How to stop HIV spreading in Zambia's prisons

Moral concerns are stopping condom distribution in Zambia's prisons

Bright spent two years in Zambia's Lusaka Central Prison for selling cannabis but fears he now faces a life sentence.

"I did it because of hunger," says Bright softly.

"There's not much food in prison. Sex has become the way of payment."

The wall prevents an inmate from going outside, but the disease has no boundary Dr Chisela Chileshe Zambia Prisons Service medical director

"Conditions were bad," he remembers. "We had nshima [maize meal] and beans two times a day. I never felt full."

One day, the cell "captain" gave Bright extra food, then asked him for sex.

"I had never had sex with a man, but I did it. The first time it was painful, but I joined a group of maybe 20 men who did that.

"Mainly they were people who were condemned, or who had been jailed for 25 years. They hadn't seen women for a long time."

Biggest risk factor

He fidgets as he talks, swallowing his words.

I'm scared. When I came out of prison I was sick with malaria, headaches, diarrhoea Bright Former inmate

His nervousness is understandable - it is illegal in Zambia for men to have sex with each other, and socially unacceptable.

A survey of prisoners in 1998 suggested that 27% were HIV-positive - eight points higher than the national rate at the time.

The organisation which carried out the research, In But Free, is updating its figures but is anticipating a similar discrepancy.

Many men will already be carrying the virus when they are imprisoned, but once inside it can be spread by tattooing and sharing razors.

The biggest risk factor, though, is sex.

Sex legislation

"When we gathered the prisoners in focus group discussions and asked how many had taken part in male-to-male sex, the answer was 'all of us'," says Dr Simooya, who heads In But Free.

"Most said it was because of boredom. But some mentioned that it was a form of exchange. You could give sex in return for soap, food, salt and so on.

Some inmates apparently want to spread HIV

"You can't legislate against sex," the doctor says.

"It's better to be practical and ask how we can prevent the transmission of HIV. We must consider putting condoms in prison."

It is a view shared by the medical director of the Zambia Prisons Service, Dr Chisela Chileshe. He refers to the ABC approach to HIV-prevention - abstain, be faithful, use a condom.

"Abstinence is the best, but I don't know how long you can be faithful if you spend 10 years in prison. Inmates are dying, and we need the well-established and recognised methods of prevention."

He has been lobbying politicians to allow condoms into prison but says moral concerns are getting in the way.

"We are talking about public health here. People must understand that health in prison is health in the community. The wall prevents an inmate from going outside, but the disease has no boundary."

For Elizabeth Mataka, the UN Secretary-General's special envoy on Aids in Africa, the solution is straightforward: do away with the law against homosexuality.

"By stopping condoms getting into prison, we are actually allowing transmission of HIV to go on unabated and losing control of the epidemic."

But the political will is lacking.

Short cut

National Aids Council (NAC) documents clearly state that "legislation to decriminalise homosexuality is urgently needed" so that condoms can be distributed to prisoners.

But when pressed, NAC admitted that the statement does not reflect government policy.

Activists believe that the answer lies in making homosexual acts legal

"Amending the law might take two or three years," worries Godfrey Malembeka, a former prisoner who is now a human rights activist.

"It's not only the Zambian government that needs to change. It's the whole of Zambia. We all believe in just one kind of sex - you must marry and beget children. These others types, we look at them as foreign, imported into our country.

"So we have the chiefs refusing this, we have the headmen refusing this, the church, the political leaders.

"But people are dying. We need to find a short cut."

One African country that has found a short cut is Lesotho.

Empty box

Homosexuality is illegal there too.

The prison authorities can't distribute condoms, but they can make them available.

So they simply leave boxes of condoms in strategic places and refill them when they are empty.

Does it work?

"The success story is that the condom box is usually empty," says Sharon Lesa Nyambe, who heads the United Nations Office on Drugs and Crime in Zambia. "Now they're trying to see how that translates into reduction in seroprevalence [the number of people with HIV]."

Would prisoners use condoms if they were made available?

She is hoping a similar scheme could be applied here.

But a big question remains. Even if condoms were made available to prisoners, would they use them?

"Surprisingly, most prisoners we've surveyed have said no," says Dr Simooya. "They think male-to-male sex is un-Christian, un-Zambian, and will promote homosexuality."

Bright has other reasons for thinking condoms might not be favoured by some of the prisoners, especially those serving long terms.

"One man told me he was HIV-positive and threatened to kill me if I didn't have sex with him. Those people don't want to use condoms. If your sentence is short, they want you to be positive like them and go and spread the disease outside."

Bright was tested for HIV when he left prison but never followed it up.

"I'm scared," he admits, catching his breath.

"When I came out of prison I was sick with malaria, headaches, diarrhoea. I was very scared that maybe they would find me with HIV, that's why I didn't go back."