Harm Reduction in PrisonsAn overview of international policy and practice

Rick Lines

Harm Reduction International

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What do we know about blood-borne infections in prisons?

Rates of HIV/HCV infection in prisons related to two factors.

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What do we know about blood-borne infections in prisons?

1. Rates of infection in the community outside prison, especially amongst vulnerable populations (i.e., people who use drugs)

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What do we know about blood-borne infections in prisons?

2. Prevalence of high risk behaviours inside prisons (i.e., sharing injecting equipment)

Home-made prison syringe

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Barriers to Harm Reduction in Prisons

• Zero-tolerance/abstinence based approaches to drug use, often more entrenched than outside prisons

• Security ethos of prisons: Admission of sex and drug use seen as an admission of security failure

• Discrimination against prisoners, people who use drugs and MSM

• Lack of legal framework (i.e., for syringe exchange or methadone therapy)

• Staff safety concerns• Funding and resources• Poor and overcrowed prison conditions

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Examples of Harm Reduction in Prisons• Needle/Syringe Programmes• Condoms and safer sex

measures• Bleach and disinfectants• Methadone and other

substitution treatment• Safer tattooing• Peer Education• Alternatives to prison for

people who use drugs• Broader prison reforms that

improve conditions and reduce overcrowding

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Harm Reduction in Prisons:Needle/Syringe Programmes

• Switzerland: First programme 1992/93– Today – PSEP in 7 prisons

• Germany: Pilots in 1996– Today – PSEP in 1 prison (down from a high point of 7 prisons)

• Spain: Pilot in 1997– Today – PSEP approved for all 69 prisons, and programs operating in over 30 prisons

• Moldova: Pilot in 1999– Today – PSEP in 7 prisons

• Kygyzstan: Pilot in 2002– Today – PSEP in all 11 prisons

• 2007 – NSP also operating in Armenia, Belarus, Iran and Luxembourg.

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Prison Syringe Exchange:Models of Distribution – machines

Anonymous Syringe Dispensing Machines

Lichtenberg Prison Berlin

Saxerriet Prison Switzerland

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Prison Syringe Exchange:Models of Distribution – hand-to-hand

Harm Reduction KitSoto de Real Prison, Madrid

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Prison Syringe Exchange:Models of Distribution – peer workers

Prison Colony 18 Branesti, Moldova

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Syringe Exchange Evaluations

• Scientific evaluations conducted in 11 prisons with syringe distribution programmes

• The provision of syringes did not lead to an increase in drug consumption or an increase in injecting

• Syringes were not used as weapons, and safe disposal of used needles was not a problem

• Syringe sharing disappeared almost completely• In prisons where blood testing was performed, no

new cases of HIV or Hepatitis infection were found• Other positive health outcomes

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Harm Reduction in Prisons:Substitution Treatment

• Substitution treatment available in approximately 40 prison systems worldwide

• Most western European systems and some central and eastern European systems

• Canada and Australia • Iran• Heroin maintenance available in two Swiss

prisons since 1995.

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Prescription Heroin Programme

Obershöngrün Prison

Switzerland

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Prescription Heroin Programme

Obershöngrün Prison

Switzerland

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Methadone Evaluated:Correctional Service Canada 2001

• Participation in a MMT programme had positive post release outcomes

• Opiate users accessing MMT during incarceration were less likely to be readmitted to prison after release and less likely to have committed new offenses than those not accessing MMT

• MMT cost effective

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Substitution Treatment in Prisons:Good Practice & Limitations

• Prison policy vs. community policy? Effects on intake and discharge

• Detox only? Continuation only? Initiation of MMT?• Perceptions of prisoners and staff are important• One component of a broader harm reduction and

drug policy• Limitations

– Often limited spaces; limited qualified physicians and participating prisons– Not an effective harm reduction option for occasional/recreational heroin users or

cocaine users– No legal framework in many countries

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Advocating for Policy Change

• Zero-tolerance/criminalisation has failed• Harm Reduction programmes are safe • Harm Reduction is evidence-based• Harm Reduction is cost-effective• Promote legal, ethical, human rights• Collaboration

– Between prisoners and health professionals– Between organisations– Between countries

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Kamiti Prison

Nairobi, Kenya - 2005

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Rick Linesrick.lines@ihra.net

Harm Reduction Internationalwww.ihra.net