Provision of syringes: the cutting edge of harm reduction in prison?

Health Outcomes for Clients of Needle and Syringe Programs in Prisons

High levels of drug dependence have been observed in the prison population globally, and the sharing of injecting drug equipment in prisons has contributed to higher prevalence of bloodborne diseases in prisoners than in the general population. Few prison needle and syringe programs (PNSPs) exist. We conducted a systematic review to assess evidence regarding health outcomes of PNSPs. We searched peer-reviewed databases for data relating to needle and syringe programs in prisons. The search methodology was conducted in accordance with accepted guidelines. Five studies met review inclusion criteria, and all presented evidence associating PNSPs with one or more health benefits, but the strength of the evidence was low. The outcomes for which the studies collectively demonstrated the strongest evidence were prevention of human immunodeficiency virus and viral hepatitis. Few negative consequences from PNSPs were observed, consistent with previous evidence assessments. More research is needed on PNSP effectiveness, and innovative study designs are needed to overcome methodological limitations of previous research. Until stronger evidence becomes available, policymakers are urged to recognize that not implementing PNSPs has the potential to cause considerable harm, in light of what is currently known about the risks and benefits of needle and syringe programs and PNSPs and about the high prevalence of human immunodeficiency virus and viral hepatitis in prisons.

"It Goes on Everywhere": Injection Drug Use in Canadian Federal Prisons

BACKGROUND

International and Canadian research on in-prison injection drug use has documented the frequency of its occurrence as well as some of the resulting consequences such as increased prevalence of HIV and hepatitis C virus. Access to prison-based harm reduction programing is thus important.

OBJECTIVES

The aim of this study was to learn from former prisoner experiences and insights on in-prison injection drug use in order to advance and improve access to harm reduction options, in particular prison-based needle and syringe programs (PNSPs).

METHODS

The qualitative and community-based study was conducted in 2014/2015 and included former prisoners from Ontario, Canada (N = 30) who had recent experience of incarceration in a federal prison and knowledge of injection drug use. Data analysis followed the deductive approach, drawing on the expertise of the academic and community-based research team members.

RESULTS

Interview and focus group participants disclosed that drugs are readily available in Canadian federal prisons and that equipment used to inject is accessed in a variety of ways, sometimes gained through illicit means and sometimes made by prisoners themselves. Equipment sharing is a frequent occurrence, and disposal of such supplies is rare. Conclusions/Importance: While not yet available in Canada, PNSPs have led to positive outcomes in international contexts, including reductions in needle sharing and transmission of HIV and hepatitis C. Support for PNSPs among numerous Canadian organizations and associations, along with a recent change in government, could suggest a renewed opportunity for PNSP implementation.

"Double burden": a qualitative study of HIV positive prisoners in Italy

PURPOSE

This paper aims to consider the influence of imprisonment on the health of prisoners with the HIV virus or AIDS and their perceptions of their quality of life.

DESIGN/METHODOLOGY/APPROACH

This is a qualitative study involving adult male prisoners in three Italian prisons. A total of 19 individual semi-structured interviews were conducted.

FINDINGS

Life in prison for HIV positive detainees is experienced as a kind of "double burden," due to the connection between the loss of freedom and the limitations imposed by their health status. The experience of being ill and sick in prison results in the prisoner exhibiting fatalism towards the future, having a sense of alienation and marginalisation as well as being afraid of the consequences of living with HIV or AIDS.

SOCIAL IMPLICATIONS

Prison can be considered as a "total institution" where prisoners are cut off from every role except the negative one of a prisoner deprived of freedom, and this situation greatly contributes to apathy and reinforces the inmates' antisocial behaviour. Originality/value - This paper gives a voice to the needs and views of Italian prisoners who are HIV positive or who have AIDS and presents these in the context of the international situation.

Injecting Drug Users Retention in Needle-Exchange Program and its Determinants in Iran Prisons

BACKGROUND

Participation and to stay in a health program depends on many factors. One of these programs is Needle Exchange Program (NEP) in prisons.

OBJECTIVES

The current study aimed to evaluate the retention of injecting drug prisoners and find the related factors in Iran.

PATIENTS AND METHODS

This cohort study analyzed data about injecting drug male prisoners who were participated in NEP in three Iranian prisons. Data was collected from October 2009 to June 2010. A proper approach of survival analyses including Kaplan-Meier method, Log-Rank test, and Cox Proportional Hazard Model were used to evaluate Injecting Drug Users (IDUs) retention in NEP and its determinants.

RESULTS

Out of 320 prisoners, 167 were from Isfahan Central Prison, 82 from Tehran-Ghezel-Hesar Prison, and 71 from Hamadan Central Prison. Two-hundred and fifty prisoners (78.4%) had history of drug injection; and drug injection was the most common choice for 115 persons (35.9%). Participants were followed up for 29 weeks, the mean (SD) time of retention in the program was 24.1 (0.6) weeks. There was a significant relationship between age, number of used needles per week, duration of addiction, age of addiction onset, as well as imprisonment age, main method of drug use, type of main using drug, Hepatitis B Virus (HBV) infection, job status, reason of arrestment, history of involvement in harm reduction programs, and the length of retention (P < 0.05). There was also significant relationship between the history of using harm reduction services (P = 0.007), tattooing (P = 0.01), longer durations of addiction (P = 0.048), and retention.

CONCLUSIONS

Tattooing and longer duration of addiction were two important factors that significantly increased retention in the program. In contrast, history of using harm reduction services was the factor that decreased persistence. The risk of quitting the program may decrease about 68% in those who did not involve in harm reduction programs.

Injecting drug use in prison: prevalence and implications for needle exchange policy

Purpose

– The purpose of this paper is to explore prison drug injecting prevalence, identify any changes in injecting prevalence and practice during imprisonment and explore views on prison needle exchange.

Design/methodology/approach

– An empirical prospective cohort survey conducted between 2006 and 2008. The study involved a random sample of 267 remand and sentenced prisoners from a large male category B prison in England where no prison needle exchange operates. Questionnaires were administered with prisoners on reception and, where possible, at one, three and six months during their sentence.

Findings

– In total, 64 per cent were injecting until admission into prison. The majority intended to stop injecting in prison (93 per cent), almost a quarter due to the lack of needle exchange (23 per cent). Yet when hypothetically asked if they would continue injecting in prison if needle exchange was freely available, a third of participants (33 per cent) believed that they would. Injecting cessation happened on prison entry and appeared to be maintained during the sentence.

Research limitations/implications

– Not providing sterile needles may increase risks associated with injecting for prisoners who continue to inject. However, providing such equipment may prolong injecting for other prisoners who currently cease injecting on account of needle exchange programmes (NEPs) not being provided in the UK prison setting.

Practical implications

– Not providing sterile needles may increase risks associated with injecting for prisoners who continue to inject. However, providing such equipment may prolong injecting for other prisoners who currently cease injecting on account of NEPs not being provided in the UK prison setting.

Originality/value

– This survey is the first to question specifically regarding the timing of injecting cessation amongst male prisoners and explore alongside intention to inject should needle exchange facilities be provided in prison.

Trend of HIV/AIDS Prevalence and Related Interventions Administered in Prisons of Iran -13 Years' Experience

BACKGROUND

HIV/AIDS epidemic is concentrated among injecting drug users in Iran. Like many other countries with HIV/AIDS concentrated epidemic, prisons are high risk areas for spreading HIV/AIDS. The aim of this paper was to study the trend of HIV/AIDS prevalence and related interventions administered in prisons of Iran during a 13 years period.

METHODS

This cross sectional study was conducted using the data collected from the sentinel sites in all prisons in the country and it also used the data about Harm Reduction interventions which has been implemented by Iran Prisons Organization. To evaluate the correlation between the prevalence and each of administered interventions in prisons the Correlation Coefficient Test was used for the second half of the mentioned time period.

RESULTS

The prevalence of HIV/AIDS in prisons had increased rapidly in the early stages of epidemic, so that in 2002 the prevalence raised to 3.83%. Followed by the expansion of Methadone Maintenance Therapy and development of Triangular Clinics, HIV/AIDS prevalence in prisons declined. There was a relationship between interventions and the prevalence of HIV/AIDS.

CONCLUSION

In regions and countries where the epidemic is highly prevalent among injecting drug users and prisoners, Methadone Maintenance Therapy and development of Triangular Clinics can be utilized to control HIV/AIDS epidemic quickly.

Behind the Bars of Paradise: HIV and Substance Use among Incarcerated Populations in Puerto Rico

For those who are incarcerated in jails and prisons, the correctional setting represents a unique context for health care access and utilization. In Puerto Rico, over 16 000 persons pass each year through a correctional facility, approximately 6.9% of the incarcerated population present HIV infection, and 73.8% and 27.1% evidence a previous history of drug and alcohol use, respectively. In addition, HIV-infected populations have comorbidity with other diseases that are associated with substance use. Several approaches have been considered to prevent, treat, and provide a continuum of care for HIV and substance disorders among incarcerated populations. Nearly 30 years of legally regulated practices for correctional health care have produced recommendations for addressing the needs of those with HIV and substance disorders within the correctional facilities in Puerto Rico. These recommendations include making prevention services available, building capacity among health care providers, and understanding the cultural and political contexts.

The health of Italian prison inmates today: a critical approach

Despite declarations about health and social inequalities by the World Health Organization (WHO) and the Italian Constitution, the Italian penitentiary health system often does not meet the needs of the prisoners. This article summarizes the findings concerning contextual and structural reasons for these deficiencies (in part as reported by a prisoner rights association) and describes an Italian Ministry of Justice project to promote health by creating homogeneous groups of comorbidity for epidemiological study. Data and analysis on certain pathologies in the prison population are presented with special regard to addictions, hepatitis C virus, and cardiovascular problems. One etiological hypothesis focuses on the factors of promiscuity, excessive smoking, sedentary life, and stress. The conclusion is that prisoner health is a problem not only of inmates but for society.

Barriers to the provision of needle-exchange services: a qualitative study in community pharmacies

Objective

To investigate the attitudes of pharmacists to the provision of needle-exchange services (NES) at community pharmacies and, if barriers exist, explore means by which they may be overcome.

Setting

Twenty-one community pharmacies across Grampian in North East Scotland during May and June 2005.

Method

Semi-structured face-to-face interviews conducted with 24 pharmacists.

Key findings

Newly identified barriers included the negative influence of security staff, a local policy against NES provision and a lack of awareness of other services available for drug users.

Conclusion

Training packages for all health professionals working with drug users and awareness training for security staff are required if the identified barriers are to be overcome. ‘Hands-on’ training and experience of NES for pharmacists and their staff should be available. Suggestions made by pharmacists for NES provision in general practitioner surgeries or community hospitals and the development of automated services should be considered.

Interventions to reduce HIV transmission related to injecting drug use in prison

The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. We reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons, and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

[The place of syringe exchange programs in reducing harm in Canadian prisoners]

The prevalence rates of illicit drug consumption within the prison system are much higher than those in the Canadian population in general. Of the substances used in detention, those of most concern to prison and public health authorities are injection drugs, as the sharing of injection drug equipment may be responsible for the high prevalence of blood-borne diseases in prison facilities. Faced with this situation, the Correctional Service of Canada put in practice a number of harm reduction strategies targeting injection drug users, such as methadone maintenance programs and access to bleach. However, despite their use in the community, needle-exchange programs are not yet allowed in penitentiaries. This article analyzes the limits of harm reduction strategies approved by the prison authorities and discusses the sources of resistance that continue to impede the realization of a pilot project to assess the feasibility of needle-exchange programs in detention in Canada.

Prisons, hepatitis C and harm minimisation

Australian prisons have been identified as a focus of the ongoing hepatitis C epidemic. Harm minimisation is the major strategy directed to community-based public health measures to control hepatitis C. Harm-minimisation strategies to protect inmates and workers are incompletely and inconsistently applied in Australian prisons. Overseas experience has demonstrated that introducing injecting-equipment exchange programs and professional tattoo parlours in prisons could at least partially reduce the risks of ongoing hepatitis C transmission, and would support prevention and treatment programs. A two-stage approach is suggested: firstly, implementing programs of proven effectiveness consistently across the eight Australian jurisdictions, and, secondly, expanding current initiatives in the light of international "best practice".

A syringe exchange programme in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany

In two prisons in Berlin, Germany, provision of sterile injection equipment for injecting drug users (IDUs) started in 1998. To assess the programme's impact, the frequency of injecting drug use and syringe sharing, and the incidence of HIV, HBV, and HCV infection were determined in a follow-up study. Of all IDUs (n=174), 75% continued to inject. After the project start the level of syringe sharing declined from 71% during a 4-month period of previous imprisonment to 11% during the first 4 months of follow-up, and to virtually zero thereafter. Baseline seroprevalences for HIV, HBV, and HCV were 18, 53, and 82%. HIV and HCV seroprevalence at baseline was significantly associated with drug injection in prison prior to the project start. No HIV and HBV seroconversions, but four HCV seroconversions occurred. The provision of syringes for IDUs in appropriate prison settings may contribute to a substantial reduction of syringe sharing. However, the prevention of HCV infection requires additional strategies.

Prevention of infectious disease transmission in correctional settings: a review

OBJECTIVES

To review studies defining risk factors for infectious disease transmission in correctional settings, to determine target objectives, and to assemble recommendations for health promotion in prisons and jails.

METHODS

Electronic databases were searched, using a specific search strategy, from 1993 to 2003.

RESULTS

The principal risk factors in correctional facilities are proximity, high-risk sexual behaviour and injection drug use. Based on the type of disease transmissions and epidemics reported in the literature, four diseases were targeted for which preventive measures should be implemented: tuberculosis, human immunodeficiency virus, hepatitis and sexually transmitted diseases. Knowledge of risk factors helps define effective preventive measures along five main themes of action: information and education, screening, limiting harm from risk behaviour by distributing condoms and exchanging syringes, treatment and vaccinations.

CONCLUSIONS

The effectiveness and feasibility of each of these actions have to be assessed in relation to the specificities of the correctional setting.

Pharmacotherapy treatment in substance-dependent correctional populations: a review

The number of drug or alcohol dependent inmates has increased dramatically in recent years. About half of all inmates meet DSM-IV criteria for dependence at the time of their arrest and require substance use treatment or detoxification. Few inmates receive treatment while in prison, increasing the likelihood that they will continue to use substances in prison and after release. While pharmacotherapy interventions have been shown to be effective with substance users in the community, few studies have investigated these treatments with a prison population. Further research is needed to better understand the feasibility and efficacy of providing pharmacotherapies for substance dependence disorders within this population.

Prior opiate injection and incarceration history predict injection drug use among inmates

AIMS

To describe injection drug use among inmates, and to identify correlates of drug injection while incarcerated.

DESIGN

Cross-sectional survey.

SETTING

Six provincial correctional centres in Ontario, Canada.

PARTICIPANTS

Face-to-face interviews were conducted with a random sample of 439 adult males and 158 females.

MEASUREMENTS

Inmates were asked about drug use in their lifetime, outside the year prior to their current incarceration, and while incarcerated in the past year. Among the 32% (189 / 597) with a prior history of drug injection, independent correlates of injection while incarcerated in the past year were identified using multiple logistic regression.

FINDINGS

Among all inmates while incarcerated in the past year, 45% (269 /597) used drugs and 19% (113 / 596) used non-cannabis drugs. Among those with a prior history of injecting, 11% (20 / 189) injected while incarcerated in the past year. Rates of injection with used needles were the same pre-incarceration as they were while incarcerated (32%). Independent correlates of drug injection while incarcerated were injection of heroin (OR = 6.4) or other opiates (OR = 7.9) and not injected with used needles (OR = 0.20) outside in the year prior to incarceration, and ever being incarcerated in a federal prison (OR = 5.3).

CONCLUSIONS

The possibility of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) or other blood-borne diseases exists in Ontario correctional centres. In this setting, drug injection while incarcerated is primarily related to opiate use prior to incarceration. The correlation between injecting and extensive incarceration history suggests missed opportunities to improve inmates' health.

A meta-analysis of needle sharing, lending, and borrowing behaviors of needle exchange program attenders

This study used meta-analysis to examine cumulatively needle exchange program (NEP) change/comparison data from 47 studies between 1988 and 2001, based on data collected between 1986 and 1997. The research question posed was: Is NEP attendance associated with reductions in risky needle-related behaviors? Results indicated that needle sharing (r = -.189), variations on the outcome measure of needle sharing (r = -.161), and needle lending/borrowing (r = -.194) consistently declined among NEP attenders, suggesting the NEPs are effective in reducing risky needle-related behaviors of IDUs. The meta-analytic results lend support to the harm-reduction philosophy often used as the rationale for the establishment and maintenance of NEPs.

Prison-based syringe exchange programmes: a review of international research and development

Journal publications and conference presentations on prison-based syringe exchange (PSE) programmes were identified by a comprehensive search of electronic databases. Experts involved with development and evaluation of current PSE programmes or policy were contacted for reports, documents and unpublished material. Spanish information on PSE was translated for this review. We identified 14 papers specifically on PSE programmes in Switzerland (six papers), Germany (four) and Spain (four). The first PSE programme started in 1992 in Switzerland. As of December 2000, seven PSEs were operating in Switzerland, seven in Germany and five in Spain. There have been six evaluations of prison syringe exchange programmes and all have been favourable. Reports of drug use decreased or remained stable over time. Reports of syringe sharing declined dramatically. No new cases of HIV, hepatitis B or hepatitis C transmission were reported. The evaluations found no reports of serious unintended negative events, such as initiation of injection or of the use of needles as weapons. Staff attitudes were generally positive but response rates to these surveys varied. Overall, this review indicated that prison syringe exchange programmes are feasible and do provide benefit in the reduction of risk behaviour and the transmission of blood-borne infection without any unintended negative consequences.

Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature

AIM

To provide a comprehensive review of the literature on harm reduction theories and strategies related primarily to licit and illicit drug use.

BACKGROUND

Although human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) disease transmission is well understood, it continues to spread, particularly among injection drug users (IDUs). Despite early indications that HIV would be contained within the IDU community, it is spreading to non-IDU sexual partners and to children of IDUs, threatening a more widespread epidemic.

METHODS

An examination of research studies and theoretical writings including reviews and policy papers published in English between 1990 and 2000.

RESULTS

Harm reduction does not seek to eliminate drug use; it focuses on minimizing the personal and social harms and costs associated with drug use and spread of HIV. It seeks to ameliorate conditions surrounding drug use responsible for the spread of HIV in the IDU community: unequal access to health services; sharing of infected needles; racial and social discrimination; poverty; exposure to street violence; inadequate housing; lack of employment; poor general or mental health and other demographic and social determinants. Some controversial harm reduction strategies are described: methadone maintenance programmes, illegal drugs dispensing under controlled conditions, needle exchanges, HIV testing, vein maintenance, safe-sex and would-care programmes.

CONCLUSION

The main challenge is to get IDUs to protect themselves against HIV when suffering physical and social privations and addiction needs. Diverse perspectives on harm reduction are problematic with consequences for success of drug use initiatives. Practical, ethical and theoretical complexities exist but further research is needed to build support for a harm-reduction orientation in practice and policy formulation.

Prisoners with HIV/AIDS: a participatory learning and action initiative in Malaysia

Rapid participatory research and project development is possible within a tightly controlled social context such as a prison. Having gained access, based on trust and mutual respect, external agents may then facilitate significant change. Given adequate support, incarcerated people with HIV/AIDS and limited medical access may be able to develop mutual care, social support and income-generating activities. In the Malaysian context, we estimated in 1998 that up to one-quarter of prisoners with HIV had indicators of significant disease. We estimated that significant indicators remained unrevealed among between one-half and two-thirds of these. Given prevailing conditions, these would probably only be amenable to peer-based care.

Syringe availability as HIV prevention: a review of modalities

This review examines recent research into modalities for improving access to sterile syringes for injection drug users (IDUs) as a means to reduce human immunodeficiency virus (HIV) transmission. English language studies with empirical data were collected through Uncover reports and MedLine searches from 1998 to 2000. Although syringe-exchange programs are the most established and well-evaluated means of improving access to sterile syringes, research on alternative modalities-such as pharmacy sale, injector-specific packs, mass distribution, and vending machines-and on coverage of special populations suggests the need to pursue multiple avenues of increasing syringe availability simultaneously and, in particular, to explore modalities other than syringe-exchange programs when HIV incidence is under control. The impacts on HIV transmission of cocaine injection and sex with IDUs need to be explored further. Finally, any evidence of declining hepatitis C incidence among young IDUs might serve as a surrogate for a sharp drop in injection-related HIV risk behaviors in that population.

Drug testing in Canadian jails: to what end?

Since 1995, Corrections Services Canada (CSC) has conducted randomized urinalysis screening of a minimum of 5% of the federal inmate population on a monthly basis. Urine samples are screened for a broad range of psychoactive substances. The stated purpose of such screening is to reduce substance use in federal jails. Analysis of data provided by CSC for testing between 1994 and 1998 reveals small but statistically significant increases in the percentage of all urine samples that tested positive over that time. Analysis of the results of screening for opiates, cocaine and THC from data provided by CSC for the same time period, shows steady rates of opiate and cocaine detection at maximum and medium levels of security, decreases in opiate and cocaine detection in minimum security, and statistically significant increases in THC detection at all levels of security. The implications of these findings are discussed.

Drug testing in Canadian jails: to what end?

Since 1995, Corrections Services Canada (CSC) has conducted randomized urinalysis screening of a minimum of 5% of the federal inmate population on a monthly basis. Urine samples are screened for a broad range of psychoactive substances. The stated purpose of such screening is to reduce substance use in federal jails. Analysis of data provided by CSC for testing between 1994 and 1998 reveals small but statistically significant increases in the percentage of all urine samples that tested positive over that time. Analysis of the results of screening for opiates, cocaine and THC from data provided by CSC for the same time period, shows steady rates of opiate and cocaine detection at maximum and medium levels of security, decreases in opiate and cocaine detection in minimum security, and statistically significant increases in THC detection at all levels of security. The implications of these findings are discussed.