1. PREVENTION OF INFECTIOUS DISEASES IN PRISONS Recent Experience from Portugal Henrique Barros Ministério da Saúde

2. Antiretroviral Therapy: direct costs (Portugal)

3. AIDS Deaths Portugal, 1988-2006 HIV/AIDS Deaths Portugal 1988-2006

4. AIDS – total number of cases by year of diagnosis

5. AIDS cases, by mode of transmission and year of diagnosis

6. Voluntary Counseling and Testing Centers Time trends in number of tests and % reactive Rapid tests

7. Drug use behaviourOR (95% CI)* Visit to DTC First Follow-up 0.18 (0.09-0.36) 1 Life use of injected drugs No Yes 1 0.90 (0.25-3.26) Injection period (years) < 5 5-9 ≥10 0.13 (0.04-0.40) 0.75 (0.27-2.09) 1 Previous month behaviourOR (95% CI)* Sharing of injection material No Yes 1 0.15 (0.06-0.36) Consistent condom use No Yes 0.23 (0.11-0.47) 1 * adjusted for gender, age, education, country of birth, first/follow-up visit and life drug injection Clients’ characteristics and awareness of serological status

8. TotalID UsersNon- ID Users Type of visit N Number of HIV infections (%)* N Number of HIV infections (%)* N First4 065234 (5,8)1 532200 (13,0)2 53334 (1,3) Follow-up17 0151 620 (9,5)10 6101 470 (13,8)6 405150 (2,3) * Comprise cases previously diagnosed + cases detected during the PICT Prevalence of HIV infection among Drug Users

9. Injecting drug use reported (column %) No. HIV positive (row%) Injecting drug use not reported (column %) No. HIV positive (row %) Prison Yes491 (36)91 (19)362 (16)10 (2.8) No775 (56)92 (12)1507 (68)17 (1.1) Missing112 (8.1)7 (6.3)352 (16)6 (1.7) No. years injectingn/a <1156 (11)17 (11)__ 1-2225 (16)16 (7.1)__ 3-5159 (12)13 (8.2)__ 6-8134 (9.7)19 (14)__ 9-11123 (8.9)16 (13)__ 12-14125 (9.1)24 (19)__ >=15313 (23)69 (22)__ Missing143 (10)16 (11)__

10. Survey of two Portuguese Prisons

13. Programs for Injection Drug Users:  Needle and syringe exchange  Substitution therapy  Medically assisted injection facilities HIV and Drug Users

14. HIV and Drug Users Syringe Exchange Kit

15. HIV and Drug Users – Portuguese Programme

18. HIV and Drug Users (Rapid tests)

19. Injection drug use (IDU) accounts for approximately half of the 35 491 cases of HIV/AIDS infection reported in Portugal from 1983 until June 2009. However, its proportion decreased from 58% in the mid-nineties to less then 20% at present. The actual crude number also decreased from a maximum of 1483 in 1999 to less then 160 in 2009. SEP, as part of a set of harm reduction measures, played an important role in those trends. The Portuguese SEP began as a partnership established in 1993, between the Ministry of Health and the National Association of Pharmacies with the collaboration of wholesalers and local municipalities. Kits containing sterile syringes and needles, disinfectant towels, condoms, filter, water, recipients and citric acid are distributed to IDU, following a dispensation policy one-free-for-one exchange. The initial kit integrated one sterile syringe, one disinfectant towel, one condom and an information leaflet. In 1999, distilled water and a filter were included, and in 2007 recipient and citric acid were added.

20. The Portuguese SEP began as a partnership between the Ministry of Health and the National Association of Pharmacies with the collaboration of wholesalers and local municipalities. The program favored a one-free-for-one exchange policy. In 2007 a pilot SEP was launched in two prisons. As of 2007, there were 1314 (out of 2790) community pharmacies and 37 NGOs (which joined the SEP since 1998) involved in the provision of this service. The participation of pharmacies is voluntary and the service is not paid. A few community pharmacies also contribute to blood-borne disease prevention among IDU by dispensing opiate substitutes (e.g. methadone) and all may sell syringes without a prescription.

21. n Syringe Exchange Programme

22. SYRINGE AND NEEDLE EXCHANGE “kit” 1st KIT 1993 2nd KIT 1998 3rd KIT 2007

23. Portuguese S&N Exchange Programme Pharmaceutical Storage DISTRIBUTIONDISTRIBUTION Community Pharmacies NGO’s

24. Portuguese S&N Exchange Programme

25. Year Syringes distributed (n) Syringes collected (n) Pharmacies involved in SEP (n) NGO and GO involved in SEP (n) Total cost ‡ of SEP (€) PharmaciesNGO/GOMobile Units 1993 NA272 215-4 8801 405-89 641 1994 NA2 011 914-428 7911 685-789 574 1995 NA2 361 501-491 5041 506-922 954 1996 NA2 342 419-571 4961 358-968 898 1997 NA2 658 793-591 3921 375-1 085 663 1998 NA2 484 561-564 7441 283-992 075 1999 NA2 456 79583 486451 8841 2788950 962 2000 3 680 0002 972 468241 757288 2121 212101 078 963 2001 3 590 0002 552 346775 231158 2901 287161 149 180 2002 3 037 0001 749 362875 27749 4741 23829971 743 2003 2 272 0001 580 7201 034 68147 4871 232 36 967 737 2004 2 990 0001 434 2341 283 47427 1931 270 34 975 365 2005 2 505 0001 412 6521 409 97322 4061 327 35 1 021 962 2006 2 845 0001 368 3221 204 71618 1121 341 35 1166369 2007 2 640 0001 340 408954 98815 9861 314 36 1 644 185 ‡ - The costs of SEP have been supported by the Ministry of Health, except in 1993 – which were undertaken by the National Pharmacies Association. This comprised the value of the injection material distributed, the functioning of the mobile units and the operational management, by means of the payment of the programme staffing by the National Pharmacies. They do not include the operational costs related to the NGO or GO involved in SEP. NA – Data not available

26.  Legislation  Information, education, communication  Learning about harm reduction  Prevention (similar to the out-side world)  Monitoring and evaluation Infectious Diseases in Prisons - Strategy

27. Prisons 2005 Inmate distribution according to types of drugs consumed (25 Prisons : 79% of prison’s population (10 182 inmates) 4073 active consumers

28. 2007 Portuguese National Action Plan for Fighting the Transmission of Infectious Diseases in Prisons A Pilot SEP was launched in two prisons. (December 2007 – December 2008) Prisons Survey 3 months after launching the programme

29. “SERYNGE EXCHANGE PROGRAMME IN PRISONS. 2007-2008” T0 n (%)T3 n (%) Total305 (100,0)300 (100,0) Had drugs more then a month ago73 (23,9)--- Had drugs during the previous month93 (30,5)101 (33,7) Injected drugs during the previous month20 (6,6)14 (4,7) Injecting material during the previous month Syringe “ home-made ” syringe Other material 6 (2,0) 7 (2,3) 1 (0,3) --- Shared injecting parafernalia No Yes Does not know No response 39 (12,8) 12 (3,9) --- 254 (83,3) 114 (38,0) 12 (4,0) 19 (6,3) 155 (51,0)

30. “Programa Experimental de Troca de Seringas em Prisões. 2007-2008” T0 n (%)T3 n (%) Total305 (100,0)300 (100,0) Injection material shared Syringe Needle cup cotton filter Lemon 13 (4,3) 9 (3,0) 20 (6,6) 6 (2,0) --- 10 (3,3) 9 (3,0) 8 (2,7) 6 (2,0) Condom use (last time) No Yes NA 131 (43,0) 105 (34,4) 69 (22,6) 124 (41,3) 92 (30,7) 84 (28,0) Ever had a tattoo in prison No Yes NA 119 (39,0) 143 (46,9) 43 (14,1) 108 (36,0) 139 (46,3) 53 (17,7) Shared tattoo material No Yes Does not know NA 125 (41,0) 21 (6,9) 20 (6,6) 139 (45,6) 139 (46,3) 17 (5,7) 22 (7,3) 122 (40,7) “SERYNGE EXCHANGE PROGRAMME IN PRISONS. 2007-2008”

31. LisboaPaços de Ferreira n (%) Total 201 (100,0)298 (100,0) Ever injected drugs in prison (last year) No Yes Do not want to answer Missing 135 (67,2) 14 (7,0) 3 (1,5) 48 (24,4) 237 (79,5) 17 (5,7) 7 (2,4) 37 (12,4) Shared injection material? No Yes Do not want to answer Missing 123 (61,2) 11 (5,5) 56 (27,9) 200 (67,1) 21 (7,0) 9 (3,0) 68 (22,8) DRUG USE BY INMATES DURING PILOTE PERIOD

32. “The AIDS epidemic is not only about revealing injustice, but also about overcoming injustice.” Peter Piot, February 2007