HIV/AIDS Prevention Intervention in Parappana Agrahara Central Prison, Bangalore, Karnataka

A Process Document

KHPT
Karnataka Health Promotion Trust

HIV/AIDS Prevention Intervention in Parappana Agrahara Central Prison, Bangalore, Karnataka

A Process Document

HIV/AIDS Prevention Intervention in Parappana Agrahara Central Prison, Bangalore, Karnataka: A Process Document, Published by Director Communications, India Health Action Trust, 4/ 13-1, Crescent Road, High Grounds, Bangalore - 560 001 The Document compiled by : Contributors : Ms Priya Pillai Dr. Leela Sampige Mr. John Anthony Mr. Shashidharan.K Mr. Kulandai Raj Dr. Praveen Gangangoudar Ms. Swetha Shetty Mr. Narendra.K.M Dr. Girish.S.K Dr. Asha.TH Mr. Nikhil Herur Mr. Praveen Kumar Mr. Senthil.K.Murugan Ms. Elizabeth Michael Ms. Poornima Gowda Mr. Rajnish Ranjan Prasad M. B. Suresh Kumar (Artwist Design Lab) 2012 200 KHPT - IHAT India Health Action Trust Technical Support Unit, Pisces Building 4/ 13-1, Crescent Road, High Grounds, Bangalore - 560 001 Tel: 080 22 20 1237-9, Fax: 080 22 20 1373

Layout and Design Year of Publication Copies Printed Copyright Publisher : : : : :

This publication was commissioned by Technical Support Unit (TSU) of the Karnataka State Aids Prevention Society (KSAPS) under the project funded by Public Health Foundation of India (PHFI) to document the TI programs in Karnataka.

Acknowledgements
This document has been enriched by valuable inputs from many people. At KSAPS, we are thankful to Salma K Fahim, IAS (Project Director), Dr. Heera Raikar (Additional Project Director), Dr. Leela Sampige, Joint Director IEC, Vijay Hugar (Joint Director, TI), Dr. Asha DH (DAPCU Bangalore), Nanje Gowda (Consultant Youth Affairs), for continuous guidance and support. Acknowledgement to the team at TSU, John Anthony Team Leader (Technical Support Unit); Shashidharan K, Team Leader Capacity Building; Joseph Francis Munjattu Team Leader Targeted Interventions, Dr. Girish S.K. Programme Officer, STI; Dr. Praveen Gangangoudar, Clinical Specialist; Nagendra K.M. Capacity Building officer; and Shwetha Shetty, Community Mobilization officer for sharing their experiences and observations on the intervention effort. Kulandai Raj, Communication Officer, TSU IHAT coordinated the prison visits, interviews and focus group discussions with the stakeholders. Balasubramanya KV, Senthil Kumaran Murugan, Elizabeth Michael, Poornima Gowda and Rajnish Ranjan Prasad from the Karnataka Health Promotion Trust (KHPT) contributed ideas and coordinated production. The Prison Officers and Staff especially prison Medical Officer, Dr. Kumar K, the prison ICTC Counsellor, Lakshminarayanaswamy, and Suresh R, Prison ICTC Lab Technician highlighted the need for an intervention in the prison and the response of the inmates to the training. A special thanks to the prison inmates for giving the team a warm reception coupled with their time, honest opinions on the need for an intervention and recommendations for future course of action. We would also like to acknowledge Priya Pillai for her assistance in preparing the document.

Contents
Abbreviations 5 Introduction 7 Training of Prison Inmates and Staff 10 Training Outcomes 21 Concluion 24 Appendix - 26 I. Questions from Prison Inmates during Training 26

Abbreviations
AIDS ART CCC DIC FSW HIV ICTC IDUs IEC IHAT KSAPS KHPT KIMS MSM PPTCT SCM STI TI TNA TSU VCTC Acquired Immune Deficiency Syndrome Anti-Retroviral Therapy Community Care Centre Drop-in-Centre Female Sex Worker Human Immunodeficiency Virus Integrated Counselling and Testing Centre Injecting Drug Users Information Education Communication India Health Action Trust Karnataka State AIDS Prevention Society Karnataka Health Promotion Trust Kempagouda Institute of Medical Science Men having Sex with Men Prevention of Parent to Child Transmission Syndromic Case Management Sexually Transmitted Infection Targeted Intervention Training Needs Assessment Technical Support Unit Voluntary Counselling and Testing Centre

Introduction

The Annual Sentinel Surveillance data (2009) reveals HIV prevalence among general population in India to be 0.88% with incidence being higher among female sex workers (FSWs: 8.44%), men-who-have-sex-with-men (MSM: 8.74%) and injecting drug users (IDUs: 10.16%)1 . The Joint United Nations Programme on AIDS lists prisoners also as one of the major at-risk and neglected populations in the HIV/AIDS pandemic2. Prisons are considered to be high-risk environments for HIV transmission due to a combination of factors. These include overcrowding, poor nutrition, limited access to health care facilities, continued drug use and unsafe injecting practices3 . These factors combined with violence, inadequate means for personal hygiene, lack of access to clean drinking water, and inadequate medical services increase the vulnerability of prisoners to HIV infection and other infectious diseases4. HIV poses a major health challenge for prison and public health authorities and national governments as substance use disorders and injecting drug use tend to be common among imprisoned populations, subsequently resulting in a higher prevalence of HIV, viral hepatitis and tuberculosis compared to general population5. Prisoners tend to resume behaviours such as drug abuse and unprotected sex6 on their release from the prisons. The risk of HIV transmission both outside and inside the prison is increased as many of these prisoners tend to be repeat offenders. In India, the Anonymous Surveillance report disclosed nearly 6 to 7% of the prison population in the country to be semantically affected by HIV infections7 . A study conducted among 1007 undertrials and 107 permanent convicts (January to December 1993) in Central Prison, Bangalore, Karnataka found 1.98% of the undertrials to be infected with HIV9 . Majority of those who tested positive were illiterate (53%), poor (69%), married (61%) and involved in a job that entailed travelling (61%) . All of them reported multiple casual sexual encounters in

http://www.nacoonline.org/National_AIDS_Control_Program/Prevention_Strategies/ 2006 Report on the Global AIDS Epidemic cited in http://the-aids-pandemic.blogspot.com/2007/03/hivaidsin prisons.html 3 http://www.unodc.org/southasia/en/frontpage/2010/december/north-east-india---hiv-and-aids-preventionin-prisons-takes-a-significant-stride.html 4 Lines Rick and Stver Heino. HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response. United Nations Office on Drugs and Crime (UNDOC), Vienna with the World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS. 2006. 5 DolanK and Larney S. HIV in Indian prisons: Risk behaviour, prevalence, prevention & treatment. Indian J Med Res. 2010 December; 132(6): 696-700. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102457/#CIT21 6 ibid 7 Sundar M, Ravikumar KK, Sudarshan MK. A cross sectional sero-prevalence survey for HIV 1 and high risk sexual behavior of seropositives in a prison in India. Public Health 1995;39:116-8
1 2 8 9

http://karnatakaprisons.kar.nic.in/inno4.html ibid

brothels and cheap hotels, with 23% having had sexual intercourse with 50-60 women; 69% reported unprotected sex; and 39% had used urine and/or soda water to wash their genitals after sexual intercourse; 15% of the positive prisoners had diarrhoea and persistent glandular lymphadenopathy and 50% suffered from weight loss10 . More significantly, 90% of the affected had no knowledge about HIV/AIDS11 . A Training Needs Assessment (TNA) conducted in the Gulbarga and Bangalore Central Prisons12 in January 2007 measured the knowledge, attitudes and beliefs with regard to HIV/AIDS among prison staff, health care providers and prison inmates. Among the prison staff, the TNA found lack of clarity on the difference between HIV and AIDS, about routes of transmission, prevention and testing procedure and myths and misconceptions related to HIV (Table 1)13 . Also, only one prison staff had received HIV/AIDS related training and, most of them expressed an interest in learning and participating in a HIV/AIDS training programme.

Table 1: Responses of Prison Staff during TNA HIV & AIDS are the same 49% 47% 04% 74% 19% 07% Of sampled prison staff reported both to be the same (true) Of sampled prison staff reported they are not same (false) Of sampled prison staff reported not having a definite response (dont know) Promotion of religious values would help control the spread of HIV Of sampled prison staff reported it to be true Of sampled prison staff reported it to be false Of sampled prison staff reported not having an opinion

The data can be more effectively presented through a pie diagram. The training needs were found to be high among the healthcare staff too with only two out of four medical officers having had undergone any training on HIV/AIDS. There was considerably good knowledge of HIV/AIDS symptoms, testing and counselling procedures, treatment and management of opportunistic infections, and basis of ART among others. However, knowledge was found to be limited on types and diagnosis of STI and SCM, disclosure procedure and sharing of HIV result, and confirmatory tests14 . They were equally enthusiastic about learning more on HIV/AIDS.
ibid ibid 12 The TNA was conducted by Karnataka Health Promotion Trust (KHPT) in consultation with the Prisons Department, KSAPS, KIMS and other stakeholders. The purpose of the assessment was to identify knowledge, attitudes and skills required to foster an effective HIV prevention care and support programme for prisons in Karnataka. The sample included 47 prisons staff, 8 health care providers and 103 inmates. 13 Draft Report. HIV/AIDS Training Needs Assessment of Prison Staff and Inmates 14 ibid
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Main observations from TNA among the participants15 included a lack of clarity on the route of HIV/AIDS transmission. Prisoners below the age of 30 years had seen and used condom, while older prisoners above 40 years of age had not seen or used a condom. Most could not differentiate between HIV and AIDS and few knew about blood test as the way to detect HIV. Many of the inmates were ignorant about measures to prevent and protect themselves from HIV/AIDS. Majority of them were unaware of VCTC, PPTCT, and ART services, and assumed that Ayurveda and other indigenous methods had a cure for HIV/AIDS. Other misconceptions include the beliefs that only uneducated and immoral people get HIV infection and that sex workers need to be removed from society as they are the main cause for spread of infection. Further, they also believed that condom availability increased sexual behaviour and women were less likely to get infected with HIV as they were cleansed by menstruation. The findings within the prison environment revealed : 1.Many of the inmates, who were repeat offenders, were clients of FSWs and MSM, thus increasing the risk of carrying HIV into the prison. 2.The ICTC within the prison recorded new infections among the inmates, with high STI prevalence, pointing to the possibility of multi-partner sexual relationships. 3. The inmates were found to be reluctant to share their STI issues, increasing the chances of untreated STI and vulnerability to HIV, suggesting the need for STI screening sensitisation initiatives. 4.The jail staff had poor awareness and knowledge about HIV along with an absence of information about specific preventive behaviours. Given this context, protecting and promoting the health of the prisoners, besides increasing workplace health and safety for prison staff, has significant positive implications for public health16 . The prison intervention programme in Parappana Agrahara Central Prison, in Bangalore, Karnataka was initiated to tackle the growing threat of HIV/AIDS among prison inmates. The inmates were keen on a continuous training programme on HIV/AIDS. The intervention was implemented jointly by Karnataka State Aids Prevention Society (KSAPS), Technical Support Unit (TSU), and the State Department of Prisons. As part of this programme, a total of 3312 individuals - jail inmates and staff - were providedwith HIV/AIDS prevention information focused on the following aspects: basis of HIV, type and symptoms of STI, vulnerability and risk factors, different types of prevention services, and the roles and responsibility of jail staff in prevention. Comprehensive training modules were developed on each of the above and training rolled out to the inmates and the staff in order to address the following concerns:

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ibid Lines Rick and Stver Heino. HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response. United Nations Office on Drugs and Crime (UNDOC), Vienna with the World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS. 2006.

Training of Prison Inmates and Staff

The process was initiated through an internal discussion in KSAPS participated by the Project Director ( KSAPS), Joint Director (IEC), Team Leader - Capacity Building (TSU), IEC Consultant and Communications Officer of TSU. The Joint Director, IEC along with the team visited the prison in January 2011 and interacted with the prison medical officer to understand the health status of the prison inmates. Special focus was placed on learning about their HIV and STI status. The HIV prevalence in the prison was found to be 2%, which was four times higher than the prevalence in general population. The team also got a broad understanding of general awareness about HIV and STI among the prison population, the STI symptoms observed in the prison inmates, their response to such symptoms, and the attitude towards HIV positive inmates. The Joint Director IEC shared this information and understanding with the Deputy Inspector General (DIG) of police to convince him about the need for an intervention in prison. The team along with the Medical Officer of the prison then met the Jail Superintendent. The Medical Officer explained the vulnerabilities of prisoners to STI and HIV, the features of a prison context that increase these vulnerabilities, the significance of sensitising the mobile undertrial population and the multiple reasons for a prison being a right context for imparting such training. Both the DIG of Police and Jail Superintendent were very open to the idea of such an intervention and agreed to cooperate for its operationalisation and success.

2.1. The Training Process

The KSAPS team planned the roll out of the training in consultation with the prison authorities. The team collected the data on the number of convicts and undertrials among both male and female prisoners, and the number of prison staff. The discussion with the authorities proved useful in realistically planning for the duration of each training session and the number of batches. The dates and venue for the training were also decided in these discussions. The Communications Officer of TSU, IHAT was responsible for day to day coordination of activities and logistical arrangements for the training.

2.1.1. Resource Persons for Training

The team of trainers for the sensitisation programme was constituted depending on the availability of the resource persons for the days of the training. This is because a single team of resource persons could not be exclusively dedicated for all seven days of training due to their prior work commitments. The pool of resource persons for the training included Team Leader - Capacity Building, Clinical Specialist, Programme Officer and Capacity Building officer from KSAPS TSU and Manager - Behaviour Change Communication from Karnataka Health Promotion Trust (KHPT).

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2.1.2. Venue and Duration of Training

The training was conducted for a total of seven days from 22nd to 28th March, 2011. The prison had nine blocks and the training was conducted in each individual block. One dormitory in each block was chosen as the training venue. Every day, the necessary arrangements for the training were made by the Logistics Coordinator from KSAPS, and a team of volunteers from the prison were chosen as support team for the programme. The KSAPS team had initially planned to hold half day training for each batch. However, during the discussion, it emerged that the prison had a day to day activities timetable for the prisoners. This allowed them with only two hours in a day to engage in extra activities. Thus, the half-day training plan was changed to two hour training sessions each in the morning and afternoon. The morning sessions were held from 11 a.m. to 1 p.m. and afternoon sessions from 1.30 p.m. to 3.30 p.m.

2.1.3. Number and Size of Batches

The number of batches to be trained was decided based on the number of days available for training, and the total number of inmates. The individual batch size was suggested by the Superintendent of Prison as the authorities wanted to reach maximum number of prisoners with the training in a single batch. The KSAPS team agreed to large batch sizes as they decided to have individual follow up sessions for those prisoners with continued doubts regarding the topics covered in the training. The counselling sessions were to be conducted by the ICTC counsellor and prison Medical Officer. The number of batches in a day varied according to the availability of the resource persons. On some days, only 3 batches were held. On an average, each batch had a participation of 100 prisoners. A total of 30 training sessions were held over a week. Each day, two simultaneous sessions were held in the morning and afternoon, in two blocks. The first five days of training were for the male prison inmates. On the last day, a single batch of female prisoners and a batch of prison staff were trained. At the end of the week, a total of 3312 individuals were trained including male and female prison inmates and prison staff.

2.1.4. Mobilising the Prisoners

The attendance in these trainings was not mandatory for the prisoners. As participation was voluntary, the training stood the risk of low attendance of inmates. This would have resulted in a less than expected outcome in terms of reaching maximum number of inmates with the sensitisation and awareness training. A key strategy formulated to address this risk was to constitute a group of volunteers from among the convicted prisoners. Thus, a group of 50 volunteers were chosen and entrusted with the responsibility of gathering as many inmates as possible for each batch. The familiarity and rapport of this group with the fellow prison inmates was considered an advantage for successful mobilisation of prisoners for the training.

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There is a group from KSAPS that is coming tomorrow to give awareness about HIV. Attend the training. It will be very useful for your life. You can get a lot of information. You can discuss with the experts You will know how HIV spreads, how it does not spread? You can give this information to others so that it will be useful for them. They will show some pictures so that you can get the knowledge about them Source: Group Interview with Prison Volunteers on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore

The volunteers would visit the barracks the night before the day of training. In these visits, they would announce about the training on the following day and inform the inmates about the timing and venue. Most importantly, they played a crucial role of impressing upon the inmates the importance of being aware about HIV/AIDS and STI. The group of volunteers were chosen by the prison doctor.

The volunteers are convicted prisoners who do not live in the barracks but in cells outside the barracks in and around the prison hospital. They work in the prison hospital from 9 a.m. to 8 p.m. assisting in medicine distribution and other activities. Hence, the doctor chose the volunteers from this group on the basis of his assessment of their abilities and prior experience with their work. The volunteers were helped in their efforts by the prison ICTC counsellor. He accompanied them in their visits to the barracks to inform the inmates about the training and the usefulness of gaining information about HIV/AIDS and STI. Box 1: Role of Prison Volunteers Choosing the barracks for the sessions Mobilising prison inmates for the training Logistical support setting up the sound box, projector, white board, and arrangement of benches and tables Collecting participant signatures at the end of each session Maintaining discipline during the session Source: Group Interview with Prison Volunteers on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore The assistance provided by the volunteers has been significant as it extended beyond mobilisation of inmates (Box 1). The arrangements within the prison were mostly handled by them as the external KSAPS team had limited access to the prison. The group of volunteers filled this gap. They identified and prepared the barracks for each days training, provided operational support, and helped to manage the large group.

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2.1.5. Ensuring Participation in the Training

Multiple reasons incentivised the participation of the inmates in the training. Each participant was provided with a bag, pen, note pad, IEC materials, and a big packet of biscuits at the end of each day of training. The return of the participants to the barracks with these set of materials was one of the factors that urged other

There was resistance from the prisoners to come and attend the training. Many thought that it is not good to attend such sessions to know about HIV/AIDS. Few thought they know everything about it.Some due to stigma thought that if someone is attending the session on HIV/ AIDS, then he might be having it Source: Interview with ICTC Counsellor on 24th September 2011, in Parappana Agrahara Central Prison, Bangalore

inmates to attend the training. Also, prior to this training, prison inmates were reached out to with messages through announcements in the loudspeaker. This was the first instance where a training and sensitisation programme was being organised with the actual participation of the inmates. Few of the prison inmates also thought of it as a good way to pass time. The efforts of the volunteers and the ICTC counsellor at mobilising participants for the training also faced mild resistance from a few inmates. Misconceptions about HIV/AIDS, lack of awareness and disinterest contributed to their initial unwillingness to receive the training. The counsellor persuaded such inmates by explaining the possible benefits of such information for the health of their families, friends and themselves.

2.1.6. Training Curriculum

The curriculum for the training was prepared by a five member team. The team consisted of Programme Officer STI, Team Leader - Capacity Building, Officer Capacity Building and Team Leader Mainstreaming from KSAPS TSU and Manager - Behaviour Change Communication from Karnataka Health Promotion Trust (KHPT). The initial content was prepared by a smaller group and then finalised by Joint Director (IEC) and Team Leader Capacity Building. The discussions with the prison authorities and the Medical Officer also aided the team in the selection of topics to be included in the curriculum. The organisation of the content (Box 2) began with an explanation of HIV and AIDS. In these sessions, the trainer explained the specificity of these conditions to only humans, the differences between HIV and AIDS, and the existence or non-existence of curative or preventative medicine for HIV and AIDS. This was followed by sharing of data on HIV infections at the global level, and gender disaggregated data on these infections. Data on adult HIV prevalence across different states in India was then shown. The inmates were curious about the reasons for high HIV prevalence in Karnataka and the district wise prevalence. The trainer responded that all thirty districts in Karnataka were in high prevalence category. Next topic to be discussed was the various routes of HIV transmission. The participants were educated on the four modes of HIV transmission. Statistical data on routes of transmission

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Box 2: Topics Covered in the Training What is HIV? What is AIDS? Estimated HIV Prevalence across States in India Routes of Transmission of HIV Ways in which HIV does not spread Progression of HIV Infection Ways to Prevent HIV Common Myths & Misconceptions about HIV What is STI? Symptoms & Signs of RTIs/STIs in Men Symptoms & Signs of RTIs/STIs in Women Reasons for Infected Persons not Sharing their Problems Why are Prisoners at Higher Risk of HIV? Source: Power Point Presentation used for training inmates in Parappana Agrahara Central Prison, Bangalore in India pointed out heterosexual sex as the main mode of transmission. The reasons for the primacy of heterosexual sex over others in HIV transmission were explained. The participants were also informed that blood, semen and vaginal secretions are the only three body fluids that spread HIV. This made it clear to the inmates that HIV cannot spread through saliva or sweat. Clubbed with this was a session on the various ways in which HIV does not spread. It helped dispel the misconceptions related to spread of HIV. The final few sessions on HIV included the different stages of infection from HIV to AIDS. The symptomatic and asymptomatic periods in the evolution of the infection was discussed. This was followed by a discussion on methods for prevention of HIV through sexual, blood borne and mother to child transmission. Detailed explanations were given on the measures to prevent transmission of HIV through each of these routes. The sessions on HIV were concluded with a discussion on the common myths and misconceptions associated with both the spread of HIV and its cure. It set the ground to

Society looks at HIV positive people very differently. They usually look down upon them. In the training, we got to know that it is not the end of lifethat an HIV positive person can lead a happy normal life Source: Focus Group Discussion with Male Prison Inmates on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore

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discuss issues of stigma and discrimination towards HIV positive patients. Key lessons were reinforced in this session such as the difference between HIV and AIDS, the available treatment, the ways in which HIV does not spread and positive living. The training then moved on to the topic of Sexually Transmitted Infections (STIs). The following sessions focussed on helping the inmates understand the concept of STIs and its manifestations in men and women, the link between HIV and STI, and the reasons for individual inhibition in seeking treatment for STI problems. The signs and symptoms of STI were discussed using both text and images. The images of Herpes, swelling, warts, lesions, urethritis and others were used to aid better understanding and identification of the different symptoms by the inmates. The trainers used the opportunity to reiterate the importance of safe sex. This was done by explaining the connection between HIV and STI and the need to avoid unsafe sexual practices. Finally, the trainers discussed the various reasons for lack of attention to STI conditions. The participants were encouraged to think about causes apart from poor awareness or lack of knowledge that prevented timely treatment and care of STIs. These included shame, fear of stigmatisation, misconception such as STIs curing by itself, and false belief that This cannot happen to me. The final session of each training module focussed on the reasons for higher vulnerability of prisoners to HIV/AIDS. Open discussions were held on issues such as increased chances for homosexual activity within the prison prompted by long durations of separation from family. Lack of knowledge about sexual infections and their modes of treatment, curiosity about same sex activities, and sexual exploitation within the prison were also talked about. The doubts from the participants (Appendix) are reflective of the limited awareness on STIs and HIV/AIDS. Of significance is the fact that the programme content underwent multiple iterations over the first few days of the training.The content on STI, its various types and symptoms were modified to make it both verbal and visual. Also, information on general symptoms of HIV infected persons was added after the feedback from the participants. In short, the training curriculum included comprehensive coverage of topics related to HIV/ AIDS and STI. These included basics of HIV/AIDS and STI, ways of transmission, prevention and treatment, myths and misconceptions and higher risk of prison inmates to HIV/AIDS.

2.1.7.Training Methodology
Each training session started with self introduction by the team of trainers and a short speech welcoming the participants for the training. The first day of the training was for young undertrials, aged below twenty years. The reactions and questions were muted due to the presence of prison officers in the room. This inhibited the group from actively engaging with the trainers. The team discussed this observation with the Jail Superintendent and subsequently, a decision was taken to not have the officers present among the group. However, for security reasons, they continued to stay around the training room, away from the direct sight of the participant

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group. The difference was evident from the next day of training, where the questions and responses flowed freely from the participants in the absence of authority figures. Visual aids were liberally used all through the training to generate curiosity, to break the monotony of continuous speech, to retain attention and most importantly, to enhance understanding of the topics being discussed. For instance, the group was initiated to the concepts of HIV/AIDS through a video song Tod do Deewarein17 (breaking down barriers) with a message against stigma and discrimination towards HIV positive individuals. The song was used as an ice-breaking tool. It also increased the quorum for the training. The use of video song

For those who are illiterate, the training was very useful because they cannot read and understand Source: Focus Group Discussion with Male Prison Inmates on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore
once the song started playing.

aided in mobilisation of inmates for the training, as more inmates walked into the training hall The master trainer explained the meaning of the song, which urges people to question and change their discriminatory perceptions towards HIV/AIDS infected individuals. As the song was in Hindi, and not in the local language (Kannada), the trainer explained its meaning to the participants, asked basic questions about HIV and sought their responses. Further, video spots were used at various points during the course of the training to add variety and sustain the interest of the participants. Altogether, three video spots were used. These were short video messages by popular Kannada film actors promoting the use of condoms, informing about ICTC services, and generating awareness on ART services, and living with HIV. The spots were used before the introduction of each

PicturesOpen discussionEven those who were not interested in the programmewere interested after it started. Most are illiterate, so good to have used films and songs Oh! Our hero is talking... Upendra spoke, so thats right. Source: Group Interview with Prison Volunteers on 14th October 2011 in Parappana Agrahara Central Prison, Bangalore

topic, for e.g. the video spot on condom use was shown before the session on HIV prevention. These were very popular with the participants and ensured high recall of the messages. Similarly, a film on services Sevegalu18 was screened, which informed the participants about condom usage, Integrated Counselling and Testing Centre (ICTC), Antiretroviral Therapy (ART), Community Care Centres (CCCs), and Drop-In-Centres (DICs). The film had a demonstration on

17 Tod Do Deewarein is a music video which was launched as part of the World AIDS Campaign in 2004-05. It was conceived by the Network for People Living with HIV/AIDS in Maharashtra and produced in close collaboration with the Indian Network of Positive People, National AIDS Control Programme and UNAIDS.http://upaidscontrol.up.nic. in/anv/tod%20do%20deewarein.mpg 18 The film Sevegalu is a film on services related to HIV/AIDS produced by the Karnataka Sate Aids Prevention Society (KSAPS).

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how to use condoms. Parts of the film were set in ICTC, CCC and DICs, thus making the concept of institutional care and services real and tangible for the participants. The session on STI infections also used visual aids for enhanced understanding of the symptoms among the participants. Photos of different types of STI infections were included in the power point presentation along with the text. Initially, the presentation had only text and no pictures. The interaction sessions after the first two days of training elicited large number of questions from the participants. Most of the doubts were on STIs. The team felt that better clarity of concepts and symptoms would emerge if the inmates were shown actual images of STI infections. Thus, from the third day of the training, the presentation was modified to include both text and images. The images used were clear and large colour photos of various STI infections. The images supplemented the explanations by the trainer and the text in the power point presentation. Additionally, it generated greater

On the first day, we had not used many STI photos. We were apprehensive as to whether it would look appropriate or not? Photos can be gruesome for an untrained eye. After the first and second day, they were asking so many questions that we changed the presentation. After the 2nd day, with the pictures, the number of doubts increased. There was a huge increase in attentionno more shuffling no one trying to go out there was pin drop silence and attention Source: Interview with Dr.Girish S.K., Programme Officer STI, on 27th September 2011, in KSAPS office

interest in the session, garnered more attention from the participants, effectively communicated the messages and ensured increased impact of the training. Another key feature of the training methodology was the use of Information Education and Communication (IEC) materials. Information booklet on HIV/AIDS and STI in Kannada, Mahithi Kaipidi, was given to each participant. The booklet contained pictures and text explaining the basics of HIV, routes of infection and methods for prevention. Further, it also had information on the basics of STI, the services available for treatment of STI and HIV and importance of condom usage. The booklet also dwelt upon the various myths and misconceptions associated with HIV/AIDS and guidance on ways to healthy living for HIV positive individuals. In addition to the information booklet, posters about HIV/AIDS and STI were used. The posters contained messages about four ways of HIV infection, myths and misconceptions about HIV/ AIDS, living with HIV, correct use of condoms and ICTC services available in the district. Before the start of the training, the KSAPS team discussed with the prison authorities and identified the locations where the posters could be displayed.

Books are shared with the new prisoners who come in so knowledge spreads Source: Group Interview with Prison Volunteers on 14th October 2011 in Parappana Agrahara Central Prison, Bangalore

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The posters were displayed in those locations in the prison which had a high footfall. Thus, they were pasted on the walls of the passage leading to the barracks. During the training, the posters were put up on the walls of the barracks in which the training took place. However, these were taken off at the end of the training by the inmates themselves. All the materials, including the presentation used during the session were prepared in the local language, Kannada. The pedagogy included techniques such as discussion, feedback after every session, and use of lead questions to initiate the thinking process of the participants about each subject. On the first day, the questions from the participants were invited after the session. The training team realised that many in the group forgot the questions by the end of the session. After the experience of the first day, participants were encouraged to ask questions at any point during the training, as and when they needed a clarification. The sessions on vulnerability had the trainers shift to a more facilitative role. The methodology for these sessions deviated from the predominant methodology of continuous presentation interspersed with occasional questions. The trainers started by asking questions on relationships and love, and the experience of the participants in these spheres (Box 3). Box 3: Facilitating Participant Thinking on Vulnerabilities Trainer: Love madithira? (Have you loved someone?) Life nodithira?(Have you known or thought about life in all its facets?) Participant: No sirwe have not thought about life like that Trainer: Have you loved someone? Have you had sex with them? Participant: Yes, we have lovers. No, we have not had sex. They dont let us do all that Trainer: Then, how do you release those feelings? What do you do when you have feeling like that? Participant: We go out to other women, Masturbate Source: Interview with Shashidharan.K, Team Leader Capacity Building, on 8th August 2011 in KSAPS office, Bangalore They then led and linked the participant responses to discussions on risks associated with unsafe sex, and socio-economic and psychological factors that increase the vulnerability of young men to HIV/AIDS. In summary, the training used participatory methodology and interactive pedagogical techniques such as presentation and discussion, and use of visual aids such as short films, video songs, video spots and posters. In addition, the participants were provided with information booklets with key messages about prevention and services for HIV/AIDS. These were to serve as reminders of the training and could be used by the participants at leisure. The sessions were interactive with the trainers asking lead questions, seeking participant responses, and facilitating discussions.

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2.2. Training of Female Prisoners

The United Nations Office on Drugs and Crime (UNODC)19 notes, The combination of gender inequality, stigma and discrimination increases imprisoned womens vulnerability to HIV infection. As the female prisoners were few in number, only one session was held. The training of female prisoners was more like a single event programme than training. Apart from the inmates, the female Jail Superintendent and the prison Medical Officer were also present for the programme. The focus of the training was on concepts of HIV/AIDS, misconceptions surrounding it and issues of stigma and discrimination. The training methodology was the same as for male inmates. However, there was a marked difference in the participation between the male and female inmates. The Joint Director, IEC of KSAPS, who attended the session, reports that the female inmates were depressed, shy to ask questions, and were not proactive in asking questions. Their primary response was to deny the relevance of the issue to their lives. Also, there was no discussion or presentation on STI with the female prisoners due to lack of time. The main discussion was centred on issues of stigma, discrimination and fear of someone who has HIV/AIDS. At the time of the training, one of the inmates was HIV positive. She was not being allowed to use the toilet by other inmates as they feared getting infected with HIV. The pregnant woman herself wondered whether common use of the toilet was a

We dont need thiswe are in prison we have not had sex in years. This is not relevant for us. Source: Interview with Leela Sampige, Joint Director IEC, KSAPS on 16th August 2011 in KSAPS office, Bangalore

possible route of transmission. This provided a ripe opportunity for an extended discussion on stigma and discrimination.

2.3. Training of Prison Staff

The session with the prison staff mainly focused on vulnerability of the prisoners, role of the prison staff in ensuring prevention and the challenges involved in it. These discussions followed the presentation on HIV/AIDS and STI, using the same training material as with the male inmates. The session was for two and a half hours, attended by about 35 police personnel from the highest to lowest rank. The response of the staff mirrored that of female inmates, which was primarily denial of their vulnerabilities and risk to HIV/AIDS. They acknowledged their role in sensitising every prison inmate. However, they were reluctant to commit to ensuring prevention of HIV/AIDS for many reasons (Box 4). The staffs were hesitant to admit to the significance of their role in prevention efforts as they feared it will become an additional responsibility at the job. They said the best contribution

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UNODC. Women and HIV in prison settings. UNAIDS, Joint United Nations Programme on HIV/AIDS

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Box 4: Prison Staffs Response to their Role in Prevention Cannot foresee the behaviour of those coming inside because they are not close to them Intimacy with the prisoners not possible because of demands of the job (discipline maintenance), and hence cannot spend time talking to the prisoners and getting personal information Cant monitor each and every activity of the prisoners Solid sub-groups force others to have forcible sex Since its a personal behaviour staff cannot control Most of it happens during nights and inside toilets More number of prisoners (overcrowded), so monitoring is not possible This type of behaviour seen more with undertrials Only education can change their behaviour Source: Interview with Shashidharan.K, Team Leader Capacity Building, on 8th August 2011 in KSAPS office, Bangalore they could make was to pass on the message about importance of ICTC, health check-up, and awareness about HIV/AIDS and STI to groups of prisoners, whenever possible. The training team responded by suggesting strategies for enhancing their role in prevention. These included, (a) considering the inmates as their own family members, (b) to be on the watch for high risk groups, risky behaviour and pay additional attention to such groups, (c) to constantly seek information from the prison volunteers about risky behaviour, (d) to motivate the volunteers to share all information about activities that happen within the prison and (e) to fully utilise the presence of the ICTC counsellor by referring those cases which require counselling.

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Training Outcomes

The training focused on concepts of HIV/AIDS and related vulnerabilities of prison inmates, importance of adherence to testing and treatment, and impact mitigation for those diagnosed with HIV. The direct outcomes have been better health seeking behaviour as evidenced by increased uptake of HIV testing services, enhanced awareness and knowledge about STI and HIV/AIDS, and improved sensitisation to the lives of HIV infected persons. An unintended outcome has been the potential spread of messages to a larger group through the mobile undertrial prisoners.

3.1. Increase in ICTC Visits and Testing

The most visible impact since the training has been the increase in number of male prison inmates who has undergone voluntary HIV testing at the prison ICTC. The training was conducted at the end of March 2011. As shown in the graph below, there has been an increase in the number of HIV testing done every month after the training20 . The month of May 2011 registered a 17% increase in the number of inmates tested for HIV. Overall, with the exception of April 2011, there has been an increase of 29% and more in ICTC tests from February 2011. This clearly demonstrates the effectiveness of training in conveying the importance of HIV testing to the prison inmates.

Total Tested for HIV in Prison ICTC

Sep/11 Aug/11 Jul/11 Jun/11 Months May/11 Apr/11 Mar/11 Feb/11 Jan/11 Dec/10 Nov/10 0 100 194 200 300 400 500 197 178 226 140 279 Total Tested for HIV 327 380 254 417 323

Number of Inmates Tested

20 The number of inmates tested for HIV shows a decline in April 2011 as the service utilisation was affected by a strike within the prison by the inmates

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As Gopi21 , an inmate reports, I was motivated to undergo testing after the training and came to the clinic. I had a suspicion whether I had HIV. They asked me to come the next day. The test results were negative, so I felt very happy.

Before the training, I used to think that it (STI) will go after ten days. But now, I will go to the doctor When I am out and in contact with other women, I use condoms. I am happy that I can identify symptoms such as itching in the genital area. I know I have to show the doctor. Source: Focus Group Discussion with Male Prison Inmates on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore.

3.2. Improved Knowledge and Awareness

The training has resulted in enhanced awareness of STI and HIV/AIDS, perceptions, myths and misconceptions. The information was disseminated through presentations, video messages, IEC materials and songs. The participants reported better identification of STI symptoms and immediate access of treatment for the conditions, increased willingness to undergo HIV testing, engaging in dialogue with their friends on these subjects, and being aware of the risks of multiple partners and unsafe sex.

They also reported increased willingness to openly share and discuss STI issues and access treatment. In short, after the training, the prison inmates know about causal factors that increase their risk and vulnerability to HIV and AIDS, where to get tested, and how to lead a healthy life if found positive.

Before the training, I used to think that it (STI) will go after ten days. But now, I will go to the doctor When I am out and in contact with other women, I use condoms. I am happy that I can identify symptoms such as itching in the genital area. I know I have to show the doctor. Source: Focus Group Discussion with Male Prison Inmates on 14th October 2011, in Parappana Agrahara Central Prison, Bangalore.

3.3. Reduced Stigma and Discrimination

It has been found that stigma and discrimination adversely affect disclosure to partners22, healthcare providers and family and lead to a reduced utilisation of HIV prevention services. In this context, the response of the participants in terms of increased uptake of HIV testing services at the prison ICTC centre after the training can be considered as a significant outcome. The participants reported being more aware of the

22

Name changed UNAIDS (2007). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. Geneva: Joint United Nations Programme on HIV/AIDS.
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misconceptions that resulted in them discriminating against fellow HIV positive inmates. They no longer feared contracting HIV through casual contact, sharing of toilets or staying in the same cell. The prison volunteers also stated disclosure of HIV positive status by few prison inmates after the training.

3.4. Wider Dissemination of Prevention Messages

The prison population is predominantly constituted of under-trials, who are a mobile population. Hence, the dissemination of prevention messages among this group can enable them to reach an expanded audience. Once out of prison, these short term inmates are potential carriers of information to their family and friends. The distributed IEC materials with a comprehensive coverage of STI and HIV/AIDS will also reach a larger group of people through the under trial population.

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Conclusion

In many countries, the rate of HIV infection among prison inmates has been found to be significantly higher than in the general population23. There is pre-existing evidence of prevention programmes which have been effective in reducing risk of HIV transmission in prisons unaccompanied by any unintended negative consequences. These include education on HIV/AIDS, voluntary testing and counselling, the distribution of condoms, bleach, needles and syringes, and substitution therapy for injecting drug users24. Further, prisons offer an environment conducive for a HIV/AIDS prevention intervention as it brings together diverse groups of people at risk of HIV25. Also, for many prisoners incarceration presents the first opportunity to access medical care and receive risk reduction information, as in most cases, the lives of the inmates tend to be characterised by poverty and poor access to preventive and primary healthcare services before coming to prisons26 . The fear of both the prison inmates and staff that condom availability license increased sexual activity maybe misplaced. Provision of condoms in the prison has been found to result in higher levels of safer sex among those who indulged in sex within the prisons27. The prisoners did acknowledge the existence of homosexual activity and forced sex among the inmates28. Hence, a condom distribution mechanism is recommended and need to be worked out. Specific to the training methodology, prison inmates suggested using the medium of television to telecast messages on HIV/AIDS. There is a television in the admissions room and in each cell. Video messages aired at regular intervals offer the potential to generate interest in the new inmates waiting in the admissions room. Further, it can also result in continuous

WHO (2004-05). Evidence for action on HIV/AIDS and injecting drug use; Policy Brief: Reduction of HIV Transmission in Prisons. 24 ibid 25 American Journal of Public Health (1996). Editorial: Improving HIV/AIDS Prevention in Prisons is Good Public Health Policy 26 ibid 27 WHO (2004-05), Evidence for action on HIV/AIDS and injecting drug use; Policy Brief: Reduction of HIV Transmission in Prisons. 28 Group Interview with Prison Volunteers on 14th October 2011 in Parappana Agrahara Central Prison, Bangalore, Karnataka.
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reinforcement of messages among the inmates who have already undergone training. This assumes importance as most inmates are illiterate29 , so cannot access the IEC materials and are able to absorb information better when provided through audio-visual medium. A second suggestion was to use IEC materials developed as murals, instead of wall posters, to help spread awareness of issues relating to HIV/AIDS. The wall posters had very little longevity and tended to be removed by the inmates within a short period of time. The creation of murals could be conceived as a participatory exercise where the inmates conceptualise, design and paint themes relevant to the prison populations. The low convict population, overcrowding, unsafe sexual behaviour associated with sexual violence, undertrials facilitating the spread of infection to the non-incarcerated community all present a strong case for Interventions Programmes in the Parappana Agrahara Central prison. The improvement in the uptake of ICTC services immediately after a week-long training combined with a reported increase in sensitisation of prisoners to fellow HIV positive inmates post training should be considered as positive pointers for further such interventions. Ongoing capacity building of both the staff and the inmates can ensure improved knowledge and awareness of HIV/AIDS and support their continued commitment for implementation of prevention activities within the prisons.

29 The Training Needs Assessment in Gulbarga and Bangalore Central Prison found 40 out of 103 (41%) sampled prison inmates to be illiterate.

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Appendix
Questions from Prison Inmates during Training
1. What are the initial symptoms of HIV? What do these symptoms mean? 2. I have heard that there is a cure for HIV? Is it true? 3. I have heard that having sex with a virgin cures HIV? 4. Does HIV get transmitted through mosquito bites? 5. Does HIV get transmitted through used blades in the barber shops? 6. Does it get transmitted through sitting on a toilet seat? Or using the public urinals? 7. Can we get HIV through shaking hands, hugging, kissing? 8. Will we get HIV if we share utensils? 9. Is it possible that I am infected with HIV because I have a STI? 10. I had sex 5 months back. It was unprotected sex. But it was my girlfriend. Should I undergo testing? 11. I never had sex with anybody, but doctor has given me injection with syringes which is not boiled. Is it necessary for me to undergo test? 12. Semen discharge happens during urination? What is the treatment? Because of that, is there a chance that I will get infected with something else? 13. Is it healthy to masturbate? Does it lead to weight loss or infection? How frequently one should masturbate? 14. MSM they engage in sex with other prisoners, so should they use condoms? 15. Is it necessary to use condoms during oral sex? 16. I have ejaculation while sleeping. Is that a symptom of STI? 17. Un-descended testis on one side is that a symptom of STI? 18. Will an STI become AIDS? Long ago I had STI symptoms, is it possible I will have HIV now? 19. What happens after one is positive? 20. I get itching in the genital parts. Is that a symptom of STI? Does it cause risk? 21. Long ago I had sex with a lady without a condom. Is it possible that I have HIV? 22. Is masturbation bad for health? 23. I am feeling weak. Is that because I masturbate too much?

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India Health Action Trust Technical Support Unit, Pisces Building 4/ 13-1, Crescent Road, High Grounds, Bangalore - 560 001 Tel: 080 22 20 1237-9, Fax: 080 22 20 1373