Those who are among the most likely to contract HIV are the same people who are most likely to go to prison: young, unemployed, un- or under-educated, black men. This is because many of the same socio-economic factors which result in high risk behaviours for contracting HIV are the same factors which lead to criminal activity and incarceration.

Inside prison, high risk behaviours for transmitting HIV include homosexual activity, intravenous (IV) drug use, and the use of contaminated cutting instruments. Conditions of overcrowding, stress and malnutrition compromise health and safety and have the effect of worsening the overall health of all inmates, and particularly those living with HIV or AIDS. The institutionalised victimisation of younger, weaker prisoners appears to be a direct result of the relatively unobstructed power of gangs, facilitated by corruption within the Department of Correctional Services. Gang activity also increases the incidence of tattooing and violence between prisoners, both of which can create the risk of HIV transmission.

Many governments, with the assistance of international organisations such as the World Health Organisation (WHO) and UNAIDS, have attempted to devise policies to appropriately respond to HIV/AIDS in prison. The practice of mandatory HIV testing and segregation is not supported internationally because it violates the rights of HIV positive individuals and cannot be medically justified.

The importance of HIV/AIDS education has been emphasised by governments and non-governmental organisations alike, although any education programme must be carefully thought out and adapted to the prison environment in order to be effective. Distributing condoms and lubricant is advocated by WHO and UNAIDS although the difficulties in getting authorities to acknowledge homosexual activity in prison has impeded the development of condom policies in some countries. Equally important has been the distribution of bleach and/or needle exchange programmes in those countries where IV drug use presents a problem amongst the incarcerated population.

The challenge of treating HIV in the prison environment is related to limited resources and problems with ensuring the crucially important level of adherence to treatment programmes. International guidelines advocate the ‘equivalence principle’, or the idea that the same care should be provided in prisons that is available to the general public.

Specific health concerns related to HIV/AIDS outside of prison, such as Tuberculosis (TB) and other sexually transmitted infections (STIs), are of particular importance inside prison. Given that the burden of disease amongst the prisoner population is consistently greater than that of the outside community, some governments have opted to make the provision of health services in prisons the responsibility of the department of health, rather than correctional services.

The Department of Correctional Services in South Africa has introduced policies to address HIV/AIDS in prison. These policies have some good features which are implemented extremely well, some excellent features which are not appropriately implemented, and some features which are neither correctly designed nor implemented.

Correct implementation of the HIV testing policy as it is written will improve adherence to the international standard of the equivalence principle. The condom distribution policy would be considerably improved if it were to include the discreet provision of condoms in common areas rather than requiring prisoners to request condoms face to face with a member of the health staff. Furthermore, the provision of water-based lubricant in a similarly accessible manner would reduce the probability of condom breakage and/or rectal tearing, both of which contribute to the risk of HIV transmission.

For prisoners in the late stages of AIDS, the early release policy must be updated and streamlined. Additional assistance for this, and other much needed HIV-related initiatives, can be provided by various NGOs and funding organisations. The Department would do well to encourage and facilitate partnerships with NGOs, including academic and research institutions, in order to understand and provide better solutions to the challenges of the prison environment. Given the very real budget constraints faced by DCS, consolidation and re-allocation of resources, particularly in the form of increased co-operation with the Department of Health, will help make sure that more is achieved for each rand spent.

Recommended HIV/AIDS policies will accomplish little in the absence of basic prison reforms. Overcrowding has adversely affected prison conditions to the point that they are entirely unconstitutional. Anyone who visits a prison or otherwise knows of this situation has the right to be outraged, but the demand for action must be correctly directed as the Department does not determine the size of the prisoner population. Rather reforms in the Department of Justice and Constitutional Development are necessary to reduce prison overcrowding, including addressing the problem of prisoners awaiting trial.

An endemic problem over which DCS has exclusive control is the lack of proper nutrition provided for prisoners. Outsourcing options should be explored, both to provide a higher quality of service at a lower price but also to provide an environment of greater accountability amongst kitchen workers. Finally, allowing greater access to the prison, both for purposes of research and in the interest of impacting policy, is an imperative for upgrading the effectiveness of DCS service delivery.

All but a small percentage of prisoners return to the community. Hundreds of thousands of young men are released from prison each year. Many of these former prisoners are drawn from, and will return to, those communities which are hardest hit by public health issues, including HIV. The impact of this marginalised segment on the rest of the South African population can either be that of positive change or of further hardship. The determining factor will be the appropriate design and implementation of the government’s response to the challenge of HIV/AIDS in prison.