007.01848.x Watson, R., Stimpson, A., & Hostick, T. (2004). Prison health care: A review of the literature. International Journal of Nursing Studies, 41, 119–128. doi:10.1016/S0020-7489 (03)00128-7 Weiser, S. D., Tuller, D. M., Frongillo, E. A., Senkungu, J., Mukiibi, N., & Bangsberg, D. R. (2010). Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS One, 5, e10340. doi:10.1371/journal.pone. 0010340 Weiser, S., Wolfe, W., Bangsberg, D., Thior, I., Gilbert, P., Makhema, J., … Marlink, R. (2003). Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. Journal of Acquired Immune Deficiency syndromes, 34, 281–288. doi:10.1097/0012633 4-200311010-00004 WHO. (2010). Antiretroviral therapy for HIV infection in adults and adolescents–Recommendations for a public health approach: 2010 revision. Geneva: Author. WHO, UNODC, & UNAIDS. (2007). Interventions to address HIV in prisons: HIV care, treatment and support evidence for action technical papers. Geneva: Author. Williams, H., Axten, D., Makia, F., Naylor, E., Leonard, O., Teague, A., … Fox, J. (2012). The prevalence of HIV and hepatitis C in individuals leaving prison and entering drug and alcohol treatment services. Sexually Transmitted Infections, 88(7), 538. doi:10.1136/sextrans-2012-050534 Wohl, D. A., Scheyett, A., Golin, C. E., White, B., Matuszewski, J., Bowling, M., … Earp, J. (2011). Intensive case management before and after prison release is no more effective than comprehensive pre-release discharge planning in linking HIV-infected prisoners to care: A randomized trial. AIDS and Behavior, 15, 356–364. doi:10.1007/s10461010-9843-4 Wohl, D. A., Stephenson, B. L., Golin, C. E., Kiziah, C. N., Rosen, D., Ngo, B., … Kaplan, A. H. (2003). Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clinical Infectious Diseases, 36, 1572–1576. doi:10.1086/375076 Zulu, R. M., Byrne, N. M., Munthali, G. K., Chipeta, J., Handema, R., Musonda, M., & Hills, A. P. (2011). Assessing the impact of a food supplement on the nutritional status and body composition of HIV-infected Zambian women on ARVs. BMC Public Health, 11, 714.
