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HIV Research In Correctional Services

South Africa has the 10th highest detention rate in the world.
Approximately 300,000 detainees pass through the prison system each year
with a population of 144,453 inmates in 2017, placed in 227
correctional facilities across the country.

Of these, 97% are male and 50% go back to the community every year.
Many inmates have a short duration of stay, and parole is generally offered
halfway through the sentence.

HIV in correctional facilities

Studies have reported an HIV prevalence rate among inmates of between 7% and 25%. Many inmates are already infected before incarceration due to the high prevalence and high-risk behaviours in the community. Nevertheless, studies have demonstrated higher HIV prevalence rates among inmates being released than those being admitted (34% and 20% respectively in one such study), indicating that there is a notable rate of new infections within correctional facilities.

This aligns with evidence from a range of similar settings suggesting a high risk-environment for HIV acquisition and other conditions with similar transmission mechanisms, such as viral hepatitis and sexually transmitted infections (STIs). Sharing of razors and of needles during tattooing and intravenous drug use, and unsafe sexual practices such as transactional sex, forced/coerced sex and gang rituals, elevate the risk of HIV transmission among incarcerated individuals. As a result, correctional facilities are reservoirs for HIV infection and onward transmission when inmates return to their communities.

The risk is worsened by the high rates of treatment interruption upon release. Research done by Aurum with 492 South African ex-inmates (CDC GH000515) demonstrated that only 38% of inmates on ART had clinic-verified linkage to care following release. While this is generally attributed to poor coordination between health services in the Department of Correctional Services (DCS) and the Department of Health (DOH), other contributing causes were identified which will be described later under the Approach for Program 5: Linkage to Health Services after Release.

HIV prevention strategies in correctional facilities

Due to SA’s large inmate population (328 per 100,000), the total number of persons living with HIV in detention is significant.
The Department of Correctional Services (DCS), with support from the CDC and Global Fund, has therefore established a comprehensive HIV, tuberculosis (TB) and STI prevention, care and treatment program in its facilities. CDC’s previous five-year award to Aurum and its consortium partners (GH001175) focused on strengthening DCS health systems to ensure that inmates had access to TB and HIV treatment within Correctional facilities.


Several of the prevention interventions recommended by the United Nations Office on Drugs and Crime (UNODC) was also introduced under this grant such as condom and lubricant provision, risk reduction education, voluntary medical male circumcision (VMMC) and HIV testing services (HTS). However, given the context described above, the focus in the next decade needs to be on providing a more comprehensive package of prevention services in order to reduce new infections among inmates; and to create more effective systems for ensuring linkage into care upon release to reduce HIV transmission from inmates to the community. Critical to the effective implementation of this strategy is to involve and educate Correctional Services staff and other stakeholders to support the uptake by inmates of services provided and to mitigate the risk of stigma and discrimination preventing such uptake.
Treatment as prevention
The Aurum Institute and Johns Hopkins researchers Tonderai Mabuto and Chris Hoffmann were funded by DFID to conduct a project on Treatment as Prevention (TASP) in correctional facilities in Southern Africa. The study was conducted in 3 facilities: 2 in South Africa and 1 in Zambia and its aims were to 1) assess system-level and inmate-level barriers to and facilitators of TasP implementation in Southern African correctional settings, and 2) Characterize resources, activities, and other programmatic inputs required for TasP implementation in correctional facilities. Using existing service delivery platforms, the study determined 1) Universal HIV testing within 2 months of facility entry and annually, 2) Access to ART for all inmates testing HIV-positive, 3) Accelerated ART initiation after diagnosis, 4) Clear integration of TB screening and treatment, 5) Scaling-up inmate peer supporters and support groups, 6) Enhanced laboratory monitoring and 7) Improved continuity of care for inmates initiating ART. 
The study was completed in 2018 and the project report has been submitted to the funders and is under review.

Aurum and Johns Hopkins researchers Tonderai Mabuto and Chris Hoffmann were funded by the National Institute of Mental Health (NIMH) & Johns Hopkins University to conduct an HIV treatment project among prisoners called Community-to-corrections study. The aim of this study was to pilot additional interventions to facilitate post-release linkage to care among released inmates on HIV treatment and to prepare for a larger randomised trial, if successful. This study will be conducted in the Gauteng Management Area of the Department of Correctional Services and will run from September 2018 to November 2020. By the end of 2018, Ethics approval had been obtained and permission to conduct the study had been obtained from the Department of Correctional Services

In another HIV treatment project among prisoners, Aurum and Johns Hopkins researchers Tonderai Mabuto and Chris Hoffmann were funded by the National Institute of Health (NIMH) to conduct a Corrections2Community study called post-release retention in HIV care for ex-inmates in South Africa. The aim of this study is to pilot a randomized pragmatic trial of a transitional community adherence club (TCAC) versus traditional care in 4 Correctional Facilities in the Gauteng Province. The study started in November 2017 and ends in October 2019 and is in the implementation phase.

Bio-behavioural and structural factors driving HIV

Aurum researchers Tonderai Mabuto, Lucy Chimoyi and Geoffrey Setswe are funded by CDC/PEPFAR through the Public Health Division to conduct a HASH study: Bio-behavioural and structural factors driving HIV/AIDS, STIs and Hepatitis (HASH) risk in correctional facilities in South Africa. The aim of this study is to conduct a situational analysis of the individual, social and structural factors driving HIV/AIDS, sexually transmitted infections (STI) & hepatitis B&C (HASH) risk in incarcerated inmates. The study will be conducted in 4 correctional services in Gauteng (Kgosi Mampuru), North West (Rustenburg), Limpopo (Polokwane) and Mpumalanga (Barberton) and will comprise a biological study to determine the prevalence of HIV/AIDS, STIs, Hepatitis B & C and a behavioural survey of associated risk factors. The study is anticipated to take approximately 9 months in 2019.
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