AIDS in Zambia

KAMFINSA PRISON, Zambia Many have gaunt, expressionless faces, their bodies almost lost in baggy, olive-drab uniforms.

Their attention is focused on the young man addressing them. Ochas Pupwe, a university student, is lecturing three dozen thieves, robbers and killers on HIV and AIDS in one of central Africa's largest prisons.

He explains how the disease spreads and tells the inmates how to avoid it. Pupwe also offers them free tests - there is little free HIV testing in Zambia - and tells them how they can best cope with the virus if they have it.

With the cooperation of Zambian prison authorities, Pupwe, 26, and a handful of other volunteers with an American-based program called Arise have brought HIV and AIDS education and testing into a corner of society many would rather forget.

The walls and barbed wire offer no protection from the epidemic outside. The medium-security prison holds about 1,000 inmates either awaiting trial or serving sentences of less than 10 years. About 40 of the inmates are women.

For those found to have the virus, there is more bad news: The prison diet is so poor, it will work against their health; there are no antiretroviral drugs to treat them; and conditions can be so crowded that other diseases, such as tuberculosis, can easily spread.

An investigation by the Inter-African Network for Human Rights and Development found that 34 inmates died at Kamfinsa Prison from January to September 1997, most from malnutrition and a lack of medical care. Current fatality rates were not available.

Most of the inmates live in wooden buildings and appear free to walk the grounds. The place resembles an Army camp more than a prison. A guard tower stands out, but it is unmanned. Unarmed officers mix easily among the inmates.

The hard-core inmates, those with the most serious offenses, live in four small penal blocks of roughly three dozen inmates each, where they have far less freedom of movement and sleep in crowded cells.

When Pupwe started the program, he was shocked to discover that many inmates shared razor blades and toothbrushes, thus risking the spread of HIV. He began passing out razor blades to the prisoners before each lecture.

Thus far, 26 percent of the inmates volunteering for tests have the virus that causes AIDS.

A study conducted in 1998 and 1999 at three prisons, including Kamfinsa, found that one in four inmates had HIV.

In his lectures, Pupwe urges the prisoners to be tested. Without knowing their status, they cannot make needed adjustments in their lives. But he is honest with them: If they have the virus, no medicine is available for them.

And their food, one of the key ingredients in staying as healthy as possible if they have HIV, will work against them. "It's quite unfortunate, but the diet is really important," Pupwe told the inmates.

"Even on the outside, the diet is bad. The economy is really bad," he said. He told another group of inmates that a complaint had been made to the appropriate authorities about the food.

According to a United Nations study, 50 percent of the Zambian population is undernourished.

The inmates complain of being fed one meal a day that is too small to maintain their weight. They also complain about a lack of medicines. Many of the inmates are thin but healthy-looking. Others appear to be wasting away.

Those familiar with Zambian prisons say inmates must depend on their families for medicine and for food to supplement their diets.

A recent Amnesty International report was critical of Zambian prisons for overcrowding and food shortages.

"Their diet is completely inadequate," said Dr. Charles Lalusha, a physician who volunteers at the prison. It is often just a serving of nshima, a maize-based gruel that is a national staple. The nshima is accompanied by a small amount of beans or soup.

The nshima arrives at the blocks in a large black kettle. It is dished out and handed through a hole in the metal door one bowl at a time.

Lalusha arranges for the free HIV tests, counsels the inmates and gives them their test results a week later.

The doctor concedes that the diet of many Zambians outside the prison is also poor. But he said that even the most destitute at least have some chance of eating better than the inmates.

Dennis Phiri, the prison's commanding officer, supports the testing program. He says he strives to maintain respect between the inmates and the officers, and he wants the inmates to be as healthy as possible.

He says he recognizes the problems with the food and medicine, but he says those are budget problems beyond his control.

Much of the discipline and control over the daily lives of the inmates appears to be in the hands of other inmates who decide, for example, what food other prisoners will eat and even when they can use the toilet.

The inmates have their own informal courts, as well, and there have been instances when inmates who have attempted escape have been beaten by other inmates.

As Pupwe lectured a group of inmates one Friday in July, a volunteer mixed fruit-juice concentrate with some rust-tinted water for the inmates. At the end of the presentation, each prisoner also would receive three buns.

Pupwe was talking to the inmates occupying one of the blocks for those convicted of the most serious crimes. Each block is a prison within a prison. Made of concrete, each block has six cells and a bathroom.

As many as eight inmates sleep on floor mats in a cell. The cell doors open into a courtyard that has fencing for a roof.

Plumbing is limited, but the area is clean and there are no unpleasant odors. However, Lalusha said, one of the consequences of crowding inmates together in close quarters can be the spread of tuberculosis, the biggest health problem in the prison.

Health authorities say tuberculosis is a dangerous ailment for someone with AIDS to contract. It is not unusual to find Zambians suffering from both diseases.

In 1999, a Human Rights Watch report complained about crowding in Zambian prisons and jails that led to the spread of respiratory illnesses and other diseases. There are about 15,000 inmates in Zambia, half the number that are in Virginia. (Virginia has roughly two-thirds the population of Zambia.)

Human Rights Watch is an independent, nongovernmental organization supported by contributions from private individuals and foundations worldwide. It accepts no government funds.

As Pupwe lectured in English and Bemba, a local language, the inmates sat on the concrete floor of the yard. The block leader, an inmate who runs many aspects of their lives, stood at the rear, a beaming smile on his face.

Unlike his fellow prisoners, he appeared well-fed. He wore clean clothes and polished shoes, in striking contrast to the rest of the prisoners, who were poorly garbed or wearing prison-issued uniforms. Most were barefoot or wore crude sandals.

Pupwe discussed the ways HIV can be contracted and answered questions from inmates. "No," said Pupwe, responding to one query - mosquitoes and bedbugs cannot transmit it.

Sodomy, however, can spread it, Pupwe warned. The inmates denied it took place in their block. Yet earlier surveys have shown that some of the men engage in it, and they are among the most likely - about 60 percent of them - to acquire HIV.

An inmate listening to a lecture from Patrick Lukama, 22, another Arise volunteer, conceded that sodomy occurs in the prison.

There is another group offering inmates AIDS education: "In But Free," an effort by Copperbelt University and the Zambian Prisons Service that was started in 1995. However, it does not offer testing and counseling. It trained some inmates as peer counselors.

As of July, more than 100 inmates had been tested, Pupwe said. An additional 300 were waiting to be tested. One of them is Everlyn Chinse, 27, who is in the women's compound awaiting trial for murder.

A petite woman with bare feet heavily callused, she said she is concerned about AIDS and wants to be sure she does not have it. Cradled on her hip was her 2½-year-old son, James Mayani. She does not believe he has the virus.

Female inmates with young children are allowed to keep them in the prison. Lalusha gave the AIDS presentation to the women, and the session was far more relaxed and animated than those with the male prisoners.

Pupwe also lectured juvenile inmates, ranging in age from 16 to 18, in one of the blocks.

"It's not automatic that you die of AIDS," he told them. But it is key for them to know their status.

Pupwe told another group that his project is contacting authorities and organizations looking for some way to obtain the drugs needed by those with HIV and AIDS. "We are doing that out of a moral obligation," he said.

Lalusha said that if the government wants to say it is at war with AIDS, "let's also extend it to the prisons. The inmates come from society and they'll go back to society. And, therefore, to protect inmates, you protect society."

The inmates listened closely and soberly to Pupwe. Some already knew a great deal about the disease, but many appeared to have been dangerously ignorant.

The odds are long that anything can be done to obtain medicine, Pupwe told them. "It's not just the prison, it's the entire country," and AIDS drugs for prisons are likely on the bottom of all lists, if on a list at all.

"We are not promising anything at all," Pupwe said. Nevertheless, "we are trying. We are trying."