An international look at prison-based syringe exchange programs.
In December 2001, the U.S. Department of Health and Human Services Office of Minority Health reported that the rate of HIV in prisons is five times the rate of HIV in the general population. The two most common ways HIV/AIDS is spread in correctional facilities is through unprotected sex and intravenous drug use. The moral/legal/ethical question facing correctional practitioners is complicated and politically emotional. If infection is spread through unprotected sex, and sex among inmates is illegal, should the facility acknowledge the illegal activity and hand out condoms, as do most Canadian and about 10 percent of U.S. correctional facilities?
Heroin, cocaine, amphetamine and other illegal drugs are a source of HIV/AIDS transmission when a drug user shares a needle with an infected drug user. The user will "clear" the drug from the syringe by drawing his or her blood back into the syringe and re-inject it into a vein. This mixes the blood and passes on the disease. HIV is not very strong and does not easily survive outside the bloodstream. Thus, cleaning syringes with diluted bleach or other disinfectants easily sterilizes them. However, if intravenous drug use is illegal. but "dirty" needles spread the disease, should corrections "condone" the drug use by providing bleach to clean the needles or by having a needle exchange program? In the United States, the answer is "no." So what do other nations do?
This article is not meant to speak for or against a particular protocol or to advocate a course of action. Rather, it is intended to look at the experience of some systems outside of the United States to see what they have done. To narrow the scope of the article, the most controversial of programs have been chosen--those involving needle exchange within correctional facilities. Before looking at others, the reader is reminded that this is not a "liberal" or "conservative" issue. Use of federal funds for needle exchange programs anywhere in the United States was first rejected by the Clinton administration. That policy has not been changed by the Bush administration.
History of Prison Syringe Exchange
In the 1995 Lancet article. "Preventing HIV Transmission in Prison: A Tale of Medical Disobedience and Swiss Pragmatism," Dr. Joachim Nelles described how the world's first distribution of injection material inside a prison began as an act of medical disobedience. Nelles explained that while Dr. Probst was a part-time physician at the Oberschongrun prison for men in the Swiss canton of Solothurn in 1992 and 1993, 20 percent of the inmates were intravenous drug users. "Unlike most of his fellow prison doctors, all of whom felt obliged to compromise their ethical and public health principles daily, Probst began distributing sterile injection material without informing the prison director. When this courageous, but apparently foolhardy gesture was discovered, the director, instead of firing Probst on the spot, listened to his argument about prevention of HIV and hepatitis, as well as injection-site abscesses, and sought approval from the cantonal authorities to sanction the distribution of needles and syringes," explained Nelles, a psychiatrist at the University of Berne who specializes in the problems of drug addiction.
In 1994, a second Swiss program was established in the women's prison in Hindelbank, according to Rick Lines of the Irish Penal Trust. This program was scientifically evaluated after one year, during which time more than 5,000 syringes had been distributed. The program was a great success in all indicators of health and safety, and shortly thereafter, syringe exchange programs began to expand in number, first in Switzerland and later internationally. By early 2004, sterile syringes were available to inmates in more than 50 prisons in the countries of Switzerland, Germany, Spain, Moldova, Kyrgyzstan and Belarus. In Spain and Kyrgystan, such programs are available in all prisons.
At the beginning of the pilot program in Switzerland, the program was carried out by the prisons' health service. which provided packages of condoms, syringes and needles. The exchange is one provided for one returned in an attempt to avoid increasing the number of needles and syringes in the prison, explained Dr. Margaret Rihs-Middel, coordinator of Drug Research and Evaluation at the Swiss Office of Public Health, in an interview by the Canadian HIV/AIDS Policy & Law Newsletter in July 1995.
Inmates are able to exchange up to five needles and syringes, so that they can exchange on behalf of others, but each inmate can only keep one syringe. To ensure that prison officers axe in less danger of accidental needle sticks when searching cells, inmates are allowed to keep one syringe in a glass in a cupboard near the toilet. Rihs-Middel indicated that the involvement of staff, including custodial staff, was very important to the success of the program, as were rules about where needles can be kept to increase safety for custodial staff. The use of drugs in prisons in Switzerland is not legal. The exchange program is a harm-reduction program for dealing with HIV/AIDS.
In the women's prison, a needle and syringe vending machine was installed in a storage area for cleaning materials and is easily accessible to inmates. A syringe must be put into the machine to allow a clean needle and syringe to be accessed. Female inmates are also allowed to keep one syringe in a toilet cabinet.
The first needle exchange program in Spain began in the city of Bilbao in 1987. It was operated by a nongovernmental organization (NGO). The government of Spain and the government of the Basque Country agreed to implement a pilot project at the Bilbao prison in 1995. The Bilbao prison is a male facility for 250 offenders. Though some remand inmates are held at the facility, most are convicted offenders. Of 180 inmates admitted to the prison in 2000, 48 percent were regular drug users.
After the needle exchange program was started in 1996, a program Planning Committee was created. The actual needle exchange program began in July 1997, after a series of educational and information activities were undertaken for staff and inmates. The two places in the prison where needles could be exchanged were discreet and the service was available five hours a day. Used needles were returned in hard plastic containers and inmates were given an "anti-AIDS" kit. These kits were identical to the ones given to drug users at pharmacies in Spain since 1989 and contained a needle, an ampul of distilled water. an alcohol-soaked disinfectant wipe, a hard container for carrying the needle and a condom. After a year and a half of operating, the planning committee recommended that the prison needle exchange program should be run by NGO staff who were working at the prison, rather than use needle exchange machines because the NGO could provide health education; NGOs and community pharmacies had a record of operating needle exchange programs effectively; needle exchange dispensing machines used in Spain had experienced problems; and an effective NGO was already working inside the prison. The committee also recommended that the prison rule preventing the possession of needles should be modified, and an external evaluation of the program should be undertaken.
In the first two and a half years of the program, 16,500 needles were exchanged for more than 600 drug users. A monitoring committee was placed in charge of an ongoing program evaluation. Inmates and correctional officers participated in the evaluation process at zero, three and six months. A one-year evaluation was not deemed practical because most of the inmates who had used the program were no longer in prison. However, NGO staff and correctional officer evaluations were carried out at 22 months. Inmates reported during the evaluation that:
* They had no program-related problems with the correctional officers;
* They saw the personalized aspect of the program (in contrast to a needle dispensing machine) and the fact that it was run by an NGO as positive;
* Drug consumption had not increased; and
* Their risk behaviors had been reduced.
Correctional officers indicated that:
* They had not experienced any conflicts due to the program;
* Inmates had at no time used needles as weapons;
* They considered the program positive; but
* They would rather see the program run by prison personnel than by external NGO staff.
The evaluation of the performing team (the NGO) and of the health personnel showed that participation in the program did not influence prison benefits (e.g., weekend leave privileges for good behavior). In other words, inmates were not "punished" for exchanging needles. Also, the program assists in the task of health education and encourages drug users to be channeled toward other types of programs (drug-free, methadone, etc.). Further, a certain amount of flexibility must be allowed instead of insisting that sterile needles can only be obtained in exchange for used ones. This point was intensely debated by the monitoring committee, with the NGO focusing on HIV-risk reduction and the correctional officers focusing on security.
In 2001, the Spanish government decreed that all prisons in the country are required to provide drug users with sterile injection equipment.
The January 2004 report of the Canadian Human Rights Commission recommended that Correctional Service Canada implement a pilot needle exchange program in three or more correctional facilities, with at least one being a women's facility.
The decision of the Canadian Human Rights Commission was based on several studies, but the most influential was probably the one reported in the December 2003 issue of the International Journal of Drug Policy, which presented the results of needle and syringe exchange programs in prisons based on 10 years experience in Switzerland, Germany, Spain and Moldova. The article reported that, "syringe exchange programs (SEPs) have been introduced in 46 European prisons, predominantly as pilot projects. Forty-three of these projects were still operating at the time of writing. In 11 prisons, SEPs were evaluated to assess feasibility and efficacy. Results did not support fears that commonly arise in the start-up of implementation of SEPs. Syringe distribution was not followed by an increase in drug use or injection drug use. Syringes were not misused, and disposal of used syringes was uncomplicated. Sharing of syringes among drug users was reduced. Based on these experiences, it can be concluded that in these settings, harm-reduction measures--including syringe exchange--were not only feasible but efficient."
Though all evidence indicates that needle exchange programs are effective, there still remains a great deal of resistance to them. The last information this author was able to Find in terms of the acceptance of needle exchange programs in the United States came from a February 2002 article in the magazine of the National Conference of State Legislatures. It indicated that 10 states allowed buyers to purchase syringes in pharmacies without a prescription and 15 others allow for the possession of clean, unused needles. Though these are not needle exchange programs per se, it does indicate a growing interest. In 2002, the National Conference of State Legislatures estimated that there were 150 needle exchange programs operating in nearly all states, many without the benefit of state legislation. On July 20, The New York Times reported that the City Council of Atlantic City voted to create a needle exchange program despite the state law in New Jersey making it a crime to possess needles without a prescription. The article indicated that only five states have such legislation.
IS it time for professional correctional organizations to put the topic of needle exchange programs on their agendas for an open and vigorous debate? It should be left to those working in the field to evaluate the issues that directly impact the corrections community and to decide if current research is adequate enough to use as the basis for a decision, if inmates are helped or hindered by a particular program, and, if there are security concerns, that employee and inmate safety issues are appropriately addressed. Once that debate has been held, then it is up to corrections professionals to provide their legislators and policy-makers with an informed opinion and recommendations.
Gary Hill is president of CEGA Services Inc., an international consultant in crime prevention, criminal justice and corrections, and chairman of the functional committee of the U.N. Crime Center's International Scientific and Professional Council.
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|Date:||Sep 1, 2004|
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