Injection Drug Use in Prisons A quick sketch of the global situation and a review of prison-based needle exchange

1. Injection Drug Use in PrisonsA quick sketch of the global situation and a review of prison-based needle exchange Matt Curtis International Harm Reduction Development Program Open Society Institute mcurtis@sorosny.org

2. Big thanks to:Ralf J�rgens, Canadian HIV/AIDS Legal NetworkAndrew Ball, World Health Organization

3. Background Worldwide, rates of HIV-infection in prisons are higher than in the general population Hepatitis C rates are even higher Risk behaviours are prevalent in prisons around the world. Drugs can and do enter prisons Large outbreaks of injection-related HIV in prisons have been documented in Australia, Scotland, Russia, Lithuania, Thailand, and a number of other countries. Need to introduce comprehensive, large-scale programmes Rates of HIV infection among prisoners in many countries are significantly higher than those in the general population.. HCV seroprevalence rates are even higher (Macalino et al., 2004). Studies from around the world show that injecting drug use is a reality in many prisons and that most prisoners who inject will share injecting equipment. Even countries that have invested heavily in drug demand and drug supply reduction efforts in prisons have not been able to stop injecting drug use. Sexual activity, including rape and other forms of non-consensual sexual activity, also are reported from prisons around the world. Finally, tattooing and other activities, including body piercing, sharing of razors and toothbrushes, and fights, assaults and accidents, occur in many prisons and put prisoners at risk of blood-borne infections. Outbreaks of HIV infection have been documented in a number of prison systems (Scotland, Australia, Russia, Lithuania, Iran), demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. Since the early 1990s, various countries have introduced HIV programmes in prisons. However, many of them are small in scale, restricted to a few prisons, or exclude those interventions which are most effective. There is an urgent need to introduce comprehensive programmes, and to scale them up rapidly. Programmes should not be restricted to education only, but should include other interventions such as substitution treatment, condoms, and NSP for which evidence existsRates of HIV infection among prisoners in many countries are significantly higher than those in the general population.. HCV seroprevalence rates are even higher (Macalino et al., 2004). Studies from around the world show that injecting drug use is a reality in many prisons and that most prisoners who inject will share injecting equipment. Even countries that have invested heavily in drug demand and drug supply reduction efforts in prisons have not been able to stop injecting drug use. Sexual activity, including rape and other forms of non-consensual sexual activity, also are reported from prisons around the world. Finally, tattooing and other activities, including body piercing, sharing of razors and toothbrushes, and fights, assaults and accidents, occur in many prisons and put prisoners at risk of blood-borne infections. Outbreaks of HIV infection have been documented in a number of prison systems (Scotland, Australia, Russia, Lithuania, Iran), demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. Since the early 1990s, various countries have introduced HIV programmes in prisons. However, many of them are small in scale, restricted to a few prisons, or exclude those interventions which are most effective. There is an urgent need to introduce comprehensive programmes, and to scale them up rapidly. Programmes should not be restricted to education only, but should include other interventions such as substitution treatment, condoms, and NSP for which evidence exists

4. Background:Injecting Drug Use in Prison Injecting is generally less frequent in prison than in the community, but is more risky due to the scarcity of injecting equipment and strictly controlled environment. Many start injecting in prison. Prisoners have far more changes in injecting partners than IDUs in the community. There is considerable interaction between prisoner and community injecting populations.

5. Proportion of Illicit Drug Users in EU prisons(EMCDDA, 2002)

6. Injecting & Syringe Sharing in Prison * France, Germany, Italy, Netherlands, Scotland, Sweden* France, Germany, Italy, Netherlands, Scotland, Sweden

8. Prevalence of Drug Use in Russian Prisons A recent study among 1,087 prisoners showed that 43% had injected drugs previously 20% injected in the penal institution 64% had used injection equipment that had already been used by somebody else 13.5% started injecting in prison

9. �Drugs were around but you see a syringe is a forbidden thing. And so they didn�t really figure very much. With drugs it is possible to hide them somehow, somewhere, but well, how do you hide a syringe? So, if someone somehow got hold of a syringe�maybe they brought it in or stole it from the medical centre�then it was just superachievement. Then that syringe would do the rounds and rounds and rounds of the whole camp. And then you get loads of syphilis, AIDS and . . . Someone would shoot up once and then in the course of the next 2 months about 20 people would be in the isolation ward with viral hepatitis.� (Barnaul, male, 18)

10. �Last time [I shared] � we shared one syringe between five. We took heroin. A person brought a gram of heroin, and we took it using one syringe. [And after, what did you do with the syringe?] We kept washing it out, and then hid it in order to use it the next time. Because in prison they are hard to get hold of.� (Volgograd, male, 27)

11. �We got a gram, shot up, five of us shot up. [With the same syringe?] Of course, of course, what else? Then, no-one . . . There�s the HIV section, well a whole section of people who�re infected with HIV, they live separately and that�s it. There they don�t have anything in common . . . And they check you immediately for HIV in the camp, as soon as you arrive and they check immediately there.� (Barnaul, male, 56)

12. Prison-Based Needle Exchange (PNEP) �By the end of 2005, more than 50 PNEPs were operating in: well-funded prison systems (Switzerland, Spain, Germany) and severely under-funded prison systems (Moldova, Belarus, Kyrgyzstan, Iran) in civilian prison systems and military prison systems in institutions with drastically different physical arrangement for the housing of prisoners in men�s and women�s institutions; and in prisons of all security classifications and all sizes

13. � PNEPs utilize various methods for distributing syringes: hand-to-hand exchange by nurses and/or the prison physician distribution by one-for-one automated syringe dispensing machines distribution by prisoners trained as peer outreach workers distribution by external NGOs or other health professionals who come into the prison for this purpose

14. Needle & Syringe Programs The first prison NSP in the world was established in Switzerland in 1992. Since then, NSPs have been introduced (or are about to be introduced) in various prison environments in over 50 prisons in 11 countries in Western and Eastern Europe and Central Asia.The first prison NSP in the world was established in Switzerland in 1992. Since then, NSPs have been introduced (or are about to be introduced) in various prison environments in over 50 prisons in 11 countries in Western and Eastern Europe and Central Asia.

15. Evidence: Needle Syringe Programs Systematic evaluations of the effects of NSPs on risk behaviours and of their overall effectiveness in prisons were carried out in at least 10 projects in Switzerland, Germany, and Spain. There is evidence that NSPs are feasible in a wide range of prison settings, including in men�s and women�s prisons, prisons of all security levels, and small and large prisons. There is also evidence that providing clean needles and syringes is readily accepted by IDUs in prisons and may contribute to a significant reduction of syringe sharing over time. It also appears to be effective in reducing HIV transmission. Note: For Berlin 2 people who had previously only inhaled heroin reported injecting drug use on single occasions. Systematic evaluations of the effects of NSPs on risk behaviours and of their overall effectiveness in prisons were carried out in at least 10 projects in Switzerland, Germany, and Spain. There is evidence that NSPs are feasible in a wide range of prison settings, including in men�s and women�s prisons, prisons of all security levels, and small and large prisons. There is also evidence that providing clean needles and syringes is readily accepted by IDUs in prisons and may contribute to a significant reduction of syringe sharing over time. It also appears to be effective in reducing HIV transmission. Note: For Berlin 2 people who had previously only inhaled heroin reported injecting drug use on single occasions.

16. Evidence: Take Home Messages No evidence that PNEPs have serious, unintended negative consequences Needles have not been used as weapons No increase in drug use has been observed PNEPs are associated with sharp reductions in syringe sharing and reduced HIV incidence. Determinants of success: Confidential access: syringe exchange or distribution methods must gain the trust of prisoners, and thus maximize participation in the program Easy access PNEP should be one component of a broader health strategy, and be accompanied by other harm reduction interventions incl. drug treatment, opiate substitution therapy, sexual health services, etc. At the same time, there is no evidence to suggest that prison-based NSPs have serious, unintended negative consequences. In particular, they do not appear to lead to increased drug use or injecting, and needles have never been used as weapons. Evaluations have found that NSPs in prisons actually facilitate referral of drug users to drug dependence treatment programmes.At the same time, there is no evidence to suggest that prison-based NSPs have serious, unintended negative consequences. In particular, they do not appear to lead to increased drug use or injecting, and needles have never been used as weapons. Evaluations have found that NSPs in prisons actually facilitate referral of drug users to drug dependence treatment programmes.

17. Addressing prison systems� concerns Any measure undertaken now to prevent the spread of HIV will benefit prisoners, staff, and the public. It will protect the health of prisoners, who should not be exposed to the risk of infection. It will protect staff. Lowering the prevalence of infections in prisons means that the risk of exposure to these infections will also be lowered. It will protect the public. Most inmates are in prison only for relatively short periods of time and are then released into their communities. In order to protect the general population, HIV prevention measures need to be available in prisons, as they are outside.

18. For more information on PNEP and other prison harm reduction ? Canadian HIV/AIDS Legal Network www.aidslaw.ca International Harm Reduction Development Open Society Institute www.soros.org/harm-reduction European Network on Drugs & Infections Prevention in Prisons www.endipp.net