Bringing health behind the bars: how prisoners have joined the fight against HIV in Kenya
John, a convicted criminal at Kisii district prison, Kenya, might seem an unlikely candidate to be spearheading the fight against HIV.
But since being imprisoned for manslaughter two years ago, the former teacher has been trained to educate fellow inmates about how HIV is prevented, transmitted, and treated – in doing so helping to fill the gap between Kenya's severe disease burden and its shortage of skilled health staff.
He hopes that upon his release, he will find a job with an NGO and continue his work as a peer educator.
Prisoners were designated as a "most-at-risk population" by the government of Kenya in 2009, following a study by the National AIDS Council, UNAIDS and the World Bank which found that prison inmates and men who have sex with men account for 15 per cent of the country's new HIV infections.
Testing and treatment is freely available to HIV patients in Kenya at public health facilities, but the complex nature of initiating and sustaining care, particularly antiretroviral (ART) medication, requires well-trained health staff. Although over 330,000 HIV patients received ART treatment in 2009, UNAIDS estimates that the number of people needing it is much higher at 520,000 to 710,000 - a situation which has earned its own nickname, "medicines without doctors."
Moreover, preventing the spread of HIV requires knowledgeable personnel who can dispel myths about transmission and encourage testing.
Misconceptions are particularly rife in a prison setting, says Peter Magati, the officer in charge of welfare at the prison: "Education levels are often low and the problem is compounded by practices such as sex in exchange for food, sharing of sharp objects and little access to condoms."
"People thought condoms weren't 100 per cent effective, so you should use more than one at the same time. Or that shaking hands, eating with someone who is HIV positive or any other close association could transmit the disease," says Didacus, another inmate-turned-peer educator.
"All I knew about HIV when I arrived here was that it was killing people."
With strong side effects, ART treatment requires monitoring and support - Didacus recalls that one of his fellow inmates defaulted on his medication simply because it was a different brand to what he had been prescribed previously.
Although Kenya has a functioning Ministry of Health, migration of qualified staff from the public to the better-paid private sector is common and the country is one of 57 considered by the World Health Organisation to have a critical shortage of health workers.
HIV prevention and treatment programmes tailored to vulnerable groups like prisoners are not currently supported by government expenditure.
John and Didacus were trained to be peer educators by the medical charity Merlin in February 2011. Human resource needs are particularly acute in Nyanza province, where Kisii is located, due to an HIV prevalence rate of 15 per cent – double the national average. At Kisii district prison – which is better served than most - there is only one government-employed nurse and one clinical officer for 1,200 inmates, 350 officers and 2,000 civilians from the local area.
The good news is that tasks such as education and counselling are increasingly being successfully allocated to non-specialists, relieving the burden on scarcer personnel such as nurses and ultimately allowing more people to be treated.
Indeed, prisoners' trust and acceptance of peer educators shows that there can even be advantages to task shifting. John says: "I stay with them, understand them, know how to approach them so they listen to me. I even use myself as an example, telling people I have been tested."
With close interaction on a daily basis, inmates are ideally placed to reinforce prevention messages and identify those living with HIV and in need of support.
Certification for this new type of health worker is dependent on completion of a three day course and submission of a report demonstrating that at least ten peers have been reached with key HIV messages. To date 33 inmates and 31 prison officers in Kisii have been trained to disseminate information about HIV transmission, testing and treatment, and act as peer counsellors.
Results were immediate. In February 2011, the prison health facility recorded 88 male and female inmates coming forward for testing. By March, this number had more than doubled to 196.
Scroll forward to spring 2012 and over 71 are receiving ART treatment compared to 34 a year ago. Peer educators have also encouraged over 300 male prisoners to come forward for voluntary circumcision, which a study by UNAIDS and NACC has recently proved to reduce the chance of HIV transmission in men by 60 per cent.
In a country where it has been estimated that the nursing workforce needs to be doubled to attain its Millennium Development targets, task shifting is a cost effective alternative which can both stem the spread of HIV and improve efficiency in delivering treatment and care. HIV testing has been offered at Kisii prison since 2005, but nurses used to face resistance from inmates with little knowledge about HIV.
But it is the contrast between the empowerment of prisoners like John and Didacus and their status on paper as a vulnerable group that is perhaps the most compelling reason to continue bringing health services behind the bars.