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
“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
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
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
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
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.”