KEY POPULATIONS BRIEF

PRISONERS Overview

ver the past several decades, the weakening of Ocriminal justice systems and reliance on ineffective, overly punitive policies have led to the deterioration of prisons globally. This has caused overcrowding and facilitated the spread of infectious diseases such as TB and multidrug-resistant TB (MDR-TB). Prisons are intrinsically linked to communities; thus, the TB and MDR-TB epidemics in prisons have impacted health outcomes in countries where excessive incarceration is prevalent. The inability of governments to address the needs of large prison populations, the lack of financial support and training for prison health staff, and various comorbidities presenting among prisoners with TB make it difficult to deliver effective TB treatment in prisons, cause delays in diagnosis, facilitate rapid spread of infection, and trigger frequent treatment interruptions. The issue of TB and MDR-TB in prisons cannot be addressed without focusing on alternatives to incarceration, promoting the rights of prisoners and prison staff, providing adequate support to health infrastructures within prisons, and working alongside communities and prisoners to provide for more effective rights- based TB treatment and care-delivery models. Global Plan to End TB and key populations / 3 Reach at least Reach countries: all that suggests also Plan The targets. 90-(90)-90 the achieve to countries different allow will that packages investment for models provides and populations” “key TB as risk at or underserved vulnerable, are who to people refers Plan The latest. the 2025 at or by 2020, achieved to be targets following the outlines TB to End Plan Global The Global PlantoEndTBandkeypopulations Achieve at least Achieve at least reach approach, of this apart As 90 90 ( 90 as required as therapy preventive and second‑line therapy—first‑line, on appropriate of them all place and social support. and treatment, correct and toadherence complete treatment services, affordable through TB with diagnosed for people all populations at‑risk underserved, vulnerable, most the SUCCESS TREATMENT POPULATIONS KEY OF THE WITH TB PEOPLE OF ALL % % ) % systems. obligations and reconsider the structure of their their to fulfill governments on calls and TB, with promotesoners, the involvement of prisoners legal solutions for addressing TB among pris clinical operational, to and structural, discuss utilizesThis Guide the above recommendations • • • • provision of TB care in safe environments. safe in care of TB provision the and of services delivery the in ulations of key pop participation active the Ensure population; by key disaggregated are that data using to TB respect with progress on Report treatment; able afford and effective with need in people andproviding case-findingmethods, all tematic screening where required and new sys to services, access improved through least 90% of people in key populations at ofreaching target operational an Set gender-related challenges; to barriers accessing TBparticular care and mates of the risks faced, population size, and subnational levels according to esti Identify their key populations at national - - - - -

4 / Global Plan to End TB and key populations TAKING ACTION TAKING Prison and criminal criminal and Prison justice reform is to fundamental making progress multiple the on health public plaguing issues prisons. global Collaboration staff, prison with increased resources for health care in holding and prisons governments for responsible international their commitments to are health prisoner important. also Meaningful involvement of in TB with prisoners various of design the critical. is strategies - -

Despite calls by UN agencies to consider alternatives to prison global incarceration, increase. to continue populations demonstrate also Countries international for disregard health. prisoner to commitments retributionist Combined with policies in some settings, such growing to contributes disregard TB and MDR-TB epidemics among prisoners. tionately made up of those from from those of up made tionately margin economically and socially Delays in diagnosis and and diagnosis in Delays are treatment in interruptions for experiences characteristic largely are and TB with prisoners caused by poor infrastructures, proper of lack and funding of lack prisons. within management TB dispropor are populations Prison can culture Prison groups. alized vulnerabilities, these exacerbate and behaviours health influencing access to care in prison.

TREATMENT TREATMENT TREATMENT TREATMENT RIGHTS

BARRIERS TO TO BARRIERS BARRIERS TO TO BARRIERS POLICY AND HUMAN HUMAN AND POLICY

SOCIOCULTURAL SOCIOCULTURAL STRUCTURAL STRUCTURAL IMPLICATIONS FOR LAWS, LAWS, FOR IMPLICATIONS

PROFILE EPIDEMIOLOGICAL EPIDEMIOLOGICAL pose globally. MDR-TB challenges challenges while other This section effective TB with TB and RECOMMENDATIONS Recommendations for improving the situation with TB in prisons focus on advocacy for alternatives alternatives for advocacy on focus prisons in TB with situation the improving for Recommendations to incarceration, the documentation of abuses, an increase in the capacities of prison staff, and collaborative activities to improve access to health services during and after incarceration. dire situation situation dire discusses the to timely and to be 4500 of care delivery. comorbidities comorbidities compounding compounding prisoners with with prisoners The number of every 100 000, TB is estimated What’s in this guide? in this What’s Epidemiological profile / 5 4500 of every 100 000, with WHO considering considering WHO with 000, 100 of every 4500 to be estimated is TB with of prisoners number the rapid spread of TB among The prisoners. withtion overcrowding associated facilitate with the ventilation, poor sanitation and nutri exceeded 10% (6) in prisons, 20 countries had HIV prevalence that prevalence HIV reporting of 75 countries a study problem for prisoners around the world (1,5) health amajor –is infection TB latent with uals risk factor for developing TB disease in individ general population the in people for than higher times 26 is tion infec TB alatent having ofprisoners chance the thanhigher in population; the general similarly, times 23 average on prison in disease of TB risk the with of TB, spread to the contributes greatly than double prison capacity (3) more was occupation prison countries, 21 in ity; (>90%) neared capac or exceeded that tion Policy Research, 143 prison reported occupa Criminal for Institute by the surveyed countries of 204 Out prisons. world’s of the majority the in (1,2) year every prisons six times this number passing through the world’s to four with time, any one at institutions penal in Globally, more than 10.2 million peopleare held Epidemiological profile ** Data from a review of studies by Biadglegne, Rodloff, and Sack (1)Sack and Rodloff, Biadglegne, by studies of areview from ** Data (3) Research Policy Criminal for Institute the from *Data SETTINGS COUNTRY PLAN BYTABLE AVERTED GLOBAL CASES TB 1. Russian Federation Bangladesh Cameroon Country Zambia Mexico Brazil . High rates of HIV, combined of HIV, combined rates . High (4) . HIV – the most important important most – the . HIV . Overcrowding is an issue issue an is . Overcrowding Occupancy* Prison Prison 153.9% 125.7% 229.1% 137.7% 94.2% 201% . Overcrowding Overcrowding . Rate in Prisons in Rate TB Prevalence Prevalence TB 2.6¬–64.5% . In . In 13.8% - - - - - 5.9% 3.5% n/a 4% some locales where data are available. in prevalence of TB severity the and crowding over between parallels the Table 1highlights Thailand in 19.5% and MDR-TB Azerbaijan, in strated demon TB with of prisoners 52.3% of cases; 40% in over MDR-TB identified was prisons, Russian in conducted studies six of out five in that, found of evidence review A systematic (9,10) countries some in resistance drug ing demonstrat prison in cases TB of all to 50% have noted been among prisoners ulation pop general the in than greater times 1000 be to found been have ofTB rates prisons, some In epidemic an to be 000 100 per cases 250 (1) (1) . In addition, high rates of MDR-TB rates high addition, . In General Population at the Time of Time at the Population General TB Prevalence Rate Compared to Compared Rate Prevalence TB . Study (fold higher)** (fold Study 42–70 1000 200 20 35 10 (8) , with up , with (7) - - - - . . 6 / Epidemiological profile

------. Studies have shown 17.7 14.8 64.4 as people use who drugs . % of prison population identify who (14–16) risk exposureof TB. to People chargedwith or convicted offences of relatedto drugsconsti that 8.5% TB of infections be can attributed to coun transmission prisons high-income from in tute a large proportion of those imprisoned imprisoned those of proportion large a tute Table (see countries many in trial awaiting or reports, several by one including Similarly, 2). the UN Special Rapporteur on Extreme Poverty underlined the have that Rights, Human and glob imprisoned are people who majority of allyare those who are extremely have poor, the opportunities throughout to access lacked coursetheir of lives, and are the most margin alized those who are at high risk for TB face compet other and employment housing, priorities; ing essential services may be prioritized over access TBto facilities. For example, in Eastern European countries, 60–70% prisoners of do not refer to and prisoners Prisons, release. after facilities TB communities, to linked intrinsically are prison staff impact direct a has prisoners of health the and is There population. general the of health the on countries the in incarceration mass that evidence Easternof Europe and Central Asia has been associated with anincrease in TB prevalencein (21) population general the ------33 65 45 14.3 offence is a drug offence % of prison population whose main is frequently notprotected. (17–20) WHO USE DRUGS*SETTINGS USE WHO Latvia Bolivia Thailand Argentina . They are also more likely be to incar Country Russian Federation Russian The presence other of comorbidities and vul * Data from Global Prison Trends report (7) extremely the and prisoners among nerabilities overcrowd by caused prisons in conditions poor ing in the majority the of world’s locales mean very at high individuals are incarcerated that risk for TB transmission. TB in prisons is also a Despite concern. health public and rights human obligations and international existing multiple agreements, the right prisoners of the to “high men and physical of est attainable standard health” tal Moreover, thereMoreover, are limited effortsconnectto the in services health to prisons leaving those community. People with TB who are released or treatment, completing without prisons from cerated repeatedly and spend to time in pre- their increasing thereby centres, detention trial TABLE 2. PRISONERSTABLE WHOSE MAIN OFFENCE IS DRUG-RELATED OR WHO IDENTIFY AS PEOPLE Sex workers, people who are prosecuted for peo identity, gender or orientation sexual their ple who use drugs, people who are homeless, homeless, are people who drugs, use who ple or people who are otherwise marginalized and burden disproportionate the carry may poor otherof infectious diseases such as HIV and populations these time, same the At hepatitis. due incarceration highest risk of the at are policies retributionist and punitive existing to (11–13) Epidemiological profile / 7 regions are limited or absent. There is a clear aclear is There absent. or limited are regions other in prisons in TB on data researched, better been have Asia Central and Europe Eastern in (1,10,23) HIV with present prisoners are often malnourished and may also ditions that facilitate the rapid of spread TB, con overcrowded severely in custody in held Africa,sub-Saharan where, in addition to being in countries from emerging been has evidence (2,4) world the in largest of the some mer Soviet Union, where prison populations are for of the countries to the challenge particular tries and low-income in middle- tries and 6.3% coun *adopted from Biadglegne, Rodloff, andSack (1) and furthersupplemented FIGURE 1. within the prison system prison the within criminal justice systems justice criminal prisons or poor prison Lack of health care in in care health of Lack Inadequate policies Frequent transfers transfers Frequent Under-resourced (22) health services health . TB and MDR-TB in prisons present a a present MDR-TB prisons and . TB in FACTORS THAT FUEL TB EPIDEMICS IN PRISONS* IN THAT FACTORS EPIDEMICS TB FUEL . Whereas the prisons Treatment delays and . Recent . Recent Long stays in prison Amplification Reincarceration interruptions Overcrowding in prison of TB of - - - throughout this Guide. 1and Figure in discussed as conditions, and tors fac accompanying of other result the are turn (1,8) release upon follow-up mobility of prison populations and the lack of to the due interruptions treatment frequent and delays, treatment infrastructures, health of factors, such as overcrowding, inadequate MDR-TB in prisons results from a multitude The high prevalence and incidence of TB and issue. this to address strategies rights-based and health public both to inform which with data ical empir imperative to generate more high-quality to exit to Portal Prison culture/factors TB in the community the in TB specific to prisoners Transfer to another another to Transfer HIV, Hepatitis, drug drug HIV, Hepatitis, and/or alcohol use prison or release Judiciary system Judiciary . These factors in in factors . These Prison staff Family visit - - 8 / Implications for laws, policy and human rights ------. The fact that . The re-emergence re-emergence The . noted that the majority the of world’s (30) tral to pursuing paying these while alternatives, to tral special attention the to current burden TB of and at public the of health prisoners, the on MDR-TB budgets. national and large, prisoners were “confined in conditions of filth and filth of conditions in “confined were prisoners medical or food adequate without corruption, care, with little or nothing do, to and in circum Prisoner health: an appalling status quo In 1993, Human Rights GlobalWatch’s Report on Prisons stances in which violence from other inmates, their keepers or both is a constant A threat.” decade the 2013 U.S. later, Department State of (31) Conditions Prison International Report on majoritystated: “A the of world’s prison systems do not function at the level the of ’ Standard Minimum Rules for the Treatment of Prisoners. In some countries, relevant interna deliberately are obligations standards tional and report The universal highlighted disregarded.” prison of lives and health the threatening issues san of lack overcrowding, prison populations: denial of and facilities, medical and/or itation (31) prisoners to care health TBof and the rapid spread in pris MDR-TB of ons across the world recently ledseveral human rightsbodies express to their grave concern over question to and prisons world’s the of state the interna meets prisoners of health the whether (32) standards rights human tional tis and mental health conditions. Studies have prevalence C hepatitis globally that estimated highest prevalence 26%, with is prisoners among these standards are not observed is one of the the of one observed is not are standards these epidemics prisons within TB and of drivers key globally. communities plagued are prisoners HIV, and TB to addition In hepati ailments, viral including variety of a by . ------(2) . Policies Policies . . About. one and theUnited , have called for , but evidence is (28) . The financial and and financial The . . Still these policies remain, along Still . . Experts attribute the population growth growth Experts population . the attribute (7,25–27) with others that target those who are already and addition, under-resourced In marginalized. con systems poorlyjustice regulated criminal However, this increaseHowever, has not been reflected in been declining have which seriousrates, crime (24) that philosophies retributionist the to prisons in guide many policy makers. Such policies are based on the demand for harsher punishments in response violence to (24) does lit incarceration on reliance emerging that tle reduce to or prevent violent crime (7) imprisonment and prosecution the on focused crimes, drug-related for offenders low-grade of individuals based of on criminalization the and have identity gender and orientation sexual their been contested multiple by global stakehold ers tribute both to delays in sentencing and oversen (7)offenders nonviolent of tencing population prison million 10.2 world’s the of third is in pre-trial detention, with some awaiting trial for up four to years (7,15) UN and society civil and organizations ceration, bodies, Nations Agency United the including on Drugsand Crime (UNODC) There are numerous additional negative social, numerous social, additional negative are There impacts mass cultural and incar economic of societal costs associated with imprisonment are increasingly are governments and tremendous, budget overcrowding, prison with struggling and health, prisoner declining overburdening, ratio. prisoner-to-staff the in imbalance an countries seek to alternatives imprisonment. to on impose prisons that costs the Considering cen be could argument economic societies, an Nations Office of the High Commissioner for for Commissioner High the of Office Nations Human Rights (OHCHR) (29) ing consistent growth for the last decade decade last the for growth consistent ing World incarceration rates have been experienc have rates incarceration World Overuse of imprisonment of Overuse Implications for laws, policy and human rights human and policy for laws, Implications Implications for laws, policy and human rights / 9 • • on the organization of prison health”, 2013) (36) brief Apolicy century. 21st the in health prison for nance for prison health (from “Good governance oped the following principles of good gover devel have UNODC and WHO prisoners, for care stakeholders devise policies for providing health society civil and governments to help order In of detention. places in epidemic TB the halt to difficult extremely be will governments take these obligations seriously, it (35) health to prisoner of countries tions the obliga mental underlined also has health standard of attainable the highest physical and of enjoyment to the of everyone right the on (19) of Treatment Prisoners the for Rules Minimum (20) of Treatment Prisoners the of Principles Basic the on Resolution Assembly’s and Cultural Rights (17) International Covenant on Economic, Social, (34) Rights Political and Civil on Covenant International by the notably most obligations, of international arange under protected is ers of prison to health right The prisons. in services health to adequate access to maintain resources of lack resulting the and above described policies poor by the on brought again is situation critical prisoners than in the general population (11). among higher times to 10 up of suicide rates among prisoners have also noted, been with (33) among prisoners in Central Asia and Australasia . A report from the UN Special Rapporteur Rapporteur Special UN the from . Areport . Disparities in the rates of mental illness illness of mental rates the in . Disparities general population. and noncommunicable diseases than the acarry higher burden of communicable and community of the segments vantaged Prisoners mostly come from socially disad else. anyone as wellbeing and Prisoners have the same rights to health , and the UN General General UN the , and and Standard . Unless . Unless , the , the This This - - - - - : below. described and sociocultural barriers structural the of some address to help can offenders, level low- target that policies punitive of the some ing as to wellAdhering asprinciples, eliminat these • • • • • • fessional development of health care staff. including in regard to the training and pro into and national policies health systems, integrated be should services health Prison them. with effectively liaise pendent of prison administrations and yet Prison health should services be fully inde prisoners. of punishment the in involved be never must and prisoners for to care exclusively Prison health should services be provided community. the in services health nical standards to to applying those public equivalent ethical professional, and tech of least at be should services health Prison contacts. social and ity heating, lighting, ventilation, physical activ space, catering, to hygiene, respect with measures or inadequate prison conditions oners caused by inadequate health care all to avoidable impairments health pris for accountable are They prisoners. for care of duty sovereign aspecial, have States TB. or HIV as such diseases communicable with regard especially health, to tackling for challenge publicplex and difficult acom present they outside, communities their inhabitantschange between and inter a constant is there Because ease. of dis risks high with settings are Prisons ------10 / Structural barriers to diagnosis and treatment ------. In . . These . . The. use portable of . The lack resources of (11,41) . be completely out of reach. Reports from some overcrowded severely depicted have prisons facilities where prisoners are locked up in cells for 23 hours per day; this increases the oppor transmission the eliminates and TB for tunities lack a to due all – possibility circulation air of staffof and resourcesto maintain such a large (38) population prison with deal to workers health prison among ness health crises such as TB and higher MDR-TB, cohe poor to leading ratios prisoner-to-staff other many and populations, prison of sion issues that may prevent effectivecase-find ing and patient-centric TB treatment delivery (11,39,40) also results in poor health care infrastructures poor healthalso results care in prepared and training prisons,within of lack and other creative methods need be to tested for not are recommendations WHO settings where technolo new addition, In implemented. easily gies must be urgently developed improve to and simplify diagnostics. and affordable radiography has proven effec proven has radiography affordable and low-resource settings with high HIV prevalence, researchers have also found that low body mass reliable infection, are chest pain and HIV index, (43) populations prison in TB of predictors phy, tuberculin skin tuberculin (TST) testing interferon and phy, combina a or (IGRA), assay release gamma tionthese of methods tive for rapid TB detection and TB prevention in other resource-limited environments (42) ------. However, even such . However, . Active case-finding should occur . Since TB is spread through the (37) . This issue is universal and found in high-, Delayed diagnosis and logistics at intake and housing and intake at logistics and diagnosis Delayed things other among TB prison Addressing requires aggressive case-finding. Case-finding increased number an improved requires and capacity prison of medical staff, andcommit both at initial prisoner intake and throughout the prison period, time which during incarceration screen TB undergo regularly should populations ted effortsby prison authoritiesto prevent the spread TB of in prisons. WHO recommends two active prisons: in case-finding to approaches and passive (11) exam medical a prisoner initial intake, At ing. respectful is that of conducted be should ination a includes and incarcerated being individual the screenusing questionnaires, TB radiograchest crowded and lack adequate health resources resources health adequate lack and crowded (37) mid In countries. middle- low-income and of lack this countries, low-income and dle- resources, might be so however, drastic that even prisoners’ basic needscannot be met, which has serious a impact on individuals’ health outcomes trol inside prisons include a decent level air of through achieved be could which circulation, (11) ventilation improved As detailedabove, prisons arenotoriously over some elementaryair, measures for TB con Lack of resourcesLack of and poor infrastructures measuresinstalling and opening as windows exhaust fans might be difficult to implementin settings, of installation the and low-resource could devices germicidal irradiation ultraviolet Structural barriers to diagnosis and treatment and to diagnosis barriers Structural Structural barriers to diagnosis and treatment / 11 FIGURE 1. (11) prisoners of all health the protect prison authorities to fulfill their obligation to enables astrategy Such peers. their from TB the general prison population from contracting and treatment, on initiated be may who TB, aration protects both prisoners with possible sep temporary HIV. with This living are who ulation and especially from those prisoners pop prison general the from separated be TB suspected with prisoners intake, at that, mend (11,44) agencies other and WHO

detainee Pre-trial PRISON SYSTEM PRISON et al. (22) article) al. full et for MAP OF SCREENING AND REDIRECTING PRISONERS WITH TB ACROSS MONGOLIA’S MONGOLIA’S ACROSS TB WITH PRISONERS REDIRECTING AND SCREENING OF MAP 1 Screening Detention detention centre on

(see Yanjindulam P, Oyuntsetseg P, Sarantsetseg B, Ganzaya S, Amgalan B, Narantuya J, J, Narantuya B, Amgalan S, Ganzaya B, P, Sarantsetseg P, Oyuntsetseg (see Yanjindulam Sentenced prisoners also recom . A recent . Arecent 2 - - - Screening allocation hospital general Prison available. always not are that resources requires a model such that noted 2). be However,Figure should it (45) hospitals to prison-based TB with and isolation, and the redirection of prisoners of screening aprocess through half than more by prison in rates notification TB cut country the period, anine-year over prison; in of TB trajectory the on impact asignificant had TB withtial of and screening separation prisoners that the demonstrated ini instudy Mongolia on

TB patients Without TB Without 2) Patient transfer 2) Patient 1) Sputum referral 1) Sputum Female TB patients TB Symptomatic 4 Prison TB hospital 3 Women’s Women’s Prisons prison (see also - 12 / Structural barriers to diagnosis and treatment ------. When people with . Interruptions and nonadherence nonadherence and Interruptions . . Former prisoners might not want . If the imprisoned individual with TB TB with individual imprisoned the If . As mentioned, populations that are susceptible susceptible are that populations mentioned, As TBto might also be at higher risk imprison of ment. At the time arrest of and detention, some be incarcerated to about individuals are who might have already been receiving treatment receiv while Similarly, community. the in TB for ingtreatment in prison, range a punitive of and/ confine solitary as such measures, logistical or ment, transfers between prisons and jails, and other practices might interfere with treatment (1,11,22,39) is also using drugs, provide it to is key substi tutiontreatment in order ensure to adherence. such treatmentHowever, is often unavailable (13) prisons in are also sometimes the result prison of culture sociocultural(see factors Nevertheless, below). com of lack and negligence, logistics, prison mitment improve to conditions and careby precedence take staff and authorities prison over these other factors (1) TB are released from prisons, their treatment regimen might also be interrupted and might where communities the in unavailable be even they live (39) pursueto treatment for a variety of reasons; authorities health to them connecting however, the supportive in and society civil organizations community is extremely important for facilitat success. and continuation treatment ing Treatment interruptions Treatment ------. Not. following (40) . It is clear that neither . This methodology is chal is methodology This . , nor should they suffer undue undue suffer they should nor , . (39) approach succeed can without the involvement themselves. prisoners and staff prison both of lenging, however, because it relies on prisoners prisoners on relies it because however, lenging, self-reportto symptoms. While prisoners might abil issues, their health report their to eager be ity doto so sometimes depends ontheir stand ing within the prison The hierarchy. seriousness with which their concerns are taken also can attitudes and professionalism the on depend prisonof health staff (11) Passive case-finding should occur through pris through occur should case-finding Passive gate prisoners by the nature of their crimes, crimes, their of nature the by prisoners gate not public by health directives. Keeping people requires incarcerated while separate TB with prison and prison from commitment strong a and examination health authorities. initial The discussion with prisoners at also intake can help establishto whether they have been obtaining TB treatment in the community and therefore stron Thus, regimen. their with continue should community and between prison linkages ger required are healthfacilities these simple steps often can result in lengthy sometimes can which diagnosis, TB in delays lead massive to outbreaks in the general prison (46)population onerself-referral prison to health units and the prison at present who prisoners all of testing health centres with concerns that could indicate (11) diagnosis TB a discrimination on the grounds of their health health their of grounds the on discrimination make often constraints existing However, status. it difficult to implement this simplestep. Finding prison overcrowded in challenging is space extra segre correctional and environments, facilities This separation should course of not equal pro longed isolation; prisoners undergoing evalua undergoing prisoners isolation; longed tion for TB should not be spending time in Sociocultural barriers to treatment / 13 with TB who also present with other conditions. conditions. other with present also who TB with (39) other comorbidities are faced and interactions of side witheffects medications enduring various and TB with prisoners while treatment, to triaging regard with decisions to make need authorities (4) HIV and hepatitis viral including comorbidities, of other a variety with present often prisons in TB with People Other comorbidities Sociocultural barrierstotreatment . These challenges cannot be overlooked, and adequate must support be provided for prisoners . This presents challenges for both prison health staff and prisoners with TB. Prison health 14 / Sociocultural barriers to treatment . . . ------(55) (53,54) . Alternatives to and sole provid sole and For example, female (52). . There is also evidence that the health . These phenomena need be to taken into . Considering that the majority of women women majority of the that Considering . In some prisons where TB programmes are with prisoners and funded, better be to known are or benefits nutrition additional receive TB pris some hospitals, TB in-prison to relocated close the promote to need agencies and account, education and intake observation medication of unfinished of dangers the on prisoners among treatmentand developingof resistance if erro in prison are mothers (48) keepers for access medical to and other ser vices and might use this accesscoerce to those who are considered lower of standing (39,47) oners may wish TB symptoms fake to and swap transfer to order in diagnosis ensure to sputum locations appealing more seemingly these to (39,40) treated. repeatedly or neously Easternof Europe and Central Asia, are incar offences drug-related nonviolent for cerated (7) ers,the overincarceration women of poses an broken to leads and burden societal additional are prisoners female among TB on Data homes. lacking.a study in However, Brazil found that time in imprisonment increased risk women’s TBof (51) of female prisoners is often ignored weak by infrastructures prison wherein “senior” prisoners might act as gate act as might prisoners “senior” wherein of levels reported lower Zambia in prisoners TB testing than their male counterparts and a needs health their for disregard general These experiences are thought be to common (7) globally prisoners female for services are gender-specific and incarceration underlined in the UN Rules for the Treatment of Measures Non-Custodial and Prisoners Women Rules) Bangkok (the Offenders Women for These rules should be adhered to when consid when to adhered be should rules These ering policies targeting female offenders female and ering policies targeting prisoners. female services for devising . - - - - - It has . A high. proportionwomen of . According the to UN Division Research has shown that female . The highest levels of imprisonment (49,50) (48). (7) . Moreover, the majority of female prisoners prisoners female majority of the Moreover, . prisoners have experienced multiple forms of of forms multiple experienced have prisoners marginalization poverty and abuse, oppression, (7) motivated crimes nonviolent committed have (7). situation financial their improving by also been documented that the overwhelming majority those of women who have committed violent crimes have themselves been victims of extreme violence or have committed the crimes in response systematic to abuse and domestic violence Women in prison in Women women, are prisoners world’s the of 6.5% to Up and this figure represents a five-fold increase 15 last the over populations prison female in years across all regions, and especially in the region Prison culture and hierarchy and Prison culture While research few reports have addressed these issues, it is evident that the hard culture of cer in engage to prisoners drives prisons many tain behaviours that might interfere with even the mostefficient of TB programmes. Considering that TB interventions are already fragile in the hierarchy and culture prison prisons, majority of seriously theseactivities. interferewith might The existence informal of markets in prisons has been well documented. TB medications might on prisoners when market this part of become TB treatment start feel to sufficiently better from or circumstances medications, and/or receiving them force hierarchy prison the in standing their (22,39) medications their selling trading or into Informal and anecdotal reports have also high functioning prison the hierarchies of lighted of womenof have been noted in Eastern Europe and Central Asia, while levelsare above aver age in Latin America and south-eastern and and south-eastern and America Latin in age eastern Asia (7) for the Advancement Women, of racial minori “represent women indigenous including ties pop prison the of sector growing fastest the ulation” Taking action / 15 in community health systems. systems. health community in treatment receive would rather but ventilation, no with spaces overcrowded into crammed be longer no would who TB, with of people ment significantlyalso aid in and the treat diagnosis (28) communities into tion incarcera for destined ofpeople integration significant savings andencourage thebetter community schemes that supervision produce and of establishment the in result and policies sentencing and of laws review the with begin that to imprisonment alternatives mends recom UNODC persist. will of detention places violent offenders in prison, the issue of TB in sions to the strict penal codes that put non in prison conditions globally and without revi improvements overall without that, clear is It improving conditions in prisons Advocating for and Taking action rary shelter and nutrition (56) rary tempo as services essential such provide also prisoners and provide treatment can support former with work that organizations Community ensuring treatment adherence and completion. oners to community organizations is essential to another. Furthermore, connecting released pris to location one from TB with individual the with tem and creating medical records that can move strengthening connections within the prison sys on to focus essential is it Thus, programmes. success of prison TB prevention and control key is to the of treatment continuity Ensuring of treatment continuity Ensuring needs ofneeds newly prisoners (40,56,57) released incarceration the and understand might better experienced have who people themselves are who workers peer engage also might nizations . These schemes could could schemes . These . Community orga . ------Human Rights for Court European by the made decisions tive posi by several exposed been have infection, TB rampant includes which of prisoners, ment conditionsdecrepit prison and treat inhumane tion of TB while incarcerated (58,59) terrifying conditions that facilitated his acquisi the to light brought has Africa South in authorities ofcourt victory a former prisoner over prison and A international human rights mechanisms. country through cases filed have groups rights several former by prisoners supported human prison, in of TB issues of the To awareness raise Taking action legal and prison systems to take action. governments on pressure to put help cases these TB, by affected person the for gain a direct ing (60) . While not always represent always not . While . Russia’s . Russia’s - - - - 16 / Taking action ------

. In addi . Some prison prison Some . . Prisoner edu Prisoner . . Implementers, how

ever, warn that educationalever, and empowerment misunderstand no leave should programming ing as the to dangers interrupting of treatment, faking TB illness or engaging in other strategies circum the to due consider prisoners might that stances their of environment (39) society civil organizations allowed have systems models Such prisons. in prisoners with work to may be even more effective, as they function through peer networks and thus foster can trust prisoners. among adherence better and tion, training and other educational activities educational other and training tion, forprison staff may serve as incentive/encour agement make to difficult circumstances more pro other to linkages provide and manageable support. for settings prison in working fessionals ration with prisoners in the implementation TB in engagement prisoner and activities screening health service delivery are the to keys success of (11,39,64) prisons in programming TB Providing education and training for prison staff, staff, prison for training and education Providing as well as creating a staff “buy-in” collaboon Training and fostering collaboration with with collaboration fostering and Training staff prison cation and the involvement of prisoners in devis in prisoners of involvement the and cation TB to related campaigns health information ing have also been noted as effective and produc (39,63) methodologies tive grammes involving prisoners, at least two prison prison two least prisoners, at involving grammes “incarcerated reported engaging have systems health workers” as peers who are trained much like community health workers supervise to (40,61,62) prisons in treatment As with other communities, including and and rights their know to prisoners empowering engageto in TB prevention and treatment is essential prison to TB control. While there are few documented examples successful of pro Including and empowering prisoners empowering and Including Recommendations / 17 treatment of TB in prisons. prisons. in of TB treatment of new diagnostics and other technologies that can accelerate and facilitate the detection and public and private should take partners note of recommendations that concern the development addition, In prisoners. for care and treatment prevention, TB improving in use for potential their assess and take note should collectives, worker health global and local and Agencies UN including While these recommendations provide an outline for action for a range of key stakeholders, others, Recommendations prisoner health; prisoners that impact against violations responsible for governments litigation to hold strategicPursue prison health services; organizations and prisoner collectives/ organizations, society civil between Foster relationships prisoners; prisoners and former for makers policy to access promote TB; to vulnerable be might who offenders especially for nonviolent incarceration, to alternatives for Advocate Civil Society Civil of neglect; cases in systems prison against cases bring to collectives legal and human rights groups obligations; work with international to accountable governments hold of prisoner rights and Document violations community; the in services health to systems health connecting prison interventions better all prisoners and for for services health to access for Advocate stories; prisoner tell to makers policy access TB; with prisoners of lives the of incarceration on impacts the Document Prisoners with TB with Prisoners Former and Prisoners of Organizations health; obligations on prisoner Adhere to international involvement of civil society; society; civil of involvement with the authorities health between prison and facilitate collaboration creative approaches; other using and staff byrotating delivery service models for prison health cost–effective develop prisons; all in well-staffed are and fully functional Ensure that health facilities for nonviolent offenders; alternatives to incarceration criminal justice reform and consider society; on TB public health burden of Reduce the economic and Governments guidelines; with international adherence in are programmes that obligations; support international to adhere to governments pressure to society civil and work alongside violations in prisons documentation of Support programming; TB and services health jump-start prison initial funding to prisoners; provide for care health to increasing access for models effective Promote cost– incarceration; to alternatives at targeted reform reviewpolicy and Fund programming, Donors 18 / Recommendations Donors Help governments sustainable devise providing for plans TB treatment in promote and prisons, diagnosis of models and treatment that continuity maintain and are effective; Support and Support and disseminate results of programmes that effectively empower and prisoners involve civil society in the design and of implementation post- and prison release TB treatment programming; Fund research that can produce data to improve interventions. Governments Ensure that there are resources adequate dedicated to TB treatment in prisons, that staff are trained, adequately resourced and supported, and that there are systems in place for testing providing for and prisoners treatment; of continuity Work with civil society to ensure their involvement programming prison TB in and to create linkages to supportive treatment in the community for released prisoners; Encourage multi-sector multi-sector Encourage conduct to collaboration research on health and prisons in conditions produce data that can be sectors. across shared Organizations of Prisoners and Former Prisoners with TB Advocate for system- for Advocate wide improvements of in care TB and medical prison; Work at the community level to create safety being people for nets prison, from released who might need supportive treatment; advocate for access to prisons, where peer prisoners support for with TB is essential; Support health Support health research among improve to prisoners understanding the of how to increase the effectiveness of interventions. Civil Society Advocate for financing adequate health prison for care; use resource advocate shortages to for alternatives to imprisonment; Advocate for access of civil society work to organizations prisoners; with Promote independent independent Promote research to encourage the documentation of prisons. in conditions References / 19 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References

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Cover Layout Stop TB Partnership TB Stop Main Writers Main The Stop TB Partnership acknowledges with gratitude everyone’s contribution. thank We each of them for together. this implement to hope we support and and feedback enthusiastic their Acknowledgements Contributors - - Contributors Participants of the TB Key Workshop Populations 2015 November 23 the Global Fund to Fight AIDS, TB &Malaria. TB AIDS, Fight to Fund Global the from received support technical and acknowledges with gratitude the financial Partnership TB Stop The Chemin de Blandonnet 2, Geneva, www.stoptb.org 1241 Vernier 1241