Lessons in perseverance and a common vision
Port au Prince’s National Penitentiary was built with 800 inmates in mind. But between 2006 and that fateful Tuesday evening in January 2010, the central prison’s population had risen to more than 4000. There, and in seven other prison facilities, the tremour left fractured walls and bewildered guards in its wake. Almost all the prisoners escaped.
As far as setbacks go, this one was major. A team had been working on developing an HIV response in Haiti’s prisons as part of the country’s 2008 – 2012 National Multi-sectoral Plan on AIDS. Prisoners are more vulnerable to HIV everywhere. In Haiti the situation was compounded by a spike in arrests due to intensified law enforcement, the sluggish judicial system and a limited healthcare in the penal system.
In 2008 the Joint United Nations Programme on HIV/AIDS (UNAIDS) commissioned a study on the status of tuberculosis and HIV in Haitian prisons. Implemented by Panos, the research presented the views of a wide range of partners. It found that non-action regarding HIV had resulted in far more than frustration. For instance higher degrees of risk and lower access to prevention and treatment services led to an estimated HIV rate of three percent in the central prison. (Haiti’s national adult HIV prevalence is 2.2 percent.)
After consultations with key partners such as the Penitentiary Administration, MINUSTAH Corrections Unit, Red Cross International and Office for the Coordination of Humanitarian Affairs (OCHA), UNAIDS partnered with Health Through Walls (HtW) to introduce the first HIV Peer Education program in a Haitian Prison in 2009. (HtW is an NGO that has been engaged in the delivery of health care in Haiti’s prison context for more than 15 years.)
The model was adapted from a successful program implemented in the United States in the Florida Department of Corrections and sponsored by the Florida Department of Health. There were tricky issues to address. These ranged from how risk would be managed in this sensitive environment to how patients in need of treatment would be helped with limited budget and no access to a laboratory.
65 peer educators were trained by Health Through Walls to address the taboo topic of HIV in the penitentiary. Follow up care and support was assured through the support of the United States Agency for International Development (USAID), GHESKIO and the United Nations Development Programme (UNDP). The support of the Department of Penitentiary Administration of the Ministry of Justice was instrumental in getting started and in expanding the programme to the female prison as well as the 30 staff members of the National Police of Haiti who were trained by the MINUSTAH HIV Unit.
Despite positive feedback from the first crop of inmates it wasn’t all smooth sailing. Buy-in was slow and for a while collaboration with the administration was crippled by the absence of a Medical Director of the National Penitentiary System. Funding was not sufficient to completely cover the cost of logistics for the facilitators, and implementers had to mobilise more funds and bring along other partners in order to develop creative solutions to complete the programme.
Then the earthquake came. Not only did all the trained prisoner peer educators escape, but a health facility that the penitentiary had nearly completed with support from partners came down, wiping out the progress made toward bringing health to the penal system.
Since then the programme has steadily regrouped. The strategic choice of partners to ensure healthcare delivery within the prison context was critical. Both HtW and MINUSTAH used facilitators who were HIV positive, had prison experience and spoke creole. In terms of peer educators, the programme selected inmates who were influencers in their cell. The majority had already been sentenced. This meant that they would remain in the system for a sufficiently long time to ensure the stability of the programme. The trained prisons officers are expected, in turn, to train others.
Also key was the consensus to take measures that could prevent people living with HIV in prison from dying of tuberculosis. UNAIDS Haiti Monitoring and Evaluation Advisor, Kate Spring, noted that the sustainability of the effort relies on on-going commitment and ownership by the penitentiary administration.
“The elements of the programme could be developed within a framework sensitive to the requirements of the administration of the system, staff and inmates,” she noted. “Already the National Director of the penitentiary system has aligned partners to a vision for improvements in the penal system with time bound interventions.”
She added that while the transient nature of life in the prison posed some challenges to the programme, it could also lead to positive impacts for the wider society.
“If 95 percent of people who pass through the system have short-term stays, this programme can be strategic to provide inmates—most of whom come from economically disadvantaged households—with the knowledge and skills to negotiate and preserve health when out of the system,” Spring said.
Male inmates commit to ending AIDS in prison (Credit: UNAIDS Haiti)
A prisons officer opens World AIDS Day 2011 commemorations in the female penitentiary. (Credit: UNAIDS Haiti)