Limited provision of TB services in prison in countries receiving Global Fund grants

Only 50% of countries in receipt of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria provide tuberculosis (TB) services in prisons, according to research published in a special supplement of the Journal of Infectious Diseases. The study also showed that even when TB services were provided to prisoners they were limited in scope. Few of the programmes receiving a grant from the Global Fund offered services dedicated to the treatment and prevention of multi-drug resistant TB (MDR-TB).

“Most prison-based tuberculosis programmes supported through Global Fund grants offer limited services for prisoners,” comment the investigators. “There is a need to better define and promote a more comprehensive package of tuberculosis care tailored and adapted to delivery within congregate settings.”

There have been concerted efforts over the past two decades to scale up the control of tuberculosis. In 2010 the World Health Organization (WHO) produced a Global Plan to Stop TB 2011-2015.

Despite this, TB continues to be a major global health problem. In 2009 over 9 million new cases of the infection were diagnosed. MDR-TB is an increasing threat to public health, and strains of the infection have also emerged with resistance to second-line treatment options.

Marginalised populations such as prisoners are disproportionately affected by TB. The infection is a leading cause of serious illness and death among the 10 million individuals incarcerated worldwide.

“The physical environment of prisons concentrates and disseminates tuberculosis through overcrowding, poor ventilation, poor personal hygiene and risk behaviours,” note the researchers. “In addition, structural deficiencies of prison healthcare management, such as lack of funding for healthcare and inadequate infrastructure, staff resources, and expertise, adversely affect the quality of tuberculosis treatment and care.”

Since its establishment in 2003, the Global Fund has been the largest contributor to TB programmes. Investigators examined the Fund’s database to identify grants that were used to provide TB services to incarcerated populations.

By the end of 2010, 53 of the 105 countries (50%) with TB programmes supported by the Global Fund were delivering services in prison settings.

The number of countries providing these services increased steadily from 2003 onwards.

The total funding allocated to grants which included programmes in prisons was $558 million. This represented 28% of $2 billion invested by the Fund in TB initiatives.

But the investigators note that “no systematically captured data were available that would enable quantification of direct funding allocated in tuberculosis care and delivery within penitentiary settings.”

There were wide regional variations in the provision of prison services. Nearly 90% of countries in Eastern Europe and Central Asia with grants from the Fund had TB services for prisoners. However, only one country in Southern Africa delivered a TB programme in prisons.

“The particularly low coverage of tuberculosis services in Southern Africa, a region with a heavy HIV and tuberculosis burden, merits further investigation, especially given its relatively high median regional prison population,” comment the authors.

In all, 50% of the 38 countries with the worst TB epidemics provided prisoners with TB services.

Almost half (49%) of Global Fund-supported grants delivering TB services in prisons focused on the diagnosis and treatment of TB cases. Just over a quarter (27%) provided screening and monitoring services.

Only 7% delivered MDR-TB services in prisons. The investigators suggest that this is because “drug-resistance management requires extensive expert resources and dedicated infrastructure and is even more of a challenge in prison settings, where medical and specialized skills and available resources are severely constrained.” Despite this they believe “this issue will need to be addressed with a sense of urgency given that MDR-TB is particularly prone to propagation within prison walls.”

The range of services provided to prisoners using Global Fund grants was limited in scope. Some 69% of programmes only provided one service, usually focused on diagnosis and treatment, and less than a fifth offered two types of service.

“Our study is an important first step in establishing an overall picture of financial support for prison-based tuberculosis services from international sources to protect and improve the health of prisoners, a disadvantaged and marginalized group,” conclude the authors. “There is an urgent need to better understand the financing needs and cost-effective service delivery models for tuberculosis care in prisons.”

Lee D et al. Global Fund financing of tuberculosis services delivery in prisons. J Infect Dis, online edition. DOI: 10. 1093/infdis/jis042, 2012.