Print version ISSN 0043-3144
West Indian med. j. vol.56 no.1 Mona Jan. 2007
Evaluación del conocimiento y la actitud hacia el VIH/SIDA entre los reclusos de la prisión de Quthing, en Lesotho
VA AkekeI; M MokgatleII; OO OguntibejuIII
IQuthing Government Hospital, Quthing 700, Lesotho
IINational School of Public Health, University of Limpopo (MEDUNSA Campus), South Africa
IIISchool of Health Technology, Central University of Technology, Free State, Bloemfontein 9300, South Africa
OBJECTIVE: To assess the knowledge of and attitudes towards HIV/AIDS among the inmates in Quthing Prison, Lesotho.
OBJECTIVE: A semi-structured questionnaire was used to interview the prisoners. Of the 138 prisoners, 123 inmates were successfully interviewed. The data were collated and analyzed quantitatively using the SPSS computer software programme.
RESULTS: Ninety-two per cent of the respondents were in the age group 2044 years, while 57.7% were single and had never married. Knowledge about HIV/AIDS was found to be high, as 95.5% of the inmates knew the cause of the disease and over 70% of the inmates knew how it could be transmitted or prevented. A majority of the respondents (68.1%) agreed that people with the disease should be isolated (evidence of unfavourable attitudes); 31.2% believed that there were holes and worms in the condoms (misconception) and 41.5% would not use condom (prevent full sexual enjoyment) despite the risk associated with non-use.
CONCLUSION: Knowledge about HIV/AIDS was found to be high and prisoners had misconceptions about HIV/AIDS and use of condoms.
OBJETIVO: Evaluar el conocimiento y actitud hacia el VIH/SIDA entre los reclusos de la prisión de Quthing, en Lesotho.
MÉTODO: Se aplicó un cuestionario semiestructurado para entrevistar a los prisioneros. De los 138 prisioneros, 123 fueron entrevistados con éxito. Los datos fueron recopilados y analizados cuantitativamente usando el programa SPSS.
RESULTADOS: Noventa y dos de los encuestados estaban en el grupo etario de 20 a 44 años, mientras que el 57.7% eran solteros y no habían estado casados nunca. Se halló que el conocimiento sobre el VIH/SIDA era alto, ya que 95.5% de los reclusos conocía la causa de la enfermedad, y más del 70% de ellos sabía como podía trasmitirse y prevenirse. Una mayoría de encuestados (68.1%) estuvo de acuerdo en que las personas con esa enfermedad debían ser aisladas (evidencia de actitudes desfavorables); el 31.2% creia que habían huecos y gusanos en los condones (concepción errónea); y 41.5% no usaría condones (alegando que impiden el pleno goce sexual), a pesar del riesgo asociado con el abandono de su uso.
CONCLUSIÓN: Se hallo que el; conocimiento sobre el VIH/SIDA era alto, y que los prisioneras tenían
concepciones erróneas sobre el VIH/SIDA, y el uso de los condones.
Despite the remarkable progress that has been achieved in gaining a scientific understanding of the HIV infection as well as the nature and progression of AIDS, the search for an effective treatment has proven to be elusive. The main response worldwide to the HIV/AIDS epidemic has been preventive intervention (1). Knowledge and attitudes studies are generally used in designing health promotion and health education programme interventions that would be used to impact knowledge, alter attitudes and behaviour that are risky to health (2).
In Lesotho, prevention of HIV in prisons is a neglected area and so a review of the literature showed no published report about HIV/AIDS in prisons in Lesotho. However, according to the final report of a government commission of inquiry in 2003, the Lesotho Prison Service is faced with numerous problems ranging from the antiquated and dilapidated state of the buildings of the majority of the prisons, overcrowding, lack of resources and that the prisoners are idle, bored and unhappy. The Quthing district has only one prison, which is a medium security prison for males, and it was built in 1940. The official capacity of Quthing prison is 66 inmates, but at the time of this study, there were 138 prisoners, making the percentage occupation to be 209.1% (3).
The first case of AIDS in Lesotho was reported in 1986 in the district of Mokhotlong, while the first case in the Quthing district was recorded in 1989 (4). Ever since the first reported HIV case in Lesotho, the infection has made rapid and devastating advances and new cases have been on the increase. The epidemic has reached crises-like proportion. The median prevalence of HIV among antenatal clinic (ANC) attendees in Lesotho has increased by 41.8% between 2000 and 2003, with the highest rate of increase of 42.5% observed in Quthing district (5, 6). The prison is not excluded from this crisis. A rise in the incidence of HIV/AIDS among the prisoners will be an additional cost to governments spending on health, since these prisoners usually receive free medical care. For the majority of people in detention or custody there is no provision of condoms and clean needles. Also, there is paucity of counselling and support for prisoners living with AIDS. The lack of retrievable data not-withstanding, anecdotal reports from clinical practice have shown that there is a high prevalence of STDs in Quthing prison. This study is aimed at assessing the level of know-ledge of prisoners about HIV/AIDS and the attitudes of these prisoners towards HIV/AIDS and to identify ways to improve the prisoners understanding of the issue of HIV/AIDS.
SUBJECTS AND METHODS
Unlike the general population, the prison has peculiar characteristics such as gender composition and exertion of rights. All these characteristics were taken into consideration in designing this study. The study was a descriptive survey where quantitative data were gathered to address the objectives of the study. It was carried out at Quthing District Prison, Lesotho. This serves as a correctional and punitive facility for males.
Although some inmates can read and write in Sesotho (the national language), very few of them can do the same in English, therefore it was necessary to interview them in Sesotho.
The ages of the prisoners ranged from 1855 years with over 90% of the inmates in the 2544 years age group. The majority of them came from Quthing District and were mostly herdsmen. The offences committed were mostly against properties and persons. The inclusion criteria were participants who were registered inmates of Quthing prison at the time of the study, all age groups in the prison were eligible for the study, all nationalities that were inmates in this prison were eligible to participate in this study. The exclusion criteria were refusal to participate or sign the consent forms and too ill to participate.
Data Collection Instrument
The instrument for data collection was a questionnaire consisting of semi-structured questions. The questionnaire was divided into four sections. The first section elicited questions on the personal data and demographic characteristics, while the second section dwelt on the knowledge about HIV/AIDS regarding its cause, modes of transmission, and signs and symptoms. The third section assessed the attitudes regarding HIV/AIDS. The questionnaire was written in English and translated into Sesotho so that the respondents understood the questions clearly. The consent forms were also translated into Sesotho. The questionnaires were prevalidated by the Ministry of Education for the authenticity and accuracy of the Sesotho translation before use.
Field workers were recruited and received one-day training on how to use the questionnaire. These field workers were undergraduate students of Theology at the National University of Lesotho (NUL) doing a three-month attachment at Quthing hospital on HIV/AIDS related issues such as voluntary counselling and testing (VCT). This team of fieldworkers consisted of two males and four females, all of whom spoke Sesotho. Written permission to interview the inmates was obtained from the prison authorities before the interview. Prior to the interview, a two-hour session was spent with the prison inmates to explain to them the nature of the study. Informed consent was obtained from the inmates by signing of the consent forms after the contents of the form had been explained to them in Sesotho. The field workers also helped to fill in the responses of the inmates. Confidentiality of the respondents was maintained. No names were recorded as part of the personal data. Personal data included the age, marital status, educational level and previous home address. All completed questionnaires were enclosed and sealed in envelopes that were provided for the respondents before submission. The data were collated and analyzed quantitatively by the use of SPSS computer software.
Limitations of the study
The study was limited by the paucity of literature regarding knowledge and attitudes on HIV/AIDS in prisons in Lesotho since this is the first study carried out among prison inmates in Lesotho. The study was done in only one prison in the country due to the problems of logistics and financial constraints, however the findings in this work are expected to give an insight into what prevails in other prisons in the country. Another drawback of the study is non-coverage of females so as to have a gender comparison. Out of the 138 inmates in the prison, only 123 were satisfactorily interviewed. The reasons cited for non-participation is unwillingness to discuss sex and sexually transmitted diseases (5/15) or that they were not interested (3/15), or engaged in sanitary exercise in the prison (3/15), and illness (1/15). Three inmates did not respond to almost half of the questions presented and so their questionnaires were discarded.
This result is based on the complete information collected by interviewing the 123 inmates of the Quthing Prison. All the completed questionnaires from the 123 inmates were back translated from Sesotho into English. A descriptive analysis of the quantitative data collated was done as presented below.
The age distribution is shown in Table 1. Ninety-two per cent of prisoners were in the age group 2044 years, while the age group 2529 years alone accounted for more than a third of this (35.8%). The inmates between the age of 1519 years and those 45 years and above accounted for 4.1% and 4% respectively. The mean age of the inmates was 29 years while the modal age was 27 years.
The marital status of the prison inmates is represented as follows: 71 (57.7%) of the inmates were single and had never being married, 39 (31.7%) were married. Five (4.1%) of the inmates were divorced, three (2.4%) widowed and five (4.1%) were separated.
Ninety-nine per cent (80.5%) of the prison inmates were Christians; 13 (10.6%) were followers of traditional religion; three (2.4%) were Muslims and others, six (6.5%).
Most of the prisoners had little or no formal education. For example, those who had never been to school were 43 (35.0%) and those with primary school education were in the majority 49 (39.8%) while those with secondary and high school education were 23 (18.7%) and 8 (6.5%) respectively.
The occupations of the inmates showed that about 101 (82.1%) of 123 of the inmates were herdsmen, while 15 (12.2%) were self-employed and 7 (5.7%) were unemployed.
Knowledge of HIV/AIDS
Although most of the prisoners had heard of HIV/AIDS (81.2%), about one out of five prisoners had never heard of the infection/disease.
Source of Information about HIV/AIDS
Among the respondents who had heard about HIV/AIDS, the source of information for most of them was through the electronic media namely, radio/television (25.4%), followed by those who obtained information from friends and relatives (19.8%). Those who heard through healthcare workers, public gathering speech and posters/fliers were 17.2%, 13.8% and 11.6% respectively and 8.2% of prisoners heard from within the prison from other inmates or from prison officials (Table 2).
Causes of HIV/AIDS
The current study showed that among the inmates who had heard of HIV/AIDS, 95.8% of them thought that it was a disease caused by a virus while 2.1% believed that it was a disease caused by witchcraft and another 2.1% thought that the cause was unknown.
Mode of transmission
Most of the respondents who had heard about HIV/AIDS knew most risk factors for the transmission of HIV from one person to another. For instance, most of them knew that un-protected sexual intercourse with an infected person (95.7%), transfusion of infected blood and blood products (93.4%), sharing/exchanging used needles with an infected person (83.1%), transmission from an infected mother to an unborn baby during pregnancy, were some of the actions that could transmit the virus from one person to another. It was noted that a substantial number, namely one in two of those who had heard about the infection believed that sharing cups and plates with infected persons could transmit the virus. Also, most of them did not know that a child could contract HIV during breast-feeding from an infected mother. Only 54% were aware of this and 46.2% of those who had heard of HIV/AIDS believed that the infection might be transmitted by sharing bathroom with an infected person (Table 3).
Table 4 illustrated that most of those who had heard about HIV/AIDS knew some of the preventive measures like abstinence from sex (73.7%), regular use of condom during sexual intercourse (74.4%), and being faithful to ones sexual partner (74.2%). However, a third of the inmates felt that having sexual intercourse with virgins could prevent the disease. Similarly, about one in five would believe in traditional protective measures.
Of those who had heard about HIV/AIDS, 15.5% (13/84) believed that HIV/AIDS had no signs and symptoms. Most of them knew that chronic diarrhoea (75%: 63/84) and swollen glands (76.2%: 64/84) were associated with HIV/ AIDS. Fever (54.8%: 46/84; loss of appetite (61.9%: 52/84; feeling weak and easily tired (60.7%: 51/84) were other signs and symptoms identified by the inmates.
Cure of HIV/AIDS
The majority believed that HIV/AIDS could not be cured (88.4%). Among those who believed that HIV/AIDS could be cured (11.6%), a third believed that it could be cured using natural herbs (33.3%). Some 28.6% of the inmates thought that traditional healers could cure it, and this compared with only 23.8% that believed that doctors in the hospitals could do so. However, 9.5% believed that having sex with virgins could cure HIV/AIDS while 4.8% of the inmates felt that casting out evil spirits could cure the disease.
Views on People with HIV/AIDS
Most of the respondents about 7 out of 10 who claimed that they had heard about HIV/AIDS believed that people living with HIV/AIDS should be isolated, while about 90% of the respondents believed that prospective prison inmates should be tested for HIV before admission into the prison and 90% believed that people should be tested for the virus before marriage. Only half of the respondents disagreed that people who had the disease deserved their fate because they led immoral lives (Table 5).
Attitudes about Prevention /contracting HIV/AIDS
Abstinence, faithfulness to ones sexual partner and regular use of condom during sexual intercourse would prevent or reduce the sexual transmission of HIV [78.5% (73/93)]. On the other hand, about a third thought that there were holes and worms in the condoms and so it was not healthy to use it while the same number of inmates were not sure of this. About three in ten did not want to discuss HIV/AIDS because they felt it was immoral to discuss sex and sexually transmitted diseases. However, substantial number of them about nine out of ten agreed to accept HIV prevention programme in the prison. It is significant to note that 41.5% would not use condom, as they believed it prevented sexual enjoyment in spite of the risk of non-use.
Testing for HIV and reasons for not testing
Among those who had heard of the disease, 91.5% would like to have the HIV test. For those who did not want to be tested (8.5%), most of the reasons advanced were that it was of no use since there was no cure (37.5%: 3/8), and that they were scared of the outcome of the test (37.5%: 3/8). Only a quarter thought people would isolate them if they were positive for the test.
The results of this study compared very well with the report of the 2002 reproductive health survey of Lesotho (7). Most of the singles may eventually get married and the married inmates would return to their wives after their release from the prison. Hence the importance of HIV/AIDS intervention programmes for the inmates. These HIV/AIDS programmes should include education and counselling in the prison. This will help them to have a healthy life-style both within and outside the prison.
According to a report, the Basotho are predominantly Christian. The main denominations are Roman Catholic, Lesotho Evangelical and Church of England (Anglican). The congregations of Methodists, Seventh Day Adventists and Pentecostal churches are in the minority (8). There is a very small Moslem community. The religion of the prison in-mates mirror that of the general Basotho population with 80.5% of the inmates being Christians. Religious beliefs of individuals do have significant bearings on the knowledge and attitudes and beliefs that affect the transmission of HIV/ AIDS in both positive and negative ways, for example the Catholic Christians frown at the use of condom. Also, all religions or denominations in Quthing do not support pre-marital sex, sexual promiscuity or homosexuality.
Most of the inmates could not read or write in English. Based on these facts, any campaign programme against HIV/ AIDS for the prison inmates will have to be in Sesotho for easy understanding. The results of the study showed that the majority of the inmates (82.1%) were herdsmen not employed by the government. Most of the prisoners were from impoverished, communities and low socio-economic status and ignorance were risk factors for the transmission of HIV/ AIDS. From this study, more than 70% of the prisoners were jailed for less than one year and 10% were incarcerated for 4 years or more. This implies that an intensive programme on HIV/AIDS that would involve frequent interactions between the prisoners and those who implement the programmes would be needed in the prison so that the programmes could impact meaningfully on the prisoners before their discharge from the prison.
In the Lesotho reproductive health survey in 2002, over 90% of the respondents had heard of HIV/AIDS though not all of them knew that it was a sexually transmitted disease (7). Comparatively, the figure was lower in the prison (about 80%), perhaps because of the small sample studied. The source of information about HIV is very important. Most of the respondents who had heard of HIV/AIDS heard it for the first time from the electronic media ie radio and television (25.4%). Friends and relatives as sources of information about HIV/AIDS followed this (19.8%). Only 0.4% of the inmates had heard about HIV/AIDS for the first time in the Church and 1.7% heard at school prior to incarceration. This means that the churches and schools are probably not playing their expected roles in the campaign against HIV/AIDS since most of the inmates were Christians and had primary school education. Although it could not be verified if the prisoners who claimed to be Christians actually attended the Church regularly prior to incarceration. Issues regarding HIV/AIDS could be discussed at public gatherings and in churches and the schools from the primary school. This would have benefitted the prison inmates since most of them had primary school education. More programmes concerning HIV/AIDS should be discussed on radio and television since they are already major sources of information about HIV. There should be more open discussion of HIV/ AIDS at home and among friends. The print media, healthcare workers and the prison officials still have a major role to play in the dissemination of information regarding HIV/AIDS. Among the inmates that had heard about HIV/AIDS, a majority (95.8%) knew that HIV infection was caused by a virus (95.8%) and heard of factors that could increase the chances of transmission from one person to another. This notwithstanding, misconceptions about the mode of HIV/ AIDS transmission were rife among the prisoners. Some of the inmates believed that HIV could be transmitted from one person to another by sharing cups and plates with HIV-infected persons (53.8%) and that it could also be transmitted from one person to another by sharing bathrooms (46.2%). These misconceptions are dangerous and could fuel stigmatization and discrimination against persons living with HIV/AIDS. Also about one in five inmates did not know that HIV/AIDS could be transmitted from an infected mother to an unborn child during pregnancy. It is essential that this knowledge be passed on to the prisoners and the community at large because it is now possible to reduce the transmission of the virus from a pregnant mother to the unborn child through the use of anti-retroviral medications (10). For-tunately, Lesotho is one of the few African countries that provide the Prevention of Mother to Child Transmission of HIV (PMTCT) programme to the HIV positive mothers, by the provision of free nevirapine treatment. The pilot project started in eight centres in 2003 and the implementation of the programme is expected to be countrywide by 2004. Again, 54.9% were unaware that the child could be infected with HIV from an infected mother through breast-feeding. This mode of transmission can be prevented or reduced either by exclusion of breast feeding and feeding with artificial formulae alone.
Over 70% of those who had heard of HIV/AIDS knew the facts about preventing HIV transmission through sexual intercourse, namely abstinence, faithfulness to ones sexual partner and regular use of condom. One out of three of the respondents believed that having sexual intercourse with virgins could prevent HIV; this could encourage raping of innocent children including babies. About 22.8% of them believed that HIV infection could be prevented by the use of traditional protective measures. Over 60% of the inmates who had heard about HIV/AIDS knew that the infection/disease has signs and symptoms like weight loss, chronic diarrhoea, poor appetite and feeling weak or tired. The knowledge about the signs and symptoms of the disease is good because it will help patients to seek medical help early.
Only few inmates, about one in ten of those who knew about the disease believed that it could be cured. The more people believe that HIV/AIDS could be cured, the less likely they are to practice safe sex or abstain from risky behaviour that increases the transmission of the infection. The non-availability of cure for HIV/AIDS creates fear in the minds of people and motivates them to protect themselves against the disease.
It was noted during this study that about seven out of ten of the inmates that had heard of HIV/AIDS believed that people living with HIV/AIDS should be isolated. Also, only half of them disagreed that people who had HIV/AIDS deserve their fate because they led immoral lives. This is unfortunate since such attitudes towards people living with HIV/AIDS will further enhance stigmatization and discrimination against them. This will further reduce the rate of voluntary testing for the virus and self-reporting of HIV status, thereby militating against the campaign for safe sex and other behavioural modifications that will prevent the spread of HIV infection.
In the opinion of 90.4% of those who knew about the disease, prison inmates should be tested before admission to the prison. This contravenes the WHOs guidelines on HIV infections and AIDS in prisons (11). These guidelines do not support the mandatory testing of inmates for HIV and the segregation of seropositive inmates. Mandatory testing is not practised outside the prison and so it should not be practised inside the prison. About 9 out of 10 of the inmates who knew about HIV/AIDS also agreed that people should be tested before marriage. This would be a welcome practice but will have to be accompanied by voluntary counselling and testing (VCT), and the partners will have to be willing to disclose their HIV status to each other (12).
Education on sex, condoms and condom use is needed in the prison in order to clarify the misconceptions regarding abstinence and condom use. It was noted that some of the prisoners, about a third of them did not want to discuss HIV/ AIDS and sexually transmitted diseases because they felt it was immoral to do so. Communication is very important in the prevention against HIV/AIDS. For people to know about the infection and ways to protect them against it, every aspect of the infection and its prevention must be discussed freely. It was very encouraging to note that 91.5% of the respondents were ready to accept HIV/AIDS prevention programmes in the prison. If their acceptance and participation are guaranteed, chances are that the implementation of any HIV prevention programme in the prison would succeed.
Prisoners were asked if they would like to be tested for HIV. Most of them (91.5%) said that they would like to be tested for the virus. Some did not want to be tested because of fear of the result, fear of stigmatization and lack of a cure for HIV/AIDS. Voluntary testing and counselling is crucial to the prevention of HIV/AIDS and it is an integral part of the campaign programmes especially among individuals at high risk of contracting HIV.
The following conclusions and recommendations were made from this study. Knowledge about HIV/AIDS among inmates was high. Misconceptions about HIV/AIDS were rife among the prisoners and educational programmes would be needed to correct these. Most of the prisoners still have unfavourable attitudes towards people living with HIV/AIDS and this would encourage stigmatization and discrimination against those who are HIV-positive. This would also militate against voluntary counselling and testing, as people would not want to be tested for the fear of being isolated if they were positive. The churches and schools need to play more active roles in the campaign against HIV/AIDS. Intravenous drug use was not a common practice among the inmates of Quthing prison.
Recommendations and Policy Implications
Any intervention programme against HIV/AIDS in prison must involve not only the prisoners but the prison officials and the entire community from which they come. The sup-port of the government, non-governmental organizations (NGOs) and all other stakeholders would be needed in the campaign against HIV/AIDS in the prison and the community. Based on the results of this study, it is recommended that the following interventions and strategies should be put in place.
HIV/AIDS education and counselling in the prison
Education about HIV/AIDS is recommended. Multi-sectoral approach should be adopted. Partners in this effort should include the correctional service authority, ministry of health and social welfare, private sector, non-governmental organi-zations (NGOs), Lesotho AIDS programme co-ordinating authority (LAPCA), National AIDS Committee, community based AIDS and health organizations as well as concerned individuals.
There should be preventive educational programmes for the prison staff and authority. The aim should be to create and promote awareness on safe working methods. This pro-gramme should be available as an induction course imme-diately upon entering the prison service. The syllabus of such a programme should include topics like identification and prevention of communicable diseases, response to the needs of prisoners, HIV/AIDS and other STDs.
Accommodation for the prisoners and staff
Overcrowding in the prison will militate against the HIV/ AIDS prevention campaign in the prison, as it will increase high-risk sexual behaviour and worsen the clinical condition of those who are already ill. Overcrowding is linked to the spread of tuberculosis in prison and tuberculosis is known to worsen the immune status of people living with HIV/AIDS. According to the United Nations (13) Committee on Crime Prevention and Control, recommendations on the standard minimum rules for the treatment of prisoners, stipulate that when sleeping accommodation is in individual cells or rooms, each prisoner shall occupy by night a cell or room by himself (UN, 1984). This is not so in Lesotho. Efforts should be doubled to provide adequate and healthy accommodation for the prisoners.
The prison authority must try as much as possible to provide the prisoners with facilities for the proper care of their hairs and beard. Men should be able to shave regularly and should not be allowed to share sharp shaving instruments like razor blades, as sharing will facilitate the spread of HIV among inmates if an instrument contaminated with blood infected with HIV is used by an uninfected inmate.
Provision of Condoms
Condoms should be provided freely and regularly in the prison. They should be kept at strategic places as is done in other institutions.
Inmates who are dying from full-blown AIDS should be granted compassionate early release from the prison as soon as possible. This will enable them to make contacts with their relatives and friends and to face death with dignity and freedom. However, the social worker must investigate before hand if the prisoner will have adequate housing and care upon release.
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Dr OO Oguntibeju
School of Health Technology3
Central University of Technology
Free State, Bloemfontein 9300, South Africa