Four clusters of problems can be discerned which are worth further consideration:
Drug use in the correctional centre (including tobacco)
Study findings indicate that a large proportion of offenders use drugs before entering the correctional centre, similar findings to that in the survey undertaken by Stöver and Michels . Heroin and cannabis mixed together and smoked, which were most commonly used prior to incarceration, are also drugs that are prevalent within the greater vicinity of Tshwane . Both KI offenders and staff state that drugs are smuggled into the centre by officials, by visitors and from the adult sections of the correctional centre. Notwithstanding, the KI offenders did feel that it is harder to obtain drugs in the correctional centre than in a rehabilitation centre—this may inadvertently provide an ideal window period for proactive rehabilitation programming. An encouraging outcome of the study is that offenders addicted to heroin, for example, are treated symptomatically for their withdrawal symptoms; however, there may still be a need for pharmacological maintenance regimes within correctional service facilities in South Africa. The study by Stöver and Michels  demonstrates how the implementation of opioid substitution therapy (OST) programmes, for example, benefits not only offenders but also correctional centre staff and the community at large, and reduces the rate of infectious diseases. There is one specific feature of Emthonjeni which is worth some consideration: past Emthonjeni Correctional Centre Head and middle management banned tobacco and cigarette smoking a number of years ago in an effort to protect the health of the youth offenders. Unfortunately, this measure proves to have some negative unintended consequences, in particular, bringing about and maintaining black-market features such as smuggling and transactional sex in order to obtain cigarettes and violence (fighting about tobacco deals), features comparable to the illicit underworld. Moreover, the tobacco ban is causing a great deal of unnecessary (monitoring) work by staff.
Health risks of staff and offenders
According to the KI offenders, violence is the most important health risk for staff, while staff regarded infectious diseases as the major health risk for themselves. Overall, the frequency of (serious) violence against staff seems to us rather low. However, having discussed this with the KI offenders and staff, the impression is held that this is the result of luck rather than security policy. The measures taken to secure staff are, according to the study investigators, insufficient. Staff members have a panic button, a cell phone-sized device producing a danger signal which is relatively loud. Experimenting with it by some of the study investigators and KI staff showed that nobody responds to the alarm. There are no clear instructions or trainings for staff on how to deal with (threats of) violence. The development of a best practice comprehensive security plan explicitly describing measures and means is a necessity, for example, a device that includes GPS enabling the other staff/the control room to locate a staff member in danger.
The provision of condoms by the correctional services is in line with public health recommendations; however, the provision of condoms without lubricant is a public health issue due to increased risk of physical trauma. Regarding other health risks for offenders, the staff's emphasis on infectious diseases was evident. Offenders also recognise this problem, but their view is rather diverse, mentioning a variety of health risks. The risk for HIV contraction is also fuelled by a black market of illegal drugs and prohibited tobacco (and related transactional and coerced sex that occurs). Furthermore, offender participants stated that injection drug use (IDU) was the second most common mode of drug administration, and IDU is a known contributor to the spread of HIV infection. Further research is needed to corroborate this finding as staff do not mention it, and a review of the literature suggests that no studies have been undertaken in South Africa focusing on IDU in correctional settings. Surprisingly enough, the KI staff participants reported that in 2011, 105 (out of approximately 380) offenders were voluntarily tested for HIV, and only two tested HIV positive. It is uncertain if this is a generalisable finding to the rest of the offenders in the centre, or if offenders who have already been tested positive or suspect that they are HIV positive were reluctant to be tested; there may also be other unidentified reasons for possible underreporting of HIV, suggesting a need for further research on this aspect. There is a fair chance that both HIV and TB are underreported by offenders and therefore occur at a rate higher than that which is officially reported. Part of the problem is that the statistics regarding the number of HIV-positive offenders are unknown. The Department of Correctional Services estimates the figure to be 3% . Yet, Goyer , a researcher with the Institute for Security Studies, currently places the figure at a little over 40%, while Inspecting Judge of Correctional Service Centres Johannes Fagan suggests that the figure could be as high as 60% . There exists only one instance of independent research regarding HIV prevalence in South African correctional centres. The research was undertaken in Midlands Medical B, a correctional centre in the province of KwaZulu-Natal, an area with a very high HIV infection rate among the general population. The report has been withheld by the Department of Correctional Service due to fears that it might be used as an indicator of figures for the correctional centre system as a whole. This basic lack of knowledge is a key problem facing those looking to fight the problem. Whatever the actual rate of infection, it is undeniable that HIV and AIDS are having an impact on the Correctional Service population in South Africa. Goyer's  research revealed a 750% increase in the number of natural deaths in South African correctional centres since 1995. Of these, 90%–95% are attributed to diseases often associated with the weakened immune system that AIDS produces; Goyer's  figure of the role of AIDS in correctional centre deaths is further supported by a study of postmortem reports carried out in 1995 that placed the number of correctional centre deaths from similar diseases also at 90%. Additionally, Fagan's report showed a record number of natural deaths in correctional centres, with 1,169 in 2001, an increase over 600% from 186 in 1995. The South African justice system releases and takes on approximately 25,000 offenders every month . This emphasises the fact that the problem of HIV and AIDS in South African correctional centres cannot be seen as an isolated problem, but rather as one that has a serious effect on South African society as a whole . Furthermore, in correctional centres, overcrowding, lack of ventilation and poor prevention practices dramatically increase the risks of TB transmission. Data from sub-Saharan correctional centres indicates an ominous situation. The prevalence of TB in South African correctional centres is estimated to be 6 to 30 times higher than that in the general population, which is a risk for both staff and offenders . Furthermore, prisons in South Africa do not have proper isolation facilities to treat multi- and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB) . Such facilities are also scarce in district and referral hospitals, expounding the problem further. So, the questions remain: where should offenders with XDR-TB be housed and what will happen to them ? Overcrowded correctional centres are a breach of United Nations and other international standards, as well as offenders' constitutional rights, which require that all offenders are to be treated with respect to their inherent dignity and value as human beings, including being accorded a reasonable amount of space [24, 25]. Furthermore, penile-anal penetration is in general a substantial problem. These findings mirror the UNODC/UNAIDS/World Bank  report which reveals that much of the sex among men in offenders is consensual; rape and sexual abuse are often used to exercise dominance in the culture of violence that is typical of correctional centre life. Offender male rape is considered one of the most ignored crimes, and victims of rape and other forms of sexual violence are at higher risk of contracting HIV .
Management and staff capacity
The functioning of the central management in the centre needs to be improved. Increasing staff capacity is clearly a prerequisite for increasing security and safety for staff and offenders. The minimum requirement should be to live up to the existing South African standards that specify the number of staff (for example, security, social workers, teachers and psychologists) per ratio of offenders. For the purposes of this study, of particular importance are the issues mentioned with regard to human resource management. The most urgent problem is understaffing. According to Walmsley , when there is growth in correctional centre numbers, the ratio of staff to offenders invariably falls. Reduced staff-to-offender ratios are likely to mean less effective supervision by the staff and less time for them to organise activities to ensure the existence of a positive regime that maximises the chances of former offenders being successfully reintegrated into the community. In particular, treatment programmes, including pre-release courses, are likely to be negatively affected. Furthermore, there are likely to be harmful effects on staff in terms of increased stress and sickness. The World Health Organization  substantiates these findings, stating that many correctional centres experience an increasing absence rate due to illness among staff members. Such problems should be addressed by counselling and the supervision of individual staff members. Intervision (group supervision) is one option which has proved to be very effective (and cost effective) for this purpose in other projects conducted by the Trimbos Institute.
Programmes/activities for offenders
The available range of programmes and activities for offenders is limited, similarly to the study by Taxman et al , in which agencies reported a high frequency of providing drug abuse services; the prevalence rates were misleading because less than a quarter of the offenders in correctional centres and less than 10% of those in community correctional agencies had daily access to these services through correctional agencies. In addition, these are predominantly drug treatment services that offered few clinical services . Given that drug-involved offenders are likely to have addiction rates that are four times greater than those among the general public, the drug treatment services and correctional programmes available to offenders do not appear to be appropriate for the needs of this population [28, 29]. A needs assessment might be a useful tool to develop programmes and activities which are relevant for and appreciated by offenders. The re-introduction of life-skill programmes should also be considered as they have proved to be effective for the social rehabilitation of offenders after release [28, 29]. A closer cooperation between the correctional centre and the community can be helpful for improving the service offered and for assuring the continuity of care, as corroborated in other studies .
The findings of this study are subject to the limitations of the study design and sample size. In particular, this study focused on incarcerated youth at one correctional centres, and thus, the findings might not be generalisable to other correctional centres. The sample size of both KI offenders and staff was also small, and thus cannot be regarded as representative of the broader correctional service population. Also, participant inclusion criteria required staff to be committed to improving health situations in the centre; thus staff working at the centre who are not committed to improving the situation may have imparted different views. Furthermore, offender participants could have also had different drug-use knowledge and perceptions to other people and due to the fact that they were incarcerated, may also have held specific views. The analysis of material from the focus groups (as opposed to the individual questionnaires) is also potentially subject to more interviewer and author bias. Although it is obviously important to bear in mind any potential sample representivity shortcoming of biases, ultimately, the aim of the study was not to provide a basis for substantial generalisation, but rather to provide a descriptive account that can inform practices in a practical manner.