Uganda was once hailed as one of the world's early leaders in combating HIV. In the past decade, this success has been undermined by a focus on abstinence-only programs, widespread corruption, and more recently by stigmatizing and misguided policies. While the anti-homosexuality bill received global attention, a confused anti-HIV bill prompted less reaction. Among other provisions, the bill mandated up to ten years imprisonment for failing to protect oneself from HIV infection, illustrating the lack of clear thinking and government leadership in the fight against HIV.
Prisons sidelined from funding
Uganda remains a darling of international health donors, though its incoherent approach to targeting HIV is now notable for leaving out people at risk of infection, such as sex workers, migrants, men who have sex with men, people with disabilities, and prisoners.
Prisoners are a case in point. The rates of HIV and tuberculosis in prisons are roughly double the rates in the country as a whole, yet prisoners are largely left out of treatment or prevention. When Robert, who is HIV-positive, was sent to prison, an officer simply told him, "fight on, complete the sentence, go home and get treatment". The prison would not provide him with anti-retrovirals.
Prisons have very limited funds for treatment. Less than 0.1% of U.S. funding to fight HIV in Uganda goes to programs for prisoners. The UK Department for International Development (DFID) does not contribute to the prison health services. Nor has the Global Fund to Fight AIDS Tuberculosis and Malaria been a significant contributor, though Uganda's most recent proposal to the organisation called for the strengthening of TB control in prisons.
The spread of infection
But the spread of HIV and TB within and from the prisons poses a serious risk. Every year 50,000 people pass through Uganda's prisons. If they can't get prevention or treatment services in prison, they may be carrying infections with them when they come out.
As we researched prison health conditions in Uganda over the past months, we found conditions ripe for the spread of both TB and HIV. Prisoners told us they were packed together in cells with tiny air vents, in some places day and night, while their fellow prisoners coughed violently. Sometimes sex is traded by the most vulnerable in exchange for food, but condoms are prohibited.
Testing and treatment for both diseases remain inadequate. Only one prison medical facility among the country's 223 prisons is accredited to provide comprehensive HIV and TB treatment. Prison officers frequently delay or deny prisoners' access to medical treatment at community-based facilities.
But that's only part of the story. An abusive forced prison labour system compounds the devastating effect of both diseases.
Take Muinaina Farm Prison, where almost two-thirds of the inmates are awaiting trial. Some have not set foot in a courtroom in five years. Prisoners plead guilty just so that they will know their release date. They sleep crammed together on cement floors. They farm government lands to produce the maize meal that feeds prisoners countrywide. Or they dig on the wardens' personal farms, growing produce that the wardens sell for personal profit. Prisoners also sometimes work for private farmers, who pay the prison authorities. Prisoners at Muinaina and at other prisons have been known to be beaten to the point of broken limbs or temporary paralysis, handcuffed to a tree, or burned - all for lagging behind or refusing to work.
Hardly any medical care is available at Muinaina, or at many of Uganda's rural prisons. HIV-positive prisoners are sent to work until they are too weak to keep up, then may finally be transferred to Kampala for treatment. There is little TB testing and treatment. However, prisoners with HIV and TB are transferred to these rural prisons. As the prison medical authority aptly explained, "if they are on TB treatment, and you take them to a farm, you create resistance".
Drug-resistant TB is a deadly strain that has emerged due to poor management of TB and inadequate infection control. The World Health Organisation (WHO) estimates that there were 440,000 new cases of multi drug-resistant TB in 2008 alone.
"There are no sick people here"
Addressing HIV and TB in prisons requires increased investment in health services by both the Ugandan government and international donors, as well as a focus on the persistent human rights issues plaguing prisons in Uganda and neighbouring countries. Ugandan government agencies and international donors have teamed up to reduce the case backlog in the criminal justice system and the attendant prison overcrowding. But more progress needs to be made on bail and community service options, and providing lawyers to suspects earlier in the legal process.
The brutal forced labour system must also be changed immediately. Prisoners should not be sent away from a prison where they could receive treatment to work, enriching their captors whilst risking the development of drug resistance strains of infection.
Over and over again, the rural prisoners we spoke with said the same thing: when they told the prison officers they were too ill to work, they were simply beaten. "There are no sick people here", the wardens told them. But there are of course thousands of sick people in Uganda's prisons. Not only increased funding, but also pressure from donors is needed if they are to be treated and rehabilitated, rather than abused and enslaved.
Katherine Todrys is a health and human rights researcher at Human Rights Watch.