Accelerating Services for Key Populations in Uganda and South Africa

Tuberculosis (TB) is the leading cause of death for people living with HIV (PLHIV). For many key populations – including gay and bisexual men, people who inject drugs, female sex workers, and incarcerated populations – timely TB testing and treatment has historically been out of reach due to stigma and discrimination. With support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), CDC is tailoring  HIV and TB services and programs in Uganda and South Africa to meet the unique needs of these populations and provide high-quality care. The results have been life-changing.

HIV and TB Among the Incarcerated

Internationally, prisons have reported high prevalence rates of both HIV and TB. The United Nations Office on Drugs and Crime estimates that among the 11 million people held in prisons and other closed settings at any given time globally, 528,000 are living with HIV. According to USAID, TB incidence among the incarcerated is 5 to 70 times greater than in outside communities due to severe overcrowding, poor nutrition and ventilation, and insufficient access to healthcare. Additionally, Multi-Drug Resistant (MDR) TB, which is defined as resistance to the two first-line TB drugs, is four times higher in prisons than in the general population. CDC Uganda TB expert, Dr. Deus Lukoye, recognizes the issue that MDR-TB causes among populations. “Many MDR-TB patients are diagnosed late. Some outrightly refuse to take medication due to associated side effects, poor feeding, or drug stock-outs, as often happens with TB treatment programs. Then there is the problem of re-infection because of continued exposure while in prison —all contributing factors to MDR-TB, especially in prisons,” says Dr. Lukoye.

“I now feel much better and believe I will totally be healed.”

CDC Uganda has supported the Uganda Prison System (UPS) since 2005 to address MDR-TB in prisons. With support from PEPFAR, CDC provides diagnostic and clinical services within a dedicated treatment center for inmates with MDR-TB. CDC equipped and furnished the ward and provides ongoing training and mentorship for the UPS medical team to manage MDR-TB safely and effectively in prisons. Additionally, CDC renovated laboratories in five regional referral hospitals to improve the time to diagnosis and referral of MDR-TB cases among prisoners and is now renovating the UPS primary reference laboratory. CDC also provided six GeneXpert® machines (state-of-the-art diagnostic equipment for TB that shortens the time to diagnose drug-resistant strains of TB from weeks to only a few hours) to regional prison facilities. Finally, to ensure no prisoner with suspected MDR-TB is left undetected, CDC helped provide 14 motorcycles to facilities without GeneXpert machines to aid in the delivery of specimens for testing. Before these diagnostic services were established in prisons, MDR-TB was often diagnosed late leading to devastating outcomes.

The impact of the new ward continues to be felt. Eli, 42 years, is just a few months away from finishing treatment and he cannot wait. “Three months, to be exact,” he says, waving three fingers on his right hand. “I have religiously taken my medicines and counting down to a clean bill of health.”

Eli, who has been in prison for six years now, first tested positive for TB in July 2019 while incarcerated in a regional facility. In 2020, he checked himself into the prison clinic and was diagnosed—this time—with MDR TB after the  dreaded symptoms resurfaced: chest pain, major joint pains, fever and night sweats, loss of appetite, and drastic weight loss.

“I was very sad and depressed that I had not only got TB again, but a more difficult strain,” he says. “On being initiated on treatment, I suffered serious treatment side effects and was unable to walk for four months. But the health workers told me this would subside and encouraged me to continue taking my drugs as prescribed. They also supported me with better meals, unlike during the first infection, which was difficult to adhere to because of poor feeding. I now feel much better and believe I will totally be healed,” he says.

Eli is now culture-negative, off the ward, and re-integrated with other inmates. With all he has learned, Eli now provides peer support to those who test positive for TB—encouraging them look beyond the treatment side effects and adhere to their treatment in order to get well.

Leveraging Impact in South Africa

In 2021, CDC South Africa, with support from PEPFAR and implementing partner TB HIV Care, piloted a novel study to assess integrating viral hepatitis services into the existing HIV program in the Goodwood Correctional Centre.

Dr. Joel Steingo, Correctional Services Programme Director at TB HIV Care, said conducting this study in a correctional setting is critical as hepatitis B (HBV) and hepatitis C (HCV) have similar transmission routes as HIV. “The limited data available from South Africa shows a high prevalence of both HBV (up to 3.4%) and HCV (up to 6.4%) in correctional settings. If untreated, both HBV and HCV can lead to life-threatening complications such as liver cirrhosis and liver cancer. Despite this, viral hepatitis has been largely neglected at a primary healthcare level – including in the correctional centers – in South Africa,” he explained.

The study investigators aim to administer the hepatitis B vaccine to 750 people by mid-2022. As of March 2022, 201 individuals had received their first dose of the vaccine, 98 had received the second dose, and 54 had received the third dose. Additionally, 738 people have been tested for hepatitis since the study began – 30 had hepatitis B, 4 had hepatitis C, and 5 had HIV.

Helen Savva, CDC Key Populations Lead, said the study results would strengthen the knowledge and programmatic implementation in prisons in South Africa. “The data will also provide a platform for strengthening government policy, particularly supporting inmates in correctional facilities and other members of key populations,” she added.

A Call for Quality Care for All

Providing quality and timely care for incarcerated individuals improves their health outcomes and reduces community spread beyond prisons. Penitentiaries can often become reservoirs for infectious diseases like TB, HIV, and hepatitis. This endangers not only inmates but also guards, civilians, and visitors, which can threaten the health of the public outside of the prison systems. CDC is dedicated to supporting testing, quality treatment, and disease prevention measures in this key population to help eliminate TB and achieve HIV epidemic control.