Health
The prevalence rate of 1.8% in the Rajahmundry Central Prison is much above the national prevalence rate of HIV among adults at 0.22%.
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A prisoner serving a life sentence in the Rajahmundry Central Prison in Andhra Pradesh since February 2018, recently approached the High Court seeking interim bail for a couple of months. His reason - the 30-year-old man who had been diagnosed with HIV and started therapy in 2006, wanted a shot at better treatment outside of the prison.

When his petition came up for hearing last week, the Andhra Pradesh High Court had directed the Rajahmundry Central Prison to submit a statement regarding HIV positive cases among prisoners. The bench comprising of Andhra HC Acting Chief Justice Chagari Praveen Kumar and Justice M Satyanarayana Murthy had asked the prison authorities to furnish the details in an affidavit on Tuesday. According to reports, the court had directed the government to investigate the matter seriously and had warned that firm action would be taken against the jail superintendent if it was found that any of the patients had contracted HIV after they had entered the jail. 

G Jayavardhan, Inspector General of Prisons in Andhra Pradesh, confirmed that 19 of the 27 prisoners were HIV positive at the time of being admitted into the jail. “The remaining eight were subsequently diagnosed on occasions when they fell sick and were tested. It’s likely that these eight prisoners had already contracted HIV. We don’t know if they already knew about it and failed to inform us,” he said. 

Raja Rao, Superintendent of the Rajahmundry jail, said, “The court had mainly asked if it was possible that the eight prisoners had contracted HIV after entering our prison. In our affidavit, we have made it clear that there is no such possibility. We make sure medical syringes and razors are not reused. We only provide disposable ones. Also, we have 24-hour CCTV surveillance, so there is no possibility of sexual activity among prisoners.”

Raja Rao claimed that the judges seemed convinced by the details produced, but the court has reserved its judgement and is yet to provide directions to the prison on the future course of action. 

The number of cases has been reported in the media with alarm. 27 HIV positive patients out of a total of 1,500 prisoners puts the prevalence rate in the prison at 1.8%. According tofigures from the India HIV Estimation 2017 report, the national prevalence rate of HIV among adults was estimated at 0.22 %, with the rate among males estimated to be 0.25 %. Dr Amrose Pradeep, who works with YRG Healthcare, an HIV/AIDS care centre in Chennai, shows concern that the prison’s rate is indeed high. “The current numbers are just from testing prisoners who have shown symptoms. If they were to test everyone, the number might turn out to be higher,” he said. 

He observed that at this point, it’s hard to tell whether the remaining eight prisoners contracted HIV before or after they entered the prison, as the tests do not give information about the timeline of infection.

High-risk environment in prisons

The World Health Organisation observes that prisons are “extremely high-risk environments for transmission of HIV”, for different reasons including overcrowding, poor nutrition, limited access to health care, unsafe injecting practices and unprotected sex. 

Last year, a prison intervention programme by the National AIDS Control Organisation had revealed in its initial data that out of 35,000 prisoners tested, 2.5% were found to be positive

“It’s likely that if you look at the profiles of men who are sent to jails, some of them might have been using or selling drugs. So, they could have already been at risk of contracting HIV, Hepatitis B, Hepatitis C, etc. Moreover, inside prisons, people are in close contact with each other. So contagious diseases like tuberculosis are also a big concern among prisoners,” Dr Pradeep said. 

Awareness of voluntary screening tests

A few local media reports suggested that the prison authorities had failed in their duties by not screening all prisoners for HIV before entering jail.  “Obviously we cannot impose the test. Only if they come forward voluntarily or doctors find it necessary to perform the tests, they are done,” Jayavardhan said. 

Dr Pradeep feels that a mechanism for regular opportunities for consensual screening needs to be in place. “Most of the time when you talk to people sensitively, they are willing to take the test. Of course, this is provided they are not discriminated against in the process,” he said. 

According to Jayavardhan, a project on AIDS awareness is being run by the AP AIDS Control Society in collaboration with the NGO SAATHI in jails across AP. “The NGO staff visits all jails in the state every week and conducts awareness programs with the prisoners,” he said. 

However, Rajashekhar M, Program Manager at SAATHII, said that they had not yet begun any major activities at the Rajahmundry Central Prison. “Our project in AP has begun only recently in March. We’ve started work in a few jails, but so far in Rajahmundry, there has been one sensitisation programme where we explained what HIV is, how to prevent infection and why they should get tested.”

So far, he said that there has been no follow up. “We got to know that there’s a shortage of kits in East Godavari (the district in which the jail is located). We need to plan this with the superintendent. We haven’t yet determined how many prisoners are willing to undergo testing,” he said. 

Raja Rao said that although awareness programs are conducted, no voluntary screenings have happened so far as a result. 

Healthcare systems in prisons

According to public health researcher Dr Sylvia Karpagam, like many public health concerns in India, not enough effort has been put into prevention and early detection for HIV. “A lot of money had come in for HIV care, but it hasn’t been made a sustained part of the state healthcare policy. In Kerala, the way they’ve successfully handled Nipah is because they have a strong public health system in place,” she said. 

“It’s not always easy to work in the prison system. Once an HIV positive person is sent to jail, the supply of medication could be interrupted for various reasons,” said Dr Pradeep.  “It must be ensured that the prisoners take their medication regularly, that they are linked to the government ART (Antiretroviral therapy) programme, and their viral loads are monitored periodically,” he adds. 

According to Jayavardhan, the Rajahmundry Central Prison has three doctors who ensure that the HIV positive prisoners are regularly provided medicines and sent to ART centers. 

But Dr Pradeep said that even if prison healthcare systems are being managed well, societal biases towards HIV patients and prisoners cannot be disregarded. “There’s this attitude that people inside jails are all sinners. Having worked with HIV patients, I’ve seen an attitude of judgement towards HIV patients even among senior doctors. So prisoners who are HIV positive are doubly stigmatised,” he said.   

Dr Sylvia echoed this thought. “Unless there are strong policies and commitment towards confidentiality in place so that prison officials do not stigmatise them, it’s difficult for prisoners to come forward and disclose such information,” she said. 

Diagnosis and treatment for prisoners 

Dr Pradeep said that when a person acquires HIV, in most cases, they develop symptoms like fever, sore throat, body pains. “Those symptoms disappear in a couple of weeks. After that, there’s a long gap of anywhere between 3 to 15 years. That’s when we see more ‘classical’ HIV symptoms and tests are done. So in a place like this prison with high prevalence rate, even if you have a minor fever, it would be better to get tested for HIV so it can be detected early on,” he said. 

But not all doctors are discerning enough to do so, according to Dr Sylvia. “You would need proper medical records to really see a pattern and make connections to HIV, instead of simply treating the symptoms. Even symptoms like recurring diarrhoea or severe weight loss could be picked up on if proper records are maintained,” she said. 

Raja Rao said that prisoners who are transferred from district jails to the central prison, usually when sentenced to life imprisonment, do not usually come with any accompanying medical records. “But once they’re here, if they are found to have serious health conditions like HIV or cancer, then we keep their records,” he says.  

“If you can treat a patient and suppress their viral load to an undetectable level, the chances that they can transmit HIV to another person even through unprotected sex is almost zero,” said Dr Pradeep. 

So detection is only the tip of the iceberg, after which the patient must be put on therapy consistently, he said. 

Taboos around sex and sexuality

According to NACO’s intervention programme, a large number of prisoners had contracted HIV because of unsafe sex and sharing of needles within prisons. 

As Rajashekhar points out, although sex is only one of the multiple ways in which HIV is transmitted, it ends up dominating the narrative around the disease and results in harsh stigma and judgement. 

Dr Sylvia observes that the topic of sex is avoided in conversations particularly when it comes to such settings. “For instance, you have women who were involved in sex work who are put in shelter homes for years. Nobody really wants to talk about what is happening to their sexual lives, they just want some moral notion that women are safe and all that. In the case of prisoners, people are incarcerated for years, and sexual desire is a natural instinct. There needs to be a way of addressing it. But it remains a total taboo topic,” she says. 

Dr Pradeep says that although same-sex relations have been decriminalised, there is evidently still a lot of stigma around it. “We need to acknowledge that there could be homosexual men in prisons, and they could be having sex inside prisons. It’s important that STD protection like condoms is made available, instead of stigmatising sex or pretending it doesn’t happen,” he says. 

But implementing such measures seems unlikely at the moment, Dr Sylvia says. “It would make sense to make condoms available, but I feel there is a culture of penalising officials for such things. If it comes to light that people are having sex in prison, then the fact that it wasn’t prevented is what is going to get attention. There are all these issues of morality that can be brought up. To avoid that, it’s possible that such data is downplayed. Because it’s not clear how to deal with it,” she says. 

When asked if there was any possibility of taking measures to provide protection, IG Jayavardhan said that there is no scope for sexual activities inside the prisons. “Our jails have 24-hour lighting and surveillance. Even at night, some of the prisoners themselves stay guard over the others,” he says.