My Brother’s Keeper: Helping inmates protect themselves and each other from tuberculosis in a prison in Malawi

MSF has long experience treating people living with TB. We also advocate for better treatment for people with tuberculosis (TB) beyond our projects. Last month saw the publication of a joint report with ‘Stop TB’ on recent progress in improving TB care around the world. Here we zoom in on one project undertaken by MSF in Malawi to protect prison inmates from the disease. We spoke to Dr Patrick Mangochi, MSF’s Medical Coordinator in the project.

A woman looks for her husband during the daily family visits to Maula prison. © Luca Sola

How big a problem is TB among prisoners where you work?

TB is a scourge in prisons. We see how the physical conditions of overcrowding and bad nutrition turn these places in to factories for TB. It’s a very stressful situation for the prisoners and challenging for us as caregivers. The people we support have often lost all hope — they are expecting to die. The psychological impact of incarceration can also contribute to a deterioration in their physical condition and make them vulnerable to disease.

On the clinical side, there’s a high number of people who are living with HIV which means their immune systems are very weak and this opens them up to all sorts of other infections, primarily TB. So, this all contributes to the very high rate of both active TB disease and latent TB infection among incarcerated populations.

What has MSF done to speed up the detection and treatment of TB among prisoners?

We have initiated a pilot project of intensive screening. So when new inmates arrive, we make sure to screen them for TB within the first weeks of entry. We then also test them during their prison term and then again just before their release. Early diagnosis using molecular-based diagnostic tools is critical to ensure that we catch patients with TB before they reach an advanced stage of illness.

There are also other essential diagnostic tools for use in the prison setting –including TB LAM[1]. We’ve pushed for this diagnostic tool- which is a urine-based rapid test for diagnosing TB among people living with HIV — to be made more widely available in prison settings and at inpatient and outpatient health care facilities. The government of Malawi has now adopted a policy and guidelines that ensures TB LAM’s availability for routine testing across the country.

MSF was instrumental in supporting the rollout of molecular-based tests for TB in many places where we work © Matthew Smeal

What are the challenges of providing TB treatment, once people have been diagnosed with TB?

TB drugs are widely available and accessible in Malawi. If someone is found to have active disease, they are started on TB treatment. And if they are found to have latent TB, with their consent, we put them on the drug rifapentine to prevent them developing active TB disease. Rifapentine is not so widely available elsewhere across the country, but following our encouragement, the government does now have plans to make the drug more available to specific targeted populations (at the moment, those people most at risk of contracting TB in key populations in five districts in the country) and we are trying to get them to make it available in all prisons.

But if access to the drugs themselves isn’t a problem, the prison setting is very ‘mobile’ which means that prisoners can be moved between cells at a moment’s notice or have to leave to attend court hearings. It makes ensuring people can take their medicines regularly each day very tricky.

Can you describe in more detail what day to day living is like for people in these institutions and how it impacts on their ability to fight the disease?

It’s quite desperate — overcrowding remains a real challenge — the prison in 2018 accommodated well over three times the numbers of inmates for which it was originally built. There’s simply no room to lie down to sleep in the cells. The food is really not appropriate for human needs, maybe maize flour and cabbage, so they get terrible skin diseases such as scabies that spreads like wildfire among the population in close proximity. TB treatment needs people to be properly nourished to be effective That’s why MSF decided to supplement meals for people with drug-sensitive TB as it makes them hungry all the time while there’s only one meal a day provided by the prison.

“IIt’s quite desperate — overcrowding remains a real challenge….There’s simply no room to lie down to sleep in the cells”

This all makes for a very stressful and challenging environment and to make an impact, the inmates really need to understand and buy in to the care we are offering. Counselling and education are therefore very important. We have had inmates who said, ok, when I actually understood why I had to take my drugs, that’s when I was actually able to take them. Critically too, they understood the need to protect both themselves AND others around them, because of the risks of infection. It seems to be a common feeling that prisoners believe they are their ‘brothers’ keepers’ in this respect.

How successful has this pilot project has been?

Terrific! 90% of those who tested positive for latent TB and were given treatment, actually completed the three-month course — that’s really quite remarkable. The prisoners with latent TB understood the benefits of taking the medication to protect them from developing TB disease.

I’d like to point to other less obvious successes too — for instance the valuable knowledge about TB that prisoners take back with them to their communities, when they are released and re-integrated.

Can you see how what you’ve learned from this project could benefit prisoners elsewhere?

Even though we have carried these activities out in just one prison, it’s quite obvious that this could be done potentially in several other prisons. We have been engaging with the prison authorities, the Department of Home Affairs, that is responsible for all prisons, and with the Ministry of Health to push this forward and replicate our experience in other prisons.

We are more ambitious too! The screening system we have now in place, although it’s actually earmarked for TB, could work for other things. So prisoners could be screened for other diseases too, and by establishing contacts with the health authorities inside prison, they can then benefit from that connection after their release back in to their communities and their new lives.

Read the full report ‘Step up for TB report 2020’

[1] TB LAM is a simple urine-based test to detect active TB in clients. It is a urine test for the detection of LAM antigen, a lipopolysaccharide present in mycobacterial cell walls, which is released from metabolically active or degenerating bacterial cells. LAM appears to be present predominately in people with active TB disease.

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This blog is a place to reflect on our experiences working for access to medicines. For the official MSF Access Campaign website please visit msfaccess.org.