The provision of treatment and care for HIV/ AIDS offenders is more complex in a correctional setting. UNAIDS (2003:1) reports that patientswith HIV and AIDS in the general population have rights to health, security of person, equality before the law and freedom from inhuman and degrading treatment. The World Health Organization's equivalence rule states unequivocally that whatever health care and prevention is available to the community at large should also be available to the incarcerated community (WHO/GPAlDIR/93.3:1).
The upholding of patients rights are more complicated when dealing with
prisoners as other stakeholders who come into contact with prisoners also have rights. Therefore, the rights of prisoners, prison personnel, and those of
communities from where prisoners come and to which they return, have got to be balanced and carefully considered in treatment and care models (Human Rights Watch Prison Project, 2003:3). Protecting those on the inside ultimately protects those on the outside, as offenders come from and return to communities.
In South Africa" more than 25 000 prisoners were released from prison every month and the same number received from the courts" (Fagan, 2004: 18), highlighting the large number of offenders that move in and out of prisons to communities on a monthly basis, making the problem difficultto handle.
According to Perez (1997: 3) and Haggerty (2000: 2-5), someof the challenges faced in providing care and treatment to HIV/AIDS patients in correctional settings are as follows:
• Security Versus Care
Prisons are mostly concerned with security, limiting prisonermovement and keeping tight control on when and where prisoners are in specified locations (Haggerty, 2000: 2). This focus on security impacts negativelyon the provision of and access to care and treatment. Haggerty (2000: 2) further states that more resources, energy and time are spent on security rather than on treatment and
• Inadequate Access To Health Care
Perez (1997:3) is of the opinion that the most serious problem faced by HIV- infected prisoners is the lack of adequate medical care in prisonsfor the
treatment of HIV and AIDS. Perez (1997:3) further states thatpatients with HIV infections do not receive appropriate medication or physical examinations, and lack access to proper laboratory monitoring of viral levels and T-cell counts. This lack of services fosters a system in which inmates suffer with severe
complications, despite proven prophylaxis medication thatmight offer relief.
Perez (1997:3) also states that there is often no chronic care system that exists within correctional systems. Health care, including HIV care, is managed incident to incident, with no continuity of care and no one providerwho is managing the whole patient.
• Supportive Services and Counselling
As reflected in the treatment and care model (Avert.Org: 2004) supportive services are essential in the proper management of HIV andAIDS patients.
Supportive services are also central to palliative care. In prisons there are very few support systems for inmates with HIV or AIDS. Prisoners lack support from family and friends from the outside as visiting times are restricted by prison policy. In addition offender-patients who are hospitalized are removed from other inmates in the prison. These inmates can be a tremendous source of support for the patient.
Staff may be also culturally insensitive or outwardly reluctantto effectively counsel people infected with HIV (Perez, 1997: 3).
In many facilities, the staff are either poorly trained, or nottrained at all to understand the nature of the HIV pandemic and how to react or empathize with prisoners.
This, coupled with correctional staff having to deal with large numbers of patients with limited resources at their disposal, and the lack of active support from
management may overwhelm them. The lack of support and counseling for patients who are ill with HIV and AIDS in a prison situation tends to disempower patients and increases their feelings of hopelessness and helplessness.
• Stigmatization and Lack Of Confidentiality In Prisons
AIDS is a disease that causes the sufferer to be stigmatizedand marginalized by society (Perez, 1997: 3). The stigma of the disease is of particularsignificance in prison, because of the institutional nature of the environment. Many prisoners refuse to be tested and remain undiagnosed because there is little confidentiality in prison. There are many mechanisms in prison that maycause an offender's status from being revealed without him/her wanting to disclose his/her status, for example, non-medical people may get access to medical recordsthat are
confidential; staff may have a list of all inmates who are scheduled to see a visiting doctor; or they are exposed when having to wait in medical lines outside the prison hospital. The negative attitudes of staff towardsprisoners may also prevent the former from maintaining confidentiality (Haggerty, 2000: 3).
• Adherence To Medication
Adherence to medication is vital to treatment and successful patient outcomes. In the general community there are two ways of dispensing medication, namely, keeping on person (KOP) and directly observed therapy (DOT). These methods are used to administer medication in prisons.
With KOP, inmates are issued a days or a week's worth ofmedication to keep in their cells and take at the appropriate times. However, prison rules and policies make the implementation of this system a challenge, as the prison schedule may not allow for appropriate meals or fluids being available atthe appropriate time (Haggerty, 2000: 4).
Medication is often stolen for re-sale to other inmates. Also as discussed earlier the issue of lack of confidentiality in the prison compoundsthe problem. DOT means that the inmates must be released from their cells to stand in a pill line.
Someone supervises the taking of the medicine and ensuresthat it is swallowed.
Lock-up or strict security rules often make it impossible for inmates to go to the pill line. To make matters worse, medication delivery often breaks down when inmates are transferred from one institution to another or even one section to another within the same institution, or are taken to court (Haggerty, 2000: 4).
According to Haggerty (2000:4) a further challenge is thatthe HIV population is spread throughout the entire prison system and amongst all health care
providers, making the dispensation and monitoring of adherence to medication even more difficult.