Assessing the social acceptability of harm reduction policy scale-ups in French prison settings: results from the ANRS-Pride Research Marie Jauffret-Roustide, Carole Chauvin, Olivier Maguet, Laurent Michel

Drug Policy in France Since 1994, the Ministry of Health is responsible for providing healthcare in French prisons. A 1996 circular regulates which harm reduction interventions are authorized in prisons. This circular does not respect the principle of equivalence of care between correctional and common settings (despite the 1994 ruling). OSTs are authorized but there is no access to sterile syringes in prison. 2010: researchers issue report on “reducing risks of infection among drug users” What is the epidemiological situation in prison environments? What treatments, tools and arrangements already exist? What evaluations of the impact of these tools are available? January 2016: a new « health law » states that harm reduction services should be equivalent in correctional and regular settings. Need a governmental decree to be implemented Increasing overpopulation (more than 200% in some prisons)… > 70 000 prisoners in facilities built for 58 000 In this context, it was crucial to evaluate the social acceptability of harm reduction measures in prison.

SOCIOLOGICAL STUDY We conducted our sociological research with the following objectives: to understand the social acceptability of harm reduction measures in prison. to describe the fears and barriers against the implementation of new harm reduction measures (including Needle Exchange Programs). to document drug use practices -- especially injecting practices -- in prison settings. to prepare the conditions of implementation for an intervention trial with the aim of respecting the principle pf equivalence of care between correctional and common settings.

METHODOLOGY We investigated two prisons: one in the suburbs of Paris and the other in the South of France. We conducted: Semi-structured interviews with prisoners (16) who are exposed to risks of infection (ex-drug user, OST patient, …) Semi-structured interviews with prison staff (12) Focus groups with prison health staff (17) Interview topics: Social perception of harm reduction measures among prisoners, prison staff and prison health staff. With the prisoners: data collection on life trajectories and past practices; drug use and “DIY” harm reduction equipment; adaptation and survival strategies in prison settings and identity transformations caused by the incarceration.

PRISON health STAFF – DRUG USE by injection IS A TABOO Injecting drug users exist but they are often difficult to quantify: « We assume they exist, but no patient has told me that he injects drug. » Prisoners face difficulties in discussing this matter with some prison health staff, and prison health staff face difficulties in addressing drug use and injection. Recent studies inside these two prisons have shown that drug injection exists inside prison. Each prison presents its own specific situation. In one prison, health staff report an increasing trend of medication injections, especially of anabolitic steroids. When it comes to injection, prison health staff are mostly concerned about « OST misuse » than about injection itself.

PRISON Health STAFF – HARM REDUCTION AND NEP ACCEPTABILITY No unanimous stance among health staff on harm reduction in prison (especially on NEP). Individual members develop opinions in relation with their professional reference framework (care delivery, objective of abstinence, psychiatric care, …) A diversity of arguments: some professionals are adverse to harm reduction because they do not wish to “contribute to addiction”, while other professionals decide to intervene (by distributing sterile syringes) because they want to avoid “becoming a passive spectator of injection”. A “capillary” rather than institutional approach: through the implementation of harm reduction measures (ie. sniffing equipment), health staff can be gradually convinced of the necessity implementing harm reduction in prison. Harm reduction is not considered a priority compared to prison working conditions (workload, physical safety) or to the living conditions of inmates (survival strategies and basic needs). The NEP are perceived as serving only a minority of prisoners. For NEPimplementation in prison: we have noted the importance of working with consenting, dedicated staff, and of using a global health education approach.

PRISON STAFF – DRUG USE IN PRISON Drug use and especially drug injection is not a priority concern for prison staff either. Prison staff frequently mention massive cannabis use in cells, and consider that cannabis and other illicit drug smuggling in prison is inevitable. Injections are less frequent or less visible than in the 80-90’s, but there is an increase in sniffing practices. Injections are seen as an epiphenomenon by the prison staff. Few syringes found in cells but prison staff consider that “injection presents a very high risk of infectious contamination in prison due to lack of access to sterile injecting equipment”. Cannabis use is not allowed by prison staff, but it is regarded as a health issue rather than a moral one. Cannabis use is « tolerated » in prison by the majority of prison staff, who understand cannabis use as an inmate’s strategy to cope with prison’s living conditions.

PRISON STAFF HARM REDUCTION PERCEPTION Drug users are perceived as any other inmates, especially when they receive OST. Positive perception of OST because “OST allows us to manage drug users who would be unmanageable when in withdrawal”. Medical work is respected in that field. Prison staff decry the strict separation between health staff and prison staff. Some prison staff members wish to be better informed and involved in medical operations, while also maintaining medical confidentiality. A rather high-level of social acceptability of Needle Exchange Programs in prison. The majority of prison staff have very little knowledge of harm reduction measures and of their implementation in prison. Very few prison staff professionals express an opinion on the conditions of implementation, but some ask for NEP (strictly limited, structured, and contained to the medical unit).

Inmates and ex-inmates Sample: 16 inmates/ex-inmates interviewed. 10 interviews conducted inside prisons. 6 were conducted in addiction treatment or rehabilitation centers, just after release. Consumption behaviors in prison: 6 subjects stated that they injected and for two of them the first injection was in prison. 14 stated that they sniffed in prison. 2 stated that they smoked crack in prison. Only 2 stated that they didn’t take drugs in prison.

Inmates harm reduction perception Perception of harm reduction measures in prison: Bleach is distributed without any particular harm reduction instructions. 5 inmates state that they are in favor of NEP inside the medical unit to avoid sharing and reusing: “if they have to do it, it’s better to do it in clean conditions”, or in a medical care setting where treatment is “not trivialized but structured; it would help because there would be a follow-up”. 5 state that they are not in favor of a NEP for security reasons: “an inmate can take revenge with a syringe and they always a prisoner to steal something” or because it would encourage drug use. 1 is not concerned and has a negative image of PWID « I don’t mix with them, I’m scared, if they come close to talk to me I move away ».

CONCLUSION We overcame difficulties linked to conducting research in prison and we managed to create an atmosphere of trust during interviewies. Prison staff, health staff, and prisoners spoke very freely. The interviews were mostly focused on harm reduction, but they also highlighted an opportunity to raise working and living conditions for professionals and living conditions for prisoners. Risky practices still exist in prison, although injection drug use seems to be decreasing. It’s important to note that two initiations to injecting drug use occurred in prison. Reticence against new harm reduction measures in prison does not stem from an “ideological” opposition from prison staff, but rather to the conditions under which they will be implemented. Implementation of the interventional trial PRIDE (including NEP) will start at the beginning of 2018.