1. The ANRS-PRIDE Program
Access to harm reduction – the example of France
The ANRS-PRIDE Program
L Michel, CESP/Inserm U1018, Centre Pierre Nicole, Paris, France
M Jauffret-Roustide, Cermes 3 (Inserm U988/UMR CNRS 8211/EHESS/Paris Descartes University), rue des Saint Pères, Paris, France

2. French Context ≅ 70 000 prisoners for 58 000 places
Since 1994, the Ministry of health is in charge of care organization in French prisons
A 1996 circular define which harm reduction interventions are authorized in prison, without respect of the principle of equivalence with the community despite the 1994 law
January 2016: new « Health Law » stating that harm reduction services should be equivalent in prison to the free world
Need a governmental decree to be implemented….≃≅
Increasing overpopulation (more than 200% in some prisons)…
≅ prisoners for places
For the first time, some prison Directors report they cannot accept any new prisoner in their prison
A not very friendly election context…..

3. The ANRS-PRIDE program
Program created in 2009 (AC25).
Main topic: Prevention of infectious diseases in the prison setting.
Different steps of the program:
Inventory of infectious disease prevention and HR measures for French prisoners.
Preliminary qualitative assessment of the needs:
Drug-related risk behaviours among prisoners inside prison.
Acceptability of new harm reduction measures among prisoners, sanitary and security staffs.
Assessment of the social acceptability of the implementation of a package of new harm reduction measures in prison in France.

4. The ANRS-PRIDE program - Inventory
Inventory of infectious diseases prevention and HR measures
Extension to Belgium, Denmark, Austria
and Italy
Bleach, Condoms and lubricants, Opioid Substitution Treatment (OST), Information-Education-Communication (IEC), Blood-borne virus (BBV) testing, HBV vaccination, Post-exposition Prophylaxis (PEP), Needle/syringe
exchange programs (NEP), access to ARV and prevention measures for tattooing/piercing
2011
2015

5. The ANRS-PRIDE program - Inventory
Inventory of harm reduction measures, main conclusions:
Very low availability and accessibility of the harm reduction tools in prison setting, including those officially recommanded, despite scientific evidence.
Structural factors associated with harm reduction measure availability at the European level: overpopulation.
Clear gap between French but also international recommandations and situation in French prisons.

6. The ANRS-PRIDE program Qualitative research
Preliminary qualitative assessment of the acceptability of new harm reduction measures among prisoners, sanitary and security staffs (2015):
Sanitary staffs met during ANRS-PRIDE inventory + focus groups (15).
Security staffs: face-to face interviews (15).
Prisoners: face to face interviews in prison and in post-release settings (15).
Main conclusions:
Security staffs: drug use not considered as a major problem especially injecting practices, cannabis very common and seen as an health concern and a way to support, high level of social acceptability of NEP, no real ideological oppositions, but only some organizational concerns.
Health staffs: harm reduction is not seen as a priority, more ideological concerns towards NEP than security staffs, linked to the psychoanalytical view of drug use.
Prisoners: 1/3 of these high-risk prisoners reported injection practices inside prison and 2 started to inject inside prison.

7. The ANRS-Coquelicot Study (Drug and Alcohol Review, In press)
Cross-sectional survey focusing on human immunodeficiency virus (HIV) and hepatitis C virus (HCV) exposure in people who use drugs (injecting or snorting drugs)
Data collected in the community (specialized settings, )
Results
Among drug users with a history of injection and incarceration:
14% reported injection practices inside prison
40.5% of them sharing needles/sharing
2.8% reported initiating injection inside prison
Factors associated with injection practices inside prison:
being a Russian-speaking detainee, having spent more time in prison, having started to inject before and especially before 1987.
Being Russian-speaking was also associated with needle/syringe sharing in prison

8. The prison ANRS-Coquelicot Study
Assessment of drug-related risk behaviours among prisoners inside prison included in ANRS-Coquelicot Study.
4 prisons (Lille, Fresnes (Paris area), Marseille and Martinique)
Epidemiological study among 350 prisoners:
receiving an opioid agonist treatment.
or reporting injection practices, sniffing or inhaling crack during the last 12 months.
Focus on drug use, exposure to infectious risks (drug or sex-related, tattooing, piercing,…), access to care, needs towards harm reduction,… inside prison.
The data collection is ongoing.
Face to face interviews.

9. The ANRS-PRIDE program
Intervention:
Assessment of the social acceptability of the implementation of a package of harm reduction services according to the UNODC recommandations.
Mixed methods and 2 phases:
First phase:
Sociological research including ethnographic observations, face-to-face interviews with detainees (30), health professionals (30) and security staffs (30). The data collection is ongoing in Marseille (Les Baumettes).
 draft some recommendations for the scale-up of the interventions to other prisons.
Quantitative questionnaire (in prison Les Baumettes) to evaluate the social acceptability of harm reduction services. Methodology still in discussion with the team of Pr Bruno Falissard (Scientific advisor of PRIDE- Program).
Second phase:
Extension to 2-3 other prisons following the recommendations of the first step with a quantitative assessment.

10. The ANRS-PRIDE program
Social acceptability outcomes
Prisoners, security and sanitary staffs satisfaction
Perceived accessibility of the harm reduction measures
Level of consistency with prisoner’s needs/expectations
Suggested improvements (sanitary/security staffs, prisoners)
Level of implementation of the different measures
Level of use of the different measures
Quality of interactions between staffs and prisoners related to the harm reduction measures
Perceived feeling of competence concerning harm reduction measures (sanitary staff)
Level of adherence with the HR policy implemented
Perceived health benefit for the whole prison community
Perceived security benefit for the prison
Outcomes related with harm reduction intervention per se
Assessment of risky practices
 Questionnaire will be designed according to the first phase

11. The ANRS-PRIDE program - Schedule
National steering committee including Ministry of Health, Justice, NGOs, professionals, researchers since 2014.
Authorization from the Ministry of Justice on August 2015.
Call submission in (including funding from the penitentiary administration)
Funding from ANRS, SIDACTION, Ministry of Justice, Ministry of Health, Regional Health Authorities, MILDECA
January 2016: new ”health law”
Agreement from the prison of Baumettes in Marseille in 2016
Operational committee including sanitary/security staffs, NGOs, researchers starting at the end of 2016.
Definition of the interventions including NEP.
Design of the practical organization of the NEP.
Implementation to start in May 2017 after transfer in the new prison building.
In February 2017: Ministry of Justice asked to stop the intervention.

12. The ANRS-PRIDE program - Schedule
Situation in October 2017:
ANRS-Coquelicot Study : Assessment of drug use and at-risk behaviours starting in the selected prisons (Marseille, Fresnes (Paris area), Lille, Martinique) is ongoing.
Sociological research: Ethnographic observation and face-to face interviews just started in the prison of Marseille (Les Baumettes). Completed by a research work on the analysis of the controversy about harm reduction implementation in prisons, at a national level.
Sanitary and administrative authorities are strongly supportive and willing to go forward (at national and local levels). Use of the ANRS-PRIDE program and ANRS-Coquelicot data to document the governmental decree.
Social acceptability of the harm reduction measures or of the research project?
Research implementation in prison setting still face barriers at a national level. Political stakes may overcome the public health concerns.
At the local level, a strong willing to implement harm reduction measures (including NEP) in all areas (medical staffs, security staffs, administrative staff). There are only some organizational concerns and the conditions of work to define that will be documented by the current sociological research.

13. Merci !