1. Needle and syringe programmes in prisons
Dr Fabienne Hariga
Senior Adviser
UNODC HIV/AIDS Section

2. HIV in prisons: a public health issue The facts
30 million people go through prisons each year
People who inject drugs represent up-to 70% of prison population
Number of PWID go 1-6 times through prisons during life
HIV prevalence prisons up-to 50 times higher than general population
HIV transmission via injection equipment does occur in prisons
Ex: Thailand: HIV incidence 4.18 per 100 person--years among all inmates injection inmates (Thaisri et al 2003)
Hepatitis C xx? times more
HIV and TB first causes of mortality in prisons in many countries
HIV epidemics have been well documented (Thailand, Scotland, Lithuania ..)

3. DRUG INJECTION IN PRISONS
Reduced
Initiation
In the absence of NSP, people share syringe and needles and/ home made syringes
Source: The Fix

4. Needle and syringe programs (NSPs)
WHO/UNODC/UNAIDS Comprehensive package for HIV and PWID
Needle and syringe programs (NSPs)
Opioid substitution therapy (OST) and other evidence-based drug dependence treatment
HIV testing and counselling (HTC)
Antiretroviral therapy (ART)
Prevention and treatment of sexually transmitted infections (STIs)
Condom programmes for people who inject drugs and their sexual partners
Targeted information, education and communication (IEC) for people who inject drugs and their sexual partners
Prevention, vaccination, diagnosis and treatment of viral hepatitis
Prevention, diagnosis and treatment of tuberculosis (TB)
(52 CND Political declaration ECOSOC resolution E/2009/L.23)

5. The evidences: Feasibility & Effectiveness of NSP in prison settings
Drug consumption by participating stable or decreased
No reported instances of initiation of injecting
Sharp decline in reported sharing of needles and syringes - virtually non-existent
No reported new HIV, hepatitis B or hepatitis C
Facilitate the referral to drug treatment
Reduce the occurrence of abscesses
No reported use of needles or syringes as weapons
No accidental puncture for prison officers

6. Harm reduction in prisons works

7. HIV in prisons: a human rights issue Global policies on access to health care/HIV in prisons
Alternatives to imprisonment (GA A/RES/S-20/3) Declaration on the Guiding Principles of Drug Demand Reduction – (CND Res 55/12) Alternatives to imprisonment for certain offences as demand reduction strategies that promote public health and public safety and GA A/RES/45/110 (Tokyo rules)
Article 12 of the Covenant on Economic, Social and Cultural Rights, “[t]he States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” RES AG 2200 A (XXI) (1966)
…..the obligation of States to respect the right to health implies to refrain from ‘denying or limiting equal access for all persons, including prisoners or detainees (…) to preventive, curative and palliative health services
In its General Comment No. 14 on the right to the highest attainable standard of health, the Committee on Economic, Social and Cultural Rights held that the obligation of States to respect the right to health implies to refrain from ‘denying or limiting equal access for all persons, including prisoners or detainees (…) to preventive, curative and palliative health services
Basic Principles for the Treatment of Prisoners, Principle 9, that “Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.” GA RES 45/ (1990)

8. Equivalence ? Needle and syringe programmes in community and in prisons (2013)
Afghanistan ( pilot)
Germany (1)
Iran
Kyrgyzstan (all)
(Luxembourg)
Moldova (9)
Portugal?
Romania
Spain (38)
Tajikistan 1 (pilot)
Switzerland (7)
Australia?
France?
Canada ?
Adapted from Global State of Harm Reduction, 2012

9. Total N. Prisons settings Implementation modality
Country
Total N. Prisons settings
Start
Year
Implementation modality
Nb. Prisons w/NSP
2006
2011
2013
Switzerland
114
1992
Disp. machines/Health services/NGOs 7
Germany
185
1996
Dispensing machine 1
Spain 82
1997
Prison Health service/NGO 38
Moldova 17
1999
Peer based/health services 9
Kyrgyzstan
2002
Peer-based + health services /NGO 11 16
Belarus 32
2003
1 Pilot
Armenia 12
2004
Health Service
3 Pilot
Iran
253
2005
Health services
1 pilot
3 pilot
Luxembourg 2
review
Portugal 49
2007
Romania 45
2009 3
Tajikistan 19
2010
Afghanistan
(1 pilot)

10. Prison Needle & Syringe Programmes Models of Distribution
Photographs by Rick Lines
Photograph UNODC
Moldova
Romania
Germany

11. Observations
Very limited number of pre-trial or penitentiary establishments with needle and syringe in prisons
Low coverage
Many programmes do not work very well:
Too strict control / lost of privileges
Lack of confidentiality and anonymity
Peer based NSP seemed to be the most effective and the most sustainable

12. After 12 months no syringes were exchanged in either of the prisons
CASE STUDY: PORTUGAL
By-law 3/2007 and Order /2007 Ministry of Health and Justice authorized a pilot PNSP in Lisbon and Paços de Ferreira in 2008–2009.
The participant, after giving specific information on his pattern of use, received a kit with two syringes, filters, disinfecting towel, clean cup, citric acid, bi-distilled water and a condom.
The rules were that the kit should be kept inside its box; if the cell were inspected, the inmate should state that he is in possession of the kit; and the kit should only be taken outside the cell to be exchanged by the health-care unit.
After 12 months no syringes were exchanged in either of the prisons
An outcome evaluation showed that reasons for not taking part in the programme included that most prisoners were afraid of being discriminated against, feared negative consequences for their penal situation, feared lack of confidentiality, did not want to declare themselves to be using drugs and were afraid of being identified as such or as participating in the PNSP

13. Conclusions
Mixed system seems the best measure (Peer based /dispensing machines/health service)
No exceeding control measures
Training
Quality control and M&E
Part of comprehensive package of interventions including overdoses prevention & management

14. Evidences Legal framework Preparation Programme framework Budget
Part I :Background
Evidences
Legal framework
Part II: Elements of PNSP
Models advantage/disadvantages
Guides of an effective programme
Materiel
Part III: Advocacy for PNSP
Part IV: Planning and implementation
Preparation
Programme framework
Budget
Implementation
Part V: Quality assurance
Monitoring
Evaluation
Training
Annexes

15. General Principles
A commitment to public-health objectives & to the rights to health.
Clear policy direction and oversight of the programme
Consistent guidelines and protocols + flexibility to take into account variations in population profile and security levels.
Participation of prisoners and staff in the planning and operational process
Training to raise understanding, allay fears of staff and prisoners and encourage prisoner participation.
including training to raise understanding, allay fears of staff and prisoners and encourage prisoner participation

16. Part of a comprehensive approach
Information, education, communication
Condom programmes
Prevention of sexual violence
Drug dependence treatment including OST
Needle and syringe programmes
Prevention of transmission through medical services
Prevention through tattooing, piercing and other skin penetration
Post exposure prophylaxis
HIV testing & counselling
HIV Treatment, care and support
Prevention, diagnosis and treatment of TB
PMTC
Prevention of STIs
Vaccination, diagnosis & treatment of hepatitis
Protecting staff from occupational hazards

17. Participants in different consultations
Acknowledgements
Heino Stöver
Participants in different consultations

18. Thank You
UNODC HIV Website LINK