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Lancet. 2016 Sep 17;388(10050):1215-27. doi: 10.1016/S0140-6736(16)30578-5. Epub 2016 Jul 14.

HIV and tuberculosis in prisons in sub-Saharan Africa.

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Field Epidemiology Services, Public Health England, Bristol, UK; University of Bristol, Bristol, UK. Electronic address:
The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Management Sciences for Health, Lilongwe, Malawi.
Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, USA.
Médecins Sans Frontières, Brussels Operational Centre, Operational Research Unit, Luxembourg City, Luxembourg.
International Union Against Tuberculosis and Lung Disease, Paris, France; London School of Hygiene & Tropical Medicine, London, UK.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Health and Human Rights Division, Human Rights Watch, New York, NY, USA.


Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.

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