Monday, February 12, 2007

Bushenyi Prison screening day report


Busheyni is a small town in southwest Uganda and is the site of the district administrative headquarters and the district prison. There is a brisk turnover of prisoners since many are on remand.
Ishaka Adventist Hospital (IAH) has a pre-existing relationship with the prison. Some of the hospital staff undertake pastoral work in the prison, which includes an element of health promotion. PEPFAR funding has been applied for to begin HIV outreach work in the prison. The prisoners are brought to the hospital for medical treatment though attendance is limited by the lack of fuel for transport.
A large proportion of presentations to IAH outpatient department were for sexually transmitted infections (STIs). With the support of the prison officer in charge it was decided to screen and treat all the prisoners on a single day. Prison staff were also invited to take part in the screening.
Prior to the visit the main identified health problems were scabies, diarrhoeal illnesses, malaria, STIs (including HIV) and malnutrition. Poor funding results in very limited access to clean water, nutritious food, fuel for cooking and healthcare.

The prison was visited on 4 occasions before the testing and treatment date. The first visit was in mid January to establish the approximate numbers involved and that the project was feasible. The second visit was 10 days before the date, to check facts and confirm feasibility. The third visit was 6 days before the date, to undertake sensitisation amongst the prisoners. The final visit was the day before the test date to set up the site.
On the afternoon of 8th February, a meeting was held with all members of the screening team. At this meeting everybody was familiarised with the screening process(Appendix A), questionnaire(Appendix B) and treatment protocol(Appendix C).

The members of the screening team were as follows;
2 Medical Officers
3 Clinical Officers
4 Enrolled Nurses
2 Nurse Assistants
14 2nd year Student Nurses
4 HIV Counsellors (3 from Bushenyi Medical Centre)
1 Volunteer Counsellor
2 Laboratory Technicians
12 Laboratory Students
Bushenyi Medical Centre also supplied a centrifuge and some of the HIV determine rapidtests.

After group counselling sessions all prisoners and staff were invited to opt into the screening programme. We used two rapid tests supplied free by Qualpro Diagnostics of India. The first, ‘retrocheck’ is a sensitive screening test for HIV antibodies in blood and serum samples. The second test, ‘syphicheck’ is a sensitive screening test for antibodies to Treponema Pallidum and indicates a previous or current syphilis infection. All who volunteered to be screened were also subjected to a sexual health questionnaire and a consultation with a clinical or medical officer.
All the prisoners were de-wormed with mebendazole.
All prisoners with symptomatic scabies were treated with benzyl benzoate.
All who tested positive for syphilis were treated with benzathine penicillin.
Genital ulcer disease, urethral/ vaginal discharge and lower abdominal pain in women were treated syndromically according to a pre-agreed protocol.
Those symptomatic for malaria were treated with co-artem (artemether and lumefantrine).
Some prisoners had bloody diarrhoea and were treated with ciprofloxacin and oral rehydration solution (ORS).
All those who tested positive for HIV received post test counselling(Appendix D) and were offered co-trimoxazole prophylaxis, multivitamins and a 2 week follow up for CD4 count.

On the day of testing, there were 407 inmates. Of the 21 female prisoners, 17 (81%) agreed to test. Of the 386 male prisoners, 320 (82.9%).
A total of 390 people were seen for testing and treatment. This comprised 17 female prisoners (4.36%), 12 female staff (3.1%), 18 staff children (4.62%), 1 prisoner child (0.26%), 320 male prisoners (82.06%) and 22 male staff (5.64%)

A total of 55 are HIV positive. Of these, five already knew they had HIV, two female and three male prisoners. Of the 50 new cases, 1 was a female staff member, 47 were male prisoners and 2 were male staff.
One prisoner was taken to court and released after testing but before the results were available (he tested positive for syphilis as well as HIV). One staff member requested syphilis testing only. His blood was tested for HIV in error, he was positive, but declined when informed of the mistake and offered the result.
Of the 17 female prisoners, 2 are positive (11.76%)
Of the 320 male prisoners, 47 are positive (14.69%)
Of the 12 female staff, 1 is positive (8.33%)
Of the 22 male staff, 2 are positive (9.09%)
Two male prisoners’ results were indeterminate. They tested positive with retrocheck, and were negative with HIV ‘determine’ and HIV ‘statpack’ (confirmatory tests). They were told their result was negative and were advised to retest after 3 months.
There were 108 positive syphilis tests.
Of the 17 female prisoners, 4 (23.53%) were positive.
Of the 320 male prisoners104 (32.5%) were positive.
No staff members tested positive for syphilis.
Sexually Transmitted Infections
There were 10 cases of Genital Ulcer Disease (GUD).
There were 37 cases of Urethral or Vaginal Discharge Syndrome (U/VDS)
There were 5 women with Pelvic Inflammatory Disease (PID)
There were 239 people with scabies.
Of the 17 female prisoners, 4 (23.53%) had scabies.
Of the 12 female staff, 2 (16.7%) had scabies.
Of the 18 staff children, 1 (5.6%) had scabies.
Of the 1 prisoner child, 1 (100%) had scabies.
Of the 320 male prisoners, 231 (72.2%) had scabies.
Of the 22 male staff, none had scabies.
23 prisoners were treated for malaria
12 prisoners were treated for gastroenteritis

A dispensary was set up and drugs were dispensed according to the protocol. Where possible single dosages were used, and prisoners were observed taking medication. Any prisoner who had received IM penicillin was observed for 30 minutes in case of anaphylaxis.
An estimate had been made of the incidence of HIV, syphilis, STI’s and scabies. Sufficient mebendazole was taken to treat everyone. Supplies ran out of doxycycline, erythromicin, benzyl benzoate and benzathine penicillin, and we restocked from the hospital pharmacy and local drug shops.

Total cost (rapid tests and labour provided free) 1,012,937 Ugandan Sh

This works out at 2600Ush ($1.45 USD) per test and treatment unit.

Sensitisation at the prison worked well. The prison in-charge and staff were well briefed and cooperated very well on the day. The high take up rate amongst prisoners and staff indicates that the sensitisation was successful.
The briefing of health personnel was less successful. It was conducted in English, with no translation into Runyankore. On reflection, this was an error. Many of the forms were incorrectly filled, although this did not present a major problem on the day. The two visiting English Medical Officers had introduced protocols into the wards and outpatient departments at IAH, and had conducted weekly teaching sessions. It was intended that the week of the prison visit a session on STI’s was given, concentrating on syndromic management and discussing the protocol at length. This session was cancelled at short notice by the Clinical Officers. As a result, they were not as familiar with the protocol as they should have been. Some of their prescribing was not correct. This resulted in two prisoners being inadequately treated for syphilis (doxycycline 100mg bd for 7 days only), and several prisoners being over treated (doxycycline in addition to benzathine penicillin). This over treatment contributed to the shortage of some drugs later in the day.
We opted to use a TPHA based test kit. The weakness in this decision was the inability to differentiate between previous and current infection. We were aware of this at the outset, and made a pragmatic decision to treat with a single dose of benzathine penicillin alone.
We were very surprised at the low incidence of genital ulcer disease, and conclude that many of these positive tests reflect previous rather than current infection. It has been our impression from our work at IAH that syphilis is over diagnosed and genital herpes under diagnosed.
We decided to treat prisoners with symptomatic scabies only. This was a mistake. On reflection we should have treated all prisoners with benzyl benzoate as well as mebendazole.

We make the following recommendations;
IAH and Bushenyi Medical Centre to liaise about follow up of all HIV positive prisoners on the 22nd February.
The weekly health promotion talk by IAH staff should reinforce preventative methods of transmission of scabies and diarrhoea
The practice of using a single razor to shave the heads of several prisoners should stop immediately
All new admissions to the prison should receive testing and treatment for HIV and syphilis
All new admissions are treated with mebendazole and benzyl benzoate
Any cases of scabies are treated promptly to avoid spread of infection, the prison nurse will need a supply of benzyl benzoate
The prison nurse has ORS available to her for treatment of diarrhoea
The prison nurse stops dispensing chloroquine for malaria and has a supply of coartem instead
HIV positive prisoners who have indicated a willingness to disclose to the prison in charge and attend for follow up should be seen monthly and receive co-trimoxazole, multivitamins and antiretroviral drugs, if indicated. Any HIV positive prisoner should be seen promptly by a medical or clinical officer if they become unwell.
IAH should start the prison outreach as soon as possible.
Clinical officers at IAH should participate in training in the management of STI’s as soon as is practicable.

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