For most inmates in Cote d’Ivoire, the arrival of a friend or loved one with a bowl of rice or attiéké, the local staple of fermented cassava pulp, is a highlight of a long and exhausting day of doing nothing but self-preservation.
But for those inmates infected with HIV or TB, that nourishing bowl can make the difference between life and death can, helping to stave off the dizziness, shakes and stomach cramps that are side effects from taking the medicinal cocktail of anti-retrovirals or first-line TB drugs. And on the days they don’t come, many inmates – like one at the Abidjan correctional facility, Maca – just don’t eat.
“I am too afraid of catching something” from the rations served by the prison, he told Aidspan on condition of anonymity during a recent visit, standing in the health ward waiting to receive his daily dose of anti-retroviral therapy. “I have seen cockroaches in the rice and sauce they serve us. And someone in my ward died from beriberi.”
The daily food budget per inmate in the Ivorian prison system in 2013 works out to roughly $0.65: enough for some cassava, or rice and sauce, but not nearly enough for a piece of fish, or chicken or even a handful of beans. “We just don’t have the money to spend more to improve the food rations,” lamented Babacar Ouatta, the director of the prison administration.
How to provide proper nutrition to all inmates on tight budgets remains a perennial challenge for prison administrators across the country, a challenge compounded by the nutritional needs of HIV positive or active TB prisoners. The meagre, poor quality rations served to inmates pose a particular threat to treatment success for HIV or TB. Even when drug stocks are available, many infected prisoners decline to take their medication for fear of the impact on their bodies of taking them on an empty stomach.
Malnutrition among people infected with HIV or TB can lead to secondary immunodeficiency, which can increase the risk of infection. Malnutrition can alter the metabolism of TB patients and keep them from properly absorbing nutrients and proteins, causing wasting, delaying recovery and increasing the risk of complications leading to death.
Although there are no current national statistics for the number of infected inmates incarcerated in any one of the 33 Ivorian national penitentiaries, a 2010 survey conducted jointly by the Justice and Health ministries suggested HIV prevalence a year earlier was 10%.
At Maca, the country’s largest penal institution, at least 100 of the 4,800 inmates are HIV positive, according to Rodrigue Abro, who runs the prison’s ARV treatment program, although he thinks the figure is likely much higher. Just 29 inmates were on daily ARVs in February, he said.
Côte d’Ivoire joins a handful of other countries in sub-Saharan Africa where Global Fund money supports feeding programs in prisons, helping to avert the malnutrition problems that can produce complications that lead to death among TB and HIV infected patients. In Rwanda and Namibia, the Fund supports nutrition support for prisoners with multi-drug resistant TB, while 150 prisoners in Madagascar are also enrolled in a Global Fund-supported feeding program.
Under a $17,200-distribution program carried out by a inmates' rights and care group called ESTHER, a sub-recipient of a grant administered by a national program providing care to people living with HIV, 22 prisons around Côte d’Ivoire will be furnished with nutrition kits. The kits are destined for HIV-positive inmates enrolled in an ARV treatment program and contain rice, palm oil and fortified flour. The distribution, to be launched in conjunction with the World Food Program from March 2014, will run for three years, with each $57-kit containing enough food to last an HIV-positive inmate six months.
Another challenge : where those chosen inmates will eat their fortified meals. Stigma and discrimination can carry rough penalties in prison, one inmate said – and so can being singled out for special treatment.
When it was suggested that he just plan to eat in the infirmary, he demurred. “So I should be going to take my meals in the infirmary every day? No. People will ask too many questions.”