Organized by Kyrgyzstan with the support of the Republic of Moldova, and Switzerland, and the UNODC HIV/AIDS Section
Kyrgyz Republic (Ainura Esenamanova, Republican Center of Narcology, Ministry of Health – Moderator): Welcome
UNODC (Fariba Soltani, HIV/AIDS section, Global Coordinator for HIV/AIDS): People in prison are highly vulnerable to the risk of infections, including HIV amongst people who inject drugs and more broadly COVID-19 pandemic. They should have access to healthcare services without discrimination. Infection control and healthcare measures in some measures remain very inadequate. COVID-19 prevention and care measure are urgently needed, in line with the UN standard minimum rules of the treatment of prisoners. The UNODC has several guidance on the provision of evidence-based services. While harm reduction services are evidence-based, they are rarely provided, hindered by political and other obstacles. Only 56 countries provide OST in prisons. Other sectors also need to be involved, including justice, law enforcement and civil society. Continuum of care is also needed, including anti-retroviral therapy for people living with HIV and opioid agonist therapies, in close collaboration with services in the community to ensure continuity of care before, during and after imprisonment. An enabling environment is critical, which requires efforts against stigma and discrimination and gender-based violence.
Moldova (Alexandru Simionov, Counselor, Charge d’Affaires of the Permanent Mission of the Republic of Moldova to the UN Office and International Organizations): I would like to commend our colleagues and partners from Kyrgyz, Switzerland and UNODC in making this event possible during this difficult time given the pandemic. We also would like to thank the UNODC for their assistance, including to the penitentiary system. The challenges the entire world is facing shows how important it is to respond in a coordinated manner, as the virus knows no border nor nationality.
Kyrgyz Republic (Usenakunova Aizada, Narcologist, Ministry of Health): Kyrgyz Republic is in Central Asia and has a population of just over 6 million people. Geographically it is near Afghanistan, located on the northern trafficking route. Opioids including heroin account for most of the psychoactive substances used in the country. Amongst people who inject drugs, over the last 10 years, the number of people has decreased, e.g. in 2013 there were around 8,000 people and fell to just over 5,000 in 2021. By region, the highest number of people who inject drugs is highest in the South and the capital. Only 48 cases of all cases of people living with HIV were people who inject drugs. We initiated a number of programmes for people who inject drugs in the community and in prison. We have mobile testing facilities, needle/syringe exchange and distribution programmes, ART, and PReP. We also work jointly with other sectors to cover broader populations with our HIV testing programmes, e.g. migrants. ART drugs are offered using the single window one-stop-shop approach. At all OST sites, we have peer counsellors available who are making an important contribution to promoting ART adherence. There are 27 different penitentiary institutions and 13 of them have needle/syringe programmes – ART and condoms are also provided, along with psychological services and naloxone. All services are offered confidentially. Syringe exchange points have another purpose: referring the people who are active drug users to OST – we are seeing some good results, e.g. the number of referrals was 48. In 2020 the number of people covered was 1400. This last year was particularly difficult especially for prisons, due to COVID-19 and quarantine measures. Many of our clients stopped using the needle/syring programmes, and the coverage of services in prisons also went down, due to travel restrictions though some continued their access with the assistance of outreach volunteers. There is a new law on probation services which meant that a lot of clients were released so there are fewer people who inject drugs in prison than previously. There are 24 OST sites, some are in the penitentiary system. There is an overall reduction in the numbers of people going to the OST site because the number of people who inject drugs is going down. We have some successful strategies for OST, including a methadone distribution point at a women prison. If a person ends up in pre-trial, they can maintain their access to methadone. When clients on methadone are sentenced to prison, they will be sent to a prison with methadone services available. We also have TB services. There are some difficulties due to COVID as the lockdown was quite strict, so we worked hard to keep distributing methadone, TB drugs, as well as OST medication together with NGOs.
Switzerland (Prof Hans Wolff, Geneva University Hospitals): there are seven fundamental principles for health care in prisons including access to a doctor and equivalence of care. On equivalence of care, it is important to consider a needs-based approach and therefore the equity principle that needs to be applied. I recall the UNODC publication on good governance on public health in prisons and the importance of independence of the healthcare service from the prison administration, and also the WHO and UNODC package of interventions for the prevention, treatment and care of HIV. There is a lot of evidence on the effectiveness of opioid agonist treatment (OAT), e.g. it reduces mortality and the risk of infections. Care needs to be be given to prevalence of hepatitis C virus in injecting drug users. OAT is also cost effective; an Australian study showed that each $1 invested in OAT saves $38 in the long run. But the reality in the community and in prison is that provision is inadequate. There are also important human rights consequences, e.g. decision by the European Court of Human Rights against Germany for denying a person in prison of access to methadone. We need to assume that drug using occurs in all prisons, including by injecting and measures therefore need to be in place in all prisons to prevent HIV transmission including NSP. However it is not well implemented worldwide except in Spain and perhaps the Kyrgyz as well. There is an example of OAT in the prison of Champ-Dollon in Geneva: since 1970, pragmatic approach, politics of 4 pillars (prevention, harm reduction, treatment, repression), throughcare (systematic contact with follow-up services). About 5 – 10% of people in prison need OAT and are assessed for dependence before being offered it. Condoms and lubricants are also offered but not well taken up and confidentiality is being assessed to understand how it could improve take-up. The needle exchange at the prison sees a very small number of people who access it.
Problems and solutions include initial mistrust, fear of the syringe as potential weapon (detention officers), acceptance by the detainees e.g. due to fear of denunciation (importance of confidentiality, independence of healthcare service from prison administration, and considering distribution of needles/syringes including through automats).
Conclusions are that prisons pose high (deadly) risks for health, access to treatment and prevention are important, and we propose harm reduction services provided through a pragmatic approach and ensuring throughcare.
Moldova (Irina Barbiros, Ministry of Justice): The population of Moldova is about 3.6 million people and more than 6,000 are in prison. 5.5% are women and about 1% are juveniles or teenagers. The HIV prevalence in prison is about 2.4% and last year it was 3.8%. ARV enrolment rate is about 82%. Prevalence of HCV is about 64%, with TB a bit more than 1%. People who use drugs or dependence on drugs that are officially registered on prison records is 6.4%. Moldova is implementing 13 out of 15 interventions in the WHO and UNODC comprehensive package of services for people who use drugs in prison. In 1999, we started the needle/syringe programme, then later TB, then ARV in 2004, and 2005 the methadone programme started. In 2007, we tested people for HIV on a voluntary basis and later also for HCV and syphilis. In 2012, HIV testing services via NGOs began, and naloxone became available in 2013, then in 2015 guidance procedure manuals on implementing NSP and OST were established. We tracked data on the numbers of people accessing the various services before and after the pandemic, including on the number of sterile syringes and condoms distributed (which decreased slightly) and number of HIV testing conducted (increased).
Moldova: with the assistance of UNODC, 4 new remote e-justice rooms (in Balti, Chisinau, Cahul and Rezina) were created to allow people access to justice during the COVID-19 pandemic – each room includes soundproof cabins with ventilation and a window to prevent physical contact between people in prison and visitors.
Moldova (Cojocanu Vladimir, Ministry of Justice): The impact of COVID-19 on prisons has been serious, involving unfortunately 2 deaths amongst prison staff. We are thankful for the establishment of the e-justice rooms in pre-trial detention facilities so that meetings can take place without physical contact.
UNODC (Ehab Salah, HIV/AIDS Section): I refer to the international standards and guidelines on treatment and care for people who inject drugs: the Nelson Mandela Rules and the Bangkok Rules on the standards and norms for the treatment of people in prison, including specifically relating to women. The UNGASS Outcome Document also calls for evidence- and human rights-based services for people in prison and the community. Our work is also aligned with the Sustainable Development Goals, particularly Goal 3 especially the target on ending AIDS by 2030. The UNAIDS Strategy: Global AIDS Strategy 2021 – 2026 is focussed on ending AIDS and inequality, which is very important. Many of the strategic priority areas under this strategy covers people in prison. Other specific guidance address prevention of mother-to-child transmission of HIV (PMTCT). We have also set up an informal civil society group on HIV in prisons, as we believe in the important role of civil society. UNODC also offers COVID-19 specific technical guidance, together with the WHO.
Moldova (Moderator): there were some questions (including from Morgana Daniele of the Lithuanian Parliament on how NSPs can be implemented in prisons given the opposition to them in Lithuanie) in the chat but unfortunately we have run out of time. Thank you.