17 décembre 2004Particularly because of the questionable efficacy of bleach in destroying HIV and other viruses (see info sheet 5), providing sterile needles to prisoners has been widely recommended. In its 1994 report, the Expert Committee on AIDS and Prisons (ECAP) observed that the scarcity of injection equipment in prisons almost guarantees that prisoners who persist in drug-injecting behaviour will share their equipment :
Some injection drug users have stated that the only time they ever shared needles was during imprisonment and that they would not otherwise have done so. Access to clean drug-injection equipment would ensure that inmates would not have to share their equipment.
The Committee concluded that making injection equipment available in prisons would be “inevitable.”
International Developments
Recently, an increasing number of prisons have established needle exchange or distribution programs.
Switzerland
In Switzerland, distribution of sterile injection equipment has been a reality in some prisons since the early 1990s. Sterile injection equipment first became available to inmates in 1992, at Oberschöngrün prison for men. Dr Probst, a part-time medical officer working at Oberschöngrün, was faced with the ethical dilemma of as many as 15 of 70 prisoners regularly injecting drugs, with no adequate preventive measures. Probst began distributing sterile injection equipment without informing the warden. When the warden discovered this, instead of firing Probst he listened to Probst’s arguments and sought approval to sanction the distribution of needles and syringes. As of 2004 distribution is ongoing, has never resulted in any negative consequences, and is supported by prisoners, staff, and the prison administration. Initial scepticism by staff has been replaced by their full support :
Staff have realized that distribution of sterile injection equipment is in their own interest. They feel safer now than before the distribution started. Three years ago, they were always afraid of sticking themselves with a hidden needle during cell searches. Now, inmates are allowed to keep needles, but only in a glass in their medical cabinet over their sink. No staff has suffered needle-stick injuries since 1993.
In June 1994 another Swiss prison - Hindelbank institution for women - started a one-year pilot IDS prevention program including needle distribution. Hindelbank’s program has been evaluated by external experts, with very positive results : the health status of prisoners improved ; no new cases of infection with HIV or hepatitis occurred ; a significant decrease in needle sharing was observed ; there was no increase in drug consumption ; needles were not used as weapons ; and only about 20 percent of staff did not agree with the project. Following the first evaluation, a decision was taken to continue the program. The prison has also experienced a drastic reduction in fatal overdoses since the program started. Other Swiss prisons have since started their own programs, and in 2004, distribution of sterile needles was being undertaken in seven prisons in different parts of the country.
Germany
In Germany, a green light to the development and implementation of the first two pilot schemes was given in 1995, and the first pilot project started on 15 April 1996 in Lower Saxony. An evaluation undertaken after two years showed positive results, and recommended not only to continue the two existing pilot projects but to expand them to all prisons in Lower Saxony. At the end of 2000, needle exchange schemes had been successfully introduced in seven prisons in Berlin, Hamburg, and Lower Saxony, and others were looking at how to implement them. However, since then six of the programs were closed down, not because of any problems with the programs, but as a result of political decisions by newly elected centre-right wing state governments.
In each of these cases, the decision to cancel the programs was made without consultation with prison staff, and without an opportunity to prepare prisoners for the impending loss of access to the programs. It has been reported that since the programs closed, prisoners have gone back to sharing needles and to hiding them, increasing the likelihood of transmission of HIV and HCV, as well as the risk of accidental needle stick injuries for staff. Staff have been among the most vocal critics of the governments’ decision to close down the programs, and have lobbied the governments to reinstate the programs.
Spain
In Spain, the first pilot project started in August 1997. An evaluation undertaken after 22 months showed positive results and, as a result, in June 2001, the Directorate General for Prisons ordered that needle exchange programs be implemented in all prisons. As of early 2004, exchanges were operating in more than 30 prisons, and a pilot program had also been established in a prison in the autonomous region of Catalonia.
Eastern Europe
In recent years, countries in Eastern Europe and the former Soviet Union have also begun implementing prison needle exchange programs. The Republic of Moldova started a pilot project in one prison in 1999. Based on its success, the program has been expanded to two other prisons, with further expansion planned.
The Republic of Moldova started a pilot project in one prison in 1999. Based on its success, the program has been expanded to two other prisons, with further expansion planned.
Kyrgystan started a pilot project in one prison in October 2002. In 2003, approval was given to expand the program to all 11 prisons in the country. By April 2004, all prisons had needle distribution programs.
The Republic of Belarus started a pilot project in one prison in April 2003. In 2004, needle exchange programs will be introduced in two other prisons, and the Ministry of Internal Affairs has stated that it is prepared to establish them in all prisons in the country.
Canadian Situation
As of 2004, no Canadian prison system had started a needle- exchange program. However, a few systems, including the federal prison system, are studying the issue. A 1999 committee established by the Correctional Service of Canada (CSC) to examine the feasibility of establishing needle exchange programs in Canadian federal institutions recommended that pilot programs be initiated across Canada
People opposed to making needles available have said that distributing sterile needles in Canadian prisons would be seen as condoning drug use. In reality, it is not an endorsement of illicit drug use by prisoners. Rather, it is a pragmatic public health measure that recognizes that drugs get into prisons, prisoners inject drugs, and that efforts to eliminate drugs from prisons are doomed to fail. Not undertaking pilot needle-distribution projects, in the knowledge that HIV and other infections are being transmitted in prisons, could be seen as condoning the spread of infections among prisoners and ultimately to the general public.
What Can We Learn ?
The experience of prisons in which needles have been made available, including scientific evaluation of the pilot phases carried out in 11 projects, provides many lessons. Among the most important are :
Prison needle exchange programs are safe
Needles can be made available in prisons in a manner that is non-threatening to staff and that increases staff safety. Since the first prison needle exchange program started in 1992, there are no reported cases of a needle being used as a weapon either against prison staff or other prisoners. A In addition, prisoners are usually required to keep their kit in a pre-determined location in their cells. This assists staff when they enter the cell to conduct searches and has decreased accidental needle stick injuries to staff.
Prison needle exchange programs do not lead to increased drug use
Evaluations of existing programs have consistently found that the availability of needles does not result in an increased number of drug injectors, an increase in overall drug use, or an increase in the amount of drugs in the institutions.
Prison needle exchange programs do not condone illegal drug use and do not undermine abstinence-based programs
Drugs remain prohibited within institutions where needle exchange programs are in place. Security staff remain responsible for locating and confiscating illegal drugs. However, it is recognized that if and when drugs find their way into the prison and are used by prisoners, the priority must be to prevent the transmission of HIV and HCV via unsafe injecting practices. Therefore, while drugs themselves remain illegal, needles that are part of the official needle exchange program are not. In most cases, prison needle exchange programs have been introduced as only one component of a more comprehensive approach to dealing with drug-related harms, including abstinence-based programs, drug treatment, drug-free units, and harm reduction measures. Evaluations have found that needle exchange programs in prisons actually facilitate referral of drug users to drug treatment programs, and have led to an increase in the number of prisoners accessing such programs.
Prison needle exchange programs have been successfully introduced in various prison environments
While programs were first introduced in small Swiss prisons, they have since been successfully implemented in prisons for men and for women, in small, medium, and large institutions, as well as in prisons of all security classifications. Finally, after having been introduced in well resourced prison systems, programs have been established in systems with very limited resources. There are several models of distribution of sterile injection equipment, including automatic dispensing machines, distribution by medical staff or counsellors, and distribution by prisoners trained as peer outreach workers. What is appropriate in a particular institution depends on many factors : the size of the institution, the extent of injection drug use, the security level, whether it is a prison for men or for women, the commitment of health-care staff, and the “stability” of the relations between staff and prisoners.
Prison needle exchange programs reduce risk behaviour and prevent disease transmission
Most importantly, evaluations of existing programs have shown that reports of syringe sharing declined dramatically, and that no new cases of HIV, hepatitis B, or hepatitis C transmission were reported. In addition, other positive health outcomes have been documented in some prisons, such as a decrease in fatal and non-fatal overdoses and a decrease in abscesses and other injection-related infections.
Prison needle exchange programs function best when prison administration, staff, and prisoners support them
The support of the prison administration and staff is important, and educational workshops and consultations with prison staff should be undertaken. This is not to say, however, that staff in prisons in which such programs have been introduced have been universally supportive from the start. In several cases, as shown by the evaluations, they were reluctant at first, but supported the program after they experienced its benefits.
Prison needle exchange programs are best introduced as pilot projects
Experience has shown that a good way for a prison system to start a needle-distribution program, and to overcome objections, is to operate a program as a pilot project and to evaluate it after the first year of operation.
Recommendation
Sterile injection equipment should be made available in prisons where prisoners inject illegal drugs. In prison systems where distribution has not yet started, pilot projects should be undertaken immediately.
Additional Reading
R Lines, R Jürgens, H Stöver, D Latishevschi, J. Nelles. Prison Needle Exchange : A Review of International Evidence and Experience. Montreal : Canadian HIV/AIDS Legal Network, 2004. The most comprehensive and detailed report available on the international experience of prison syringe exchange. Available via www.aidslaw.ca/Maincontent/issues/prisons.htm.
Ministerio Del Interior/Ministerio De Sanidad y Consumo. Needle Exchange in Prison FrameworkProgram. Madrid : Ministerio Del Interior/Ministerio De Sanidad y Consumo, 2002. Detailed implementation plan for needle exchange programs in all Spanish prisons. A must read for anyone wishing to see how a successful needle exchange program is established in a prison. Available in English and Spanish.
H Stöver, J Nelles. 10 years of experience with needle and syringe exchange programmes in European prisons : A review of different evaluation studies. International Journal of Drug Policy 2003 ; 14 : 437-444.
K Dolan, S Rutter, A Wodak. Prison-based syringe exchange programmes : a review of international research and development in Addiction 2003, 98, 153-158.
R. Jürgens. HIV/AIDS in Prisons : Final Report. Montréal : Canadian HIV/AIDS Legal Network and Canadian AIDS Society, 1996, at 52-66. Still relevant for an account of the early history of the introduction of prison needle exchange programs. Available at at www.aidslaw.ca/Maincontent/issues/prisons/download1.html . For developments after 1996, see the many articles on this issue in the Canadian HIV/AIDS Policy & Law Review (at www.aidslaw.ca/Maincontent/otherdocs/Newsletter/newsletter-toc.htm#p) and the other documents in this list.
J Nelles, A Fuhrer. Drug and HIV Prevention at the Hindelbank Penitentiary. Abridged Report of the Evaluation Results of the Pilot Project. Berne : Swiss Federal Office of Public Health, 1995. The first-ever evaluation of a needle-distribution program. Copies : Swiss Federal Office of Public Health, 3001 Berne, Switzerland.
H Stöver. Study on Assistance to Drug Users in Prisons. Lisbon, European Monitoring Centre for Drugs and Drug Addiction, 2001 (EMCDDA/2001). A now out-dated, but still relevant overview of needle exchange programs in prison. Available at www.emcdda.org .
T Kerr, R Jürgens. Syringe Exchange Programs in Prisons : Reviewing the Evidence. Montreal : Canadian HIV/AIDS Legal Network, 2004. A 10-page review of the evidence. Available via www.aidslaw.ca/Maincontent/issues/prisons.htm .
Canadian Human Rights Commission. Protecting Their Rights. A Systemic Review of Human Rights in Correctional Services for Federally SentencedWomen. Ottawa : The Commission, December 2003. Available at www.chrc-ccdp.ca/Legis&Poli/IndexFSW_FSF.asp ?l=e . In its report, the Canadian Human Rights Commission recommended that the Correctional Service of Canada implement a pilot needle exchange program in three or more correctional facilities, at least one of them a women’s facility, by June 2004.
Third, revised and updated version, 2004. Copies of this info sheet are available on the Network website at http://www.aidslaw.ca/Maincontent/issues/prisons.htm and through the Canadian HIV/AIDS Information Centre (email : aidssida@cpha.ca). Reproduction of the info sheet is encouraged, but copies may not be sold, and the Canadian HIV/AIDS Legal Network must be cited as the source of this information. For further information, contact the Network (tel : 514 397-6828 ; fax : 514 397-8570 ; email : info@aidslaw.ca). Ce feuillet d’information est également disponible en français.
Funded by Health Canada under the Canadian Strategy on HIV/AIDS. The findings, interpretations, and views expressed in this publication are entirely those of the author and do not necessarily reflect the official policy or position of Health Canada.
© Canadian HIV/AIDS Legal Network, 2004
