Jonathan Berger Senior researcher Head of policy and research AIDS Law Project

1. _________________________________________________________ Towards a national framework for a comprehensive HIV and AIDS plan for correctional centres: implementing the NSP in prisons Jonathan Berger Senior researcher Head of policy and research AIDS Law Project Towards the Comprehensive Management of HIV/AIDS in Prisons Thursday, 7th June 2007 3rd South African AIDS Conference

2. Overview of presentation _________________________________________________________ • Introduction to the National Framework • “Unpacking” the framework • Factors to consider and/or address in developing and implementing a plan • Preventing HIV infection • Increasing uptake of HIV testing services • Providing access to comprehensive services • Antiretroviral (ARV) treatment • Internal systems • External independent assessment of framework’s implementation • The way forward

3. Introduction to the framework _________________________________________________________ • Recognition • Existence of various DCS policies and programmes • Significant progress since legal proceedings initiated • Framework consolidates, clarifies and complements, and where necessary, amends • Basis for revision of policy in accordance with NSP • Steps to avoid unnecessary conflict • Rights pamphlet • Partnership forum • Dispute settlement and conflict resolution procedures • Ongoing consultation with prisoners • Ensuring adequacy of budgets

4. Factors to consider _________________________________________________________ • Prevalence • Wide variety of relevant data, including DCS survey • Wherever possible, use data at most appropriate level • Use updated and/or better sources when available • Stigma and discrimination • Mitigate negative impact on prevention and treatment • Investigate and follow up on allegations of compelled disclosure • Other factors to consider • Male aggression and sexual violence in prisons • MSM sex • Masculinity and reluctance of men to access services

5. Preventing HIV infection _________________________________________________________ • Access to condoms • Supply to match monitored demand • Male and female condoms (and water-based lubricant) • Address confidentiality concerns in distribution • Sexual violence and PEP • Address concerns regarding reporting to access PEP • Implementation of Jali Commission recommendations • PMTCT • Align plan and revise guidelines and protocols in accordance with NSP and DoH developments • Harm reduction • Develop and implement a harm reduction plan

6. Increasing uptake of testing _________________________________________________________ • Recognition • Too few prisoners are testing • Challenges in providing VCT services • Creating an appropriate environment • Proper implementation of existing policy • Issues to be addressed in all materials and programmes • Characterise testing as a gateway to appropriate services • Highlight potential benefits of disclosure • Monitor and address breaches of confidentiality and acts of unfair discrimination • Communicate availability of HIV testing services • HIV testing services • Recognition that certain policy changes have taken place • Commitment to investigate ways to increase uptake

7. Access to services (1) _________________________________________________________ • Why provide comprehensive services? • Delay progression of HIV infection to AIDS • Ensure that prisoners are best able to benefit from ART • TB management • Develop a TB prevention, early diagnosis and management plan (including focus on MDR and XDR) • In accordance with NSP, provide – and monitor – INH and co-trimoxazole prophylaxis to medically eligible prisoners • Prophylaxis and treatment of other OIs and STIs • Confirmation that DCS implementing: • New Standard Treatment Guidelines and Essential Drugs List (Hospital Level Adults, 2006) • Standard Treatment Guidelines and Essential Drugs List (Primary Health Care, 2003) • DCS finalising new policy on communicable diseases

8. Access to services (2) _________________________________________________________ • Nutrition • Three separate meals; three distinct mealtimes • Commitment to develop and implement phased plan • Concerns about quality of food • Finalising review of Therapeutic Diet Manual (TDM) • Recognition that diet can and should be supplemented • Wellness programme • Commitment to clarify what constitutes such a programme • Facilitating TAC “treatment literacy” programmes • Monitoring of CD4 counts • Recognition of possible need for unique approach to CD4 count testing in prison context • Expert panel to advise on how best to ensure timely access to ART

9. ARV treatment _________________________________________________________ • Accreditation of prisons to provide ART • Clarification of accreditation process • DoH commitment to ensure timely accreditation • Identifying those in need and ensuring access • Clarification of process once medically eligible • Treatment preparedness sessions • TB co-infection • Developing and implementing a centre-appropriate HIV management guideline • Process begun • Possibility of convening an expert panel to finalise • Continuum of care • Access to ART following release • Continued access following incarceration

10. Internal systems _________________________________________________________ • Resource allocation • Recognition of impact of HRH shortages • Short-, medium- and long-term commitments • Essential commodities supply • Recognition of need to guard against stockouts • DoH and DCS commitments • DoH: ARVs • DCS: TB, OI and STI drugs (prophylaxis and treatment) • Access to private medical care • Review of application form requirements • Internal monitoring and evaluation (M&E) • Alignment with NSP • Importance of using M&E to assess and improve programmes • Strengthen relationship between DoH and DCS

11. External assessment _________________________________________________________ • Recognition of relevant role-players • Judicial Inspectorate of Prisons (JIOP) • SAHRC • Portfolio Committee (NA) and Select Committee (NCOP) • JIOP and SAHRC • ALP and TAC to engage JIOP and SAHRC • Whether, and if so, the extent to and the manner in which each body will monitor implementation • In accordance with statutory and/or constitutional mandates • DCS simply to be informed within a reasonable time • DCS to ensure reasonable access to prisons • Parliament • Framework to be provided to two committees

12. Way forward _________________________________________________________ • Partnership – the preferred route • Settlement in Westville • Establishment of partnership forum • Commitment to finalising and implementing the National Framework • Within a reasonable time period • In consultation with key stakeholders • Under auspices of SANAC • Conflict – only if and when necessary • Ongoing Westville litigation • New litigation on a comprehensive HIV/AIDS plan • Decision rests with DCS, DoH and Presidency