Provision of ART in the Kenya National Prison System

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Provision of ART in the Kenya National Prison
System

• Nathaniel Smith, MD, MPH
• Evans Majune, RCO
• Frederik Kimemia, KRCHN
• A.I.C. Kijabe Hospital
• AIDSRelief
• 5 August, 2008

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Legal Framework

• The fundamental rights in the Kenyan constitution
  provide every person with the right to equality
  and nondiscrimination.
  
• The implementation of these clauses are the
  guiding framework for Kenya prisons service
  Act(rev)1977(cap90 and cap92), prisons rules and
  regulations, and other relevant legislation
  proposed and in place.

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Naivasha Maximum Security Prison

• One of the largest and most modern prisons in
  Kenya and Africa
  
• Population of over 2000 inmates
• Inmates are kept in 5 blocks, each with over 400
  inmates.
  
• Most inmates have received death sentence, life
  sentence, or are serving sentences of over 5
  years.

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Naivasha Prison VCT

• More than 5000 inmates tested since 2005
• 95-100 inmates tested per month
• 5-10 test positive per month
• Overall HIV seroprevalence of 6.7

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Current Naivasha Prison Healthcare Staff

• 1 Clinical Officer
• 3 nurses
• 2 adherence officers (provide DOT for all inmates
  on ART)
  
• 6 VCT counselors
• 1 lab technologist
• 1 part-time Public Health Technician

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Support for HIV Inmates

• Inmates have organized themselves to form the
  Naivasha Inmates HIV/AIDS Health Group, which
  meets monthly.
  
• The group is very well-trusted by the inmates and
  offers counseling to inmates.
  
• Through the group, many patients have been
  willing to talk about their HIV status.
  
• The group is supported by the prisons VCT
  counselors and healthcare staff.

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HIV Treatment for Inmates

• Naivasha Maximum Security inmates with HIV
  infection were previously taken to Naivasha
  District Hospital for ART care.
  
• This arrangement for offsite ART became difficult
  to sustain due to
  
• Logistics of transport and security
• Inmate fears regarding stigma
• Other programmatic issues

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Naivasha Prison Clinical Capacity

• The prison owns a spacious clinic inside the
  prison walls that has the capacity to handle many
  patients.
  
• Inpatient services include an operating theatre,
  pharmacy and limited laboratory.
  
• However, Naivasha prison medical staff were not
  trained or equipped to provide comprehensive ART
  services.

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Naivasha Prison Clinic
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Partnership with Kijabe AIDSRelief

• The A.I.C. Kijabe Hospital AIDSRelief program
  operates a satellite clinic in Naivasha, which
  provides comprehensive HIV care, including ART,
  to almost one thousand Naivasha-area residents.
• Through a series of meetings between Kijabe
  AIDSRelief and Naivasha Prison staff, a unique
  collaboration developed.

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Goals

• Implement comprehensive HIV care, including ART,
  for Naivasha inmates within the Naivasha Maximum
  Security Prison healthcare clinic
  
• Equip the Naivasha Prison healthcare staff with
  basic information followed by comprehensive
  training in ART delivery
  
• Improve HIV awareness among inmates

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Ensuring Continuity of Care

• Inmate transfers to other prisons are common in
  Kenya, and these transfers can adversely effect
  ART adherence and retention in care.
  
• To address this issue, prison officials agreed to
  minimize transfers for inmates already on ART.
  
• For inmates who are transferred or released, a
  transfer letter was drafted to ensure patients
  continue HIV care wherever they may be.

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Implementation Steps

• All prison healthcare staff were given
  information on ART regimens and common
  opportunistic infections.
  
• HIV awareness campaigns were carried out among
  the inmate population.
  
• Twenty (20) inmates were enrolled in HIV care on
  8 January, 2007.
  
• Clinical care has been supported by Kijabe
  AIDSRelief staff on a weekly basis.

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Progress

• As of July 2008, 149 inmates were actively
  receiving HIV care, including 86 on ART.
  
• Only 4 HIV-related deaths have been reported
  since inception of the program.
  
• Due to the good performance of the program, the
  Naivasha Prison hosted the launch of the KENYA
  PRISON SERVICE HIV/AIDS POLICY on 31May, 2007 by
  HIS EXCELLENCY V.P. MOODY AWORI.

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Naivasha Prison vs. Clinicin care and on ART
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Naivasha Prison vs. Clinicpatient characteristics
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Naivasha Prison vs. Clinicfollow up of patients
on ART
Differences not statistically significant.
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Challenges

• Stigma and denial among prison inmates and staff
  leading to suboptimal response
  
• Limited prison healthcare staff - only 3 nurses
  and 1 RCO to care for the Naivasha Prison inmates
  and staff
  
• Limited diagnostic services
• HIV prevention - modes of transmission are not
  well-defined within the prison

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Lessons Learned

• Provision of ART services to long term prisoners
  in Kenya is feasible and has political support.
  
• Partnerships between government prison facilities
  and faith-based HIV care providers are an
  effective model for ART provision.
  
• Extending the partnership between AIDSRelief and
  the Kenya prison system would allow scale up of
  ART services to other prison facilities in Kenya.

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• How a society treats its prisoners is a good
  gauge of its character and humanity. As we stand
  at the verge of this new and exciting venture, we
  can declare with confidence that Kenya has not
  forgotten its prisoners. They are not forgotten
  by their families, by their government or by
  their God. It is my prayer that the HIV care
  provided through this program will be a channel
  of blessing and peace to these inmates and bring
  glory to God.

Excerpt from Naivasha Prison HIV clinic
dedication speech - Justus Marete (Exec Dir, Kija
be Hospital) 31 May, 2007
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Thanks

• Naivasha Maximum Security Prison staff
• Patrick Mwenda, Officer In-charge
• Duncan Ogore, Former Officer In-charge
• Toroitich Isaiah, RCO In-charge
• Gerishon Wachira, VCT In-charge
• Steve Akaka, Nursing Officer
• AIC Kijabe Hospital HIV program staff
• AIDSRelief is generously funded by PEPFAR Grant
  U51HA02521.

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Acknowledgements

• A.I.C. Kijabe Hospital
• Jonathan Mwiindi
• Kenneth Miriti, RCO
• Catherine Mureithi (Clinics Manager)
• Joel Siatabau, RCO
• Lydia Korir, KRCHN
• Esther Thuo

• Naivasha Prison
• Emmanuel B. Misiko (KECHN)
• Shadrack K. Boinett (Adherence Officer)
• Shadrack Gachiuri (Adherence Officer)

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