Many prisoners living with HIV are denied access to adequate antiretroviral drugs, leaving them susceptible to opportunistic infections. Recently, prisoners have increasingly demanded HIV treatment. In 2006, South African inmates launched a hunger strike, demanding that the government provide antiretroviral (ARV) treatment for infected prisoners. In response, Judge Thumba Pillay of the High Court ordered the Department of Correctional Services to adopt a comprehensive HIV/AIDS plan for prisons throughout South Africa. The ruling mandated that prisoners be provided access not only to ARVs but also to health facilities, regular counseling, and adequate nutrition. Unfortunately, this integrated ideal has yet to be translated into practical implementation.
Three years later, inmates at the Westville Correctional Centre, where the hunger strike occurred, and lobbyists from the South Africa-based Treatment Action Campaign (TAC) continue to push for full compliance with the judicial decree. In a recent Plus News article, prisoners remarked on the uneven results of the court order, stating that while ARVs are now more available, the prison support services remain inadequate. Successful ARV treatment therapies depend upon consistent drug regimens and good nutrition, but unsanitary conditions, food shortages, and overcrowding make it difficult for prisoners to benefit fully from the drugs.
According to the United Nations Human Rights Committee, prisoners should have access to medical care equivalent to that available in the community without discrimination on the grounds of their legal status. As the World Health Organization points out in its report Effectiveness of Interventions to Address HIV in Prisons, institutions like the Westville Correctional Centre represent key points of contact with millions of individuals living with or at high risk of HIV infection. This population, normally largely out of the reach of community medical systems, can greatly benefit from care, support, and education. Most inmates will eventually be released, and a comprehensive HIV protocol in prisons can help spread awareness to the larger community.
The 1976 US Supreme Court case Estelle v. Gamble guaranteed inmates’ right to care and held that deliberate indifference to serious medical needs constituted cruel and unusual punishment. Estelle v. Gamble set a precedent for international law, and in 1982 the UN General Assembly adopted a code of Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. The code works toward ensuring ARV provision in prisons, where the rate of HIV infection is often higher than that of the general population. In their 2006 guidelines HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings, the WHO and UNAIDS state that “the relationship between prison health and overall public health is fundamental. Reducing the transmission of HIV in prisons is an important element in reducing the spread of infection in the broader society, and should not be left to prison authorities alone to address.”
Although the Treatment Action Campaign is continuing to lobby for better prison treatment plans, a recent IRIN article described the program as poorly budgeted and financially mismanaged, reporting that 40% of HIV-positive people in need of sustained treatment are unable to access ARVs. Activists are calling for a reevaluation of South Africa’s health expenditures and better oversight from the national departments of health and finance.
The level of care provided to HIV-positive patients should not be dictated by their criminal status. Rather, prison policies and national public health policies need to coalesce in order to treat the general epidemic. Government authorities and medical professionals have an ethical responsibility to heed international law, looking beyond the two-fold stigma that comes with being an HIV-positive convict to deliver the best health care possible. The plight of inmates at the Westville Correctional Centre is representative of a larger global dilemma, one that needs to be addressed as both a public health and ethical issue.