Spotlight: HIV Management in a Malian Women's Prison
Mali continues to rank among the few sub-Saharan African countries with a low prevalence of HIV/AIDS in the general population. UNAIDS estimated at yearned 2001 that 110,000 adults and children in Mali were living with HIV/AIDS, with an adult prevalence of 1.7 percent -- comparable to that of the U.S. Yet a suspected higher prevalence in "bridge" populations, such as long-distance truck drivers, ambulatory vendors, and female sex workers portends a wider epidemic. UNAIDS also estimates that 55 percent of adults living with HIV/AIDS in Mali are women.
The Bollé Correctional and Rehabilitation Facility for Women and Girls, (Centre Spécialisé de Détention de Réeducation et de Réinsértion pour Femmes et Filles Mineurs de Bollé), which lies on the outskirts of the capitol city of Bamako, Mali, is one of seven prisons in the nation. Bollé, the largest facility for female inmates in the country, opened its doors in 1998, and houses from 50 to 70 women and girls at a time. Malians make up the majority of the detainees; however, nearly all West African countries are represented.
Apart from the lack of resources and medical care, the Bollé facility greatly differs from its U.S. counterparts in that the inmates are entirely self-sufficient. In the past, non-governmental organizations were able to support the prison with donations of food and medical supplies, but prison director Diarra Assétou Kouyaté said that these organizations could no longer afford to provide assistance. Trades such as cloth-dying, sewing, and soapmaking not only afford these women with skills to survive once they are released, but also function as a means of economic support for the facility. Children of the inmates are permitted to live at the prison until the age of four, and are completely in their mother's charge since the prison cannot afford to feed, clothe, or provide medicines for them.
Relative to the U.S., there are very few women imprisoned in Mali. Kouyaté, who toured prisons in the U.S. several years ago, explained that "in Mali the women are well-behaved." While the Bollé prison is recognized as being one of the best correctional facilities in West Africa for preserving the dignity of inmates, Kouyaté stated bluntly that "this is no hotel." Surprisingly, most of the women are not incarcerated for prostitution or drug-related charges. They are serving sentences for infanticide. The influx of young women to urban areas is fueled by a desire to earn a better living and find a husband. Many of them, however, end up involved in prostitution. Faced with an unwanted pregnancy or lack of financial means to provide for the baby, the woman may resort to "the worst of crimes," said Kouyaté. The other small percentage of crimes for which the women are convicted include involuntary homicide, fraud, and having abandoned their families.
Routine HIV testing does not exist in the women's prison. Occasionally, HIV tests are performed when a woman is chronically ill, or goes to the hospital to have a child or undergo surgery. Accordingly, HIV prevalence is unknown. As in Malian society, AIDS remains a taboo subject in the correctional environment. "Because of the stigma associated with AIDS in Mali, the women here simply do not believe the facts about AIDS," said Kouyaté. Not surprisingly, most incarcerated women here would likely refuse to be tested even if given the opportunity. The administration has always made concerted efforts to keep testing as discreet as possible but personal information travels fast inside the prison walls. "These women are very perceptive," Kouyaté said. "They know what goes on here better than the staff does." The Bollé prison does not have recourse to legislation on informed consent or any laws regarding HIV testing in the correctional setting. Upon further investigation of what is an extremely delicate -- but not a litigious -- issue in Malian corrections, Kouyaté acknowledged the need for protocols for a confidential and effective testing system.
As a general rule, prisoners who are confirmed to be HIV-infected are sent to appear before a district judge and are routinely granted compassionate release. "We simply don't have the means to provide care and treatment for them. ... These women are not left to die in prison," said Kouyaté. Antibiotics for treatment of OIs are sorely needed. Not only are antiretrovirals (ARVs) not available on the inside, but the medical staff is also not trained in pre- or post-test counseling. By the time a case of HIV is suspected by the medical staff, the woman has usually progressed to full-blown AIDS. Since 1999, there have been six women who have tested positive for HIV at Bollé, five of whom died of AIDS following compassionate release. The sixth woman, who has not developed full-blown AIDS, is being treated with ARVs and followed by CESAC (Centre de Soins, d'Animation et de Conseil), a Malian governmental organization that provides HIV/AIDS prevention, treatment and counseling. Created in 1996, one of the organization's primary objectives is the prevention of mother-to-child transmission of the virus. Following release by the judge, a prisoner who tests positive for HIV is referred to this center for treatment and follow-up.
Supply, distribution and cost constitute the triumvirate of challenges in the fight against the AIDS pandemic in Africa. Currently, the following ARVs are approved for treatment of HIV infection in Mali: didanoside, zidovudine, lamivudine, stavudine, nevirapine, efavirenz, nelfinavir and indinavir. There are not enough of these medications, however, to keep them in stock at the pharmacy, which renders treatment interruption inevitable. An infrastructure for dispensing these drugs does not exist, nor does the personnel for distributing them. Furthermore, difficulties in accessing transportation to and from the hospital or clinic for treatment and proper follow-up are realities in Mali.
Cost reduction of ARVs -- the issue that seems to be dominating recent discourse on AIDS in the developing world -- is a key factor for making treatment more accessible to the population. IMAARV (Initiative Malienne d'Accès aux Antirétroviraux) is a program financed by the state and private sector whereby eligible individuals can receive ARVs and medications for opportunistic infections at reduced cost since they come from bulk suppliers. Although IMAARV has committed to instituting two-year treatment programs that aim to improve the quantity and quality of available ART, cost remains a formidable barrier. For example, 50 percent cost reduction in ARVs translates into about 45,000 CFA/month (about US$88). Yet, given that the cost is higher than the average monthly household income, ARVs are still inaccessible to 90 percent of the HIV-infected population of Mali.
Today, the AIDS situation in Mali is not as dire as it is in some African nations. However, significant seasonal migration of agricultural workers to Senegal, Côte d'Ivoire, (which has the highest HIV prevalence in West Africa), and France during Mali's off-agricultural season could have a serious effect on the spread of HIV in Mali in years to come. The past decade bears witness to the fact that no country is insulated from the risk of the epidemic. The Bollé prison has many stories to tell about the women for whom release into the free world has equated further confinement by AIDS. The prison medical staff shared only a handful of these inmates' stories, each one unique but with the same tragic ending. The hope is that one day these young women will re-enter the free world as healthier and more confident individuals; this can be accomplished with the help of governments, NGOs, and individuals committing to care more -- and to care sooner.
Julia Noguchi is Managing Editor of HEPP Report. Disclosures: Nothing to disclose.