Worldwide one of the main types of high-risk behaviour in prisons is the sharing of contaminated needles by injecting drug users – this is not a major problem in African countries. However the already extraordinarily high HIV infection rates in the wider community, lack of medical care and unprotected sex between men are the major factors that see mortality rates in African prisons outstripping African societies at large.

According to the UN Regional Report 2003, the extent of sexual activity in prisons is difficult to determine because studies must rely on self-reporting, which is distorted by embarrassment or fear of reprisal. Sex is prohibited in most prison systems, leading inmates to deny their involvement in sexual activity. Sex in prison usually takes place in situations of violence or intimidation, thus both perpetrators and victims are disinclined to discuss its occurrence.

In women’s prisons where there are male prison staff, sex between men and women may also take place, UNAIDS pointed out, creating a risk of HIV transmission.

Homosexual activity is illegal in every southern African country with the exception of South Africa. However, according to UNAIDS, 8.4% of men in the Zambian prison of Kamfinsa, reported anal sex in a study in 1995, the true figure is likely to be higher (IRIN PlusNews 2005).

Voluntary counselling and testing project was started at Kamfinsa Prison in Zambia in 2003 (Pupwe). Kamfinsa has 10,000 inmates male and female and all were invited to attend educational classes around HIV with voluntary testing and counselling available at the prison. 35 peer counsellors were trained to give support to fellow inmates. Out of 200 inmates tested 24% were found to be HIV-positive. Education classes had a 100% take up rate.

A 1999 Penal Reform International study of Zomba prison in Malawi reported respondents as estimating that between 10-60% of prisoners had participated in homosexual activity at least once (IRIN PlusNews 2003).

Three aspects of man-to-man sexual activity in prison make it a high risk for HIV transmission: anal intercourse, rape and the presence of sexually transmitted infections (STIs). Related problems in prisons across southern Africa include overcrowding, shortages, corruption, and the presence of juveniles alongside adult prisoners.

The Zomba study noted that those who served as the "receptive partner" were usually: "recently detained, either juveniles or young adults, who have no blanket, soap, plates or food. They have no relatives from the outside to help them and care for them, they are in physical need and confused by their recent detention, and they turn to somebody to care for them. The ones they usually turn to are those who have outside supplies. The relationship between them was described as similar to that between a poor prostitute and a rich client."

The report also noted the existence of "prostitution rings", in which guards were involved in smuggling juveniles into the adult blocks, sometimes for as little as 30 US cents. The practice was assisted by inadequate supervision and segregation of juveniles from adult inmates.

The appalling physical conditions of most prisons in Southern Africa, along with inadequate nutrition and health services, exacerbates the incidence of AIDS. Particularly serious is tuberculosis (TB), which can easily spread in overcrowded prison conditions. People with HIV are especially vulnerable to TB, and HIV-positive people can transmit the disease to those not infected with HIV, the UNAIDS report warned.

Rather than accepting the reality of sexual activity and the attendant risks, most prison authorities in Southern Africa refuse to provide condoms for inmates in the belief that it will encourage homosexuality. Attitudes of denial will have to change if societies want to see the rate of HIV infection - inside prison and outside - decrease.

UNAIDS says: "Recognising the fact that sexual contact does occur and cannot be stopped in prison settings, together with the high risk of disease transmission that it carries; UNAIDS believes that it is vital that condoms and lubricant should be readily available to prisoners. This should be done either using dispensing machines, or supplies in the prison medical service."