Providing healthcare to a ‘captive’ audience in prison settings should be easy, yet in reality poses a whole range of challenges. So how has MSF in Malawi looked to solve some of them? MSF has been supporting the Malawian Prison Health Service to provide comprehensive health services in two central prisons, Maula (Lilongwe) and Chichiri (Blantyre) since mid-2014.
The three-phase screening model of HIV, TB and primary health care provided is based on the Southern African Development Community (SADC) minimal recommendations for prison settings. The team developed a range of practical implementation tools and standard operating procedures to support this model, which have been documented in an ‘Operational Toolkit’ to help other prisons in Malawi structure their own healthcare response.
The toolkit outlines the core components needed to provide health services: the screening package at entry, stay and exit and the outpatient and disease specific interventions (HIV, TB, STI, nutrition, mental health, and response to physical and sexual violence) provided to inmates. One of the biggest challenges was how to regularly and systematically screen around 2000 inmates for HIV, TB and STIs. For this the team developed a schedule for a biannual screening program, including an innovative re- organization of patient flow for HIV testing allowing them to test larger numbers.
Lack of human resources is always a challenge in Malawi, not least in the country’s prisons. To overcome this the team identified where task-sharing could improve services. Prison wardens have been trained to provide counselling and testing services, and a team of peer educators were trained to work in both the clinic and the cells. Self-identified peer educators – who are prisoners who receive training - are particularly involved in the care of people living with HIV. They provide adherence support, identifying prisoners who are unwell and storing medication for those with no access to storage space, and are also crucial in identifying coughing prisoners who are then referred to the clinic for TB screening.
The team also adapted the ART adherence club model of care to prisons, creating ‘prison ART groups’. Clinical visits are every three months with monthly ART refills. The groups meet to collect their drugs together and provide peer support to each other within the prison.
In such overcrowded conditions, controlling the spread of TB has been a major challenge. Improved diagnostics using GeneXpert MTB/RIF as the first test for all prisoners and the recent introduction of mobile CXR into screening campaigns has improved case detection. Using these strategies, TB case notification increased more than fivefold between 2014 and 2017 in both prisons, and the Malawi team will present their findings at MSF UK Scientific day and MSF Brussels OR day.
However, although attempts to improve infection control have been made by installing roof turbines and early isolation of suspected TB cases, addressing the extreme congestion and living conditions within the cells and expanding systematic TB screening and preventive therapy country-wide to prevent the development of active TB will continue to be a major priority for national advocacy.
As part of their handover strategy, the team will use the toolkit to train healthcare workers in other prisons in Malawi. While the toolkit was specifically made for Malawi, the principles and tools will be helpful for other prison settings in the region and beyond.