The French System of Drug Monitoring in Prisons. Marie Jauffret-Roustide, Laurent Michel 1. Cermes 3 (Inserm U988/UMR CNRS 8211/EHESS/Paris Descartes University), Paris, France. 2. CESP-Centre Pierre Nicolle.

Drugs and health in French prisons (1) Health of prison inmates is a very critical issue in France, for structural reasons but also due to the specific characteristics that define incarcerated populations. Prisons are drastically overcrowded: 70 000 inmates in facilities built for 58000. In some cells, there are two inmates for every spot. Among inmates, there is an accumulation of factors of vulnerability (addictive behaviors, psychiatric disorders, social precariousness). Drug users are overrepresented in prisons.

Drugs and health in French prisons (2) Between 1990 and 2000, very few studies on injection practices inside prison were available in France. A study conducted in the South of France reported that 42% of PWID continue to inject drugs inside prison (Rotily BMJ 1998). There is a higher prevalence of infectious diseases in prison settings. The incidence of HIV is 3 times that of the common population and the incidence of hepatitis C is 5 times that of the common population (Semaille Eurosurveillance 2013). Access to sterile injection equipment is not allowed in prison. In such a concerning public health situation, it was essential to gather information on the use of drugs and the exposition to infectious diseases in French prisons. Since the mid-2000s, numerous research projects have been set up to document this issue in France.

The ANRS-Coquelicot Study (2004-2005 & 2011-2013) Cross-sectional sero-epidemiological study among people who use drugs in France (PI: Marie Jauffret-Roustide). Recruitment in 138 treatment centers and harm reduction facilities 61% of PWUD reported a history of incarceration in 2004-2005, 57% in 2011-2013. Among them, 12% reported previous drug use in prison and 30% shared injection equipment in this context in 2004-2005; the respective figures were 14% and 40% in 2011-2013. The ANRS-Coquelicot research supported findings that injection practices exist in prisons. However, the interviewed drug users were recruited after release. We needed to set up similar research inside the prison environment.

The ANRS-Coquelicot Study in prison settings (2017) Assessment of drug-related at-risk behavior among current inmates conducted in the ANRS-Coquelicot Study: 5 prisons (Lille, Fresnes (Paris area), Marseille, Martinique and Villeneuve-les- Maguelone) Epidemiological study among 350 inmates: receiving an opioid agonist treatment, or reporting injection practices, sniffing or inhaling crack in the last 12 months. Focus on drug use in prison settings, exposure to risks of infection (drug- or sex-related, tattooing, piercing,…), access to care, harm reduction needs,… inside prison. Face-to-face interviews. Ongoing data collection. Results expected for 2018.

The CIRCÉ Study (2017-2018) Qualitative investigation conducted through interviews of inmates (N=35) and prison staff (health and correctional) (N=35). Co-PIs: Marie Jauffret Roustide, Inserm and Caroline Protais, OFDT. The aim is to analyze life trajectories of drug users in prison and to know if they continue to use drugs inside prison and how they obtain drugs. We also want to investigate the phenomenon of “trafficking” in prison settings. Two separate parts of investigation: 1) consumption of psychoactive substances, state and integration of harm reduction in prison settings. 2) circulation and exchange of psychoactive substances in prison settings. One common research question: what is the effect of incarceration on psychoactive drug consumption? What is its effect on potential entry into narcotic trafficking? Field work is ongoing – results expected in 2018.

The ANRS-PRIDE program Created in 2009 (Co-PIs: Laurent Michel & Marie Jauffret-Roustide). Main topic: prevention of infectious diseases in prison settings. Steps of the program: Inventory of infectious disease prevention and HR measures for French inmates (2010). Preliminary qualitative assessment of the needs through sociological research (2015): Drug-related at-risk behaviors among inmates inside prison. Acceptability of new harm reduction measures among prisoners, sanitary and security staffs. Intervention trial and assessment of the social acceptability of the implementation of a series of new harm reduction measures in prisons in France (2018-2019).

The ANRS-PRIDE program Inventory (2010) Inventory of harm reduction measures. Main conclusions: Very little availability and accessibility of harm reduction equipment in prison settings, including officially recommended, despite scientific backing. Structural factors associated with harm reduction measure availability at the European level: overpopulation. Clear gap between French but also international recommendations and situation in French prisons.

The ANRS-PRIDE program Qualitative research (2015) Preliminary qualitative assessment of the acceptability of new harm reduction measures among inmates, sanitary and security staffs (2015): Sanitary staff met during ANRS-PRIDE inventory + focus groups (17). Security staff: one-on-one interviews (12). Inmates: one-on-one interviews in prison and post-release settings (16). Main conclusions: Security staff: drug use not considered a major issue, especially injection practices. Cannabis very common and seen as a health concern and as a way to cope with the living conditions in prison. High level of social acceptability of NEP: no real ideological oppositions, only some organizational concerns. Health staffs: harm reduction is not understood as a priority. More ideological concerns towards NEP than security staffs, linked to the psychoanalytical view of drug use. Inmates: 1/3 of high-risk prisoners reported injection practices inside prison and 2 started to inject inside prison.

Methodological challenges We faced difficulties when attempting to transfer our usual investigation methods into a prison setting. This was particularly the case when it came to the topic of drugs that are illegal in France. It took a very long time to secure authorizations to set up the studies. It was difficult to guarantee inmates perfect anonymity. Prison administrators must be made aware of the issues discussed in the investigation conducted in their facility. Since the inmate cannot travel independently in the facility, correctional officers could also become aware of the issues under investigation. Our collaborative efforts with the Prison Administration Committee were essential in preparing the investigation and securing the right authorizations. It was also important to maintain our independence with respect to the prison institution. We faced difficulties trying to secure true informed consent in an institution where liberty is constrained. Social desirability biais was reduced and prisoners, prison staff and health prison staff spoke very freely during semi- directive interviews about their drug use, their living conditions and their working conditions.

Perspectives Despite these hurdles, we were able to set up various projects that feature scientific collaborations between different research and monitoring institutes (ANRS, Inserm, OFDT, Santé Publique France). Such an ambitious investigation apparatus aims to document drug use and trafficking in prison settings, with a special focus on exposition to risks of infection. Beyond our scientific aims, we also wish to see harm reduction policies evolve for inmates. Particularly, this research program has the aim to improve access to sterile syringes and to reduce infectious diseases transmission in prison. This objective would be in compliance with the principle of equivalence of care in common and correctional settings. This research apparatus is also supplemented by local, one-time investigations conducted inside French prisons. Our project is part of a larger European undertaking, one that is best represented in the works conducted through the EMCDDA.