James (not his real name) is a 36-year-old man living with HIV who was convicted and sentenced to four years in Maula Prison, Malawi. While incarcerated, he received only one meal daily: nsima—a thick porridge made from maize flour and water—and pigeon peas. He shared his cell with 167 other prisoners, and they were locked up together from 3 pm to 9 am every day.
James describes the conditions in the cell as incredibly harsh. Only one water tap was located next to the toilet, which they used for drinking and bathing. There was no sanitation, and they had no soap to wash their clothes. Most prisoners slept on the floor, often without blankets, and the cells became extremely hot and humid during the summer due to the stifling heat and their perspiration. The cell had four small windows, but little fresh air was circulating.
After a few months, James began to experience chest pains and suffered from excessive sweating and coughing. He noticed that at least eight other prisoners also appeared to be ill. Among them, he was aware of three who had tuberculosis (TB). James was only able to access the prison clinic when his condition became critically serious.
James tested positive for tuberculosis (TB) and was moved to a cell designated for sick prisoners. In this cell, there were 19 prisoners, of whom 6 also had TB. James observed that this cell, like others in the prison, had high windows that prevented adequate air circulation. Although he had no issues accessing antiretroviral therapy (ARVs) for HIV, he did not receive a special diet or nutritional supplements following his TB diagnosis. James was later diagnosed with multidrug-resistant tuberculosis (MDR-TB) and admitted to Bwaila Hospital while in shackles. He believes he contracted MDR-TB due to overcrowding, poor ventilation, and inadequate healthcare in the prison.
Tuberculosis (TB) is an infectious disease that primarily affects the lungs but can also impact other organs, such as the spine, brain, or kidneys. According to the WHO’s 2024 Global Tuberculosis Report, an estimated 10.8 million people contracted TB worldwide in 2023, and 1.25 million individuals died from it.
Although there have been positive developments regarding TB in Africa, several key challenges remain. Climate change is expected to worsen food insecurity on the continent, which could hinder TB treatment efforts. While new vaccines for TB are being developed, their progress remains uncertain due to a lack of resources. TB continues to be a significant cause of death for people living with HIV. Although access to antiretrovirals for HIV has reduced co-infection rates, these advancements are at risk due to recent significant cuts in HIV treatment funding. Ultimately, families bear the financial burden when a member falls ill with TB, often spending more than 20% of their annual household income on medications, special foods, transportation, and lost wages.
HIV, hepatitis C (HCV), chronic hepatitis B (HBV), and active tuberculosis (TB) are prevalent in prisons and other closed settings around the world. HIV and TB are also leading causes of death in these environments.
Studies conducted in Malawi, Zambia, and Botswana indicate that the prevalence of TB among prisoners is ten times higher than that in the general population. How prisons manage TB is vital to controlling the overall impact of the disease in a country, yet little attention is paid to TB in prisons. To prevent further transmission, screening for active TB (TB case finding) is crucial in all places of detention. New admissions and asymptomatic TB cases contribute significantly to the TB epidemic in these facilities. A study in Tanzania highlighted the high rate of asymptomatic TB cases in prisons. When prisons rely solely on symptomatic screening for TB diagnosis, asymptomatic cases often go undetected, allowing the disease to spread unchecked.
Prisoners often face poor conditions, including overcrowding, inadequate ventilation, and insufficient hygiene and nutrition, which contribute to the spread of diseases. Additionally, the lack of quality healthcare in detention facilities worsens illnesses and their transmission. Factors such as stigma and discrimination, insufficient staff training, inadequate medical and psychosocial services, violence, and a lack of protection for vulnerable individuals further hinder effective prevention and care.
Even relatively simple issues can obstruct tuberculosis (TB) treatment. For instance, a reliable backup electricity system is essential when frequent power outages disrupt TB testing processes and refrigeration of samples.
Proper nutrition in prisons also supports TB treatment, as prisoners often struggle to take their medication on an empty stomach. Food preparation is complicated by supply shortages and issues with water, firewood, or electricity needed for cooking. The timing of meals presents challenges for individuals taking HIV or TB medication, as not eating before taking their medication can worsen side effects, such as dizziness. Lack of food forces many prisoners to depend on their families for nutritional needs.
Ventilation is essential and can be easily enhanced by opening windows to promote cross-ventilation and airflow. Sunlight is also beneficial; however, it can only reach the tuberculosis bacilli if it effectively penetrates the area. Many prisons are hampered by outdated infrastructure and may not be adequately equipped to handle infectious diseases.
As prisoners reintegrate into society, ensuring continuity of treatment and care is crucial after their release. A lack of communication between government departments can lead to interruptions in prisoners’ treatment, increasing the risk of tuberculosis transmission and the spread of multi-drug-resistant TB in communities.
Ensuring oversight of prisons is essential for effective prevention and treatment of TB, leading to improved health outcomes nationwide.
Anneke Meerkotter, Executive Director, Southern Africa Litigation Centre
