Home » Side event – Harm Reduction in Prisons

Side event – Harm Reduction in Prisons

Jose Manuel Arroyo—  in late 90s in Spain HIV rate around 60% in the community of IDUs.  Number in prisons 50%.  Infection rate among inmates in Spain about 30%.  Highest HIV and mild HCV rates the highest in Europe.  Remarkable challenge faced was to implement efficient and advanced measures for prevention and harm reduction.  Spain launched a prevention and control program for communicable diseases in prison.  Same program as was going on in community.  Main objectives was early detection of cases together with prevention of new cases.  From 24% in 1992 to 6% in 2013.  WHO and Council of Europe recommendations as well as Spanish and Civil society organization.

Such action was based on the following voluntary testing, confidentiality, no segregation, free distribution of condoms, OST, health related education, prisoners training as health mediators, access to alternatives like those outside prisoners.  Parole for terminally ill prisoners.

Methadone maintenance programs.  Ground breaking harm reduction since 1996. NSP program in prison.  Adapted from the community and one of the main tools for transferring inmates to social reintegration.  Improvement of general safety within prisons.  Number of participants have diminished.  Change of habits from opioids to stimulants, where the program is not working.  Number of drug addicts among inmates has decreased.

NSP Program.  23 prison programs now.  Number of syringes distributed has fallen dramatically.  Due to decrease of number of IDUs and change of habits from injecting to inhalation.  Reduction of HCV by almost half.  From 48.6% in 1993 to .05 in 2012.

Seroconversionshave decreased dramatically.  From 5% to 1%.  Proves that risk of transmission among inmates has been reduced.  Harm reduction programs in Spain have been effective over the years to stop the spread of blood borne diseases in and out of prison.

Deputy Director of prison health care in Spain
Ministry of Interior
Calle Alcala 38-40
Madrid, N/A
Spain Email: jmanuel.arroyoc@dgip.mir.es

Rick Lines .  Harm Reduction International.  Global state of harm reduction in prisons.  Fabienne Hariga’s work at UNODC helpful in putting this together.  Very impressed with Spanish experience.

Global state of harm reduction in prisons very poor despite Spanish and other programs showing it works.

160 countries have identified IDU in population.  80 or so have implemented NSP at some level in the community.  And OST in a few less countries.

Countries that have harm reduction in the community – 90 NSP and 79 OST .  40 had some form of OST in prison, around 18 have NSP.  Data at http://www.ihra.net
in the Global State of Harm Reduction.  Most vocal countries on harm reduction abysmally bad at expanding it in to prisons.  30 million people passing through prisons.  Many of them use drugs.  In addition, many are disproportionately from Communities marginalized or stigmatized.  So we have in prisons across the world, populations of people who suffer increased marginalization and have more extreme healthcare needs, including HCV and HIV.  Virus thrives in conditions of marginalization and exclusion.  Same population that winds up in prison.

Perplexing that those countries have not translated those programs into prisons.  Why harm reduction supporting countries don’t think HR necessary in prisons.

1) Myth that prisons are ‘drug free.’  Prisons are full of drugs.  Reaction that we can’t implement NSP in prisons, because it is an admission that drug use is going on in prison.  “Send the right message”  rather than “do the right thing.”  There are drug free prison wings … this is an admission that the rest of the prison is full of drugs.

2) Lack of control?  Perception that needs to be addressed.  Common feature of prison systems around the world.  Not a disgrace to any national prison system.  A common feature of how prisons operate in international system.

3) Security concerns.  Syringes can be used as weapons etc…fear.  No evidence for that in HRIs research.  Could not find one example where syringe from NSP program had been used as a weapon.  Experience of staff was that provision of sterile and regulated supply of syringes increased security.  Risk of hidden syringes and needle stuck is worst fear – hidden in clothes.  Regulated NSP program eliminates that risk.

4) Effectiveness.  Jose Manuel’s slides show very clearly effect of implementation.

5) Stigma against people who are incarcerated.  Shouldn’t have the right to adequate standard of healthcare. Double stigmatization.

6) Assumption about prisoners’ ability to look after health.  Not motivated.  People naturally self-destructive and don’t care.  RL experience the opposite.  Fact of living in prison is unhealthy.  Prisoners try to improve their environment.

Back to gap between countries that have HR in community but not in prison.  Same myths as countries that don’t want HR in the community.  Very interesting to think that even in countries that accepted them for community health still block HR in prisons.

Clear reason why we support HR in prison as well as community.  Tested PH intervention in community or closed custody.  HR supports human rights.  UN Human rights law.  States have enhanced legal obligations when people are in prison.  Need to prohibit cruel inhuman and degrading treatment.  Lack of medical care in prison equates to.  Strong HR mandate.  Supporting health, supporting, Human Rights, Supporting Harm reduction.

Chair.  Reminds audience of UN Goal of 50% HIV reduction in people who use drugs by 2015.

Fabienne Hariga. UNODC.  “NSP Programmes in Prisons”
We know three things
1. HIV prevalence in community…higher in prison
2 Prevalence of people who I drugs higher in prison in community
3. HIV and HCV are transmitted in prisons.
4.  drugs are circulating in prisons

Much easier to find drugs in prisons than to find NSP program in absence of those programs.  Will make their own tools with eye drop bottle, ballpoint pen.  Access to clean safe syringes is very limited, risk of transmission through sharing of contaminated syringes much higher in prison than in the community.

Human rights approach, comprehensive package for HIV and PWID.
1)   NSP Program first…on the list.  Human rights and public health approach.

Evidence and feasibility of NSP in prison settings.
Drug consumption by inmates participating in NSP programmes stable or decreased
Reported sharing declines or virtually non-existent
No reported cases of inmates acquiring HIV, hep b or HCV
No reported instances of initiation of injecting by inmates who did not inject before
Facilitate referral to drug treatment
Reduces occurrence of absence
Use of syringes as weapons not reported
Reduce risk of accidental puncture for prison officers
But effectiveness depends on access and on coverage.
Bizarre way of reporting evidence.  Way we present evidence and what we are looking at is obstacles and resistance or and answers to questions.

In 2013 only 7 countries having NSP programs in prisons.  Afghanistan (1 pilot), Germany, Kyrgystan (all), Moldova, Spain, Tajikistan, Switzerland.  Not Australia, Portugal, France, or Canada.  Thinking about it.

Why is it so poor?  Expert meeting.  Decided that what was lacking was that they lacked the how to tools.  Lessons learned not disseminated.  Reviewed different experiences.  12 or 13 countries had…same countries, different systems.  Switzerland – dispensing machines.  Germany, only dispensing machine.  Spain through health department.  Moldova, mainly peer to peer.  Sometimes participation of NGOs.

Slides of dispensing machines.  Many programmes don’t work very well.  So many stopped operating.  Because there is all this anxiety around security around risk and control, whenever the authorities start implementing a program they put so many control measures that it becomes almost impossible to access.  No anonymity using machine.

Lack of access, limited hours of service or place.  Peer based NSP programs cheaper and more accessible but other types of problems.

UNODC draft guide to managing NSP programs…in production at the moment.

Part of a comprehensive program.  Not in isolation from other measures.  Expample from Spain very illustrative.

Barriers the same in all countries.  Security question around syringes being used as a weapon.  Stigma.  Shown as a non-effective program to reduce rehabilitation.  Not against drug addiction.  Why should an administration give needles.  Doesn’t fight drug addiction.

Rick – Financial Crisis used as an excuse.  Cutting prisons best way.
Fabienne.  First program to suffer in 2008 was Harm reduction and in prisons cut.  Barely enough funds to feed prisoners.  Problem not linked to that.  Between 1992 and 2008 and nothing increased there.

NSP very cost effective and cheap.


Judith Yates MD.  Do prison guards not search people for syringes?  Have to “turn a blind eye.”  Engaging in HR is a positive program – different mindset.  NSP programs contradicts their authorities in old mindset.
When Ontario condom distribution – violated prison guards freedom of religion…”promoted buggery.”
Rick.  Good question.  Imperative that COs see value of program.  Prisoners have to trust that Cos are trained in the value – highlight workplace health and safety for them.  Similar to NSP programs in community so cops don’t bust everyone going in and out.

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