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 Jürgens, 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

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

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 Drugs are available and injecting is preferred route, syringes are extremely scarce, and risk behavior is enforced by the environment while risk perception is often misguided.

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) Sarang A., Rhodes T et. al. “Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study.” Addiction 2006 forthcoming.

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

15. Evidence: Needle Syringe Programs

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.

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