Abstract
Abstract
Objective
Malawi’s prisons are overcrowded, contributing to tuberculosis (TB) and Human Immunodeficiency Virus (HIV) transmission and service delivery gaps for both conditions. We applied an empirically supported three-stage model of HIV/TB care to guide the improvement of TB/HIV service delivery in select Malawian prisons.
Design
We conducted a pilot implementation research study using multimethods from May 2022 to April 2023.
Setting
Two semi-urban prisons in Malawi.
Participants
We purposively sampled participants detained at the study sites during the study period.
Methods and intervention
We collected data on sociodemographics, medical history and screening results for sexually transmitted infections (STIs), HIV and TB results. We conducted in-depth interviews with prison professional staff and used content analysis to explore the feasibility of implementing the three-stage model of HIV and TB care in Malawian prisons.
Results
Mean participant age was 35 years (SD 12.2 years). We screened 100 out of 647 (15%) incarcerated people for TB/HIV according to the three-stage model and identified the following: five cases of TB disease; two cases of HIV-associated TB; seven persons living with HIV; eight persons diagnosed and treated for STIs, including genital ulcer disease and syphilis. For those tested for HIV at entry, midpoint and exit screening, there was no documented case of seroconversion during the incarceration period. There was evidence of potential STI transmission during incarceration, as suggested by a 4% rate of new urethral discharge among participants. Qualitative data suggest that it is feasible to implement the three-stage model of HIV/TB in the Malawi prison setting.
Conclusions
We found evidence of HIV, TB and STIs among incarcerated people in two semi-urban prisons in Malawi, with low HIV status awareness on prison entry. It is feasible to implement the three-stage model of HIV/TB in prison settings, although with material support to overcome implementation challenges. Coordination with Ministry of Health officials could facilitate model feasibility and sustainability in Malawi’s prisons.
Keywords: prisons, feasibility studies, health, HIV & AIDS, public health
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The study contributed to the development of targeted strategies aimed at reducing the burden of HIV and tuberculosis (TB) faced by incarcerated people in Malawian prisons.
All incarcerated people recruited in the study voluntarily consented to HIV, TB and sexually transmitted infection screening.
The study employed a descriptive design using multimethods.
Only 100 of 647 (15%) incarcerated people identified at the study sites during the study period were included, limiting the study’s generalisability.
We introduced the three-stage model of HIV and TB care, but could not implement nutrition aspects of the model due to inadequate resources.
Background
Incarcerated people are disproportionately affected by tuberculosis (TB) and HIV in sub-Saharan Africa (SSA). In some prisons (used here to refer to any jail, prison, correctional facility or other closed setting) in east and southern Africa, the prevalence of TB has been reported as high as 5.3%, several fold higher than the prevalence in the general population.1 Similarly, the prevalence of HIV infection among incarcerated people was 15.6% (95% CI 11.8% to 19.8%) in east and southern Africa and 8.2% (95% CI 6.2 to 10.5) in west and central Africa, suggesting a higher prevalence of HIV in prison populations than in non-incarcerated populations.2 Poor living conditions in prisons perpetuate TB and HIV transmission, morbidity and mortality. Overcrowding, poor ventilation, HIV, poor nutrition and late case detection facilitate TB transmission, morbidity and mortality.3 4 Sexual violence, sharing of sharp objects and lack of access to condoms increase the spread of HIV.3 4 Additionally, incarcerated people often come from socioeconomically disadvantaged backgrounds where TB and HIV are more prevalent.2 The extant literature suggests that TB and HIV infection are prevalent among socioeconomically disadvantaged individuals due to factors like poverty, poor access to healthcare and limited resources.5 This makes disadvantaged populations more vulnerable to both HIV and TB.
TB constitutes a threat to both incarcerated people and the community at large.3 Various factors have contributed to the challenges of TB control in prison facilities in SSA,3 including Malawi. These include: poor or lack of TB screening and diagnostic tools; poor prison infrastructure; uncoordinated and unsupervised prison health services; weak prevention and treatment interventions for HIV and inadequate funding from the government and partners to the prison facilities, which stems from lack of political interest regarding prison conditions and the welfare of incarcerated persons.6
TB is preventable and curable. A range of evidence-based interventions (EBIs) have been recommended by WHO7 to prevent, treat and mitigate exposure to the disease in incarcerated and general populations. These interventions include entry and exit screening for all incarcerated persons, self-referral to care for incarcerated people with TB symptoms, early diagnosis, humane isolation of persons with TB disease, provision of directly observed therapy, provision of information and education on infection control to reduce transmission and mass screening if there is an increase in TB incidence.8 Despite the availability of such interventions, TB is one of the most significant epidemics faced by incarcerated people globally, particularly in low- and middle-income countries, including those in SSA.9 The rising rates of TB are associated with an increasing prevalence of drug resistance and mortality, which has implications for the health of incarcerated people, prison staff and the community.9
Another factor that contributes to increasing rates of TB in SSA prisons is the disproportionate burden of HIV in prison settings.10 11 HIV is a major TB risk factor. People living with HIV (PLHIV) have a 20 times higher risk of developing active TB during their lifetime than people without HIV.7 In SSA, the region most affected by HIV, extraordinarily high rates of HIV have been documented in prison populations,2 including the populations of South Africa (41%), Côte d’Ivoire (27.5%) and Zambia (27%). Limited data are known about HIV prevalence in Malawi’s prisons, with the most current studies completed >10 years ago. In 2012, the prevalence of HIV in Malawi prisons was higher than the general population, at 40% vs 12%, respectively.12 TB disease in PLHIV also portends a worse prognosis, with HIV-associated TB having increased mortality compared with TB without HIV co-infection.13
One critical yet frequently under-reported issue within prisons is the prevalence of sexual violence,14 15 which significantly elevates the risk of transmission of sexually transmitted infections (STIs), including HIV.15 Evidence from a study conducted in Thyolo district, southern Malawi, underscores this concern: 4.2% of male incarcerated people were diagnosed with an STI, and notably, 28% of these cases were incident infections likely acquired within the prison environment.15 Among these infections, genital ulcer disease was the most prevalent, accounting for 52% of all diagnosed STIs, which is particularly concerning given its role in facilitating HIV transmission.15 Zachariah et al15 argue that a substantial proportion of STIs among incarcerated people are contracted during imprisonment, emphasising the urgent need for comprehensive and effective STI screening and treatment programmes within correctional health services. In response to this, STI screening was integrated into HIV/TB care to enhance early detection, treatment and prevention of STI transmission among incarcerated individuals.
The three-stage model of HIV and TB care in prisons is a package of EBIs for use at ‘entry’, ‘stay’ and ‘exit’ in prisons to prevent, screen and treat TB and HIV among incarcerated people.16 The model aims to address the high prevalence of both conditions within incarcerated populations. Literature defines ‘entry’, ‘stay’ and ‘exit’ as follows: entry screening for HIV and TB is conducted on an incarcerated person’s admission to the prison. This may include TB symptom screening, X-ray, C reactive protein and HIV testing. During the incarcerated person’s time in prison (stay), ongoing monitoring and treatment are provided, including antiretroviral therapy (ART) for those with HIV and TB treatment for those diagnosed with active disease. Lastly, prior to prison release (exit), efforts are made to ensure that incarcerated people are linked to care in the community and have access to continued treatment and support for TB and HIV.16 There is evidence that using this model will improve the timing of activities for TB/HIV care and enhance the delivery of comprehensive provision of TB/HIV care to incarcerated people at entry, stay and exit.16 The utilisation of the three-stage model of TB/HIV care has been shown to be effective in TB/HIV screening and treatment in Malawi’s two central prisons, namely Maula and Chichiri prisons.16 However, it is unknown if this EBI is feasible and acceptable for lower-level prisons in Malawi.
In this study, we implemented the three-stage model of HIV and TB care in two district-level prisons in Malawi and collected data aligned with the three phases of the model, namely at ‘entry’, ‘stay’ and ‘exit’ for incarcerated people. In each phase, we assessed changes in HIV and TB screening and treatment according to implementation of the three-stage model.17 Using these data, we describe the feasibility and acceptability of replicating the three-stage model in less-resourced, semi-urban incarcerated settings in Malawi following Standards for Reporting Implementation Studies checklist (see online supplemental additional file).18
Methods
Study design
This study employed a multimethods approach17 to assess the burden of HIV and TB among incarcerated people and to evaluate the feasibility of implementing the three-stage model of HIV/TB care within prison settings. Quantitative data were collected through structured questionnaires to identify socio-demographic characteristics and risk factors related to HIV and TB, offering insight into the epidemiological profile of the prison population (see online supplemental additional file). Laboratory methods complemented the clinical screening process: all participants underwent HIV testing in accordance with Malawi national guidelines, and individuals with presumptive TB symptoms provided sputum samples for GeneXpert MTB/RIF (Xpert MTB/RIF assay; Cepheid, Sunnyvale, California, USA) testing for microbiological TB diagnostic testing. In parallel, qualitative data were collected through in-depth interviews with prison staff using a guided interview tool, aiming to explore their perceptions of the acceptability and feasibility of implementing the three-stage model of HIV and TB care encompassing screening, treatment initiation and continuity of care during incarceration and postrelease. This multimethods design allowed for a comprehensive understanding of both the health needs of incarcerated people and the practical challenges of delivering integrated health services in correctional settings.
The study was conducted in three phases: the ‘entry’, ‘stay’ and ‘exit/postscreening’ stages of incarceration. During the ‘entry’ phase, a quantitative survey design was used, while the ‘stay’ and ‘exit/screening’ phases employed a single-arm prospective cohort study.
Study context and site
The study was conducted in two semi-urban prisons in Malawi’s central and northern regions. The two prisons together had a total capacity of 400 incarcerated people, but detained an average of 830 persons during the study period. One prison facility had a medical examination room, a counselling room and one extra room for history taking. The clinic was staffed by two nurses, two prison staff working as HIV testing services (HTS) counsellors and one male incarcerated person designated as the Director of Health.
To support implementation of the study at both prison sites, we recruited additional healthcare personnel. At the first prison, we hired one clinician and two nurses from the Ministry of Health (MOH) specifically for the project. This facility already had two nurses and a prison staff member serving as an HTS counsellor. At the second prison, which had only one medical examination room and one prison staff member functioning as an HTS counsellor, we engaged two clinicians and one nurse from the MOH through the District Health Office (DHO), as well as one clinician and two nurse from St. John’s Institute for Health, a medical training institution affiliated with the Christian Health Association of Malawi.
Implementation of screening and treatment in the three-stage model
HIV testing
Determine HIV-1/2 test (AlereHIV-1/2; Abbott, Chicago, Illinois, USA) was used for HIV screening and Bioline HIV-1/2 (SD Bioline HIV-1/2; Abbott) for confirmation of a positive screening test, following the Malawi national HIV testing algorithm. All individuals received pre-test and post-test HIV counselling according to national guidelines. Incarcerated people found to be living with HIV were referred to the DHO for further counselling, registration and initiation of ART. Incarcerated PLHIV initiated ART within 1–2 days of confirmatory testing, in accordance with national guidelines. Incarcerated PLHIV already known to be on ART were documented as such and were not retested. Voluntary and confidential HTS were provided to incarcerated people, with counselling offered both before and after the HIV test.
TB screening
Incarcerated people recruited for the study who reported cough, fever, unexplained weight loss and/or night sweats, irrespective of duration, were considered to have presumptive TB and were asked to submit sputum samples for testing using Xpert MTB/RIF. Symptomatic individuals with a negative Xpert test were treated for lower respiratory tract infections with antibiotics—such as amoxicillin and cotrimoxazole—for 7 days, at the discretion of the attending clinician. After 7 days of antibiotic therapy, depending on presentation and clinical assessment, our clinician changed the course of antibiotics or planned to refer for chest X-ray (CXR) for those who did not respond to the 7- day course of antibiotics. Incarcerated people who were already on anti-TB treatment during screening were documented as TB cases and were not included in the screening count for TB.
Sputum samples were obtained through the front-loading technique (same-day diagnosis) per national guidelines.8 The first sample was collected on the spot and the second one was collected within 2 hours of the first sample. Samples were preserved in specimen transport boxes and transported on a bicycle to the Xpert site at the nearest district hospital hub for processing on the same day. Xpert results returned to the prison within 4–5 days. Incarcerated persons diagnosed with TB were put on treatment at the district hospital and accessed TB medications within the prison facility for 6 months per national TB guidelines. The district TB officer was engaged to make sure that patients adhered to and completed treatment, and the prison staff collected TB medications for patients from the DHO. The patients were nursed in isolation rooms within the prison facilities.
Sexually transmitted infection screening
Screening for STIs in Malawian prisons was conducted using the syndromic approach as recommended by the Malawi MOH. This approach is commonly employed in settings with limited resources, such as prisons, where access to laboratory diagnostic facilities is constrained.19 Instead of relying on laboratory tests, the method involves identifying clinical signs and symptoms associated with common STIs. The main syndromes evaluated included urethral discharge (UD) (indicative of infections like gonorrhoea and chlamydia), genital ulcer disease (associated with syphilis, chancroid, herpes) and inguinal bubo (groin swelling). Individuals displaying certain clinical features such as skin rash were referred for syphilis testing. This symptom-based STI screening facilitates timely diagnosis and treatment,19 minimising delays in resource-constrained environments like Malawian prisons.
We conducted ‘entry screening’ and ‘stay screening’ for the study participants, as well as ‘exit screening’ for those who were about to be released from the prison. The screening exercise was done for 2 days; clinical officers and nurses documented the history and clinical examination. The HTS counsellors and nurses carried out TB and HIV risk assessments, TB symptom screening and collection of two sputum samples from presumptive TB cases.
Conceptual model of implementation research
This study used Proctor’s Conceptual Model of Implementation Research20 to show the general flow of how the three-stage model ultimately translated to patient outcomes, depending on a set of implementation strategies and outcomes (figure 1).
Figure 1. Conceptual model for implementation research (adapted from Proctor et al20). This illustrates the translation of the three-stage model to patient outcomes. The process was influenced by specific implementation strategies and outcomes. ART, antiretroviral therapy; EBI, evidence-based intervention; TB, tuberculosis.
Acceptability and feasibility of the three-stage model of TB/HIV care for prison staff
A subset of prison staff was purposively selected for in-depth interviews (IDIs). The interviews were guided by the Conceptual Model of Implementation Research and questions focused on perceived acceptability, feasibility, barriers and facilitators of implementing the three-stage model of TB/HIV care in prisons.
Evaluating implementation using RE-AIM
The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) conceptual framework (figure 2) guided the implementation and evaluation21 .22There is evidence that RE-AIM can provide guidance in implementing and evaluating an EBI.22 The framework was used to enhance the translation of the model into practice and guided the evaluation as noted by Glasgow and Estabrooks,22 enabling us to pose implementation-relevant questions such as, how many incarcerated persons are targeted to receive the intervention? What information will the prisons require to consider adoption of the intervention? Which training, tools and/or resources will the study need to implement the proposed intervention, and what resources will be required for the facilities to maintain the intervention long-term?
Figure 2. Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework (adapted from Glasgow and Estabrooks22). The RE-AIM framework was employed to support the model’s integration into practice and guided the evaluation by enabling the formulation of implementation-relevant questions.
Sample size
A total of 100 participants took part in the study, out of an estimated 647 individuals incarcerated at the study sites during data collection. We chose our pilot sample size based on guidance from Sim and Lewis,23 who suggest a sample size of at least 50 per group. In this pilot study, quantitative data were collected from 50 incarcerated persons per facility.24
Participant recruitment, informed consent and sampling
Two prison staff members informed all incarcerated people at each facility about the study through word of mouth. Incarcerated people who expressed interest in participating were referred to the research team for eligibility screening. Researchers assessed eligibility based on the following inclusion criteria: (1) adults aged 18 years or older and (2) those who were voluntarily willing and able to provide written informed consent. Individuals whose participation would pose significant logistical challenges—such as those considered dangerous to interviewers—were excluded from the study.
A purposive sampling technique was used to select study participants. Incarcerated people were purposively selected on entry, during their stay and on exit. A copy of the ethical approval and letter of authorisation from Malawi Prisons’ Chief Commissioner was shared with the DHOs in the districts where the study was conducted. This facilitated collaboration with the hospitals during the study period, increasing the likelihood of sustainability and ensuring participant safety and care continuity for identified conditions. The researchers met with the prison staff in charge and the warden to obtain permission to conduct the study at the study sites. The researchers would not approach participants alongside an officer to avoid possible coercion in appearance or otherwise. Rather, the research team met with potential participants in private. During the meeting, the researchers described the study’s aim, data types, processes and why the participant was chosen to participate in this study. The investigator confirmed the participants’ eligibility for the study. Following that, individuals completed informed consent and enrolment procedures.
The qualitative assessment (focusing on acceptability and feasibility) was integrated into a mixed-methods evaluation of implementing the three-stage model of TB and HIV care. Six prison healthcare professionals were invited to join individual interviews to share their views on the feasibility and acceptability of applying this model in their prison setting. Participants were selected through purposive sampling, targeting healthcare staff who would be directly involved in implementing the model. All approached prison and healthcare staff provided informed consent to participate in the study.
Data collection and analysis
Trained investigators administered a structured questionnaire to collect quantitative data on socio-demographic details and TB/HIV-related risk factors from consenting participants. Clinical characteristics and laboratory results were recorded using standardised case reporting forms or project-specific documentation tools. Quantitative data were analysed using SPSS V.23.0. (SPSS, Chicago, Illinois, USA). Descriptive statistics including frequencies, means and percentages were calculated to characterise variables, including the number and percentage of incarcerated people who received HIV/TB screening. We further compared findings related to screening during incarcerated people’s ‘entry’, ‘stay’ and ‘exit’. The interviews for qualitative data were transcribed verbatim. Qualitative data were analysed manually using content analysis and generally included themes from the Conceptual Model for Implementation Research. Qualitative content analysis involved breaking down data into smaller units, coding and naming the units according to the content they represent and grouping coded material based on shared concepts.17
Qualitative data were gathered through IDIs with prison staff using an interview guide (see online supplemental additional file) to assess the acceptability of implementing the three-stage model of TB and HIV care in prisons. Data collection was conducted by EN, an expert in qualitative research in the Malawian setting. The qualitative data analysis was performed manually. Data were analysed through content analysis, which involved identifying, coding and categorising patterns and themes within the responses.17 This approach allowed for the systematic interpretation of textual data to uncover underlying meanings and recurring ideas relevant to the research objectives and our conceptual model.17 Additionally, prison staff evaluated each concept using a 3-point scale (1=disagree, 2=neutral, 3=agree) based on various feasibility criteria, such as whether the three-stage model of TB and HIV care in prisons is practical and straightforward to implement, and the challenges faced during TB, HIV and STI screening.
Patient and public involvement
No patient or participant was involved in designing this study, recruiting study participants or conducting the study. Researchers purposively recruited participants in this study. Participants were informed that the research team would disseminate the final study results to them.
Results
Implementing the three-stage model of TB/HIV care in prisons
A total of 100 participants took part in this study; all of them (100%) underwent entry screening, stay screening and exit screening/postscreening. Table 1 depicts the demographic characteristics of study participants. Most incarcerated persons (72%) were 19–39 years of age; the mean age was 35 years (SD 12.2). Eighty-nine (89%) participants were male and 11 (11%) were female. Additionally, 29% had no formal education. Overall, 98% were sentenced, while 2% were on remand.
Table 1. Socio-demographic characteristics of participants.
| Variable | Mean (SD) | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Sex | |||
| Female | 11 | 11 | |
| Male | 89 | 89 | |
| Age category (years) | |||
| <19 | 9 | 9 | |
| 19–29 | 28 | 28 | |
| 30–39 | 35 | 35 | |
| >39 | 28 | 28 | |
| Mean age | 35 (12.2) | ||
| Level of education | |||
| No formal education | 29 | 29 | |
| Primary level | 49 | 49 | |
| Secondary level | 18 | 18 | |
| Tertiary level | 2 | 2 | |
| Prior history of incarceration | 48 | 48 | |
| Prison status | |||
| Remand/Awaiting trial | 2 | 2 | |
| Sentenced/Convicted | 98 | 98 | |
| Period of incarceration (weeks) | |||
| <1 | 52 | 52 | |
| 1–2 | 13 | 13 | |
| 2–4 | 35 | 35 | |
Table 2 describes HIV-related risk behaviours among participants. The prevalence of reported HIV risk behaviours such as paying and receiving money or goods in exchange for sex was generally 5%. Sharing of tools like razor blades was more common. About 17% of participants share razor blades and 28% reported using alcohol and illicit drugs while in prison.
Table 2. Reported HIV risk behaviours.
| Characteristic | Frequency (n) | Percentage (%) |
|---|---|---|
| Ever heard or witnessed sexual violence | 53 | 53 |
| Ever been forced into sex | 15 | 15 |
| Paid/Accepted money or goods for sex in prison | 5 | 5 |
| Shared razor blades in prison | 17 | 17 |
| Ever been tattooed inside prison | 9 | 9 |
| Use of alcohol and illicit drugs in prison | 28 | 28 |
Screening status of incarcerated people at entry, midway and postscreening/exit
TB screening
Nine (9%) of study participants had a history of TB and were previously treated. All incarcerated individuals (100%) were screened on entry and 32% had presumptive signs/symptoms of TB. All of those identified (100%) were tested using Xpert MTB/RIF (table 3). One participant was diagnosed with TB at entry and did not have HIV-associated TB.
Table 3. Entry, midway (4 months) and postscreening (8 months) TB status of participants.
| Variable | Entry screening n (%) | Midway screening n (%) | Postscreening n (%) |
|---|---|---|---|
| Proportion of incarcerated people who were screened for TB | 100 (100) | 100 (100) | 100 (100) |
| Incarcerated people with presumptive signs/symptoms of TB | 32 (32) | 27 (27) | 10 (10) |
| Xpert MTB/RIF with MTB complex detected | 1 (1) | 4 (4) | 0 (0) |
| Proportion with TB who started TB treatment | 1 (1) | 4 (4) | 0 (0) |
| Proportion of TB cases who have documented HIV test result | 1 (1) | 4 (4) | 0 (0) |
| Proportion of incarcerated people with HIV-associated TB | 0 (0) | 2 (2) | 0 (0) |
MTB, Mycobacterium tuberculosis; TB, tuberculosis.
Four out of 27 (15%) who had presumptive signs of TB during their prison stay tested positive for TB by Xpert; two (2%) had HIV-associated TB. Overall, five incarcerated people were diagnosed with active TB during the study period, and all five (100%) were referred for and initiated on anti-TB treatment (table 3).
HIV testing services
Prior to screening, 67 of 100 (67%) participants had unknown HIV status. Out of 33 people who knew their status, 18 (56%) were living with HIV and already on ART. All of them were on ‘regimen 13A’ per Malawi MOH guidelines (ie, tenofovir 300/lamuvidine 300/dolutegravir 50). Seven (7%) participants were newly diagnosed with HIV at entry according to the national two-step testing algorithm, and all (100%) initiated ART (table 4). There was no documented case of HIV acquisition in prison among study participants, as all tested HIV-negative during both midway and postscreening assessment.
Table 4. Entry, midway and postscreening of HIV status of participants.
| Variable | Entry screening n (%) | Midway screening n (%) | Postscreening n (%) |
|---|---|---|---|
| HIV status | |||
| Known | 33 (33) | 100 (100) | 100 (100) |
| Unknown | 67 (67) | 0 (0) | 0 (0) |
| Eligible for HIV test per national guidelines* | 82 (82) | 76 (76) | 76 (76) |
| Incarcerated people living with HIV already on ART | 18 (18) | 24 (24) | 24 (24) |
| ART regimen | |||
| TDF/LMV/DTG | 18 (18) | 24 (24) | 24 (24) |
| HIV test result | |||
| Positive | 7 (7) | 0 (0) | 0 (0) |
| Negative | 75 (75) | 76 (76) | 76 (76) |
| Refused | 0 (0) | 0 (0) | 0 (0) |
| Proportion of new entrants newly diagnosed with HIV who were initiated on ART | 7 (7) | 0 (0) | 0 (0) |
Those who never had HIV testing before or accessed HIV testing services >3 months before the current test.
ART, antiretroviral therapy; DTG, dolutegratvir; LMV, lamivudine; TDF, tenofovir disoproxil fumarate.
STI screening status
On entry, 10 (10%) of 100 participants had a history of STI in the past 3 months (table 5).
Table 5. Entry, midway and postscreening of STI status of incarcerated people at entry.
| Variable | Entry screening n (%) | Midway screening n (%) | Postscreening n (%) | |
|---|---|---|---|---|
| History of STI infection in the past 3 months | 10 (10) | 3 (3) | 0 (0) | |
| Proportion of incarcerated people with STI | Positive (UD and syphilis) | 8 (8) | 4 (4) | 1 (1) |
STI, sexually transmitted infection; UD, urethral discharge.
Following screening, eight (8%) of the incarcerated people were diagnosed and treated for STIs. The most common syndromes/diagnoses were UD and syphilis. There were new-onset STI symptoms for four participants during their stay (UD 4%).
Perceived acceptability of using the three-stage model of TB/HIV care among prison staff
Prison health professional staff (n= 6) were asked to participate in an IDI focusing on their perceptions of implementing the three-stage model of TB and HIV care. The overall number of participating prison staff was relatively low (n=6); however, given the pivotal role of prison health professionals involved with screening incarcerated people, the success of implementing this model and its sustainability are dependent on them.
Prison staff (n=6) who were attached to the medical clinic either as a nurse or HTS counsellor participated in the feasibility component (table 6). There were four males and two females; the mean age was 39 years and they had an average work experience of 9 years at the detention facility.
Table 6. Demographic characteristics of prison staff who participated in in-depth interviews (n=6).
| Variable | Frequency (n=6) | Percentage (%) |
|---|---|---|
| Gender | ||
| Male | 4 | 67 |
| Female | 2 | 33 |
| Professional cadre | ||
| Nurse | 2 | 33 |
| HTS counsellor | 4 | 67 |
| Mean age | 39 (9.9) | |
| Average work experience | 9 years (4.7) |
HTS, HIV testing services.
The feasibility component of the implementation measure (table 7) revealed that prison staff were able to screen incarcerated people for TB and HIV at certain times. They were able to screen incarcerated people during their stay. However, they encountered difficulties in screening incarcerated people for TB and HIV at entry and when exiting.
Table 7. The feasibility implementation measure.
| Provider’s rating n=6 | Disagree | Neutral | Agree |
|---|---|---|---|
| Feasibility | |||
| I believe that using the three-stage model of TB and HIV care in prisons is feasible and straightforward | 2 | 1 | 3 |
| I encountered problems in screening incarcerated people for TB | 4 | 1 | 1 |
| I encountered problems in screening incarcerated people for HIV | 4 | 1 | 1 |
| I have been able to screen all incarcerated people for TB on entry | 6 | 0 | 0 |
| I have been able to screen all incarcerated people for TB on their stay | 0 | 1 | 5 |
| I have been able to screen all incarcerated people for TB when exiting | 5 | 1 | 0 |
| I have been able to screen all incarcerated people for HIV on entry | 5 | 1 | 0 |
| I have been able to screen all incarcerated people for HIV on their stay | 6 | ||
| I have been able to screen all incarcerated people for HIV when exiting | 6 | 0 | 0 |
| I encountered problems with incarcerated people refusing to be screened for TB and HIV | 6 | 0 | 0 |
| At times, I had to postpone screening incarcerated people due to other factors | 1 | 1 | 4 |
TB, tuberculosis.
Perceived barriers and facilitators to utilisation of the three-stage model of TB and HIV care
Qualitative interviews exposed perceived barriers to the utilisation of the three-stage model of TB and HIV care in prisons. The study disclosed that prison staff reside outside the prison facilities. So during incarcerated people’s entry, they would not be able to screen them as they may be admitted in the absence of prison health professionals. In addition, the lack of human and material resources for screening the incarcerated people for TB and HIV on entry, stay and exit was another challenge:
We live far away from the prison facility. Therefore, we are not aware when incarcerated people got into the detention facility. As a consequence, we miss screening them if they got into the prison for the first time. KI #2/M
There is a need for at least two HTS counselors to meet the demand for HIV testing and counseling in prison. Currently, I am alone, sometimes the DHO and HSC support me in HIV testing and counseling once a week. If we could have another full-time staff, it would be much better because sometimes, I’m assigned other tasks that are not health-related. As such, it becomes difficult to screen incarcerated people on time. KI #6/M
It was also discovered that incarcerated people sometimes enter prison during odd hours or weekends. This is another barrier to implementing this model. Consequently, prison staff who screen them are not available during entry:
Some incarcerated people are released without our knowledge. Some days they get released when we are off duty. We only discover that some of them have been released and amongst them some are on ART or TB treatment. Therefore, the treatment gets disrupted. KI #1/M
In summary, there is poor communication among prison staff with regard to the entry and release of incarcerated persons. Some of the incarcerated people are admitted into the facility when health staff are not on duty. This happens mostly when a prison staff member responsible for health is attending meetings or conferences. Furthermore, poor coordination among the prison officers when the incarcerated individual is being released is also a setback. For example, some prison officers do not actually know when the incarcerated people are due for release.
There is poor coordination between the officers bringing in the incarcerated people and those releasing them. Prison staff who are healthcare workers are not well informed when incarcerated people are entering into the facility or getting released. We realize too late that some incarcerated people have been released. KI #3/F
At times, when incarcerated people have just been pardoned by the president, they are released immediately, so I often miss them. However, for incarcerated people scheduled on specific dates, I try my best to screening them on exit. I usually screen them five days prior to their actual release. KI #1/M
On certain occasions, incarcerated people are released from the court of law, especially those on remand. Thus, we don’t have any opportunity to screen them. KI #6/M
This study revealed barriers to providing HIV services, one of which was lack of space as highlighted in the following verbatim quote:
The unavailability of adequate space is a barrier to providing our services effectively. We don’t have enough space, so our HIV services are poor. KI #6/M
There is lack of privacy when offering services due to poor conditions of prison facilities. KI #5/M
Key facilitators to implementing the three-stage model of TB/HIV care in prisons included the following: strong collaboration between prison health staff and external health partners (such as the DHO), existing health screening routines within the prisons and the willingness of prison staff to support health interventions. Additionally, the presence of designated health personnel within the prison system may facilitate acceptance of the model. These factors have been considered within the context of the EBI and informed our interpretation of feasibility and potential scalability.
Discussion
Implementation of the three-stage model of HIV/TB care was feasible among a subset of incarcerated persons in two semi-urban prisons in Malawi, and led to the identification of undiagnosed cases of TB and HIV, including HIV-associated TB, and linkage to care and treatment for these conditions. It also enabled identification and treatment of previously undiagnosed STIs. Participants reported HIV risk behaviours that could be associated with HIV transmission in prisons. Incarcerated people and prison stakeholders identified barriers to implementing and sustaining screening for HIV, TB and STIs at entry, stay and exit.
Evidence suggests that individuals deprived of liberty have the highest incidences of TB in the world.25 TB is more common in prison populations than in the general population.10 HIV, late diagnosis, inadequate access to TB diagnosis and treatment, poor living conditions, low socioeconomic status and poor general health appear to all contribute to higher rates of TB within prisons in SSA.26 27 WHO modified its recommendations in 2021 to advocate for systematic TB screening in jails and penal systems.28 Prisons serve as TB reservoirs, affecting incarcerated people and allowing transmission in the community via staff, visitors and released incarcerated people. Incarcerated persons living with HIV are at high risk of developing TB. In this study, two individuals diagnosed with TB disease were found to have HIV-associated TB. Several factors for HIV-associated TB among incarcerated people have been identified in the literature. First, immunosuppression from HIV infection both predisposes individuals to TB reactivation29 30 and increases the risk of progression from infection to disease.29 31 Second, the two infections share a number of socio-demographic and behavioural risk factors, including incarceration.32,34 Third, conditions in prisons such as poor ventilation and overcrowding increase the risk of transmission of TB.3 4 Nonetheless, despite the relationship of all these factors, understanding the epidemiology of HIV/TB co-infection among persons detained in Malawi prisons remains limited. Measures to reduce overcrowding and to improve living conditions for all incarcerated people should be implemented to reduce TB transmission.
Our study reported no cases of HIV infection acquired in prison because all incarcerated people maintained their HIV-negative status at the midway and exit points. This finding is similar to WHO reports from other prison settings.35 Most of our participants acquired HIV prior to incarceration. Consistent with previous studies,36,39 this study identified common HIV risk behaviours in this population, including coerced and transactional sex, STIs, sharing of sharp objects such as razor blades and drug use in prison. However, incarcerated people who were HIV-negative at entry maintained their status during their stay, implying that even if exposed to HIV, they did not acquire HIV. This could be explained by the fact that incarcerated people who tested positive for HIV were linked to ART. In Malawi, incarcerated persons have access to off-site ART by getting to the nearest district hospital. As a result, we urge that incarcerated persons should be screened for HIV and should have access to on-site ART both for their own health and to stop the spread of HIV. Such models of on-site ART services have been described in Malawi and Zambia.1 2
We also found evidence of incident STI symptoms and diagnosis during the incarceration period; the most prevalent conditions were UD and syphilis. Zachariah et al15 found similar results in a study conducted in Malawi. During a 2-year study period, 4.2% of incarcerated people were diagnosed with an STI.15 This included UD, genital ulcer disease and epididymoorchitis.15 STIs were considered incident cases acquired within the prisons (incidence risk 12 cases/1000 incarcerated people/year).40
STI screening was included in our study alongside HIV and TB screening, despite not being a formal component of the three-stage model of HIV and TB care, due to the strong epidemiological and clinical link between STIs and HIV. STIs and HIV share common modes of transmission; primarily unprotected sexual contact making co-screening a strategic approach for early detection and integrated care.41 Moreover, the presence of untreated STIs can increase the risk of HIV acquisition and transmission by disrupting mucosal barriers and increasing viral shedding.42 In the context of Malawian prisons, where overcrowding, lack of privacy and limited access to healthcare prevail, there is also concern about the potential for sexual violence and unprotected consensual sex, both of which contribute to STI and HIV transmission.43 Including STI screening allowed for a more holistic assessment of sexual health risks among incarcerated people and provided an opportunity to offer timely treatment and counselling, ultimately strengthening the public health response within correctional settings. Our study shows that a considerable proportion of incarcerated people present with STIs at entry, but some may acquire an STI within the prison walls, although this is difficult to confirm without more advanced molecular diagnostic techniques. These findings have important implications for national policy and support the introduction of additional combination HIV prevention interventions within Malawi prisons, including making condoms, pre-exposure prophylaxis for HIV and comprehensive STI diagnostic and treatment services.40
We made several practical observations regarding the feasibility of implementing the three-stage model. First, active involvement of the prison officials and health workers was critical in the implementation of interventions. Experienced and qualified counsellors provided HIV counselling to the incarcerated people in a private one-on-one setting. Second, it was feasible to supplement healthcare infrastructure, laboratory services for TB and HIV and human resources in the prison by mobilising resources. This made it possible to conduct many of the referrals, communication links, management and follow-up of incarcerated people with HIV and TB diagnosed through the study.
We also encountered several notable challenges during the implementation of our study. First, follow-up of incarcerated people after release from the prison was difficult. Therefore, it may be imperative to establish good communication links with hospitals outside the prison system to ensure appropriate continuity of care for TB and HIV. Second, prison clinics have no installed X-ray machines for screening. As such, incarcerated people with asymptomatic TB were referred to the district hospital for CXR examination, thus delaying access to diagnostic services for this population. Lastly, we found that it was difficult to screen incarcerated people for TB and HIV during entry and when exiting. Evidence suggests that screening incarcerated people for TB and HIV during entry and exit poses significant challenges in African prisons.44 These difficulties often stem from overcrowding, limited resources and logistical constraints, making it hard to implement effective screening at these critical stages.44 In many African prison systems, infrastructure is inadequate, and there is often a lack of trained personnel to conduct screenings on a large scale. Furthermore, the high turnover of incarcerated people, coupled with poor record-keeping and inconsistent healthcare delivery, exacerbates these challenges.4 16 43 45 However, there are reports of successful implementation in prisons within the region, achieved through additional investments and active engagement with health and corrections stakeholders.46 We recommend that the existing prison healthcare system should be strengthened to ensure that all the incarcerated people are screened for HIV/TB/STI during their entry and when exiting,16 as well as periodically during their stay. Furthermore, there is a need for intensified surveillance of TB and HIV, including provision of laboratory services and medicines within prison settings in Malawi. In addition, prison operational manuals should reinforce the humane isolation of people with presumptive TB and provide TB-related and HIV-related information campaigns specific to the prison setting.
There were some limitations to this study. The study might have had a short follow-up period, which would not allow for monitoring long-term outcomes like treatment outcomes, HIV viral suppression or changes in health status over time. Since we were unable to assess longitudinal HIV and TB treatment outcomes, we recommend future research to assess these HIV/TB outcomes in prisons. The prison environment itself, including overcrowding, lack of privacy or limited access to healthcare services, may have influenced the study’s outcomes and affected the health-seeking behaviours of incarcerated people. Additionally, other unmeasured factors, such as pre-existing health conditions, substance use and/or social determinants of health, may have influenced the prevalence and outcomes of HIV/TB/STI screening and treatment, potentially introducing confounding into the study.
Conclusion
The three-stage model of HIV and TB care was feasible and acceptable for TB, HIV and STI screening at the district level in Malawi and can be replicated for use in similar settings. Although it was operationally feasible to implement, additional support was needed to overcome implementation barriers related to human resources for health and medical supplies and commodities. Our findings suggest that health system barriers within the corrections sector may prevent the scale-up and sustainability of the model; however, these challenges could be addressed through strengthened coordination with the MOH, which is responsible for ensuring the health of all incarcerated people. Additional investments are needed to promote the delivery of the three-phase TB/HIV care model to safeguard the health of incarcerated people in Malawi, in alignment with international recommendations. Such investments could enhance the model’s feasibility, sustainability and potential for continued scale-up. Future research is needed to understand the effects of the three-stage model on other health and implementation outcomes.
Supplementary material
Acknowledgements
We wish to sincerely acknowledge the participants (incarcerated individuals) and the research assistants who contributed to this study. The research assistants include Tina Msowoya, Ignasio Walinase Nyirongo, Elias Lazaras, Vincent Mwangonde and Taona Mkandawire. Their tireless efforts in screening incarcerated individuals, as well as collecting and entering data, were invaluable. We also extend special thanks to the senior staff from the two district prisons for their exceptional support throughout the study.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the MHIRST.
Footnotes
Funding: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW010060, through the Malawi HIV Implementation Research Scientist Training (MHIRST) programme.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2025-104093).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study was approved by the National Health Sciences Research Commission (NHSRC) with reference number 22/03/2885. Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
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