As the world moves towards ending AIDS as a public health threat by 2030, key populations who include people in prison settings, remain underserved. UNAIDS considers gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners and other incarcerated people as the five main key population groups that are particularly vulnerable to HIV and frequently lack adequate access to services.

Now, as MOSES MAGADZA reports, Namibia, with support from UNAIDS, UNODC and I-TECH, is training nurses to initiate HIV treatment for people in prison settings, among the last frontiers in the global response to the epidemic.

WINDHOEK- The Joint United Nations Programme on HIV and AIDS (UNAIDS) in Namibia is supporting the training of nurses from the Namibian Correctional Service (NCS) to initiate inmates on antiretroviral treatment (ART) as global efforts to take health care services closer to the people gain momentum.

On Monday, approximately 30 nurses from NCS facilities throughout the country met in Windhoek for a five-day training on how to initiate inmates living with HIV on ART and manage them. UNAIDS funded the training while the United Nations Office on Drugs and Crime (UNODC), the Ministry of Health and Social Services and the International Training and Education Center for Health (I-TECH) provided technical support.

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Speaking at the start of the training, the newly-appointed Country Director for UNAIDS Namibia, Alti Zwandor, an epidemiologist, said Namibia had done remarkably well in one of 10 global targets agreed by world leaders at the High-Level Meeting in 2016 related to Ending AIDS by 2030, but there was scope for more to be done.

Progress but…

“Namibia met the 90-90-90 targets three years ahead of schedule. That is the good news. The bad news is that Namibia is unlikely to reach the target of reducing new HIV infections by 75% by 2020. That is why this training of nurses working in prison settings is very important,” Zwandor said.

The world has set ambitious targets to ensure that by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.

Other targets seek to reduce new HIV infections by 75%, ensure that there is social protection for all people, particularly the vulnerable, and ensure that 30% of all resources for responding to HIV are channeled through Civil Society Organizations (CSOs) by the year 2020.

While noting that treatment was an important tool for prevention, she said globally, the prevalence of HIV among people in prison settings was much higher than in the general population.

Plight of key populations

“People who are incarcerated have a prevalence of five times more than the general population. Key populations that include people who inject drugs, sex workers, transgender people, gay people and men who have sex with other men tend to be over-represented in prison populations,” Zwandor said.

She said certain environmental, social, cultural, human rights and biological factors exacerbate the vulnerability of people in prison settings to HIV infection.

“This could be due to risky behavior such as sharing needles and syringes, unprotected sex, sexual violence and lack of access to comprehensive HIV prevention and harm reduction services,” she said.

UNAIDS advocates for a minimum package of services for people in prison that includes but is not limited to: access to HIV testing; availability of ART programmes; access to condoms; opioid substitution therapy; and provision of sterile injecting equipment.

It calls, also, for the availability of post-exposure prophylaxis (PEP) and Pre-exposure prophylaxis (PREP) services.

Yawning gaps

At the Melbourne AIDS Conference in 2014, UNAIDS released a report now popularly known as the Gap Report, which identifies yawning gaps in the global response to HIV and AIDS.

Notably, the report identifies 12 key population groups including prisoners, who are deemed central to ending the global HIV epidemic.

The identified key population groups comprise people who have increased risk of HIV infection, who lack access to services and experience a plethora of human rights violations.

The report recommends concerted efforts and attention to providing services and increasing access to those population groups lest the target to end AIDS by the year 2030 remains a pipe dream.

Similarly, another UNAIDS global report made available on the 28th of October 2019, notes that despite the relative ease of access to HIV- related services for all people, prison populations remain underserved.

A recent review of country reports to UNAIDS in the last three years, showed that many prisoners are lacking basic HIV services.

The review found that very few countries reported programme data on the provision of HIV services in prisons with only one in three countries providing condoms, 24 countries providing opioid substitution therapy while three countries provided sterile injecting equipment in prisons.

With regards to HIV testing and treatment, the report found that 74 countries reported programme data on antiretroviral therapy coverage while 83 countries reported HIV testing in prisons.

Building capacity

On why UNAIDS had supported the nurse-initiated antiretroviral programme in Namibia, Zwandor said the last five years had demonstrated the need for Member States to rapidly expand and scale up access to HIV prevention and treatment services to everyone including key populations.

“If we are going to depend on just medical doctors, we might as well forget about our dreams of ending AIDS. We are at a point where if nurses are well-trained ,there is no reason why they cannot initiate and manage a stable person on ART. Complicated cases can be referred to medical doctors but if we are going to roll out and take services closer to the people, we must involve nurses,” she said.

She argued that bringing nurses on board to initiate patients on ART treatment would increase the pool of skilled health professionals while improving the quality of care that people living with HIV get.

She explained that the nurse-initiated antiretroviral programmes was not unique to Namibia but had been tried and tested elsewhere.

“It is a global initiative that the World Health Organization (WHO) encourages. It falls within the global guidelines for managing people
living with HIV,” she said.

Stressing that population and location are important considerations in the quest for universal access to comprehensive and equitable health care, Zwandor said capacity development and empowerment of every cadre in health was imperative given the widespread shortage of specialized human resources for health in many developing countries.

She was optimistic that the ongoing training of nurses would increase the number of skilled professionals to manage people living with HIV in correctional settings.

“It will make it possible for people who test positive for HIV to be started on ART immediately. We know that the earlier we initiate people on treatment, the better the outcome.”

Right direction

Idel Billah, a medical doctor and the Deputy Director of Clinical Services at I–TECH, also hailed the training as a giant leap in the right direction, saying it would “phenomenally increase” the number of people who can provide expert care to people living with HIV in prison settings.

“The training will boost human and organizational capacity for the NCS to respond to HIV. We are trying to task-shift the job of looking after people living with HIV from medical doctors to nurses.

There are many facilities with inmates living with HIV but not enough medical doctors. It would be good for NCS to have people able to look after such inmates,”
he said.

The trained nurses are expected to support inmates on counselling, HIV testing, initiation on treatment, adhering to treatment and managing complications that might arise.

-Moses Magadza is Communications Officer for the UNODC Regional
Office for Southern Africa.z