Health Care for Drug Users in Prisons Prof. Dr. Heino Stöver, Prof. Dr Health Care for Drug Users in Prisons Prof. Dr. Heino Stöver, Prof. Dr. Jörg Pont/ISFF

(Problem) Drug Use in European Prisons1 Set-up of core groups for prison-based trainings in CA-countries Mix of representatives from ministries, prison management, healthcare staff (doctors and nurses) and NGOs (15-25 people) Steady working group to work in 2 tranings within at least 12 months, plus partly participating in study visit(s) Multiplier, decision-making representatives Provided with Russian speaking material + websites Sensitisation for international standards of treatment with people with substance use disorders 2

(Problem) Drug Use in European Prisons1 5 CA Countries in Transition (Problem) Drug Use in European Prisons1 High prisoner population (up to >500 per 100,000; Turkm.) Mostly military-orientied: military-ranked staff, also medical Introduction of reforms in prison conditions Large dormitories, long sentences, large amount of remand prisons Introduction of OST (e.g. Tajikizstan): - Close cooperation between community – prison needed - Staff needs clear guidance from specialists in the community => SOPs - OST (and any cooperation with the prison staff) controversially debated within prison subculture HIV/AIDS still the driver of (possible) change 3

(Problem) Drug Use in European Prisons1 Capacity Building via trainings (1/2) The majority of participants was attentive, participated interactively in discussions and group work and contributed substantially to proposals for a “road map”. Participants were invited to amend the proposed agenda according to their needs if necessary and to strive for producing proposals for a “road map” of further development of healthcare for drug dependent prisoners at the end of the workshop. ‘Road Maps’ components are i.e. establishing/improving continuity of care for released drug dependent prisoners 4

(Problem) Drug Use in European Prisons1 Capacity Building via trainings (2/2) In addition to providing ID cards, shelter and social support, continuity of treatment (including OST, TB and ARVtreatment, Atlantis programmes, needle/syringe exchange programs) should be guaranteed and Naloxon programmes for prisoners on release should be rolled out; Inclusion of social workers, psychologists and non-medical staff in needle/syringe exchange programs in prison which currently are run exclusively by medical staff ; Training of health care staff on mental healthcare; Update and improvement of equipment of primary health care units and of the rooms for psychological consultations. 5

(Problem) Drug Use in European Prisons1 Roadmap + results >12months e.g. Kg Establishing/improving continuity of care for released drug dependent prisoners by proper preparation of release by the health care professionals in cooperation with actors in the civil society (NGOs, health authorities). Naloxon programmes for prisoners on release should be rolled out; done Courts should be informed that not only treatment in Atlantis programs but also OST maintenance treatment should be acknowledged as effective treatment of opiate dependent prisoners, thus allowing suspension or omission of additional court-ordered treatment of drug dependent persons; done   6

(Problem) Drug Use in European Prisons1 Roadmap + results >12months e.g. Kg Inclusion of social workers, psychologists and non-medical staff in needle/syringe exchange programs in prison (N=16), which currently are run exclusively by medical staff ; Considering establishment of vending machines for needle/syringe exchange and for condoms; Hepatitis B vaccination for prisoners and staff; Training of health care staff on mental healthcare; performed Update and improve equipment of primary health care units and of the rooms for psychological consultations; performed (supported by procurement) 7

(Problem) Drug Use in European Prisons1 International Standards (Problem) Drug Use in European Prisons1 Medical Ethics: confidentiality, independence of healthcare personnel Overcrowding Alternatives to imprisonment Throughcare, continuity of services as one of the key problems Global Fund requirements contributes to changes Good practice examples, e.g. Kg: - Prison-based needle exchange - Opioid Substitution Treatment (OST) - Provision of Naloxone - Drug-free treatment =>Lyuba‘s presentation Comprehensive package as basis 8

HIV-Prevention – The Comprehensive Packge: 15 Key Interventions (UNODC/ILO 2012) 1. Information, education and communication 2. HIV testing and counselling 3. Treatment, care and support 4. Prevention, diagnosis and treatment of tuberculosis 5. Prevention of mother-to-child transmission of HIV 6. Condom programmes 7. Prevention and treatment of sexually transmitted infections 8. Prevention of sexual violence 9. Drug dependence treatment => Opioid Substitution Treatment 10. Needle and syringe programmes 11. Vaccination, diagnosis and treatment of viral hepatitis 12. Post-exposure prophylaxis 13. Prevention of transmission through medical or dental services 14. Prevention of transmission through tattooing, piercing and other forms of skin penetration 15. Protecting staff from occupational hazards and other closed settings: a comprehensive package of interventions 1UNODC/ILO (2012): HIV prevention, treatment and care in prisons The comprehensive package consists of 15 interventions that are essential for effective HIV prevention and treatment in closed settings. While each of these interventions alone is useful in addressing HIV in prisons, together they form a package and have the greatest impact when delivered as a whole.

European Court of Human Rights in the case of Wenner vs European Court of Human Rights in the case of Wenner vs. Germany (1 Sept. 2016) manifest and long term dependence to opioids denial of opioid substitution treatment (OST) in Bavarian/German prison The Court found that the physical and mental strain that Mr Wenner suffered as a result of his untreated or inadequately treated health condition could, in principle, amount to inhuman or degrading treatment. the failure to adequately assess Mr. Wenner’s treatment needs involved a violation of the prohibition of inhuman or degrading treatment Law more powerful than science! complaint by a long-term heroin addict that he had been denied opioid substitution treatment (OST) in prison. The European Court of Human Rights acknowledged strong indications that substitution treatment could be regarded as appropriate for the applicant given his manifest and long term addiction to opioids and its enduring health consequences. The Court also found that the physical and mental strain that Mr Wenner suffered as a result of his untreated or inadequately treated health condition could, in principle, amount to inhuman or degrading treatment. The Court concluded that the failure to adequately assess Mr Wenner’s treatment needs involved a violation of the prohibition of inhuman or degrading treatment. The case of Wenner vs. Germany made its way in the European Court of Human Rights. The judgment of the European Court of Human Rights in this case delivered on 1 September 2016 was important for drugs (and substitution) treatment in prison: The case concerned the complaint by a long-term heroin addict that he had been denied opioid substitution treatment (OST) in prison. The European Court of Human Rights acknowledged strong indications that substitution treatment could be regarded as appropriate for the applicant given his manifest and long term addiction to opioids and its enduring health consequences. The Court also found that the physical and mental strain that Mr Wenner suffered as a result of his untreated or inadequately treated health condition could, in principle, amount to inhuman or degrading treatment. The Court concluded that the failure to adequately assess Mr Wenner’s treatment needs involved a violation of the prohibition of inhuman or degrading treatment. 10

Condoms: from Maputo (Mozambique) to Munich (Gemany) to Maseru (Lesotho) Maputo/Mozambique: ca. 24% of prisoners HIV+ - no condoms: „…might increase sexual activity …“ Munich/Germany: HIV-prevalence among prisoners 1,5% of men, that is 30-times higher than in the general population condoms available only via application – medical service 2005-2007 provision of 43 condoms to 13,000 prisoners Official legitimation: „prisoners are informed to behave responsibly right in the beginning“1 Lesotho prison service has installed „condotainer“ 1Bayerische Staatszeitung vom 29.08.2014

Throughcare1 Linkage to outside supporting agencies of drug services Continuity of medical treatment of chronic diseases - prevention of development of drug resistance - problem areas ART + TB? Flow of information of confidential medical data Overdose prevention – Naloxone (trraining + kit) – practice and policies? Continuous relationships to families/partners Preventive commodities and the point of release (condoms, contraceptives) Education for juveniles OST continuation Challenges The main challenges cited by Member States in terms of provision of services for HIV, TB, Hepatitis B and C and STIs were: 6.5.1 Overcrowding in prisons was seen as a very serious threat to any efforts to control diseases in prison settings. 6.5.2 Lack of continuation of care - For most Member States there was no clearly defined link or referral system of the prison health system with health services outside the prison system. This makes it difficult to follow-up ex-prisoners who are discharged while on treatment. It was also noted that some individuals coming into prisons sometimes do not have any documentation. 6.5.3 Non supportive legal environment for the provision of some prevention material. Prison population is dominated by males and for most Member States sex in prisons is illegal and male to male sex is not only criminalized but also stigmatised. Although most Member States cited that the revision of such impeding laws could make the availing of all necessary prevention material, the problem of stigmatization would still present its issues. This was evident in some states where laws do not impede, whether implicitly or explicitly. 6.5.4 Poor funding of prison sector remains a major concern for most Member States, thus limiting the number and extent of interventions that could be implemented. 6.5.5 Provision of nutritional support for prisoners especially those needing special care or on treatment. Directly related to this issue was the issue of stigma as difference in diet provided could be used an indicator for ones disease or health status. 1 WHO (2014): Prisons and Health. 2nd edition, http://www.euro.who.int/en/health-topics/health-determinants/prisons-and-health/who-health-in-prisons-programme-hipp 12