Arnaud LAURENT, Programme Manager, ESTHER France

Innovative twinning programme in prison setting

Access to HIV prevention and care in prisons of Cote d’IvoireESTHER initiative in MACA prison

(Maison d’Arrêt et de Correction d’Abidjan)

ESTHER in Côte d’Ivoire

• Since 2005

• 7 hospital twinnings (1 with ESTHER Germany in Bouaké)

• 3 projects with civil society organisations

Background National HIV prevalence: 3.9% (UNAIDS, 2008)

No data available about HIV and TB prevalence among prisoners

In November 2008, the MACA medical Center and Bordeaux Hospitals (CHU/UCSA), under the ESTHER twinning program, started a prevention and care program at the main civilian prison in Abidjan (Maison d’Arrêt et de Correction d’Abidjan)

The main objectives were: to provide HIV and TB prevention and care to prisoners,

guards and their families, to promote health policy changes for prisons in Côte d’Ivoire.

Brief MACA presentation• Location: Yopougon, Abidjan• Population:• 5400 prisoners for 1 500

places (+ 300%)• around 50% of total prisoner

population of Côte d’Ivoire (12 135 on the 31/12/09)

• 97% males, 2% females and 1% minors

• Monthly flow: 600 prisoners (in/out)

• 150 guards and penitentiary personnel

MACA

« Cité MACA »

Females block

Minors block

Medical Center

Social & Medical Center

Administration

« Disciplinary » block

A et B blocks

« VIP » block

Health situation

• Common pathologies: respiratory infectious diseases/TB/malaria/diarrhea/ skin diseases/ … and HIV/AIDS

• Poor hygienic conditions (promiscuity, water access, sanitarians, … cholera epidemic recently)

• Insufficient daily food ration: once a day (1000 Kcal/day), poor quality and poor quantity, family support if any, … malnutrition cases and beriberi outbreak

MACA Medical centers

• Medical care services in and « out of the walls »: around 10 000 persons (prisoners, guards and their family members, and local population from « cité MACA »)

• Medical facilities: 120 beds with 60 dedicated to TB, specific nursing center for females, mortuary, basic laboratory, pharmacy, …

• Personnel: 2 doctors, 4 nurses, 1 midwife, 4 medical assistants, 2 pharmacist assistants, 1 laboratory technician, and … 50 prisoner volunteers

• Organisational issues: Open 5 days/week + on-call duty for emergencies, « free » medical care, 1 800 in out-patients clinic/month

ESTHER Intervention Modalities (capacity building)

At MACA level:

• Prevention + testing activities Peer educators are making regular IEC sessions and promoting HIV

testing among prisoners. Counselors are offering HIV testing (rapid tests) and TB screening to

all new prisoners

• Care and Treatment activities A team of national and international experts providing technical

assistance and trainings. OPD and IPD Rehabilitation + procurement of small medical

equipment=> A medical team of 2 doctors and 4 nurses delivered care and treatment, including ARVs, to HIV patients.

ESTHER Interventions Modalities

At Institutional level:• ESTHER has supported Ministry of Health and

Ministry of Justice with:– a health situation analysis in 9 prisons,– national workshop about health in prisons– the development of a National Joint Committee

“Health-Justice” with the objective of defining a national plan on health in prisons

– Integration of prisoners among beneficiaries of Global Fund (Round 9)

Main results in 16 months (november 2008 - march 2010)

Counselling and HIV testing in MACA (from nov.08 to march 10)

0

200

400

600

800

1000

1200

1400

1600

Nb of prisoners counseled

Nb of tested prisoners

Nb of prisoners HIV+

Nov.08

Jan. 09

Mar. 09

Jul. 09

May 09

Sep. 09

Nov. 09

Jan. 10

Mar. 10

HIV Testing results( from nov. 08 to march 10)

• Total prisoner population for the period: 15 355 prisoners (52% tested)• HIV test acceptance rate: 74%• HIV prevalence rate among prisoners: 5.65%• Male prisoners HIV prevalence: 5.1% (2 x general male pop.)• Female prisoners HIV prevalence: 17.15% (3 x general female pop.)

Capacity building

HIV care and treatment for PLWHIVPrisoners Guards and others Total

Nb. of blood tests (CD4)

425 21 446

CD4< 200 54 10 64

CD4 between 200 et 350

71 3 74

CD4 > 350 300 8 308

Nb. of patients put on ART

76 10 8615 released

Death under ART 6 0 6

• All released prisoners under ART are lost to follow-up (n=15)• 14,3% are eligible for ARV treatment according to national criteria (<200 CD4)• All patients are on 1st line treatment• ARV : TDF-FTC-NVP: 45% (female) D4T-3TC-NVP: 35,6% (male)NB: Viral Load testing in process will give us a better view about prisoners adherence

TB and co-infection HIV/TB

Prisoners Guards and others Total

Number of TB cases 172 0 172

Nb. of TB/VIH+ cases 39 0 39 (13 ARV+) (22.7%)

• HIV prevalence rate among TB patients: 22.7%

• No chest x-ray and no access to culture for Drug Sensitivity Test => low diagnosis for TB/MDR TB

How the Health Policy has changedIn order to promote health improvement in prisons ESTHER has supported a political and institutional process as below. The 2 main acheivements are the official adoption of a national policy for health in prisons and the integration of prisoners among beneficiaries of the Global Fund.

Conclusion/Recommandation HIV infection and TB are both public health

priorities among prisoners in Africa. Prevention and care programs in prisons are still few. It is urgent to scale-up these programs in prison settings.

We show that such programs are feasible if accompanied by national mobilization and political will.

Twinning is at the center of the program and networking is important to involve local, national and international stakeholders to insure ownership and sustainability.