April 27, 2010

The Availability and Quality of Medical Care

International law dictates that prisoners be provided with health care at least equivalent to that available in the general community.[248] Health care currently provided in Zambian prisons falls far short of international standards. TB and HIV present specific challenges.

Tuberculosis

The isolation cells are death traps.
– Dr. Chileshe, director, Zambia Prisons Service Medical Directorate, October 13, 2009

TB Transmission

The conditions at each prison visited by PRISCCA, ARASA and Human Rights Watch—combining overcrowding, minimal ventilation, and a significant immuno-compromised population—are ripe for the quick spread of TB, confirmed by suspected high prevalence. As noted above, a 2000-2001 study in 13 Zambian prisons for pulmonary TB among inmates concluded that a high rate of pulmonary TB exists in Zambian prisons, speculating that true prevalence rates may approach 15-20 percent;[249]the Zambia Prisons Service has reported a case infection rate for TB of 5,285 cases per 100,000 inmates per year.[250] High turnover exists in the prison population, so spread of TB to the general public by released inmates is also a significant risk.[251] As an officer at Mwembeshi noted, “The cells are meant to accommodate 10 but they hold 135. The men don’t sleep well. If one has TB, four or five have it. Before it is identified, it has already spread.”[252]

Interviews with inmates and prison officers established that there exists a strong awareness of the possibility of transmission, and a deep fear of both contracting TB and spreading it within the community.[253] As one prison officer at Kamfinsa said, “we need to care for and prevent some diseases like TB. If so many people are sick, the officers can be affected. We necessarily worry about getting TB at our work. If I am sick, I can transfer it to my family. It worries us.”[254] According to an inmate, “the ventilation is not good. There is coughing and TB in the cells. It takes time to be detected, but by the time they detect it, the TB will have spread to many of our fellows. It keeps us worried.”[255] Dr. Chileshe confirmed: “They say, ‘you’re going to Chimbokaila [Lusaka Central Prison]? It’s a death sentence.’ Not because they are afraid you will be given beatings, but because of TB. They know the conditions are bad.”[256]

Children incarcerated at Mukobeko have shared living quarters with the TB isolation cell. The children fear TB patients—“I am worried I will catch TB. There is no window, just a small opening with wire over it—not much ventilation,” Phiri, 17, said.[257] Isaac, 17, at Mukobeko, reported that there were “23 TB patients in my living area. There are no vents, no air. I’m worried.”[258] The officer in charge of Lusaka Central prison acknowledged that the lack of ventilation was a severe problem.[259]

TB Testing

Since 1993, the World Health Organization (WHO) has explicitly recognized the need for “vigorous efforts” to detect TB cases through entry and regular screenings in prisons, and the need for effective treatment programs and continuity of treatment upon transfer or release.[260] The Zambian prison system does have the capacity to diagnose some of the prisoners it tests for TB (the diagnosis involves analysis of a sputum sample under a microscope for TB bacilli). PRISCCA, ARASA, and Human Rights Watch’s research found that, of prisoners we spoke with who had tested for TB, 35 percent had been found positive. Nevertheless, our research suggested that only a small segment of the Zambian prison population has testing to diagnose active pulmonary TB, the form of TB that spreads quickly in the overcrowded and confined spaces of Zambian prisons. Dr. Chileshe reported that, in 2009, between 300 and 400 cases of TB were estimated in the prison system based on reports from the clinics, but he was “sure there are those who have TB who may not be [diagnosed].”[261]

Table 5: TB Testing

 

Lusaka Central

Mukobeko

Kamfinsa

Mumbwa

Mwembeshi

Choma

Overall (six prisons)

Prisoners Who Reported Having Been Tested for TB While Incarcerated (%)

18

49

32

4

0

11

23

TB Testing for Prisoners

Our survey data yielded significant differences in TB testing among prisoners we interviewed both between facilities and between inmate groups within each prison. Testing was higher in larger, urban facilities (Lusaka Central, Mukobeko, and Kamfinsa), and lower in smaller, rural facilities (Mumbwa, Mwembeshi, and Choma). Among the smaller facilities, TB testing among prisoners we interviewed ranged from a low of zero percent at Mwembeshi to 11 percent at Choma; it ranged from 18 percent at Lusaka Central to 49 percent at Mukobeko.

Within each facility, certain categories of inmates—women, juveniles, remandees, and immigration detainees—were those least likely to be tested. At all prisons where testing was conducted, except for Lusaka Central, convicts were tested at significantly higher rates—overall more than twice that of remandees, and more than four times that of immigration detainees. Such a disparity is likely a result of a combination of the security fears that keep remandees from accessing medical care generally, discussed below; discrimination against immigration detainees in accessing care; and the fact that immigration detainees have, on average, spent less time in detention than convict and remandee detainees.

TB testing among juveniles was significantly lower than that for adults at each prison where testing took place, and overall, juveniles had a TB testing rate of only four percent compared to the adult rate of 25 percent. Even at Mukobeko, where juveniles were been forced to sleep with patients in the TB isolation cell, the juvenile testing rate was only 17 percent compared with an adult rate of 53 percent. Women, as well, had lower testing rates at each prison conducting testing, and overall only 11 percent of adult female prisoners we interviewed had been tested for TB, compared with 28 percent of adult male prisoners. Such a disparity is probably attributable to a combination of factors: women and juveniles had, on average, been detained and incarcerated in their current facility for a shorter time than their male counterparts; juveniles (but not women) reported experiencing fewer health problems during incarceration and thus were probably less likely to visit health facilities; and female inmates were less educated than male inmates and perhaps less aware of and able to request testing.

Table 6: TB Testing by Prisoner Type

Prisoners Who Reported Having Been Tested for TB While Incarcerated

Significant delays exist between when inmates present with symptoms of TB and when they are tested for the illness.[262] TB should be suspected and tested for in individuals with unexplained weight loss, loss of appetite, night sweats, fever, and fatigue. When the disease is in the lungs symptoms may include coughing for three weeks or more.[263] However, we spoke with two inmates at Lusaka Central on treatment for TB who had waited three months for a trip to a clinic where sputum analysis could be completed after reporting a cough to the cell captains or prison officers, and two others who had waited over four weeks.[264] Indeed, medical staff at some prisons informed us that TB is often the last cause of illness tested for when an inmate presents with coughing, and treatment for upper respiratory infections is first exhausted. The medical officer at Mukobeko confirmed that TB testing takes place after the exhaustion of efforts to address respiratory infection.[265]

Testing for preventative purposes, when an inmate has not yet shown symptoms of infection, is almost entirely unknown: as Muntala, 39, an immigration detainee at Lusaka Central, said, “they take you for tests when you are coughing but by then it is too late.”[266] Even inmates who face an elevated risk of TB infection due to their HIV status are not routinely tested: One HIV-positive inmate told us that he had received no TB test, though he had asked for one, because the Go Centre—the NGO that conducts HIV testing at his farm prison, Mwembeshi—did not have the capacity to test for TB. While they could give him a referral to the hospital, “that would be impossible to get transport from here.”[267] Across all six prisons, we found that 53 percent of HIV-positive prisoners had been tested for TB, however, there is a striking difference between prisons. While 94 percent—16 out of 17— of HIV-positive inmates at Mukobeko had received a TB test, not one of the 10 HIV-positive inmates at Mwembeshi had been tested for TB.

TB Treatment

While an initial course of treatment is provided at all prisons for inmates testing positive for TB, with medications usually consistently available at Ministry of Health facilities when inmates were able to access them, we found no testing and treatment for drug resistance. Drug resistance testing and treatment in the Zambian general population is also inconsistent and not widely available.[268] Yet drug-resistant TB is a major public health threat—the WHO estimates that 300,000-600,000 new cases of multi-drug resistant TB (MDR-TB)[269] emerge every year, with global prevalence as high as 1,000,000 cases[270]—which emerged as a result of program failures, such as interruptions in drug supplies and non-adherence to correct treatment and now may be transmitted from patient to patient. The WHO has recognized that “[t]ransmission in prisons is an important source of spread of drug-resistant TB in some countries,”[271] and that “badly managed tuberculosis treatment does not cure patients, prolongs transmission of infection and promotes multidrug-resistant tuberculosis.”[272]

At the prisons PRISCCA, ARASA, and Human Rights Watch visited, there was an almost complete lack of knowledge of issues around drug resistance—at the prisons and apparently at related hospitals—even for inmates who had previously been treated for TB and whose symptoms persisted or who appeared to be treatment failures. While the WHO has noted that appropriate treatment for drug-resistant TB includes the use of second-line drugs,[273] with individual case management including a history of drug use in the country and the individual,[274] such procedures are not routinely followed. A nurse at the clinic serving Lusaka Central prison informed us that “yes, we have encountered MDR-TB. We recommence them on the same TB drugs as on first phase, but for longer. Then if after eight months they are still not responding, we go to the relapse drugs.”[275] A significant problem is that healthcare staff report that

[We] do not know what drugs the prisoners have taken before for TB. Often they tell us they were on TB medication before but they do not recall anything about it. There are two prisoners now, they told us they were on TB drugs before and we told them to come into the clinic, but we haven’t seen them yet. We can’t just give them drugs until we see what they were on.[276]

TB Isolation

Zambian policy dictates that best practice for TB management demands case detection, isolation, supervised treatment and follow-up support, health education, and nutritional supplementation.[277] If a prisoner is found to be suffering from an infectious or contagious disease, under Zambian law, the officer in charge is required to take steps to place the prisoner under treatment and prevent the disease from spreading to other prisoners.[278] The Ministry of Health recommends “isolation for all prisoners with TB.”[279] Yet Dr. Chileshe acknowledged that isolation is rare, and reported that only in two or three prisons is there true isolation. In the rest of the prison system, there is no isolation capability.[280] “Our officers have tried their best to isolate patients, but they can’t,” he said. “There is literally no space.”[281] Two of the six prisons (Mumbwa and Mwembeshi) PRISCCA, ARASA, and Human Rights Watch visited lack TB isolation facilities entirely, leading TB patients to remain in the overcrowded and poorly ventilated general prison population cells and risking spread of the disease.

In correctional settings, persons suspected of having infectious TB should be placed immediately in an appropriate TB isolation room.[282] TB isolation can be discontinued if a diagnosis of TB is excluded or when a patient is no longer infectious.[283] In Zambian prisons, by contrast, where isolation exists, only patients diagnosed with TB are placed in the isolation cell; inmates with suspected TB based on their symptoms remain in the general population until diagnosis,[284] risking continued infection of the general population.

Even when patients are isolated (on the days of PRISCCA, ARASA, and Human Rights Watch’s visits, Mukobeko Maximum Security, Kamfinsa, Lusaka Central, and Choma claimed to isolate TB patients) the conditions of TB isolation facilities are conducive to serious deterioration of health. Indeed, the conditions of TB isolation cells—which at Lusaka Central included nearly nonexistent ventilation and light and cramped, dirty quarters for very ill patients, who sleep on foam pads on the floor—are, in fact, life-threatening. 57 inmates on the day of our visit lived in an isolation cell approximately four meters by eight meters. The medical officer at Mukobeko informed PRISCCA, ARASA, and Human Rights Watch that TB isolation facilities are improvised and that conditions are “pathetic”;[285] “there were none designed, we are doing the best we can within available resources,” another officer at Mukobeko explained.[286] At Choma, former penal block cells are either used for TB isolation or for grain storage.[287]

In fact, TB isolation facilities are likely a key site of TB infection. Actively coughing residents in a dark, unventilated cell can quickly spread TB or drug-resistant TB to uninfected cellmates. Augustine, 37, reported that he was placed in isolation in 2007 but was found not to have TB and moved out; he became ill subsequently and was diagnosed with TB. He believes that he contracted it in isolation.[288] Another inmate, 38, currently in the TB patients’ cell at Lusaka Central, reported that some in the cell did not have TB and were being exposed to a high risk of TB infection, as the cell has no ventilation and “the situation is terrible.”[289]

An important reason why TB isolation cells may serve as a source of infection is the fact that former TB patients are reluctant to leave the cells, because even their squalor is preferable to the more crowded general population cells. Kachinga, a prisoner at Lusaka Central, actually informed us that he chose to remain in the TB isolation cell after completing his TB treatment because the conditions there were slightly better than those in the other cells:

I was tested for TB and put into the [isolation] cell. I tested positive. I finished my course of treatment, tested again, and was negative. I am still in the [TB isolation] cell. I would love to move out, to give room to other patients coming in, but the other cells are congested. It’s my choice to stay.[290]

Dr. Chileshe confirmed: “Where there are TB patients there is more space, and inmates want to sleep there. You find pregnant women in the cell with TB patients. You may say it’s not medically acceptable, but what can you do?”[291] The number of inmates remaining in isolation for periods beyond their time on TB treatment is suggested by the fact that, at Lusaka Central, the prison clinic had 34 patients recorded on TB treatment the day of our visit; the TB isolation cell, by contrast, held 57 inmates.[292]

HIV/AIDS

The WHO has established standards on HIV prevention, care, and treatment in prisons.[293] The UN Office on Drugs and Crime (UNODC) has also established a framework for a national response to HIV/AIDS prevention, care, treatment, and support in prison settings.[294]While education, testing, and treatment for HIV have been drastically scaled up in recent years in Zambia’s prisons—with the help of NGO partners—significant gaps remain in the appropriate implementation of these services, as well as in prevention practices, between international standards and Zambia’s response to HIV/AIDS in prisons.

HIV Testing

To the credit of Prisons Service officials and NGO partners, recent years have seen the scaling up of HIV testing, albeit provided by an NGO. The Go Centre/CHRESO Ministries provides HIV testing and treatment on regular visits to three Lusaka area prisons (including Lusaka Central and Mwembeshi), two prisons in Mukobeko (including Mukobeko Maximum Security Prison), and a prison in Livingstone.[295] Access to testing at several of the facilities was very good as a result of this program; at others it was more limited, suggesting that even more remote facilities, which PRISCCA, ARASA, and Human Rights Watch did not visit and which are not served by the Go Centre, may have negligible access to testing and treatment. Voluntary counseling and testing is also foreseen at the prison clinics at Lusaka, Livingstone, and Mukobeko in the future; they are currently going through an accreditation process with the Ministry of Health.[296]

On the day of researchers’ visits to each facility, survey data across the six facilities confirmed that, while HIV testing is significantly higher than TB testing, it is more consistently practiced at some facilities than others. Larger facilities had higher HIV testing rates among prisoners we interviewed, ranging from 54 percent at Lusaka Central to 86 percent at Mukobeko Maximum Security; smaller facilities’ HIV testing rates ranged from 23 percent at Mumbwa to 48 percent at Mwembeshi (which is visited by the Go Centre).

Table 7: HIV Testing

 

Lusaka Central

Mukobeko

Kamfinsa

Mumbwa

Mwembeshi

Choma

Overall (six prisons)

Prisoners Who Reported Having Been Tested for HIV While Incarcerated (%)

54

86

72

23

48

33

57

Within facilities, as with TB testing, the prisoners we interviewed reported that certain categories of inmates including women, juveniles, remandees, and immigration detainees tended to be tested for HIV less frequently than their adult, male, convict counterparts, likely for similar reasons as for TB testing. Between all prisons, adult female testing was 45 percent compared to 62 percent for adult males; 44 percent of juveniles were tested compared with 59 percent of adults; and 46 percent and 21 percent of remandees and immigration detainees, respectively, had been tested compared with 65 percent of convicts.

Table 8: HIV Testing by Prisoner Type

Prisoners Who Reported Having Been Tested for HIV While Incarcerated

Aside from inconsistent implementation, other challenges still exist in the implementation of testing. The National HIV/AIDS/STI/TB Policy requires that women considering having a child be encouraged to seek counseling and testing, and ensures that every pregnant woman has access to HIV/STI screening and treatment, but does not mandate mandatory prenatal testing.[297] However, for female inmates, we heard troubling reports that HIV testing for pregnant women may be mandatory.[298] While one prison officer called HIV testing “voluntary”, additional comments suggested that it may actually be mandatory: “For those who are pregnant, they are tested for HIV....Whether you like it or not you are tested to prevent transmission to the baby.”[299]

HIV peer educators had been trained through the NGOs PRISCCA, In But Free, and Treatment Advocacy & Literacy Campaign (TALC)[300] at several of the prisons PRISCCA, ARASA, and Human Rights Watch visited, and throughout the prisons, detainees reported relatively low levels of discrimination and stigma against HIV-positive inmates from either the officers or other inmates. Researchers heard repeatedly that education campaigns have proved successful: Orbed, 26, an HIV-negative inmate concluded that “since the education campaign, there is no discrimination. The campaign has really worked.”[301]

However, some inmate harassment and prison officer breach of confidentiality lingers. Keith, 32, an HIV-positive inmate, told us: “I have never faced any discrimination from the officers because of my HIV status. From my fellow inmates I have faced a lot, though. It’s quite difficult—when I stand in front of my fellow inmates to educate them, some laugh at me.”[302] Allan, age 34—an HIV-negative inmate—confirmed, “the discrimination among inmates takes the form of mocking the person who is positive. You have to hide the drugs if you want secrecy—it’s hard to maintain....Officers will ask for a list of those wanting VCT and call the names out loud. They will tell those who are negative to leave and those who are positive to remain, so everyone knows what the results are.”[303] Additionally, peer education has not been consistently implemented across facilities within the prisons system, or sometimes within facilities themselves. Paul, 33, an inmate in the “condemned section” at Mukobeko—where inmates under sentence of death are held—reported that the condemned don’t receive the HIV education offered to other prisoners: “We feel like they think we will all die anyway so it doesn’t matter.”[304]

HIV Treatment

Table 9: Number and Percent of Prisoners Who Reported Being Started on HIV Treatment after Testing Positive

Access to ART has also improved among the prison population in recent years. For inmates who have tested positive for HIV, ART is often available to HIV-positive inmates at the prison referral hospital or through the Go Centre/CHRESO, for those six prison facilities they serve. Of the prisoners we interviewed who had tested positive for HIV, 60 percent overall were started on treatment including ART, cotrimoxazole, or any other form of treatment, 89 percent of them on ART. Prisoners at the larger prisons, particularly Lusaka Central and Mukobeko Maximum Security (both served by the Go Centre), were more likely to be started on treatment than their counterparts at smaller, rural prisons.[305]

Furthermore, cotrimoxazole—recommended for all individuals testing positive for HIV in order to treat opportunistic infections—is almost entirely unavailable at all prisons, with only one prisoner we interviewed being started on it after testing positive for HIV. In the general population, by contrast, cotrimoxazole prophylaxis is generally available at all Ministry of Health ART clinics, provided by the Ministry of Health with the Center for Infectious Disease Research in Zambia (CIDRZ) providing back-up for stock-outs.[306]

A high level of adherence is crucial for the success of ART. According to the WHO, “adherence to ART is well recognized as an essential component of individual and programmatic treatment success.”[307] Research on drug adherence has shown that “higher levels of drug adherence are associated with improved virological, immunological and clinical outcomes and that adherence rates exceeding 95 percent are necessary in order to maximize the benefits of ART.”[308] Lack of adherence can lead to the development of drug resistance, illness, or death. Zambian policy dictates that the Zambia Prisons Service—with partner support—provide food supplements to HIV-positive prison officers and inmates on ART.[309]The WHO has determined that “improved nutrition may enhance ART acceptability, adherence, and effectiveness.”[310] Food supplements are similarly important for individuals on TB treatment, adherence to which is important both to cure them of TB and to avoid the development of drug resistance.

Such supplements are not currently provided, however. “They used to give extra food for taking medications but no extra food now. It is hard to take these very strong drugs without enough food” said Willard, 25, an HIV-positive inmate at Mukobeko.[311] Even an inmate with a physician’s prescription for special food was unable to receive it because “the prison can’t afford it.”[312] Emmanuel, 35, an HIV-positive inmate at Mukobeko, had asked to be transferred closer to his family so that they could supply him with better food, but was refused: “I think all people on ART should be transferred if they can’t feed us adequately,” he said.[313]

Table 10: Reasons for Missing HIV Treatment

 

For prisoners who are on medication for HIV and TB, the unavailability of food makes taking medication extremely difficult, even frequently leading to missed doses. Among inmates on ART whom we interviewed, more than half of them (55 percent) had missed doses, and lack of food was cited by more than a third (38 percent) of those who had missed doses as the cause. Augustine, 37, an inmate on medication for TB, noted: “I am not getting enough food, now that they are no longer giving food supplements for those on drugs. I feel weak. I suspect that the drugs could be working but they are so strong I need food for them to work.”[314] Francis, 33, an HIV-positive inmate held at Mwembeshi farm prison, reported to us that he takes his ART only once a day, in the evening, because he has no breakfast in the morning to take the medication with: “I should take them in the morning as well, but if I took them in the morning I could not work, as I would be dizzy and weak.”[315]

Prison officers also lamented the health effects of lack of nutritional supplements for HIV and TB patients.[316] A nurse at the clinic serving Lusaka Central prison reported that the food is “not nutritionally adequate” and the clinic does not provide any extra food to people on HIV or TB drugs: “It is affecting whether they get well,” she concluded.[317] The HIV/AIDS coordinator at Lusaka Central has tried to obtain food supplements for those who need them, in accordance with Zambian prison regulations, but the authorities have been “sluggish” in their response. Without sufficient nutrition, she noted, “someone can be on ART but still die, as two have died of AIDS since I have been here [for nine months].”[318] The officer in charge at Choma also confirmed that the prison’s lack of capacity to provide supplementary food to both inmates and prison officers on ART and TB treatment is a major challenge.[319]

HIV treatment to prisoners is highly dependent on the intervention of the Go Centre at the facilities where that NGO operates; Go Centre health professionals dispense the medication, which may be kept on the inmates’ persons in between visits or delivered by a nurse. At Mukobeko Maximum Security Prison, where the Go Centre conducts voluntary counseling and testing (VCT) and provides drugs,[320] the prison administration reported that 142 prison inmates were on ART, 15 of whom were also on treatment for TB.[321] At Lusaka Central, 113 prisoners were on ART, and 19 on both HIV and TB medication[322] through the Go Centre and Hospital.[323] Waiting lists to access ART were reported both through government hospitals and NGOs.[324]

HIV Prevention

Zambian policy acknowledges that “[p]rison confinement can increase vulnerability to HIV due to frequent unprotected sex in the form of rape, non-availability and non-use of condoms, as well as high prevalence of STIs.”[325] Noting that “[p]revention is better than cure,” the Zambia Prisons Service has set for itself the goal of ensuring “the implementation of a comprehensive HIV prevention package.”[326] Yet we found that the total unavailability of condoms and other essential means of prevention in the context of a population with a very high HIV prevalence and widespread sexual activity, consensual and non-consensual, creates a serious risk of HIV transmission and seriously hinders HIV prevention activities.

International organizations—including the WHO, UNODC, and the Joint United Nations Programme on HIV/AIDS (UNAIDS)—all recommend that condoms be provided to prisoners.[327] In 2007, the WHO, UNODC, and UNAIDS noted that studies have found condom provision in prisons to be feasible, acceptable to prisoners, acceptable to prison staff, and did not have negative consequences such as compromising prison safety or security. Furthermore, “[f]ears about the provision of condoms leading to more consensual and non-consensual sex were not realized.”[328] Zambian prison policy has called for inmates to be provided with the means to protect themselves from HIV.[329]  Zambian public health advocates have called for condoms to be introduced for years.[330] Dr. Chileshe has espoused the need for harm reduction in prisons because “people are dying.”[331]

Yet condoms are, without exception, not provided to prisoners and in fact are contraband. Indeed, instead of distributing condoms to prisoners, the Zambia Prisons Service reportedly is considering installing closed circuit television in some prisons at great expense, ostensibly as a means of decreasing sexual activity.[332] The unavailability of condoms is linked to the criminalization of same-sex sexual activity between consenting adults (men and women) in the country as a whole.[333] Zambian law declares “carnal knowledge against the order of nature” punishable by 15 years to life in prison[334] and “acts of gross indecency” between same sex couples are punishable by seven to 14 years imprisonment.[335] Though many reports of consensual same-sex sexual conduct in the general population have been taken to the police, there have been no courtroom prosecutions.[336] The Zambia Prisons Service HIV and AIDS/STI/TB Strategic Plan 2007-2010 claims that condom distribution to inmates is forbidden by law, and provides only for condom distribution to members of staff, their family members, and inmates upon discharge.[337]

PRISCCA, ARASA, and Human Rights Watch’s findings confirmed a total lack of condoms in prisons; a strong homophobia and resistance to condom distribution within the prisons among the prisoners themselves; and a problematic association in HIV prevention messages between same-sex sexual activity between men and HIV/AIDS, with no mention of harm reduction or condom use. The issue of condom introduction currently evokes strong responses from many inmates: Elijah, 34, an inmate at Mukobeko, said “condoms can never be allowed by inmates because they are not useful. I heard that the government wants to supply condoms in prison, but we wrote a letter complaining to the commissioner. They would be a passport to sexual activity if we had them. We will demonstrate if they bring condoms here.”[338] Inmates’ responses to the idea of the introduction of condoms ranged from describing condoms as “difficult to talk about”[339]to “not necessary”[340]to “a disaster.”[341]

Cross-Cutting Failures in Delivery of All Medical Services

Lack of Prison-Based Services

Here, there is no medicine.
 – Mwamba, 26, Mwembeshi Prison, October 6, 2009

The Zambia Prisons Service is in great need of medically trained staff and equipment at the prison level, and medical facilities are virtually non-existent at most prisons. Four of the prisons we visited had no medical care available inside the prison, relying on the community clinic or hospital to provide all medical care, in addition to the TB and HIV/AIDS services discussed above. At Mumbwa, Japhet, 38, told us that, at the prison, “we have no trained, qualified medical personnel. We only have a room, no medical staff.”[342] The officer in charge at Mumbwa agreed: “We don’t have medical personnel to treat prisoners.”[343] A clinical officer used to visit the prison, but had not done so for six months at the time of our visit.[344]At Mwembeshi, Mwamba, 26, reported “here, there is no medicine. The nurse will give you a referral for the clinic, but they don’t take you.”[345]

Those prisons we visited which do have prison clinics often only have paracetemol and lack basic equipment and infrastructure including running water, disinfectant, and gloves. Despite reporting a wide range of ailments, among the prisoners we interviewed, 19 percent of men and 36 percent of women had only received painkillers and no other medicines. The chief medical inspector at Kamfinsa reported that he is not satisfied with the care provided to the inmates, as he needs more staff and better infrastructure and equipment (including a blood pressure monitor, stethoscope, and forceps). He had received no reply to his letter to the Ministry of Health requesting such equipment.[346] Prison clinics suffer from frequent shortages of medication. The chief medical inspector at Kamfinsa confirmed that a “big problem is running out of drugs at the end of each month. We get a three-week supply from the district, so a one-week shortage happens regularly.”[347]

Lack of staff and drugs make medical care inconsistent. According to Howard, 29, an inmate at Mukobeko, “sometimes they help you, other times no one is there. Sometimes there is no medicine. The clinic has no equipment.”[348] Lawrence, 33, reported:

I take drugs for epilepsy. They should be taken daily. When they are not available at the clinic, though, I don’t take. They are not available once or twice in a month, and I miss at least one week a month. I have seizures when I don’t have the drugs ... I have had three seizures in the last year because I didn’t have the drugs. I usually have problems because the medication is not available.[349]

Mumba, 44, confirmed: “Every time I try to go to the clinic there is a shortage of drugs.”[350] “Medicine is the problem; the clinic lacks medicine,” concluded an inmate at Kamfinsa—“by the time you get to the hospital it is too late, you have already been mistreated and the disease is advanced.”[351] Clifford, 41, another inmate at Kamfinsa, described a similar situation—that medical staff are serious but overworked and “they have no equipment, not even a stethoscope.”[352]

Low levels of testing for TB, and prioritization of testing for respiratory infections, may partially be attributed to the fact that capacity for TB testing does not exist within the prison clinics or nearby community clinics, whereas prison clinics (where they exist) may have antibiotics. TB testing is not offered at Mukobeko,[353] and Daniel, 39, a male convict at Mukobeko prison, said that in deciding whom to take for medical treatment, prison officers “wait until you have no strength left and then they will take you. Even with TB, lots of people are coughing and spitting and they will let it go for months before they do an x-ray....it takes a century for TB because they have to take you to the hospital.”[354] According to one officer at Mwembeshi:

Every a.m. I check my prisoners for signs and symptoms of TB. Then I take them to our nurse, who takes them to the community clinic. But they only do a sputum test; there are no further investigations.  Our only hope is UTH [University Teaching Hospital in Lusaka, 40 kilometers away].[355]

The unavailability of prison-based services is also a major barrier to proper HIV treatment. CD4 count testing currently happens only inconsistently, partly because CD4 testing machines are not available at any prison. Prison officials at Mukobeko cited the lack of a CD4 count machine, lack of fuel, and lack of transport, as a problem in providing proper HIV treatment.[356] J. Kababa, the officer in charge at Lusaka Central, informed PRISCCA, ARASA, and Human Rights Watch that “There is no CD4 count equipment at the clinic so I have to take prisoners all over the city. Officers don’t want to take dangerous people out as they might escape and [the officers] will be blamed.”[357]

Partly as a result of the lack of prison-based medical personnel and infrastructure, there is a lack of individualized HIV treatment or recognition of the possibility of drug resistance—inmates routinely reported receiving the same dosage of ART as each of their fellows every three months, without any individualized counseling, testing, or discussion, even when their CD4 count showed no improvement over time. Emmanuel, 35, a prisoner at Mukobeko, reported:

I started HIV meds two years ago, I am not doing well...I have side effects of the medication including neuropathy, swelling, diarrhea. It has been one year since I saw a specialist; they told me they have no transport to take me. So they keep bringing me the same drugs every three months.[358]

For many illnesses (aside from HIV and TB), church representatives and well-wishers frequently fill the role of pharmacist, obtaining medications for prisoners:

We visit the clinic by all means each time we are sick. We are not denied access. But the kind of treatment we need is not found there. We are referred, but we face a problem with that because the hospital is far and we need fuel and transport. Normally, when they give us a prescription, our relatives or the church people have to go and buy it.[359]

“When we are escorted [to the clinic], we are given expensive prescriptions, but we can’t afford them,” an inmate at Lusaka Central told us.[360] Inmates reported that medicines are frequently only available through church and well-wisher visitors: “Medication is provided by Father Bohan [an Irish priest who visits the prison] on prescription from the prison clinic. Deaths were so much, mostly amongst those on death row, before Father Bohan came to our assistance.”[361] Douglas, 40, an inmate at Mukobeko, concluded: “Without the priest, we would hardly have any medicine.”[362]

Drug shortages are hardly surprising, given that the Prisons Service provides minimal funding to fill the gaps when Ministry of Health-provided supplies run short. As the officer in charge at Lusaka Central lamented, “there is no prison budget for medical care. All of it is funded through the Ministry of Health, so when funds run out, they say ‘use your own prison budget,’—but there is none.”[363] The officer in charge at Mumbwa agreed: “There is no budget for medical care for inmates.”[364]

Barriers to Accessing Community-Based Medical Services

Access to community-based clinics and hospitals poses a problem for many inmates. According to the nurse at the clinic serving Lusaka Central confirmed, “There are problems with delays in prisoners getting to the hospital. It can become a delay of weeks.”[365]

PRISCCA, ARASA, and Human Rights Watch interviewed inmates who had waited long periods for referrals to outside medical services: Clifford, 41, an inmate who had water on the lung outside of prison, had received no treatment for the two years he had been in prison—he had never been to the hospital, though he had asked many times.[366] Inmates reported requesting treatment multiple times unsuccessfully: “I had tried to seek medical treatment many times but have not received it. They say sometimes they do not have an officer to escort us to the clinic. I have requested to go six times and have been refused. I have many problems. When I fell sick, I asked for attention, but was not able to go to the clinic.”[367]

According to prison officers, lack of personnel, transport, and fuel to take inmates for care are all major barriers. The officer in charge at Mumbwa said, “Sometimes we don’t have officers to take to the clinic—so they cannot go”[368]; at Kamfinsa, the officer in charge informed us that “staff shortage causes medical care problems as I lack staff to take inmates to hospital.”[369] The medical officer at Choma reported that delays in bringing patients to the clinic as a result of shortage of manpower was the primary barrier to patients accessing necessary testing and treatment.[370] Lack of transport and fuel were named as major barriers in accessing medical care by prison officers at Mukobeko,[371] and the lack of transport to take inmates for medical care for specialized care and referrals was also a challenge at Choma.[372] Even for seriously ill prisoners, according to an officer at Mwembeshi, “we just wait and find someone from the Prisons Service who is travelling to and from Lusaka.  It may take a week before a sick prisoner makes it to the hospital.”[373]

Felix, 43, an HIV-positive remandee, reported:

I also have breathing problems....I was tested in prison and was on TB treatment in 2007... in April 2009 I started developing the same symptoms again. I went to the clinic and was referred to Kabwe General Hospital for an x-ray, but the machine was not working. I have asked the officer to take me again, but the officer said that I need another referral, and the clinic hasn’t worked for the last two weeks because the clinical officer has been away.[374]

We spoke with inmates currently on TB treatment who had waited between two and three weeks and one month, respectively, to initiate treatment after TB diagnosis.[375] Concluded one, “I think that people in prison want to be tested for TB. The delay to get tested is not at the hospital or the clinic. The delay is here at the prison. For people to take us from here, it is long. Some people die before they can be treated.”[376] The officer in charge of Lusaka Central confirmed that the biggest problem he faces with medical care is transport, and he is not satisfied with the medical care for prisoners: “TB and HIV patients must go to the hospital, and the numbers are so large there are delays.”[377]

Multiple inmates reported delays in proper HIV treatment as a result of lack of prison-based services. Mwape, 47, who had tested positive for TB and HIV, reported that he was on the wrong treatment for two years as his CD4 count plummeted at Lusaka Central, where he was taken for treatment. Now on second line treatment[378], he reported feeling a bit better, but “there were delays in getting me to the hospital—they cite security reasons and I have seen people die from it.”[379] Mutale, 40, at Mukobeko, informed us that “for opportunistic infections it’s hard to get to the hospital.  It can take two weeks sometimes.  The officers think we are just malingering. I often suffer from symptoms like diarrhea and chest pains without treatment.[380] An inmate at Kamfinsa Prison reported that he had been tested for HIV and found positive, but had been waiting for a CD4 count test for five months.[381] Frederick, 23, similarly informed PRISCCA, ARASA, and Human Rights Watch that he had been waiting for a CD4 test after a referral to the community clinic, in this case “because I look healthy and am new, they won’t let me go.”[382] Another inmate, at Mukobeko told a similar story: “they are taking CD4 counts, but rarely, like every six to seven months. For example myself, I have never had my CD4 count since being here [since July 2008].”[383]

When care is delivered at outside clinics and hospitals, a number of inmates also reported the stigma that they face from the general population by virtue of their easy identifiability as prisoners.[384] Chanda, 36, a convict at Mukobeko, expressed sadness: “They are tied to shackles on both feet/legs and hands as they walk into the hospital outpatient or admission wards, where they are also tied on chains to the bed and are not allowed to go to the toilet but are provided with bowls where they should either urinate or defecate in full view of all other patients and their bedside caretakers or relatives. The majority of those who fall ill avoid being exposed to such conditions and rather prefer to die within their prison cells.”[385] Henry, 34, at Lusaka Central, reported discriminatory treatment:

At hospital the nurses discriminate against you because you are a prisoner. I am shackled, and the nurses ignore us. I think it is because we are inmates that they don’t take care of us. They have to send inmates from the prison to clean up after the prisoners who are patients because the nurses won’t do it. They discharge early, especially if the prisoner can’t get to the bathroom himself. They get rid of them. Someone died a week ago, he was very thin, very ill, and they took him to wash him but it was too late, he died.[386]

A nurse at the University Teaching Hospital, the tertiary referral hospital for the entire prison system, confirmed that when prisoners are admitted, “they cuff them at the bedside” which presents a problem as “sometimes there is no one to unlock them to take them to the bathroom.”[387]

Security Concerns

Sometimes it is difficult getting to the clinic, sometimes you may not get to go. We ask the cell leader—the guards might say no, though. For those who have big cases, they are afraid they may run away. I have seen people turned away....They have no problem taking convicts, but remandees have a problem because they are afraid we will escape.
– Peter, teenager, Choma Prison, October 8, 2009

Security  concerns prevent many inmates from accessing medical care in a timely manner. Mumba, 44, an inmate at Mukobeko, reported that the practice of training prison officers in medical care led to a cadre of medical professionals with misaligned priorities:

They used to bring in health personnel who were very good. Now they have decided that they should train [security] officers to be health personnel. But to add security when we are very sick? They may not refer someone because of the fear of escape.[388]

Officers’ security fears in allowing inmates to go to clinic facilities outside of prison grounds undoubtedly prevent prisoners from accessing care, sometimes for extended periods. One “lifer” at Mukobeko reported “I have bronchitis. I have had no treatment yet because of security problems getting me to hospital. I’ve been waiting three years...they won’t take you for treatment until it is too late.”[389] Nickson, 36, an inmate at Mukobeko, reported:

I have been trying to push to ask for care, but it has not been working....The prisoners are being oppressed here, we are suffering....We are denied access to medical care. They do everything for the security of the prisons...Last time I was sick was two weeks ago—I had malaria. I suffered a lot, and everybody knew. I came to the clinic, and was given only panadol [paracetemol]. I asked to go to the hospital, and was denied. They said to me: “You remandees, you are problems—this prison is all about security.”[390]

Chiluba, 32, a prisoner from Lusaka Central, who was injured by a beating in police custody, was able to go to only the hospital upon direct intervention by the prison’s officer in charge:

I was not examined on prison entry, and it took me one month to go to the clinic. I was referred to UTH [University Teaching Hospital]. It took so long because some prisoners would escape on way to hospital. They had almost stopped taking people. I kept pressuring and upon the officer in charge’s intervention was able to get two prison officers to take me to clinic.[391]

Remandees, in particular, suffer from restricted access to medical care. A contentious relationship between the Prisons Service and police on the subject of remandee security and responsibility for remandees[392] escorted out of the prison result in many prisoners across facilities reporting that remandees are less frequently allowed to seek care than their convict counterparts. Officially, Zambian law provides that every prisoner is in the lawful custody of the officer in charge throughout the period of his imprisonment,[393] and according the deputy commissioner of prisons, “it is the responsibility of the Prisons Service when remandees need to go out when it comes to medical attention.”[394] But the officer in charge at Mumbwa described the prison officers’ calculus:

With remandees, we fear to take them [to the hospital] because we are afraid they will run away—the police will say we let them go deliberately. The police are supposed to take them to the clinic, but it’s rare, so normally they don’t go.[395]

Such uncertainty and fears over responsibility for runaway remandees leads to denial of treatment. Semba, 34, a remandee at Mumbwa reported: “I told the officer in charge about my [HIV] status—she says the police will take you to get it because you are a remandee. I’m feeling weak.”[396] A remandee at Lusaka Central informed us:

I have ankle pain. While playing football, I injured myself on the ankle. It gives me some pain even now. I have requested the officers to take me for an x-ray but they refuse. They say I am not yet convicted, and they fear I will run away.[397]

Johnston, 41, a remandee at Mumbwa, reported:

There is no clinic here. We complain but we are not attended to....They don’t take remandees to the doctor. They take the convicts but they say the remandees are going to run away. One or two who have been very sick got taken to the doctor, but most of them just end up complaining.[398]

Cell Captains and Officers as Gatekeepers

I have seen people die in the night in the cell—there is nothing we can do. We shout for someone, but the guards will say, “He is just playing sick, he wants to escape. Let us wait two or three days, and see how he will be.” And then he dies.
– Nickson, 36, Mukobeko Maximum Security Prison, September 30, 2009

Prisoners depend upon the permission of cell captains and officers to go outside the prison to obtain medical care. At farm prisons, prisoners depend on the permission of cell captains and officers to miss work in order to seek medical care. These cell captains and officers have no medical training, but act as gatekeepers to medical treatment, occasionally with the result that a prisoner becomes very ill or dies without being allowed to seek medical care. Some inmates reported specific limits on the number of inmates allowed to receive medical care each day, though PRISCCA, ARASA, and Human Rights Watch were unable to verify what specific limits, if any, exist at each prison aside from Mumbwa, which has a limit of 10 inmates per day. A female inmate at Kamfinsa described the process of accessing care through the officers: “When I feel pain, I give a request to go to the hospital. But there is a limit of five a day to go to hospital so some get priority. Officers choose who gets care on parade in the morning. If you are sick you raise your hand, they choose five to go. There have been moments when more than five raise their hands, but even then only five are designated for the clinic. I don’t know how they choose.”[399] Angela, 23, reported: “Sometimes you can go as long as a month waiting to go to the clinic... it depends on the officers. Some officers are good, some are terrible.”[400]

Prison staff tend to discount prisoner complaints as “malingering” or “tricks” in order to escape. Mwizya, 30, an inmate at Mukobeko, told us:

Convicts and pretrial remandees looking health[y] are not being attended to at the prison clinic or referred to Kabwe General Hospital and are mostly accused of imposing a fake illness upon themselves so that they can find a way to escape once admitted in the hospital ward. Prison officers wait until the inmate’s health condition deteriorates before attending to them.[401]

A remandee at Kamfinsa reported, “They work out their personal vendettas against you by denying you access.”[402]

Other inmates—called cell captains or masters depending on the context—also act as gatekeepers to accessing medical care: “The masters decide who is sick; those who look fit—they are told to go into their [work] groups.”[403] Martin, 39, an asthmatic inmate at Mumbwa, told us, “The cell captains are preventing me from getting treatment.”[404]

Refusals by officers and cell captains to allow inmates access to treatment can lead to devastating consequences, as described by Elijah, 34:

It is a struggle to get a referral; by the time you get it, someone might die. We had three cases in my section who died in the cells before going to the General Hospital or even the clinic. One had TB—but was not tested for it—and the other two had malaria. If you want to go to the clinic, the normal procedure is that the guards are supposed to pass through and ask how we are feeling. But they don’t. So the inmates report sickness to the person manning the gate. What happens depends on the officer—sometimes you are not taken to the clinic, or the clinic officer is not there. The three people who died were critically ill; the officers knew. Three months ago, when one of them died, the officers were informed, but didn’t take him to the clinic.[405]

PRISCCA, ARASA, and Human Rights Watch requested information from the Zambia Prisons Service on the numbers and circumstances of deaths in custody. At this writing, our request has not been answered, and we are thus unable to assess claims of deaths due to officer negligence.

Immigration detainees, in particular, may face discrimination from other inmates and officers in accessing care. As Jean Marie, at Lusaka Central, told us, “I asked the officer to go to the clinic but he said, you just need to wait for deportation.  Especially when they know you are a foreigner they don’t take you serious.”[406] 

Prison officers confirmed that they—and in some cases the captains—are gatekeepers for medical care, even expressing discomfort with this position. The intelligence/offender management officer at Choma prison reported that “we [assess inmates’ health] every morning, we determine who goes to the clinic and who doesn’t, and screen them thoroughly to prevent escapes.”[407] At Mumbwa, 10 inmates are taken to the clinic each day, regardless of whether more are on the sick line. The officer on duty—who has no medical training—decides.[408] The medical officer stationed at Mukobeko informed us that “there are stages and monitoring by captains who take care of the sick.”[409] The officer in charge at Lusaka Central expressed succinctly the problems inherent in this system: “Leaving [when prisoners receive medical care] up to me is not a good option, as I and my [staff] are not medical people.”[410]

Range of Services Delivered

Between the few prison clinics, and outside clinics and hospitals, we found that inmates routinely do not receive certain types of basic and essential medical care. Despite Zambian law providing for medical examination of each prisoner upon entry,[411] our interviews almost universally found, and the physician who heads the prison medical directorate confirmed,[412] that no medical screening or testing occurs for prisoners upon entry to a facility. “We need monitoring,” said Dr. Chileshe. “It is a mammoth task, the earlier we do the better. I want files for everyone, not just the sick.”[413]

Shortages of all types of medicines (except ART and TB medication) were an element of our findings at each facility we visited, both at the prison clinics and reportedly at outside Ministry of Health hospitals and clinics (therefore also impacting the general population). Lawrence, 33, reported that at the hospital, “most of the good medicines are not available.”[414]

Mental health services are grossly insufficient for prisoners, though they are also entirely insufficient for the general population.[415] Zambian law requires that social workers, psychologists and—when necessary—psychiatrists should be seen as “crucial players in any multidisciplinary response to problems such as HIV and AIDS,”[416] and international standards provide that “the medical services of the institution shall seek to detect and shall treat any physical or mental illnesses or defects which may hamper a prisoner's rehabilitation.”[417] Current mental health facilities for prisoners are essentially non-existent. Prisoners with “complicated” mental illness are sent to the prison wing of Chainama Hospital, a Ministry of Health facility that in February 2010 housed 19 inmates found either not competent to stand trial or criminally insane.[418] However, for those mentally ill inmates in the general prison population, the Prisons Service does not employ any person responsible for mental illness and does not have any psychiatrist or other mental health professional on staff. Dr. Chileshe reported that patients with mental illness may be held at Lusaka Central, and in that case, “as is possible,” they receive medication, though there were no specific medications for mental illness in the medication cabinet of the prison clinic at the time of our visit.[419]

Multiple inmates reported symptoms suggesting mental health issues. As James, 36, a condemned inmate said, “inmates start hallucinating, planning to get out, because of an inability to have appeals, proper food, and progress in our education. As a result you see mental deterioration in the condemned. I can say this is happening to 101 percent of us.”[420] The mentally ill further suffer from the loss of the little medication they are prescribed: “benzodiazepines are stolen from the mentally ill. The government doesn’t care about the mentally ill.”[421] Artane (Trihexyphenidyl), prescribed to the mentally ill, is also frequently stolen or sold for food and other basic necessities and diverted within the prison.[422]

Women’s Health

Women face a distinct set of healthcare needs in detention.[423] Yet women are a minority and often receive little attention.[424] In addition to experiencing the problems accessing care described above, our findings suggested that incarcerated women in Zambia also face distinctive challenges.

International standards dictate that for women in detention, there shall be “special accommodation for all necessary pre-natal and post-natal care and treatment.”[425] Prenatal care is widely available in the general population.[426] However, the incarcerated pregnant women PRISCCA, ARASA, and Human Rights Watch interviewed described inadequate, and in some cases non-existent, pre-natal care. Helen, 27, who reported she was six months pregnant, said:

I have not been to the clinic yet, no antenatal care. I went to the clinic once but was told the nurses were not working. Since then I have not asked. I do not feel well, lots of ups and downs.[427]

Pregnant women face the same challenges in accessing care as other inmates: “It’s hard...they only count few of us for treatment, then tell the rest of us to wait for tomorrow and restrict us from going. I had no initial exam when I came to the facility, even though I am pregnant. No special treatment is given for pregnant women, I take whatever I can.”[428]

In other cases, pre-natal care existed but was inadequate. The WHO protocol for Prevention of Mother to Child Transmission (PMTCT) of HIV notes that even “[a]ll HIV-infected pregnant women who are not in need of ART for their own health require an effective ARV prophylaxis strategy to prevent HIV transmission to the infant. ARV prophylaxis should be started from as early as 14 weeks gestation.”[429] The chief medical inspector at Kamfinsa prison claims that the WHO PMTCT protocols are used—though they change and additional training is not provided.[430] Yet, Tasila, 24, an inmate at Kamfinsa, who was eight months pregnant, reported treatment directly in violation of WHO guidance:

I already knew when I came in that I was pregnant. I have accessed care three times since I have been in here. The first day that I went, they felt my tummy and told me that the fetus was too small. The second time, they took a blood sample and told me that the baby was growing. The third time, I had VCT—they tested my blood again and told me I was HIV-positive. They told me my CD4 court was too high for ART. I wasn’t given any HIV drugs to prevent transmission, only folic acid and vitamins.[431]

Dr. Chileshe noted that there is no PMTCT program in the prison medical directorate,[432] though PMTCT has been scaled up in recent years in the general population: Between 2004 and 2007, the estimated percentage of women living with HIV who received ART for preventing mother-to-child transmission increased from 18 to 47 percent.[433]

Pregnant women also face stigma when accessing maternity care in public hospitals, accompanied by prison officers.[434]

Women also had not received any gynecological, cervical, or breast cancer screening, though the availability of such services is also limited in the general population.[435]

Child Health

Despite provisions in the Convention on the Rights of the Child noted above guaranteeing children’s right to health, PRISCCA, ARASA, and Human Rights Watch also heard reports from mothers held in prison with their children under age four that those children do not consistently receive adequate health care, and face similar medical care challenges as incarcerated adults. We heard a report at Lusaka Central Prison that a baby had died recently of diarrhea, and was sick for three days before going to the clinic.[436] Inonge, 42, informed PRISCCA, ARASA, and Human Rights Watch that “my child had a high temperature and cough. She was taken to the [community] clinic by prison officers but there was no medicine.” Instead, a donation from a religious organization allowed the mother to purchase medicine for her daughter. “Sometimes there are no medicines for my baby,” Inonge concluded.[437]

Children detained as juvenile inmates frequently are confronted by restrictions on their ability to access medical care similar to those faced by adult prisoners, despite international law protections. Isaac, 17, was wheezing when PRISCCA, ARASA, and Human Rights Watch spoke with him. He had asked at the clinic for help with his breathing troubles, and they had said that they would take him to the hospital, but seven months had gone by and he had still not been taken to the hospital.[438]

Continuity of Care

What medical care prisoners do receive suffers from interruptions upon transfer between facilities and upon release from prison. Mulenga, an inmate at Mukobeko, reported,

I was being seen by a specialist in Lusaka [prior to arrest] but here they won’t allow me to keep seeing that doctor. I get some care at Kabwe General but there is a conflict in treatment. My medical records are still in Lusaka, and I am trying to convince my relatives to retrieve them and bring them here, because Kabwe General said that it is too tedious to request them.[439] 

In Zambia, inmates face interruptions in medical treatment upon release from prison, when no provision is made for continuity of care. The Zambia Prisons Service does not have a policy on coordinating medical care on entry to, between, or upon exit from custodial settings. Inmate files are lost, inmates have difficulty knowing where to go to receive care, and inmates returning to rural areas may find themselves entirely unable to continue treatment upon release.[440] The Prison Fellowship of Zambia operates one halfway house in Lusaka, which can accommodate up to 20 inmates; but they are the only prison reintegration program operating in Zambia. “The prisons don’t have reentry programs,” they reported.[441] One former inmate reported that, while having chest problems upon discharge, he received no medical record: “I just came out without a medical record. Who is going to give me a medical record?”[442] The prison clinic at Lusaka Central confirmed that, while they actually keep records for all patients seen, there is no mechanism for patients to obtain their medical record information upon release from prison.[443]

Non-scheduled interruptions in HIV treatment can result in illness, the development or drug resistance, or death. Yet interruptions in HIV treatment result from transfers, discharge, and in the entry process itself, at the police station. Pre-trial detainees in police custody face particular risks. Aaron, 26, informed us that he spent 42 days at the police station: “I was on ART at the time but they would not let me bring my medication from home. Between the delay at the police station and upon entering prison, I missed three months of HIV medication.”[444] Misheck, 32, reported, “I did miss doses [of ART] for a while right after I was arrested when I was in the police station for four months. They don’t give you any medicine there, or food. My family brought my drugs but the police hid them.”[445] Police Service officials acknowledge that interruptions in medical treatment may take place when individuals are taken into custody and then are taken to prison and admitted a need for a single medical directorate to coordinate care for inmates in police and prison custody. Medical records don’t transfer with an inmate, and medical services for the Police and Prisons Services are coordinated separately.[446]

Record-Keeping Problems

Accurate statistics on disease and death within prisons are important both for public health purposes—to address current morbidity and mortality, and plan for prevention and treatment—as well as to establish grounds for recourse for prisoners whose illness or death may be due to government action or inaction. However, it is currently difficult to establish the actual number of people who become ill or die in Zambian custody. Dr. Chileshe specifically warned PRISCCA, ARASA, and Human Rights Watch not to trust any of the numbers currently reported by the Prisons Service, as statistics are not compiled reliably either by the Prisons Service or the different clinics and hospitals prisoners attend.[447]

Inmate reports of illness and death were widely divergent from officer reports. At Mukobeko, one inmate told us, “people infected with TB are held together with those with HIV, who are not cared for or given supplemental foods. I would say that four to five people a month die. In April it was 15 in one month.[448] The Legal Resources Foundation claimed: “People die in the night and they bring out the corpses. Many die—three a week at Lusaka Central.”[449] At Lusaka Central, however, the officer in charge informed us that there were 20 deaths in all of 2008—14 male convicts and six male remandees, of “TB, HIV and malaria”—in 2009, one death through October 2009.[450] Death reporting is likely to be inaccurate, as inmate deaths are not officially investigated if they take place in the hospital—only if they actually take place in the cells. This contravenes Zambian law that provides for the prison medical officer to record the cause of all deaths and past illness[451] and international standards call for an inquiry into each prisoner death.[452]

Prison officers reported HIV and TB to be the primary causes of inmate deaths, but such claims are impossible to verify as the vast majority of these deaths occurred in the hospital and so were not investigated.[453]

Medical Care Challenges at Farm Prisons  

At the prison, we work all day, work all day—no good. I am feeling a pain when I’m talking. I can die. We are working. People are sick here in prison....We are not going to hospital here, please help me to go to hospital. I have told the officers. I want to die. I have no help here now. I don’t know if I can die. I have told them I am sick—I was told to wait.
– Gabriel, 45, Mumbwa Prison, October 5, 2009

Inmates at farm prisons appeared to be particularly restricted in their ability to access medical care, as their attempts to do so were frequently rejected as a ploy to avoid work. Inmates at Mwembeshi reported that they were sometimes not allowed to go to the clinic or hospital when sick, and instead were made to work: “It is not possible here to go to the doctor. At the moment we wake up, we go to the field, then we go to a different field. Even if you complain it is not ok—the officers tell you that you still have to go, and instruct the masters to say no.”[454] Only as a last resort, when inmates are too weak to work, are they taken to the hospital for treatment.[455] The ill are routinely taken to the fields to do hard labor: “At this prison, you tell the cell captain you are sick, they tell the guards you are not. Some of the prison officers are not very good. The one on duty doesn’t listen to complaints, doesn’t write down names. Those who are not very ill are taken to the hospital. I don’t know why—but the very ill are taken to the fields.”[456]

Distant from health facilities—at Mwembeshi, the nearest hospital and ambulance are 40 kilometers away in Lusaka, and even the local community clinic is four kilometers from the prison[457]—inmates are dependent on visiting medical professionals for health care. Rabun, 28, an HIV-positive detainee at Mwembeshi who reported sores on his genitals, described some of the complications attendant on relying on visits from visiting medical staff from University Teaching Hospital (UTH) or the Go Centre:

UTH visitors have monitored me, but I am on no HIV treatment and no treatment for the sores on my genitals. It is difficult because of the lack of medical facilities here—we depend on doctors from UTH. Sometimes when I feel sick the officers don’t take us to the hospital. They rarely take us for medical attention. Sometimes they allow us to remain at the prison, other times we go to work. I have had sores on my genitals for two weeks. I asked to go to the clinic, and they promised they will take me tomorrow, but when the day comes they have changed their shifts and a different officer comes in. They keep on promising, but it does not happen.[458]

Inmates reported that they sometimes had to bribe the inmate “chairman” designated to make the list for the Go Centre in order to obtain a place on the list.[459]

[248] Furthermore, international standards provide that “the medical services of the institution shall seek to detect and shall treat any physical or mental illnesses or defects which may hamper a prisoner's rehabilitation. All necessary medical, surgical and psychiatric services shall be provided to that end.” UN Standard Minimum rules for the Treatment of Prisoners, para. 62. Every institution must have at least one qualified medical officer, access to dentistry services, and transfer of sick prisoners requiring specialist treatment to specialized institutions or civil hospitals. Ibid., para. 22. See also Basic Principles for the Treatment of Prisoners, prin. 9.

[249]C. Habeenzu et al., “Tuberculosis and Multidrug Resistance in Zambian Prisons, 2000-2001,” TheInternational Journal of Tuberculosis and Lung Disease, pp. 1216-1220.

[250] Zambia Prisons Service, “Draft Operational Plan,” 2008, p. 9.

[251] Mukobeko had 118 new inmates in August-September 2009. PRISCCA, ARASA, and Human Rights Watch interview with Francis Kasanga, deputy officer in charge, Mukobeko Maximum Security Prison, September 29, 2009. Lusaka Central receives 20-40 new inmates each day (with two to three leaving each day). PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009. Choma Prison received 104 new inmates in September 2009 (out of 251 total). PRISCCA, ARASA, and Human Rights Watch interview with Patrick Chilambe, officer in charge, Choma Prison, October 8, 2009.

[252] PRISCCA, ARASA, and Human Rights Watch interview with Grief Chisenga, prison officer, Mwembeshi Prison, October 6, 2009.

[253] PRISCCA, ARASA, and Human Rights Watch interview with Francis Kasanga, deputy officer in charge, Mukobeko Maximum Security Prison, September 29, 2009. See also PRISCCA, ARASA, and Human Rights Watch interview with Albert Sakala, prison officer, Mukobeko Maximum Security Prison, September 29, 2009.

[254] PRISCCA, ARASA, and Human Rights Watch interview with Joyce Simukali, prison officer, Kamfinsa Prison, October 2, 2009. See also PRISCCA, ARASA, and Human Rights Watch interview with Karen Chibwe, prison officer, Lusaka Central Prison, October 4, 2009.

[255] PRISCCA, ARASA, and Human Rights Watch interview with KT-29-05, Mukobeko Maximum Security Prison, September 29, 2009.

[256] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[257]PRISCCA, ARASA, and Human Rights Watch interview with Phiri, Mukobeko Maximum Security Prison, September 29, 2009.

[258]PRISCCA, ARASA, and Human Rights Watch interview with Isaac, Mukobeko Maximum Security Prison, September 29, 2009.

[259] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[260] Joint United Nations Programme on HIV/AIDS (UNAIDS), “WHO Guidelines on HIV Infection and AIDS in Prisons,” UNAIDS Best Practice Collection, 1993, http://data.unaids.org/Publications/IRC-pub01/JC277-WHO-Guidel-Prisons_en.pdf (accessed March 3, 2010), pp. 7-8.

[261] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[262] PRISCCA, ARASA, and Human Rights Watch interview with DP-06-01, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-02, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-03, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-04, Lusaka Central Prison, February 6, 2010.

[263] Centers for Disease Control and Prevention, “Tuberculosis (TB): Testing & Diagnosis,” undated, http://www.cdc.gov/tb/topic/testing/default.htm (accessed March 1, 2010); Centers for Disease Control and Prevention, “Tuberculosis (TB): Diagnosis of Tuberculosis Disease,” undated, http://www.cdc.gov/tb/publications/factsheets/testing/diagnosis.htm (accessed March 1, 2010).

[264] PRISCCA, ARASA, and Human Rights Watch interview with DP-06-01, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-02, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-03, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-04, Lusaka Central Prison, February 6, 2010.

[265] PRISCCA, ARASA, and Human Rights Watch interview with Henry Mutabala, medical officer, Mukobeko Maximum Security Prison, September 29, 2009.

[266]PRISCCA, ARASA, and Human Rights Watch interview with Muntala, Lusaka Central Prison, October 4, 2009.

[267]PRISCCA, ARASA, and Human Rights Watch interview with Francis, Mwembeshi Prison, October 6, 2009.

[268] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Helen Ayles, ZAMBART, February 9, 2010; PRISCCA, ARASA, and Human Rights Watch interview with Dr. Nathan Kapata, Ministry of Health, February 8, 2010.

[269]Multidrug-resistant TB is defined as tuberculosis caused by Mycobacterium tuberculosis resistant in vitro to the effects of isoniazid and rifampicin, the two most powerful anti-TB drugs, with or without resistance to any other drugs. World Health Organization, “Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis,” 2006, http://whqlibdoc.who.int/publications/2006/9241546956_eng.pdf (accessed March 3, 2010), p.1.

[270]Ibid., p. ix

[271]Ibid., p.16.

[272] World Health Organization and International Committee for the Red Cross, “Tuberculosis Control in Prisons: A Manual for Programme Managers,” 2002, http://whqlibdoc.who.int/hq/2000/WHO_CDS_TB_2000.281.pdf (accessed March 3, 2010), p. 15.

[273] One of six classes of drugs not used in the standard regimen of treatment for TB, to which resistance may have developed.

[274]World Health Organization, “Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis,” p. 9.

[275] PRISCCA, ARASA, and Human Rights Watch interview with nurse, Lusaka Central Prison, October 3, 2009.

[276] Ibid.

[277] Zambia Prisons Service, “Zambia Prisons Service HIV and AIDS/STI/TB Strategic Plan (2007-2010),” p. 18.

[278] Prisons Rules, sec. 108.

[279] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Nathan Kapata, Ministry of Health, February 8, 2010.

[280] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[281] Ibid.

[282] Advisory Council for the Elimination of Tuberculosis, “Prevention and Control of Tuberculosis in Correctional Facilities Recommendations of the Advisory Council for the Elimination of Tuberculosis,” MMWR, vol. 45(RR-8), June 7, 1996, pp. 1-27.

[283] Ibid.

[284] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[285] PRISCCA, ARASA, and Human Rights Watch interview with Henry Mutabale, medical officer, Mukobeko Maximum Security Prison, September 29, 2009.

[286] PRISCCA, ARASA, and Human Rights Watch interview with Francis Kasanga, deputy officer in charge, Mukobeko Maximum Security Prison, September 29, 2009.

[287] PRISCCA, ARASA, and Human Rights Watch interview with Patrick Chilambe, officer in charge, Choma Prison, October 8, 2009.

[288]PRISCCA, ARASA, and Human Rights Watch interview with Augustine, Mukobeko Maximum Security Prison, September 29, 2009.

[289] PRISCCA, ARASA, and Human Rights Watch interview with CM-03-05, Lusaka Central Prison, October 3, 2009.

[290] PRISCCA, ARASA, and Human Rights Watch interview with Kachinga, Lusaka Central Prison, February 6, 2010.

[291] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[292] PRISCCA, ARASA, and Human Rights Watch interview with clinical officer, Lusaka Prison Clinic, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, February 6, 2010.

[293] World Health Organization, “WHO Guidelines on HIV Infection and AIDS in Prisons,” UNAIDS Best Practice Collection, September 1999, http://www.who.int/hiv/idu/WHO-Guidel-Prisons_en.pdf (accessed March 1, 2010).

[294] United Nations Office on Drugs and Crime (UNODC), World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS), “HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response,” 2006, http://data.unaids.org/pub/Report/2006/20060701_hiv-aids_prisons_en.pdf (accessed March 1, 2010).

[295] Email communication from Fredrick Mulenga Chitangala, director of programs, Chreso Ministries ART/VCT Clinic, to PRISCCA, ARASA, and Human Rights Watch, February 17, 2010.

[296] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[297] Republic of Zambia, Ministry of Health, “National HIV/AIDS/STI/TB Policy,” January 2005, pp. 29-30.

[298] PRISCCA, ARASA, and Human Rights Watch interview with Grace Mubanga, female officer in charge, Kamfinsa Prison, October 2, 2009.

[299] PRISCCA, ARASA, and Human Rights Watch interview with Joyce Simukali, prison officer, Kamfinsa Prison (Women’s), October 2, 2009.

[300] PRISCCA, ARASA, and Human Rights Watch interview with Felix Mwanza, TALC, October 15, 2009. Since 2000, PRISCCA has been operating at Lusaka Central, and has conducted HIV education and sensitization in each of the six prisons we visited. PRISCCA, ARASA, and Human Rights Watch interview with Godfrey Malembeka, executive director, PRISCCA, Johannesburg, November 23, 2009.

[301]PRISCCA, ARASA, and Human Rights Watch interview with Orbed, Mukobeko Maximum Security Prison, September 30, 2009.

[302]PRISCCA, ARASA, and Human Rights Watch interview with Keith, Mukobeko Maximum Security Prison, September 29, 2009.

[303] PRISCCA, ARASA, and Human Rights Watch interview with Allan, Mukobeko Maximum Security Prison, September 29, 2009.

[304]PRISCCA, ARASA, and Human Rights Watch interview with Paul, Mukobeko Maximum Security Prison, September 29, 2009.

[305] PRISCCA, ARASA, and Human Rights Watch interview with Godfrey Malembeka, executive director, PRISCCA, November 23, 2009.

[306] Email communication from Dr. Stewart Reid, CIDRZ, to PRISCCA, ARASA, and Human Rights Watch, March 1, 2010.

[307] World Health Organization, “Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach,” 2006, http://www.who.int/hiv/pub/guidelines/artadultguidelines.pdf (accessed March 4, 2010), p. 70.

[308] Ibid.

[309] Zambia Prisons Service, “HIV & AIDS/STI/TB Workplace Policy,” p. 23.

[310] World Health Organization, “Nutrient Requirements of People Living with HIV/AIDS: Report of a Technical Consultation, Geneva, Switzerland, 13-15 May 2003,” 2003, http://whqlibdoc.who.int/publications/2003/9241591196.pdf (accessed March 1, 2010).

[311] PRISCCA, ARASA, and Human Rights Watch interview with Willard, Mukobeko Maximum Security Prison, September 29, 2009.

[312] PRISCCA, ARASA, and Human Rights Watch interview with Mumba, Mukobeko Maximum Security Prison, September 30, 2009.

[313] PRISCCA, ARASA, and Human Rights Watch interview with Emmanuel, Mukobeko Maximum Security Prison, September 30, 2009.

[314] PRISCCA, ARASA, and Human Rights Watch interview with Augustine, Mukobeko Maximum Security Prison, September 29, 2009.

[315]PRISCCA, ARASA, and Human Rights Watch interview with Francis, Mwembeshi prison, October 6, 2009.

[316] PRISCCA, ARASA, and Human Rights Watch interview with Joyce Simukali, prison officer, Kamfinsa Prison (Women’s Side), October 2, 2009.

[317] PRISCCA, ARASA, and Human Rights Watch interview with nurse, Lusaka Central Prison clinic, October 3, 2009.

[318] PRISCCA, ARASA, and Human Rights Watch interview with Annie Sabuni, HIV/AIDS coordinator, Lusaka Central Prison, October 3, 2009.

[319] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Choma Prison, October 8, 2009.

[320] PRISCCA, ARASA, and Human Rights Watch interview with George S. Sikaonga, officer in charge, Mukobeko Maximum Security Prison, September 29, 2009.

[321] Ibid.

[322] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Lusaka Central Prison, October 3, 2009.

[323] PRISCCA, ARASA, and Human Rights Watch interview with nurse, Lusaka Central Prison clinic, October 3, 2009.

[324] PRISCCA, ARASA, and Human Rights Watch interview with social welfare worker, Lusaka Central Prison, October 3, 2009.

[325] Zambia Ministry of Health and National AIDS Council, “Zambia Country Report: Multi-Sectoral AIDS Response Monitoring and Evaluation Biennial Report 2006-2007: Update Version, Submitted to the United Nations General Assembly Special Session on AIDS,” January 31, 2008, p. 4.

[326] Zambia Prisons Service, “Draft Operational Plan,” 2008, p. 16.

[327] UNAIDS, “WHO Guidelines on HIV Infection and AIDS in Prisons,” UNAIDS Best Practice Collection, 1993, http://data.unaids.org/Publications/IRC-pub01/JC277-WHO-Guidel-Prisons_en.pdf (accessed March 3, 2010), p. 5. WHO, UNAIDS, UNODC, “Policy Brief: Reduction of HIV Transmission in Prisons,” Doc. No. WHO/HIV/2004.05 (2004), p. 2.

[328] WHO, UNODC, UNAIDS, “Interventions to Address HIV in Prisons: Prevention of Sexual Transmission,” 2007, p. 13.

[329] “The failure to provide inmates with the means to protect themselves against HIV and AIDS and other infectious diseases is seen to be an infringement of their basic rights. Measures to protect staff and inmates against HIV and other infectious diseases are therefore needed urgently.” Zambia Prisons Service, “Zambia Prisons Service HIV and AIDS/STI/TB Strategic Plan (2007-2010),” p. 2.

[330] Oscar O. Simooya, “Acceptability of Condoms for HIV/AIDS Prevention in an African Jail,” BMJ, June 6, 2000. O. Simooya et al., “Sexual Behavior and Issues of HIV/AIDS Prevention in an African Prison,” AIDS, pp. 1388-89.

[331] Statement made by Chisela Chileshe at NAC National HIV Prevention Conference, November 3-5, 2009.

[332] PRISCCA, ARASA, and Human Rights Watch interview with LGBT rights organization, Lusaka, October 14, 2009.

[333] As Human Rights Watch has reported, Zambian “sodomy laws” are a result of nineteenth-century British colonial legislative impulse towards social and sexual control of their subject populations in Asia and Africa. See the Human Rights Watch report “This Alien Legacy: The Origins of ‘Sodomy Laws’ in British Colonialism” for an exploration of the imposition of sexual and social regulation laws on former British colonies, http://www.hrw.org/en/reports/2008/12/17/alien-legacy.

[334]Penal Code Act, Laws of Zambia, vol. 7, chapter 87, 1996, http://www.parliament.gov.zm/index.php?option=com_content&task=view&id=21&Itemid=49 (accessed February 22, 2010), sec. 155.

[335] Ibid., art. 158.

[336] PRISCCA, ARASA, and Human Rights Watch interview with LGBT rights organization, October 14, 2009.

[337] Zambia Prisons Service, “Zambia Prisons Service HIV and AIDS/STI/TB Strategic Plan (2007-2010),” p. 16.

[338]PRISCCA, ARASA, and Human Rights Watch interview with Elijah, Mukobeko Maximum Security Prison, September 30, 2009.

[339]PRISCCA, ARASA, and Human Rights Watch interview with Joshua, Lusaka Central Prison, October 3, 2009.

[340]PRISCCA, ARASA, and Human Rights Watch interview with KT-08-01, Choma Prison, October 8, 2009.

[341]PRISCCA, ARASA, and Human Rights Watch interview with Albert, Lusaka Central Prison, October 3, 2009.

[342]PRISCCA, ARASA, and Human Rights Watch interview with Japhet, Mumbwa Prison, October 5, 2009.

[343] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009.

[344] PRISCCA, ARASA, and Human Rights Watch interview with Sergeant Kabukabu, prison officer, Mumbwa Prison, October 5, 2009.

[345] PRISCCA, ARASA, and Human Rights Watch interview with Mwamba, Mwembeshi Prison, October 6, 2009.

[346] PRISCCA, ARASA, and Human Rights Watch interview with Yutamu Lungu, chief medical inspector, Kamfinsa Prison, October 1, 2009.

[347] Ibid.

[348]PRISCCA, ARASA, and Human Rights Watch interview with Howard, Mukobeko Maximum Security Prison, September 30, 2009.

[349]PRISCCA, ARASA, and Human Rights Watch interview with Lawrence, Mukobeko Maximum Security Prison, September 30, 2009.

[350]PRISCCA, ARASA, and Human Rights Watch interview with Mumba, Mukobeko Maximum Security Prison, September 30, 2009.

[351] PRISCCA, ARASA, and Human Rights Watch interview with RS-01-13, Kamfinsa Prison, October 1, 2009.

[352] PRISCCA, ARASA, and Human Rights Watch interview with Clifford, Kamfinsa Prison, October 1, 2009.

[353] PRISCCA, ARASA, and Human Rights Watch interview with Henry Mutabala, medical officer, Mukobeko Maximum Security Prison, September 29, 2009.

[354] PRISCCA, ARASA, and Human Rights Watch interview with Daniel, Mukobeko Maximum Security Prison, September 30, 2009.

[355] PRISCCA, ARASA, and Human Rights Watch interview with Grief Chisenga, prison officer, Mwembeshi Prison, October 6, 2009.

[356] PRISCCA, ARASA, and Human Rights Watch interview with George S. Sikaonga, officer in charge, Mukobeko Maximum Security Prison, September 29, 2009.

[357] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[358]PRISCCA, ARASA, and Human Rights Watch interview with Emmanuel, Mukobeko Maximum Security Prison, September 30, 2009.

[359]PRISCCA, ARASA, and Human Rights Watch Watch interview with Norah, Kamfinsa Prison, October 1, 2009.

[360] PRISCCA, ARASA, and Human Rights Watch interview with KT-06-03, Lusaka Central Prison, February 6, 2010.

[361]PRISCCA, ARASA, and Human Rights Watch interview with Chanda, Mukobeko Maximum Security Prison, September 30, 2009.

[362]PRISCCA, ARASA, and Human Rights Watch interview with Douglas, Mukobeko Maximum Security Prison, September 29, 2009.

[363] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[364] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009.

[365] PRISCCA, ARASA, and Human Rights Watch interview with nurse, Lusaka Central Prison, October 3, 2009.

[366]PRISCCA, ARASA, and Human Rights Watch interview with Clifford, Kamfinsa Prison, October 1, 2009.

[367]PRISCCA, ARASA, and Human Rights Watch interview with Rodgers, Lusaka Central Prison, October 3, 2009.

[368] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009.

[369] PRISCCA, ARASA, and Human Rights Watch interview with Patrick Mundianawa, officer in charge, Kamfinsa Prison, October 1, 2009.

[370] PRISCCA, ARASA, and Human Rights Watch interview with B.M. Hambwalou, medical officer, Choma prison, October 8, 2009.

[371] PRISCCA, ARASA, and Human Rights Watch interview with Henry Mutabale, medical officer, Mukobeko Maximum Security Prison, September 29, 2009; PRISCCA, ARASA, and Human Rights Watch interview with George S. Sikaonga, officer in charge, Mukobeko Maximum Security Prison, September 29, 2009.

[372] PRISCCA, ARASA, and Human Rights Watch interview with Patrick Chilambe, officer in charge, Choma Prison, October 8, 2009.

[373] PRISCCA, ARASA, and Human Rights Watch interview with Ms. Kaluba, offender management officer, Mwembeshi Prison, October 6, 2009.

[374]PRISCCA, ARASA, and Human Rights Watch interview with Felix, Mukobeko Maximum Security Prison, September 29, 2009.

[375] PRISCCA, ARASA, and Human Rights Watch interview with DP-06-01, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-02, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-03, Lusaka Central Prison, February 6, 2010; PRISCCA, ARASA, and Human Rights Watch interview with DP-06-04, Lusaka Central Prison, February 6, 2010.

[376] PRISCCA, ARASA, and Human Rights Watch interview with DP-06-03, Lusaka Central Prison, February 6, 2010.

[377] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[378] According to Médecins Sans Frontières, “ As people on antiretroviral treatment (ART) develop intolerable side effects or start to develop resistance to their first set of antiretroviral medicines (ARVs), they need to switch to a different drug combination. Compliance to treatment is important to prevent viral resistance, which will allow the HIV virus to replicate and mutate. In one of MSF’s long-standing HIV/AIDS projects, in Khayelitsha, South Africa, 16 percent of patients need to be switched to ‘second-line’ therapy after five years of treatment. Indeed, in wealthy countries, many people living with AIDS have changed their treatment lines four, five or even six times. With two million people on ARVs across the developing world, the need for access to newer ARV options is growing rapidly.” Médecins Sans Frontières, “Need for Newer Drugs,” July 2009, http://www.msfaccess.org/main/hiv-aids/introduction-to-hivaids/need-for-newer-drugs/ (accessed March 2, 2010).

[379]PRISCCA, ARASA, and Human Rights Watch interview with Mwape, Mukobeko Maximum Security Prison, September 29, 2009.

[380] PRISCCA, ARASA, and Human Rights Watch interview with Mutale, Mukobeko Maximum Security Prison, September 30, 2009.

[381]PRISCCA, ARASA, and Human Rights Watch interview with Chrispine, Kamfinsa Prison, October 1, 2009.

[382]PRISCCA, ARASA, and Human Rights Watch interview with Frederick, Mwembeshi Prison, October 6, 2009.

[383] PRISCCA, ARASA, and Human Rights Watch interview with Misheck, Mukobeko Maximum Security Prison, September 30, 2009.

[384] Dr. Chileshe confirmed that when remandees are referred to the hospital, they are handcuffed to the bed. PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, October 13, 2009.

[385] PRISCCA, ARASA, and Human Rights Watch interview with Chanda, Mukobeko Maximum Security Prison, September 30, 2009.

[386] PRISCCA, ARASA, and Human Rights Watch interview with Henry, Lusaka Central Prison, October 4, 2009.

[387] PRISCCA, ARASA, and Human Rights Watch interview with emergency nurse, University Teaching Hospital, Lusaka, February 7, 2010.

[388]PRISCCA, ARASA, and Human Rights Watch interview with Mumba, Mukobeko Maximum Security Prison, September 30, 2009.

[389]PRISCCA, ARASA, and Human Rights Watch interview with MM-29-08, Mukobeko Maximum Security Prison, September 29, 2009.

[390]PRISCCA, ARASA, and Human Rights Watch interview with Nickson, Mukobeko Maximum Security Prison, September 30, 2009.

[391]PRISCCA, ARASA, and Human Rights Watch interview with Chiluba, Lusaka Central Prison, October 4, 2009.

[392] PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, October 13, 2009.

[393] Prisons Act, sec. 61(1).

[394] PRISCCA, ARASA, and Human Rights Watch interview with Frederick Chilukutu, deputy commissioner of prisons, Zambia Prisons Service, October 12, 2009.

[395] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009.

[396] PRISCCA, ARASA, and Human Rights Watch interview with Semba, Mumbwa Prison, October 5, 2009.

[397]PRISCCA, ARASA, and Human Rights Watch interview with Joshua, Lusaka Central Prison, October 3, 2009.

[398]PRISCCA, ARASA, and Human Rights Watch interview with Johnston, Mumbwa Prison, October 5, 2009.

[399]PRISCCA, ARASA, and Human Rights Watch interview with Ngosa, Kamfinsa Prison, October 1, 2009.

[400]PRISCCA, ARASA, and Human Rights Watch interview with Angela, Lusaka Central Prison, October 4, 2009.

[401] PRISCCA, ARASA, and Human Rights Watch interview with Mwizya, Mukobeko Maximum Security Prison, September 30, 2009.

[402] PRISCCA, ARASA, and Human Rights Watch interview with RS-01-09, Kamfinsa Prison, October 1, 2009.

[403]PRISCCA, ARASA, and Human Rights Watch interview with KT-06-03, Mwembeshi Prison, October 6, 2009.

[404]PRISCCA, ARASA, and Human Rights Watch interview with Martin, Mumbwa Prison, October 5, 2009.

[405]PRISCCA, ARASA, and Human Rights Watch interview with Elijah, Mukobeko Maximum Security Prison, September 30, 2009.

[406] PRISCCA, ARASA, and Human Rights Watch interview with Jean Marie, Lusaka Central Prison, October 3, 2009.

[407] PRISCCA, ARASA, and Human Rights Watch interview with Tweedman Hamunyanga, intelligence/offender management officer, Choma prison, October 8, 2009.

[408] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009.

[409] PRISCCA, ARASA, and Human Rights Watch interview with Henry Mutabale, medical officer, Mukobeko Maximum Security Prison, September 29, 2009.

[410] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[411] Prisons Act, sec. 18. See also UN Standard Minimum Rules for the Treatment of Prisoners, paras. 24-25; Body of Principles, prin. 24.

[412] PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, October 13, 2009.

[413] Ibid.

[414]PRISCCA, ARASA, and Human Rights Watch interview with Lawrence, Mukobeko Maximum Security Prison, September 30, 2009.

[415] See, e.g., John Mayeya et al., “Zambia Mental Health Country Profile,” International Review of Psychiatry, vol. 16, February 2004, pp. 63-72.

[416] Zambia Prisons Service, “Zambia Prisons Service HIV and AIDS/STI/TB Strategic Plan (2007-2010),” p. 7.

[417] UN Standard Minimum Rules for the Treatment of Prisoners, para. 62; see also paras. 82-83.

[418] PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, February 6, 2010.

[419] PRISCCA, ARASA, and Human Rights Watch tour of Lusaka Central Prison clinic, February 6, 2010.

[420] PRISCCA, ARASA, and Human Rights Watch interview with James, Mukobeko Maximum Security Prison, September 30, 2009.

[421] PRISCCA, ARASA, and Human Rights Watch interview with RS-30-03, Mukobeko Maximum Security Prison, September 30, 2009.

[422] See, e.g., PRISCCA, ARASA, and Human Rights Watch interview with Keith, Mukobeko Maximum Security Prison, September 29, 2009; PRISCCA, ARASA, and Human Rights Watch interview with RS-30-03, Mukobeko Maximum Security Prison, September 30, 2009.

[423] UNODC and UNAIDS, “Women and HIV in Prison Settings,” September 2008, http://www.unodc.org/documents/hiv-aids/Women%20and%20HIV%20in%20prison%20settings.pdf  (accessed March 3, 2010), p. 2. See also Vetten, “The Imprisonment of Women in Africa,” in Sarkin, ed., Human Rights in African Prisons.

[424] Brenda J. van den Bergh, Alex Gatherer and Lars F. Møller, “Women’s Health in Prison: Urgent Need for Improvement in Gender Equity and Social Justice,” Bulletin of the World Health Organization, vol. 87, 2009, p. 406.

[425] UN Standard Minimum Rules for the Treatment of Prisoners, para. 23.

[426] The UN Population Fund has reported that between 72 and 90 percent of women in Zambia’s general population receive prenatal care. UN Population Fund, “Recognizing the Needs in Zambia,” undated, http://www.unfpa.org/fistula/docs/eng_zambia.pdf (accessed March 2, 2010).

[427]PRISCCA, ARASA, and Human Rights Watch interview with Helen, Lusaka Central Prison, October 4, 2009.

[428] PRISCCA, ARASA, and Human Rights Watch interview with NCI-03-01, Lusaka Central Prison, October 3, 2009.

[429] World Health Organization, “Rapid Advice: Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Inmates,” November 2009, http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf (accessed March 3, 2010), p. 13.

[430] PRISCCA, ARASA, and Human Rights Watch interview with Yutamu Lungu, chief medical inspector, Kamfinsa Prison, October 1, 2009.

[431]PRISCCA, ARASA, and Human Rights Watch interview with Tasila, Kamfinsa Prison, October 1, 2009.

[432] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[433] World Health Organization, UNAIDS, and UNICEF, “Epidemiological Fact Sheet on HIV and AIDS: 2008 Update: Zambia.”

[434] PRISCCA, ARASA, and Human Rights Watch interview with Beatrice Munankopa, deputy officer in charge, Lusaka Central Prison (Women’s), October 4, 2009.

[435] Center for Infectious Disease Research in Zambia (CIDRZ), “Cervical Cancer Screening,” undated, http://www.cidrz.org/cervical_cancer_screening (accessed March 3, 2010).

[436] PRISCCA, ARASA, and Human Rights Watch interview with Angela, Lusaka Central Prison, October 4, 2009.

[437] PRISCCA, ARASA, and Human Rights Watch interview with Inonge, Lusaka Central Prison, October 3, 2009.

[438] PRISCCA, ARASA, and Human Rights Watch interview with Isaac, Mukobeko Maximum Security Prison, September 29, 2009. See also PRISCCA, ARASA, and Human Rights Watch interview with Oscar, Lusaka Central Prison,

[439] PRISCCA, ARASA, and Human Rights Watch interview with Mulenga, Mukobeko Maximum Security Prison, September 30, 2009.

[440] PRISCCA, ARASA, and Human Rights Watch interview with Paul Swala, Prison Fellowship of Zambia, October 15, 2009.

[441] Ibid.

[442] PRISCCA, ARASA, and Human Rights Watch interview with Gabriel, former prisoner, Lusaka, February 5, 2010.

[443] PRISCCA, ARASA, and Human Rights Watch interview with clinical officer, Lusaka Central prison clinic, February 6, 2010.

[444] PRISCCA, ARASA, and Human Rights Watch interview with Aaron, Choma Prison, October 8, 2009.

[445] PRISCCA, ARASA, and Human Rights Watch interview with Misheck, Mukobeko Maximum Security Prison, September 30, 2009.

[446] PRISCCA, ARASA, and Human Rights Watch interview with Donald Mwandila, Hospital Admin, Zambia Police Service Medical Directorate, Lusaka, February 4, 2010; PRISCCA, ARASA, and Human Rights Watch interview with K.N. Chikwanda, staff officer medical, Zambia Police Service Medical Directorate, Lusaka, February 4, 2010.

[447]PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, October 13, 2009.

[448] PRISCCA, ARASA, and Human Rights Watch interview with RS-30-03, Mukobeko Maximum Security Prison, September 30, 2009.

[449] PRISCCA, ARASA, and Human Rights Watch interview with Robby Shabwanga, projects officer, Legal Resources Foundation, October 14, 2009. See also PRISCCA, ARASA, and Human Rights Watch interview with Angela, Lusaka Central Prison, October 4, 2009 (“They don’t open the door in the cell at night for anything. There are no windows, no air. Someone who was 28 years old died at night in her cell and they didn’t open the door until the morning.”)

[450] PRISCCA, ARASA, and Human Rights Watch interview with J. Kababa, officer in charge, Lusaka Central Prison, October 3, 2009.

[451] Prisons Act, sec. 22.

[452] Body of Principles, prin. 34.

[453]The officer in charge at Mukobeko reported that there had been four inmate deaths in the previous month and 10 inmate deaths in 2008 at the time of our visit, 40 percent of which were attributable to TB. PRISCCA, ARASA, and Human Rights Watch interview with George S. Sikaonga, officer in charge, Mukobeko Maximum Security Prison, September 29, 2009. At Kamfinsa, the officer in charge said that there had been two deaths in 2009 until October, four in 2008, all from HIV/AIDS. PRISCCA, ARASA, and Human Rights Watch interview with Patrick Mundianawa, officer in charge, Kamfinsa Prison, October 1, 2009. At Mumbwa Prison, the officer in charge reported that three deaths had occurred in 2009, and one in 2008, all from HIV/AIDS and TB. PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mumbwa Prison, October 5, 2009. At Choma prison, the officer in charge reported to us that in 2009 there had been two inmate deaths from TB and HIV/AIDS-related illness and a short illness, respectively. In 2006, HIV/AIDS was the leading cause of death. PRISCCA, ARASA, and Human Rights Watch interview with Patrick Chilambe, officer in charge, Choma Prison, October 8, 2009.

[454]PRISCCA, ARASA, and Human Rights Watch interview with Jacob, Mwembeshi Prison, October 6, 2009.

[455]PRISCCA, ARASA, and Human Rights Watch interview with Febian, Mumbwa Prison, October 5, 2009.

[456]PRISCCA, ARASA, and Human Rights Watch interview with Clive, Mwembeshi Prison, October 6, 2009.

[457] PRISCCA, ARASA, and Human Rights Watch interview with officer in charge, Mwembeshi Prison, October 6, 2009.

[458]PRISCCA, ARASA, and Human Rights Watch interview with Rabun, Mwembeshi Prison, October 6, 2009.

[459]PRISCCA, ARASA, and Human Rights Watch interview with Francis, Mwembeshi Prison, October 6, 2009.