Cambodia: Improving TB detection and treatment in prisons

MSF has been working in CC1, CC2 and PJ prisons in Phnom Penh, which represent 25 per cent of Cambodia’s total prison population, since February 2010 to improve detection of TB and HIV, as well as provide correct care and treatment for prisoners affected by the diseases during their detention. 

As TB is spread by airborne droplets released when an infected person coughs, the overcrowded, poorly ventilated and cramped conditions in Cambodian prisons provide ideal conditions for the disease to breed.

Cambodia is one of the 22 countries in the world with a high burden of TB, and TB prevalence among Cambodian prisoners is four-to-six times higher than the general population. HIV levels are up to nine times higher.

“Prisoners are often from socioeconomically disadvantaged populations that are more vulnerable to TB and who frequently lack access to healthcare,” said head of mission in Cambodia Jean-Luc Lambert. “Compounding the problem is that prisons have a high population turnover as inmates are moved to other facilities or released, posing serious threats to overall public health.”

Improving detection

In order to respond to the growing TB epidemic in Cambodian prisons, MSF initially focused on implementing a comprehensive TB/HIV screening programme for all existing and new prisoners.  Over 3,600 prisoners were screened between February 2010 and July 2011. A quarantine area was established where inmates suspected of having TB could be separated from the others to prevent the spread of the disease.

The next step was focusing on integrating active TB detection into the routine activities of the Prison Health Posts. Approximately 200 patients have been treated for TB in the three prisons since 2008, 164 as a result of the screening, and 32 are currently under treatment in the MSF programme. Ninety-four prisoners are currently on anti-retro viral treatment for HIV/AIDS in CC1, CC2 and PJ prisons.

“We aim to build a system where every new prisoner is isolated and screened for HIV and TB within 48 hours of arrival at the prison,” said Jean-Luc. “The next challenge is setting up effective, feasible and acceptable procedures for the prisoners to continue receiving quality care after the screening period.”

In order to reduce transmission and TB incidence, MSF works closely with the national TB programme and prison health staff in order to improve detection and infection control practices. All “TB suspects” are isolated until their test results are confirmed, and identified drug-resistant (DR) TB patients are isolated for longer periods from other prisoners.

Ongoing care

Once a prisoner is diagnosed with TB and/or HIV, MSF provides care and treatment during their detention, as well as facilitates access to drugs and medical follow-up when they are released or transferred to another prison, which is essential in preventing the emergence of DR-TB.

DR-TB can be developed when a patient’s treatment for TB is prematurely stopped and the disease develops a resistance to specific drugs. This drug-resistant form of TB can then easily be passed onto other people, meaning that ensuring uninterrupted access to the full TB treatment regime is crucial in preventing the occurrence of a DR-TB epidemic in close settings like prisons.  

“The key challenge we face is guaranteeing that when prisoners are released they will continue to receive treatment,” said Jean Luc. “There’s no point beginning treatment inside the prison if the patient will stop taking the medication once they are released. In fact, this may result in the spread of more drug-resistant forms of the disease, which are much more difficult to cure.”

Early diagnosis

Twenty-nine year old Srey (not her real name) was imprisoned in March 2010 and was first screened by MSF in March 2011, where she tested positive for HIV but negative for TB.

Srey was placed on HIV medication by MSF and screened again in June due to the emergence of TB symptoms. This time she tested positive to the disease, presumably transmitted by another prisoner. Srey then joined MSF’s TB programme and received treatment until her release in October 2011.

“I wasn’t afraid when I found out I got TB because a female medical staff at the prison looked after me and explained the treatment to me,” Srey said. “She gave me good medicine and explained that I had to take them all to get rid of the germs in my body.

“I did not feel well at all in the beginning of the treatment. I felt very tired and coughed a lot. I also had fevers, chills and shivered a lot. I felt so bad but the medical staff explained that I cannot abandon the treatment, no matter how hard it was. “

Prior to her release, MSF was able to connect Srey to a local medical centre in her neighbourhood.

“When I was released, I continued the treatment at Chamkardong health center,” Srey said.

“I won’t stop treatment until I am completely cured because I live with my child and sister and I don’t want to put them in danger. If others can do it, I can do it as well.”

Chamhardong is one of the new health centres that has been receiving MSF support in staff training. 

“Srey is a good example of why it is so important to detect and treat prisoners inside the prison, both from the patients point of view, but also from a general public health perspective,” said prison project coordinator Christine Wagari. “She was only in prison for a short period of time and was infected with TB just before her release.”  

“Without diagnosis, education and treatment, she would have brought that disease back into her community. And without completion of her treatment in the local health centre, she may have developed and passed on the much more virulent drug-resistant form of the disease,” added Christine.

Neglected patients

In addition to continuing to look after the health needs of HIV and/or TB-infected prisoners, MSF is broadening its medical interventions to address the most important health issues facing inmates in the three prisons, including STDs, skin diseases and nursing care, as well as engage in preventative health support activities such as anti-dengue fever efforts and sanitation improvements. MSF mobile clinics now conduct weekly consultations in CC1 and CC2 with an average of 100 consultations per month.

MSF will also continue to train the health staff at the prison and local HIV centre to strengthen the capacity of the prison health posts and continue to integrate TB and HIV-infected prisoners into the national system by ensuring communication and collaboration with different partners.

“To reduce transmission both inside the prison and the general community, it is essential to treat the detainees as soon as HIV or TB is detected and not wait until they are released,” said Jean-Luc. “Establishing good follow up practices and ensuring treatment links between inside and outside the prison is the most effective way we can fight against this epidemic.”