HIV-AIDS status of inmates and HIV-AIDS programmes implemented: briefing by Department of Correctional Services

Meeting report

Opening remarks by Co-Chairperson
The co-Chairperson, Mr M Goqwana (ANC) said that the Department of Correctional Services (DCS) had been requested to brief the Committee on its HIV and AIDS programme for inmates, owing to the high prevalence of HIV in correctional services facilities.  The Department had been requested to confirm the existence of the problem and to explain how the problem was being handled.  The reason for the prevalence was the practice of anal sex, since the bacteria involved made people especially prone to infection.  The Committee had added tuberculosis to the topics which it oversaw, as people who were HIV positive were especially prone to TB.  The importance of geriatric medicine should be noted, since people were getting older.
He apologised for the cancellation of the previous week’s meeting.

Briefing by Department of Correctional Services
Mr James Smalberger, Chief Deputy Commissioner: Incarceration and Corrections, apologised for the absence of the Minister and the National Commissioner from the meeting.
The primary problem faced by the Department was overpopulation of the correctional service centres.  The correctional centres contained 152 000 people, but only 120 000 beds.  There were 108 000 inmates who had been sentenced, and the remaining 42 000 were awaiting trial.  About 3 500 were females, and the rest were males.  In addition 64 000 people were on parole and probation, serving their sentences outside of prison.  Roughly 23 000 to 24 000 people were admitted and released on a monthly basis.  Correctional services encompassed a wide range of services, including health care, social services, psychological services and education. 

Ms Maria Mabena, Director of Health: Correctional Services, delivered the presentation on the Department’s HIV and AIDS programme for inmates.  She said that South Africa had to adhere to international norms and standards, including the requirement that “inmates must have access to the same quality and range of health care services as the general public receives from the National Health System”.  She went on to describe the current state of health care in correctional services facilities, notably pointing out that the in-patient facilities in the correctional centres were not classified as hospitals since they did not meet the necessary requirements.  The services and programmes available within the correctional centres included health education, services for acute minor ailments, injuries and diseases, pharmaceutical services and mental health care.  The most prevalent conditions were, in no particular order, sexually transmitted infections (STIs), TB, HIV & AIDS, mental ill health, skin, musculo-skeletal, chronic (hypertension and diabetes), dental and gastro-intestinal diseases. 

Ms Mabena briefly outlined how the Department managed HIV, TB and STIs with regard to prevention, care, support groups and treatment.  She outlined the HIV performance targets and mentioned that the reason for setting a low target for the percentage of inmates to be tested for HIV (3.7%) was because HIV testing was not mandatory, but merely optional.  She also examined TB performance and commented that the reason for the decrease in the percentage of suspects tested for TB was the drastic increase in the number of people screened for TB.  Gene-Xpert machines had been used to help identify when people had AIDS or TB.  Digital chest X-rays were also used to identify TB in patients and these could be operated by nurses. 
Some of the highlights discussed included the Department’s active involvement in all South African National AIDS Council activities and the integration of the Department’s health care services into the National Health System.  The Department had entered into partnership and co-operated with non-governmental organisations, in addition to the Department of Health. 

Ms Mabena outlined some of the challenges faced by the Department.  These included overcrowding, the inability to recruit and retain health care professionals, and the lack of a national policy to allow nurses to prescribe, keep and dispense medication where there were no pharmacists and medical practitioners in a facility.  There was a lack of doctors to be mentors for nurses.  It was especially challenging to manage and take health records of people awaiting trial, since they were often moved around or acquitted.  This partly explained the poor cure rates in the third and fourth quarters.  The Turn Around Time (TAT) took six weeks to two months, but this had been reduced through to the donation of Gene-Xpert machines.  A further challenge was that some of the older correctional facilities were not conducive to the people’s health since they had various structural problems, such as lack of access to direct sunlight.  Monitoring and evaluation facilities were not integrated into the districts, which caused poor information management.  Partnerships and cooperation between the DCS and the Department of Health had to be maintained for the optimum delivery of health care programmes and services to the inmate population. 

Discussion
Co-Chairperson Ms R Rasmeni (ANC) opened the discussion.

Ms M Segale-Diswai (ANC) stated that South Africa did not perform well with its TB cure rate.  The presentation given by the Department was based on national figures, but a provincial breakdown would have been more useful for oversight purposes.  She enquired whether there were joint management meetings between the Department of Health and the Department of Correctional Services and if so, how often these meetings occured. 

Mr Smalberger replied that the reason for providing national figures was that the DCS was a national department.  It was divided into six regions, not into nine provinces, since some provinces had relatively few correctional facilities.  It was therefore easier to manage the regions by dividing them up into more equal number of facilities so that the directors of each region would be fairly placed on equal levels, based on their responsibilities.  It was possible to provide a breakdown of information, but this would have to be provided according to the six regions into which the Department was divided, not according to the nine provinces.  He added that the President had announced a special remission for offenders, and this had affected the figures for the first and second quarters of the year, as 20 000 persons had been released.

Ms Mabena said that a provincial breakdown of statistics could, and would, be made available.  The DCS did hold joint management meetings with the Department of Health in connection with TB and HIV.  However, in some of the provinces the Department of Health did not incorporate the DCS fully at the provincial level.  In these instances, there were essentially two parallel health systems, which is not at all optimal. 

Ms Segale-Diswai asked how the DCS received its medication, since as far she understood, the Department received it directly from the provincial depots.  She also asked how the incarcerated persons’ families were contacted if it was discovered that they had TB or other serious diseases, since presumably the families needed to be contacted as soon as possible.  It would be useful to know the number of people who had been seen in primary healthcare facilities, since on average about two to ten per cent of these people ought to be screened for TB in order for it to match the national averages.  It was important to include detailed explanations within the presentation handouts so that those Members who were not present could fully understand the information conveyed to the meeting.  She was concerned with the high number of TB suspects being positive in the first two quarters, as well as the fact that not 100% of the people found to be TB positive were treated for TB.  The TB cure rate listed in the presentation would presumably be related to the amount of people who were treated for TB in the previous year, yet this number seemed to be related to the present year’s TB data.   Was there an explanation for this? 

Ms Mabena replied that the Department of Health had taken over the role of contracting for medicines from the Treasury.  The DCS was not large enough to contract efficiently for medicines and therefore it had to negotiate with the provinces to order the medicines and then collect it from the depots.  She had, however, agreed recently that the DCS would be allowed to order directly from the suppliers.  Regarding the contacting of family members, she stated that whenever someone was diagnosed with TB, their family was notified.  However this was not a simple task, since people often used aliases and gave the Department fake addresses for their family.  The Department did collect primary health care statistics, but the data had not been brought to the meeting.  She added that in the future the Department would ensure that footnotes were inserted to explain those things which are not apparent from the presentation’s slides.  This would ensure that those not present at the meeting would be able to fully comprehend what had been discussed. 

Ms Segale-Diswai asked whether the Department had a retention and recruitment strategy in place in order to increase the amount of health care workers at the correctional facilities.  She requested a breakdown of the types of nurses working at the facilities, as there were different classifications of nurses.  Usually the Turn Around Time (TAT) was meant to be about 48 hours, but it had been mentioned that the TAT within the Department was six weeks to two months.  This is worrying, since it could cause disease to spread without the disease having been identified.  She also asked whether there was a dedicated person within the Department who was assigned to deal with TB. 

Ms Mabena replied that only 137 of the professional nurses employed by the Department were primary health care nurses.  The salary levels of these nurses were very high and it was therefore very difficult to retain them within the department -- they were often bought out by other facilities.  In order for nurses to be able to engage in Nurse Initiated Management of Antiretroviral Treatment (NIMART), they had to be primary healthcare nurses.  Due to the small number of such nurses, backlogs in the dispensing of medicine resulted.  In addition, private doctors could not be used in order to authorise nurses to use NIMART, thus further increasing backlogs.  At times, laws became obstacles to service delivery, in her opinion.  Due to the long TAT, treatment was initiated before the results were received, just in case.  Furthermore, record keeping was quite poor in reality and could not be considered to be completely accurate.  There were dedicated TB coordinators, but they were not always linked to the district health care services.  It was necessary that their link to the district health care services be formalised. 

The co-Chairperson thanked the Department for their work and asked how many hospitals there were within the DCS in total.  The Committee realised there was a lack of nurses and doctors within the Department and asked how it managed this, especially in light of the many open job positions within the DCS. 

Ms Mabena replied that vacant posts existed because of budgetary cuts.   However, the Department tried to ensure that posts were filled as soon as they became vacant. 

Mr V Magagula (ANC) asked about the difference in the conditions of employment for nurses.  He commented on the fact that the correctional facilities did not have hospitals, and asked what their health facilities were classified as, and what standards these facilities were required to meet.  He asked whether the target of 3.7% for inmates to be tested for HIV was too low, and whether it was set this low in order to ensure that the Department would achieve its goal without fail, as achievement in all quarters had been above 10%. 

Ms Mabena replied that while the health facilities within the correctional facilities were classified as clinics, they did work together with some hospitals.  There were no differences in the conditions of employment of the different types of nurses except for their salaries and, at times, their working environment.  The targets set by the Department were based on the previous year’s performance. 

Mr Smalberger replied that targets were not set low in order to overachieve, but were based on the previous year’s performance.  In addition the annual performance plans, including targets, were presented to the Portfolio Committee.  There was a distinction between the people who were employed to work directly with offenders, and those who did not work directly with offenders. 

The co-Chairperson, Mr Goqwana, emphasised that the reason for calling this meeting had been to ascertain the extent of the problem.  Given that 45% of HIV positive people had psychological problems, he wanted to know how the Department handled the mental health of their HIV positive patients. He asked what the mortality rate was.   Were HIV positive people allowed to leave the correctional facilities on medical parole?  He noted that TB spreads quickly when people lived in close proximity to each other, and he asked whether many people got TB in jail due to the living conditions there.  Were ten condoms per person sufficient, given the situation in which the persons lived within the correctional facilities?  He also asked why females were given condoms, since they were kept in facilities separate from the males.

Mr Smalberger replied that a new medical parole board had been established in February of last year and had started to function in April 2012.  It consisted of 11 medical practitioners from outside the Department, and they represented most of the provinces.  Any offender or their family could apply for medical parole, and in the previous year, about 150 applications had been made.  Only about 22 or 23% of applications made had been recommended by the board, so it could be seen that a lot of people took chances by applying for medical parole.  The new medical parole board ensured consistency as evidenced by the fact that only 35 persons had been recommended for medical parole, which was considerable fewer than the year before.  It should be noted, nevertheless, that not everyone recommended for medical parole was granted parole, since their application still had to go to a further parole board.  Once offenders were placed on parole, they did not receive medical care from the DCS.  These people were often unable to afford their medical bills and therefore had to go to the Department of Health for assistance. 
On the question of the mental health of HIV positive persons within the correctional facilities, Mr Smalberger stated that there would never be enough psychologists.  Psychologists were especially important to help some 54 000 persons serving long-term sentences to adjust to society before they were released.  The Department had a strategy to acquire more psychologists, but this was very difficult since once they had been appointed, they were often made a better offer to work elsewhere.  There were also very high standards to be met by psychologists, since they needed at least an honours-level degree in order to be able to practise.

Ms Mabena replied that the mortality rate would be included in future presentations.  All persons had to be screened for diseases on release and transfer.  She believed enough condoms had been distributed, since people were actually wasting many of the condoms which had been distributed.  Females did in fact utilise the condoms distributed to them by stuffing something therein, such as soap, and using them as dildos. 

Co-Chairperson Ms Rasmeni asked whether there were plans in place to compensate for the inadequacy of the current infrastructure, other than the plan to liaise with the Department of Public Works.  What was the reason for poor integration between the DCS and the Department of Health.  She asked for clarification on the role of spiritual care workers, and wanted to know whether there were people from the Department within the provincial structures.  Finally, she asked whether children in the correctional facilities were also infected with TB or HIV.

Mr Smalberger stated that some of the correctional facilities were very old -- some were even declared museums.  As a result, it was very difficult to alter these facilities, since it was not allowed to change the infrastructure drastically.  The DCS would have to rely on the Department of Public Works to solve this problem.  Nevertheless, a number of old facilities were being renewed.  Some facilities housed only 60 to 200 offenders, which was very costly due to the small size of the facilities.  The Department wished to avoid having facilities containing less than 500 people, but closing the small facilities was not easy since it went against rural development policy.  A five-year building programme existed in order to reduce the infrastructure shortages, but there was always a challenge when deciding whether to spend resources on building hospitals, schools or correctional centres instead.  The centres which were built during the apartheid era had to be changed, since rehabilitation was an important part of the correctional facilities today, which was not the case before.

Mr Smalberger said that Occupational Specific Dispensations (OSDs) existed for health care workers and teachers, for example.  The Department often dealt with OSDs.  Spiritual care workers were important for the rehabilitation of inmates.  They included permanent chaplains, but many of them were simply from the community, and were assisted by the Department.  Even if there were only one person from a specific faith, the Department would allow that person’s faith community to assist them.  Although the presence of spiritual care workers may seem like a duplication, since there were already programmes to prevent people from becoming repeat offenders and since there were already psychologists, they did nevertheless fulfil a special role.   It was often easier for people to say that they had been raped to a spiritual care worker, rather than to anyone else.  Drug and alcohol rehabilitation programmes were also provided, and although people participating in these programmes did suffer relapses, this was no different to what happened in these programmes outside of the correctional facilities. 

Ms Mabena replied that the Department has been quite creative in how it used its current limited infrastructure in order to provide the best service possible.  An example of this was the setting up of medical facilities in an upper room where there was more ventilation than in the rest of the correctional facility.  She added that prisons were often designed in order to keep costs low and as a result, health considerations were often neglected.

Mr Smalberger added that there were many vulnerable groups within the correctional facilities.  There were more than 1 000 people above the age of 60 and on any given day there were about 100 babies (zero to two years) with their mothers within the correctional centres.  In addition, children and juveniles had to be kept separate from each other and from adults -- with children being defined as those aged 14 to 18 and juveniles defined as being aged 18 to 21.  The Department defined youth for its purposes as being people under the age of 25.  There were no figures on the number of children being kept in the correctional facilities available, and the accounting system would have to be improved in order to provide these figures.
He thanked the Committee and said that he had learned a lot from their comments and questions. 

Co-Chairperson Mr Goqwana thanked the Department for their presentation.  While there were still some challenges to be looked into, the presentation had given the Committee at least some idea of the current situation within the correctional facilities.  The Committee was engaging in oversight in an attempt to rid South Africa of HIV and TB.  The reason for specifically having requested the DCS to give a presentation was due to the high prevalence of HIV and TB within correctional centres.  The Committee should consider the creation of laws which would make it easier for the Department to do their work.

The meeting was adjourned.