Adopt Harm Reduction Practices in Jails and Prisons

Introductory Paragraph

It is important to address harm reduction by offering treatment for HIV, Hepatitis and substance use disorder in prison. This is expected to reduce infectious diseases and lower SUD-related morbidity and mortality rates. Research has shown that the incarcerated are a high-risk population for potential medical issues and have barriers to access medical care. Syringes in prisons without an Needle Syringe Program (NSP) are sold on illicit markets and are very expensive, given high demand and scarcity. However, in prisons where NSPs operate, there has not been any illicit market reported where needles and syringes are accessible. Harm reduction in prisons and jails requires partnerships among communities for a public health effort to reduce mortality rates and to prevent the spread of disease such as HIV and hepatitis among groups. Those partnerships include police, public health experts, and community groups.

Key Information

The Harm Reduction Coalition defines harm reduction as "a range of widely accepted public health policies, practices, and programs that seek to reduce morbidity and mortality associated with drug use and sexual activity, while respecting the autonomy, rights, and dignity of people who use drugs or engage in sex work.” The Coalition has developed the following eight principles to guide to communities and agencies in effective harm reduction policies and programs.

• Accept, for better and/or worse, that licit and illicit drug use is part of our world and choose to work to minimize its harmful effects rather than simply ignore or condemn them.
• Do not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.
• Understand drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledge that some ways of using drug are clearly safer than others.
• Establish that quality of individual and community life and well-being do not necessarily require the cessation of all drug use as the criteria for successful interventions and policies.
• Call for the non-judgmental, non-coercive provision of services and resources to people who use drugs and to the communities in which they live in order to assist them in reducing attendant harm.
• Ensure that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirm drug users themselves as the primary agents of reducing the harms of their drug use and seek to empower users to share information and support each other in strategies that meet their actual conditions of use.
• Recognize that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect people’s vulnerability and their capacity for effectively dealing with drug-related harm.

Hepatitis C. Among people who inject drugs, Hepatitis C is three times more prevalent than HIV. In most countries, more than half the people who inject drugs live with Hepatitis C. The level of Hepatitis C infection amongst US prisoners is substantially higher than the general population. Between 12 and 35 percent of prison inmates are infected with Hepatitis C, compared to between 1 and 2 percent of the general population. Global HIV prevalence is up to 50 times higher among the prison population than in the general public, while one in four detainees worldwide is living with Hepatitis C. There is increasing evidence that experience of imprisonment is a strong predictor of HIV and Hepatitis C transmission. Nor is this an issue confined to prison. A majority of prisoners serve short-term sentences, after which they return to the wider community having been at significantly higher risk of blood-borne virus transmission. They are subsequently more likely to pass on blood-borne viruses. For this reason prisons have been called HIV and Hepatitis C incubators.

Four main models. The primary models in prison needle exchange programs are:

• Hand-to-hand distribution. This is done by prison health staff, social workers, physicians, or nurses. This method is used in several Spanish and Swiss prisons. Used syringes are either exchanged at the cell door or in the medical unit.
• Hand-to-hand distribution by trained peers. Delivery by fellow prisoners ensure confidential and increases access to syringes. This system is mostly used in Moldovan prisons.
• Hand-to-hand distribution by external personnel. This may be performed by NGOs who also provide other harm reduction services.
• Automated dispensing machines. This is based upon a one-for-one syringe exchange and has been implemented in Germany and in Hindelbank women's prison in Switzerland.

Relevant Research

• WHO Study. The World Health Organization, in collaboration with the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), performed a review of the international evidence on NSPs. The study recommended that "prison authorities in countries experiencing or threatened by an epidemic of HIV infections among people who inject drugs should introduce and scale up Needle and Syringe Programs (NSPs) urgently."

• European Analysis. This report titled "Ten Year of Experience with Needle and Syringe Exchange Programs in European Prisons" concluded that prison NSPs are not only feasible but effective, especially when embedded within a comprehensive prison-based harm reduction and health-promotion strategy." This article provides a review on the state of harm reduction in prisons in 30 European countries.

• Germany, Switzerland, and Spain. An evaluation of 19 NSP programs indicated:
  • Reduction in syringe sharing
  • Subsequent reduction in Blood borne Virus rates
  • No increase in drug use
  • No syringes used as weapons

• Documenting the Need. This article examines the correlation between U.S. incarceration rates and population health by using a novel approach of county-level data.

• Delineating Solutions. This article outlines the benefits of integration of harm reduction therapy with traditional substance abuse treatment.

• Harm Reduction in Prisons: A ‘Rights based Analysis’ This research article makes the case that governments have a legal obligation to provide prisoners the same level of healthcare that is provided in the community. This is in keeping with international human rights laws and guidelines which require that the health of prisoners is fully protected.

• Harm Reduction International Study. This study on HIV, Hepatitis C, and Tuberculosis in prisons found that important factors in the success of prison NSPs include the right type of syringes, easy and confidential access to the service, and building trust with the prisoners accessing the program. It also found that prison NSPs:
  • Are feasible and affordable across a wide range of prison settings
  • Are effective in decreasing syringe sharing among people who inject drugs in prison, thereby decreasing the risk of blood borne virus transmission between prisoners and from prisoners to prison staff
  • Are not associated with increased attacks on prison staff or other prisoners
  • Do not lead to increased initiation of drug consumption or injection
  • Contribute to workplace safety
  • Facilitate referral to available drug-dependence treatment programs
  • Can be delivered successfully via a range of methods in response to staff and inmate needs
  • Are effective in a wide range of prison systems
  • Can successfully coexist with other drug prevention and drug dependence treatment programs

Impactful Federal, State, and Local Policies

• Medicaid. This report provides policy guidance on mechanisms to utilize Medicaid funding to expand jail diversion programs, including harm reduction programs.

• The New York State Plan Amendment. allows for Medicaid Coverage for harm reduction services to be reimbursed by both Medicaid Managed Care and Medicaid fee–for–service systems.

Available Tools & Resources

Harm Reduction International is a non-profit organization that envisions "a world in which drug policies uphold dignity, health and rights." It has been hosting an annual conference since 1990. It has published "Harms of Incarceration - The Evidence Base and Human Rights Framework for Harm Reduction in Prisons," which provides a succinct 10-page overview of the inter-relationship between public issues associated with incarceration, equity, health safety, and human rights.

The John Howard Society of Ontario is a non-profit organization dedicated to effective, just, and humane responses to crime and its causes. It has a 90-year track record of work across Canada and has published a fact sheet on harm reduction and mitigation of risk in prison populations.

Promising Practices

The Gloucester ANGEL Initiative Angel Program assures anyone who walks into the police station with the remainder of their drug equipment (needles, etc) or drugs and asks for help will not be charged. The program works to guide those who come to the program towards recovery.

Law Enforcement and HIV Network (LEAHN) provides international examples of partnerships among health and law enforcement agencies to reduce HIV in the communities they serve.

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