Prison Needle Exchange:
Lessons from a Comprehensive Review of
International Evidence and Experience

Prepared by
Rick Lines
Ralf Jürgens
Glenn Betteridge
Heino Stöver
Dumitru Laticevschi
Joachim Nelles

Prison Needle Exchange: Lessons from A Comprehensive
Review of International Evidence and Experience
Published by the Canadian HIV/AIDS Legal Network
For further information about this publication, please contact:
Canadian HIV/AIDS Legal Network
Tel: 514 397-6828
Fax: 514 397-8570
Email: info@aidslaw.ca
Website: www.aidslaw.ca
Further copies can be retrieved via
www.aidslaw.ca/Maincontent/issues/prisons.htm
or obtained through the Canadian HIV/AIDS
Information Centre (email: aidssida@cpha.ca)
© 2004 Canadian HIV/AIDS Legal Network

Library and Archives Canada Cataloguing in Publication
Main entry under title :
Prison needle exchange : lessons from a comprehensive review of international evidence and experience = L'échange de seringues en prison : leçons
d'un examen complet des données et expériences internationales
Includes bibliographical references.
Text in English and French.
ISBN 1-896735-52-5
1. Prisoners - Drug use. 2. Needle exchange programs. 3. AIDS (Disease)
- Prevention. 4. HIV infections - Prevention. I. Lines, Rick. II. Canadian
HIV-AIDS Legal Network. III. Title: Échange de seringues en prison.
HV8836.5.P74 2004

362.29'086'927

C2004-941613-8E

Funding for this report was provided by Health Canada under the Canadian Strategy on HIV/AIDS.
The opinions expressed in this document are those of its authors and do not necessarily represent the views or
policies of Health Canada, the Minister of Health, or the Canadian HIV/AIDS Legal Network.
Cover design by Peter Dimakos.

In memory of
Andréa Riesch Toepell and Tommy Larkin

Acknowledgments
This report would not have been possible without the cooperation of many people around the world who assisted with
various aspects of the research and writing. We would like to thank the people who assisted us in organizing site visits to prison needle exchange programs in various countries – Christopher Eastus, Daniela DeSantis, Manuelo
Garibaldi, Marlene Laeubli, Heintz Stutz, and Hans Sulser in Switzerland; Ana Andres Ballesteros, Graciela Silvosa,
and Yolanda Nuñez in Spain; Dr Karlheinz Keppler, Matthias Blümel, Sandra Bührmann, Frau Schneider, Claudia
Rey, and Christine Kluge Haberkorn in Germany; Valentin Sereda, Vladimir Taranu, and Dr Larisa Pintelli in
Moldova. We would like to thank those who shared information on HIV, injection drug use, and harm reduction in
prisons in Eastern Europe, Central Asia, and the former Soviet Union – Jennifer Traska-Gibson and Matt Curtis of
International Harm Reduction Development in New York; Dr Gulnara Kaliakbarova of Penal Reform International; Dr
Raushan Abdyldaeyva and Elvira Muratalieva in Kyrgyzstan; Dr Larisa Savishcheva in Belarus. We would like to
thank the Pompidou Group of the Council of Europe who provided funding for the site visits to Switzerland, Spain,
and Germany under a European Fellowship for Studies and Research in Drug Abuse, and Nathalie Bargellini for her
ongoing assistance. We would like to thank Health Canada for providing partial funding for this project under the
Canadian Strategy on HIV/AIDS. We would particularly like to thank the John Howard Society of Canada, who provided financial support for this report as part of their Policy Analysis Enhancement Project, and Dr Gerald Thomas
and Graham Stewart for their ongoing support, assistance, and feedback. Thanks also to Garry Bowers for copyediting the English text, Jean Dussault and Josée Dussault for translating the English text into French, and Grant Loewen
for layout.

Table of Contents
Executive Summary

i

Prisoner Health Is a Public Health Issue

1

Methodology

3

HIV and HCV Epidemics in Prison
Prevalence of HIV and HCV in prisons
Western Europe, Australia, and the United States
Central and Eastern Europe and the former Soviet Union
Canada
Other countries
HCV infection
Drug use in prison
Injection drug use, shared needles and risk of HIV and HCV transmission
International evidence
Canadian evidence
Harm reduction

5
5
6
6
6
8
8
8
9
10
12
12

Human Rights and Legal Standards
International human rights law
International rules, guidelines, principles, and standards
Prisoners’ right to health and access to sterile needles
Obligations in Canadian law

14
14
15
16
18

Review of International Evidence of Prison Needle Exchange
Switzerland
Summary
HIV/AIDS, HCV, and IDU in Switzerland
HIV/AIDS, HCV, and IDU in Swiss prisons
History of the response to HIV/AIDS, HCV, and IDU in Swiss prisons
Introduction of needle exchange/distribution programs
The first program
Expansion to other prisons
Evaluation and lessons learned
Current situation
Germany
Summary
HIV/AIDS, HCV, and IDU in Germany
HIV/AIDS, HCV, and IDU in German prisons
History of the response to HIV/AIDS, HBV/HCV,
and IDU in German prisons
Introduction of needle exchange/distribution programs
The first programs
Expansion to other prisons
Evaluation and lessons learned
Current situation
Spain
Summary
HIV/AIDS, HCV, and IDU in Spain
HIV/AIDS, HCV, and IDU in Spanish prisons

19
20
20
20
20
21
21
21
22
22
23
24
24
24
25
25
26
26
27
28
28
29
29
30
30

History of the response to HIV/AIDS, HCV, and IDU in Spanish prisons
Introduction of needle exchange/distribution programs
The first program
Expansion to other prisons
Evaluation and lessons learned
Current situation
Moldova
Summary
HIV/AIDS, HCV, and IDU in Moldova
HIV/AIDS, HCV, and IDU in Moldovan prisons
History of the response to HIV/AIDS, HCV, and IDU in Moldovan prisons
Introduction of needle exchange/distribution programs
The first program
Expansion to other prisons
Evaluation and lessons learned
Current situation
Kyrgyzstan
Summary
HIV/AIDS, HCV, and IDU in Kyrgyzstan
HIV/AIDS, HCV, and IDU in Kyrgyz prisons
History of the response to HIV/AIDS, HCV, and IDU in Kyrgyz prisons
Introduction of needle exchange/distribution programs
The first program
Expansion to other prisons
Current situation
Belarus
Summary
HIV/AIDS, HCV, and IDU in Belarus
HIV/AIDS, HCV, and IDU in Belarus prisons
History of the response to HIV/AIDS, HCV, and IDU in Belarus prisons
Introduction of needle exchange/distribution programs
Evaluation and lessons learned
Current situation
Analysis of the Evidence
Refuting objections
Increased institutional safety
No increase in drug consumption or injecting
Part of a continuum of drug-related programming
Positive prisoner and public health outcomes
Prison needle exchange programs reduce risk behaviour
and prevent disease transmission
Other positive outcomes on prison health
Effective in a wide range of institutions
Different methods of needle distribution have been effective
Hand-to-hand distribution by prison nurse and/or physician
Hand-to-hand distribution by peer outreach workers
Hand-to-hand distribution by external non-governmental
organizations or health professionals
Automated dispensing machines
Common factors in effective prison needle exchange programs
Leadership of prison administration and support of prison staff
Need for confidentiality and trust

31
31
31
32
34
36
36
36
37
37
37
38
38
39
40
40
41
41
41
41
41
41
41
42
42
42
42
42
43
43
43
43
43
44
44
44
46
47
48
48
49
50
51
52
52
52
53
53
53
54

Adequate access to needles
Needle exchange as part of a harm-reduction program
Importance of evidenced-based decision-making: evaluating pilot projects

55
55
55

Needle Exchange Programs Should Be Implemented in Prisons in Canada
Needle exchange programs recommended since 1992
Expert Committee on AIDS and Prisons
Study Group on Needle Exchange Programs
Standing Committee on Health
Legal obligation to respect, protect, and fulfill prisoners’ right to health
Inadequacy of bleach
Methadone maintenance therapy a partial solution to the harms of IDU
Opinions of prison staff
Cost-effectiveness of prison needle exchange programs
Time for elected officials and prison authorities in Canada to act
Recommendation

57
57
58
59
60
60
61
62
63
64
64
65

Conclusion: A call for leadership on prison needle exchange programs

66

Notes

68

Bibliography

79

About the Authors

88

Executive Summary
This report examines the issue of prison needle exchange based
upon the international experience and evidence current to 31 March
2004. Evidence was gathered over an 18-month period beginning in
October 2002. The authors undertook a literature review, visited
prisons in four countries, and corresponded with people responsible
for administering prison needle exchange programs. The report provides a comprehensive review of the evidentiary and legal basis for
prison needle exchange programs. The goal of this report is to
encourage prison systems with HIV and HCV epidemics driven by
injection drug use to implement needle exchange programs.

The goal of this report is to
encourage prison systems
with HIV and HCV
epidemics driven by injection
drug use to implement
needle exchange programs.

Injection drug use, HIV, and HCV
are prison epidemics
The need for an effective response to the issues of HIV, hepatitis C
virus (HCV), and injection drug use in prisons is a significant international concern. In many countries of the world, including Canada, The failure to provide access
rates of HIV and HCV infection in prison populations are much
to essential HIV and HCV
higher than those found in the general population. In many counprevention measures to
tries, the epidemics of HIV and HCV in prison are integrally relatprisoners is a violation of
ed to injection drug use and to unsafe injection practices, both in the
prisoners’ right to health
community and in prisons. In many countries, legal prohibitions
in international law.
against drug use and increased law enforcement have resulted in the
systematic incarceration of people who inject drugs, thereby
increasing the number of injectors in prisons, where there is a great
likelihood of needle sharing due to a lack of access to sterile needles.

Executive Summary

i

Prisoners’ right to health
The failure to provide access to essential HIV and HCV prevention measures to prisoners is
a violation of prisoners’ right to health in international law. Moreover, it is inconsistent with
international instruments that deal with rights of prisoners, prison health services, and
HIV/AIDS in prisons, including the United Nations’ Basic Principles for the Treatment of
Prisoners, the World Health Organization’s (WHO) Guidelines on HIV Infection and AIDS
in Prisons, and UNAIDS documents.
In Canada, it has been argued that both the Charter of Rights and Freedoms and the
Corrections and Conditional Release Act guarantee prisoners a standard of health services
equivalent to that in the general community, which includes access to adequate HIV prevention measures such as sterile needles. The call for implementation of prison needle exchange
programs within Canada has been made by numerous community-based organizations, policy and research reports, and working groups of the Correctional Service of Canada.

Needle exchange programs are an
effective harm-reduction measure
Needle exchange programs have proven to be an effective harm-reduction measure that
reduces needle sharing, and therefore the risk of HIV and HCV transmission, among people
who inject drugs and their sexual partners. As a result, many countries have implemented
these programs within community settings to enable people who
inject drugs to minimize their risk of contracting or transmitting
Switzerland, Germany, Spain,
HIV and HCV through needle sharing. Despite the success of these
Moldova, Kyrgyzstan, and
programs in the community, only six countries (Switzerland,
Belarus have extended needle Germany, Spain, Moldova, Kyrgyzstan, and Belarus) have extendexchange programs into
ed needle exchange programs into prisons. Other countries, including Kazakhstan, Tajikistan, and Ukraine may follow soon.
prisons.
Since 1992, needle exchange programs have been implemented in
prisons in these countries, and in each case needle exchange programs were introduced in response to significant evidence of the risk of HIV transmission within the institutions through the sharing of syringes.
Prison needle exchange programs have been implemented in both men’s and women’s
prisons, in institutions of varying sizes, in both civilian and military systems, in institutions
that house prisoners in individual cells and those that house prisoners in barracks, in institutions with different security ratings, and in different forms of custody (remand and sentenced, open and closed). Needle exchanges were typically implemented on a pilot basis, and
later expanded based on the information learned during the pilot phase. Several different
methods of syringe distribution are employed, based on the specific needs and the environment of the given institution. These methods include automatic dispensing machines; handto-hand distribution by prison physicians/health-care staff or by external community health
workers; and programs using prisoners trained as peer outreach workers.

Lessons learned from prison
needle exchange programs
The experience and evidence from the six countries where prison needle exchange programs
exist demonstrate that such programs:

ii

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

• do not endanger staff or prisoner safety, and in fact, make prisons safer places to live
and work;
• do not increase drug consumption or injecting;
• reduce risk behaviour and disease (including HIV and HCV) transmission;
• have other positive outcomes for the health of prisoners;
• have been effective in a wide range of prisons; and
• have successfully employed different methods of needle distribution to meet the needs
of staff and prisoners in a range of prisons.

Recommendation
This report makes one recommendation, directed at government and prison officials in
Canada: Both federal and provincial/territorial correctional services in Canada should immediately take steps to implement multi-site pilot needle exchange programs. Although the last
chapter (“Needle Exchange Programs Should Be Implemented in Prisons in Canada”) focuses on Canada, this recommendation also applies to other countries in which prison systems
face HIV and HCV epidemics driven by injection drug use.

What does this report contain?
The first chapter (Prisoner Health Is a Public Health Issue) provides an introduction to the
issue of prisoner health and needle exchange in prisons in the context of injection drug use,
HIV, and HCV in prison. The second chapter (Methodology) reviews the methods used to
gather evidence for the report. The third chapter (HIV and HCV Epidemics in Prisons) summarizes evidence of HIV and HCV prevalence, injection drug use, and needle sharing in
prisons worldwide. The Canadian evidence is reviewed in greater detail. The fourth chapter
(Human Rights and Legal Standards) sets out the human rights, legal standards, and guidelines relevant to injection drug use, HIV, and HCV in prisons. The legal obligation of governments to respect, protect, and fulfill prisoners’ right to health, including the right to preventive health measures, is examined. The specific legal context in Canada is also examined.
The fifth chapter (Review of International Evidence of Prison Needle Exchange) reviews the
experience and evidence from the six above-mentioned countries with prison needle
exchange programs that were studied for this report – Switzerland, Germany, Spain,
Moldova, Kyrgyzstan, and Belarus. For each country the review includes, where available,
epidemiological information about HIV and HCV, both in the general population and in
prison; a history of the prison system’s response to HIV and HCV; a review of prison needle exchange programs, including historical information, evaluations, and lessons learned;
the current situation; and future directions.
The sixth chapter (Analysis of the Evidence) draws on the evidence from the literature
review and prison visits to present the findings concerning prison needle exchange programs.
The seventh chapter (Needle Exchange Programs Should Be Implemented in Prisons in
Canada) draws on the findings from the previous chapter to present the case for the implementation of needle exchange programs in federal and provincial/territorial prisons in
Canada. The eighth and final chapter (Conclusion: A call for leadership on prison needle
exchange programs”) calls for leadership on the issue from elected officials, prison authorities, individual prison staff (both correctional staff and health service staff), and outside
physicians who work in prisons.

Executive Summary

iii

Next steps
This report will be sent to a broad range of individuals and organizations working in areas
of prisons, injection drug use, and harm reduction and/or HIV/AIDS and hepatitis C, both in
Canada and internationally. It will also be sent to appropriate government policymakers in
Canada, such as ministers responsible for corrections and justice, and unions and organizations of health-care workers involved in prison issues.
The Canadian HIV/AIDS Legal Network is a member of two Canadian prison, HIV, and
hepatitis C groups: the Prisons HIV/AIDS and Hepatitis C Networking Group and the
Prison HIV/AIDS & Hepatitis C Research & Advocacy Consortium. We will work with
the other members of these groups to advocate for the implementation of prison needle
exchange programs in federal and provincial/territorial prisons in Canada.

For further information…
Contact Glenn Betteridge at the Canadian HIV/AIDS Legal Network through the Network’s
office in Montréal at tel +1 514 397-6828, fax +1 514 397-8570, email: info@aidslaw.ca. Or
contact him directly by email at gbetteridge@aidslaw.ca.
Further copies of this report can be retrieved from the website of the Canadian HIV/AIDS
Legal Network via www.aidslaw.ca/Maincontent/issues/prisons.htm, or ordered through the
Canadian HIV/AIDS Information Centre at tel + 1 613 725-3434 (toll free: + 1 877 9997740), fax +1 613 725-1205, email: aidssida@cpha.ca.

iv

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Prisoner Health Is a Public
Health Issue
In 1992, Dr Franz Probst was faced with a dilemma. A part-time physician at the
Oberschöngrün prison for men in the Swiss canton of Solothurn, Dr Probst knew that more
than 20 percent of the prisoners in the institution injected drugs. He also knew that these men
had no access to sterile syringes and, as a result, were sharing syringes by necessity. As
described by Nelles and Harding,
Unlike most of his fellow prison doctors, all of whom fe[lt] 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 arguments 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. Thus,
the world’s first distribution of injection material inside prison began as an act of
medical disobedience.1
More than 10 years later, this act of medical disobedience remains an innovative and effective prison health-care initiative, and one that continues to highlight the failure of most prison
systems worldwide to effectively address HIV and hepatitis C virus (HCV) transmission via
injection drug use occurring within their walls. It is also a development that has inspired imitation, not only in other Swiss prisons but in prisons in Spain, Moldova, Germany,
Kyrgyzstan, and Belarus. Although each of these countries deals with different social, political, correctional, and health-care circumstances, each arrived at the conclusion that providing sterile syringes to prisoners, while controversial, was necessary to prevent the transmission of HIV and HCV.

Prisoner Health Is a Public Health Issue

1

Injection drug use and high rates of HIV and HCV infection among prisoners are not
unique to these six countries. Many countries, including Canada, are faced with HIV and
HCV prevalence rates within prisons that are many times higher than those in the general
population. In many countries the high rates of these bloodborne
infections in prisons are attributable to a large extent to injection
The world’s first distribution
drug use both in the community and inside the prison itself.
of injection material inside
Throughout most of the world, the primary response to problems
prison began as an act of
associated with illicit drug use has been to intensify law enforcemedical disobedience.
ment efforts. The result has been an unprecedented growth in prison
populations and the incarceration of increasing numbers of people
who use illicit drugs. Despite the fact that drug use and possession
is illegal in prisons, and despite prison systems’ efforts to prevent drugs from entering the
prisons, drugs remain widely available. Many people enter prison with drug habits, while
others begin consuming drugs while in prison as a means of coping with the prison environment. This report focuses on prison needle exchange programs, which represent a reasoned
public health response to harms associated with injection drug use and the sharing of
syringes (and even home-made injecting equipment) within prisons.
Due to the closed nature of prisons, the health of prisoners is an issue that rarely comes
to the attention of the public at large. However, the health of prisoners is an issue of public
health concern. Everyone in the prison environment – prisoners, prison staff, or their family
members – benefits from enhancing the health of prisoners and reducing the incidence of
communicable disease. Measures to decrease the risk of HIV and HCV transmission, including measures to minimize accidental exposure to these bloodborne
infections, make prisons a safer place to live and work. The high
The health of prisoners
degree of mobility between prison and community means that comis an issue of
municable diseases and related illnesses transmitted or exacerbated
public health concern.
in prison do not remain there. When people living with HIV and
HCV are released from incarceration, prison health issues necessarily become community health issues.
Prison presents a prime opportunity to respond to behaviours that pose a high risk of HIV
and HCV transmission, such as needle sharing, using proven public health measures such as
needle exchange programs. Prison authorities and elected officials responsible for prisons
also have a legal responsibility to respect, protect, and fulfill prisoners’ right to the highest
attainable standard of health. In the context of the HIV epidemic and the transmission of
HCV in prisons, prisoners’ right to health includes access to measures to protect themselves
from infection (or re-infection) with HIV and HCV, including needle exchange programs.
Where authorities and officials fail in this duty they put the health not only of prisoners but
of the entire community at risk.

A note on the use of terms
The term “needle exchange” is used to refer to the one-for-one exchange of a used needle
for a sterile needle, as well as to the distribution of sterile needles without exchange. Unless
otherwise indicated explicitly or by context, the terms “needle” and “syringe” mean a device
used to inject fluids into the body, and are used interchangeably throughout the report.

2

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Methodology
The evidence for this report was gathered over an 18-month period beginning in October
2002.
A review of the existing international literature was undertaken. This included extensive
research on prisons and
•
•
•
•
•

HIV
HCV
injection drug use
harm-reduction measures
needle exchange programs

Sources referenced include Canadian and international published reports, journal articles,
conference presentations, government publications, and prison-service reports. These materials include previous work and research on these topics published by the authors of this
report.
In addition, original research was conducted during site visits to prison needle exchange
programs in the four countries operating such initiatives in October 2002. Site visits were
made to the following prisons:
•
•
•
•

Moldova: Prison Colony 18 (Branesti), 11-18 November 2002
Switzerland: Hindelbank (Berne), Saxerriet (Salez), Obershöngrün (Berne), 1-5 June 2003
Germany: Lichtenberg (Berlin), Vechta (Lower Saxony), 11-14 June 2003
Spain: Soto de Real (Madrid), 25-28 May 2003

During these site visits, the needle exchange programs were observed and unstructured interviews were held with prison medical staff, prison management, external professionals working in drug policy and/or harm reduction, and prisoners. In some cases government officials
and/or representatives of non-governmental organizations were also interviewed.
During the course of the research, prison needle exchange programs were initiated in two

Methodology

3

other countries – Kyrgyzstan and Belarus. Since these programs were not in operation at the
time the research plan was developed in October 2002, site visits to prisons in these countries were not possible. Therefore, research was conducted via
• personal communications with the staff involved in coordinating the needle exchange
programs
• personal communications with the organizations funding the programs
• written documentation provided to the authors by the above sources, including funding
proposals, project reports, conference presentations, and other documents

Because site visits were not possible in these cases, the information provided in the
Kyrgyzstan and Belarus sections of the report is less detailed than that for the other countries.
Finally, in March 2004, while the report was being drafted, the authors followed up with
contacts in a number of the countries to verify and clarify information previously obtained
and/or to obtain updates on the situation in a particular country’s prison system.

4

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

HIV and HCV Epidemics
in Prison
Prevalence of HIV and HCV in prisons
Worldwide, rates of HIV-infection in prison populations tend to be much higher than those
found in the general population. Canada is no exception. Much of the data regarding
HIV/AIDS in prisons come from developed, high-income countries; relatively little information is available for developing countries and countries in transition. Even within highincome countries, the precise number of HIV-positive prisoners is difficult to estimate. This
difficulty is attributable to different testing protocols (voluntary testing, testing of all new
prisoners, testing where there are outbreaks of infection). The general applicability of infection rates determined by studying populaWorldwide, rates of
tions in a particular prison or region may also be a poor reflection
HIV-infection in prison
of national prison prevalence, given that the burden of HIV infecpopulations
tend to be much
tion may vary from region to region within a country.
higher than those found in
Apart from those countries where prevalence is largely attributthe general population.
able to heterosexual risk behaviour, HIV prevalence in prisons is
closely related to two factors: (1) the proportion of prisoners who
injected drugs prior to their incarceration, and (2) the rate of HIV
infection among people who inject drugs in the wider community. The jurisdictions with the
highest HIV infection rates in prisons (apart from countries with large heterosexual HIV epidemics) are those where HIV infection in the general community is “pervasive among IV
drug users, who are dramatically over-represented in correctional institutions.”2 Commenting
in 1991 on the situation in the United States, the US National Commission on AIDS stated
that “by choosing mass imprisonment as the federal and state governments’ response to the
use of drugs, we have created a de facto policy of incarcerating more and more individuals
with HIV infection.”3 A prohibitionist approach toward drug use and drug users is not unique

HIV and HCV Epidemics in Prison

5

to the United States. Thus, the situation described by the National Commission on AIDS is
evident in numerous countries.

Western Europe, Australia, and the United States
High rates of HIV infection among incarcerated populations have been reported in numerous countries. In Spain, it is estimated that the overall rate of HIV infection among prisoners is 16.6%, with a figure as high as 38% among some prison populations.4 In Italy, a rate
of 17% has been reported.5 High HIV infection rates among prisoners have also been reported in France (13%; testing of 500 consecutive entries), Switzerland (11%; cross-sectional
study in five prisons in the Canton of Berne), and the Netherlands (11%; screening of a sample of prisoners in Amsterdam6). In contrast, some European countries, including Belgium,
Finland, Iceland, Ireland, and some Länder in Germany, report lower levels of HIV prevalence.7 Relatively low rates of HIV prevalence have also been reported from Australia.8
A recent US study found that an estimated 25% of all HIV-infected citizens pass through
a correctional facility in the US each year.9 In the US, the geographic distribution of cases of
HIV infection and AIDS is uneven. Many systems have reported HIV prevalence rates under
1%, while others have rates that approach or exceed 8%.10

Central and Eastern Europe and the former Soviet Union
In the countries of Central and Eastern Europe and the former Soviet Union, high rates of
HIV infection among people who inject drugs and among prisoners is a growing concern. In
the Russian Federation, by late 2002 the registered number of people living with HIV/AIDS in the penal system exceeded 36,000,
In the Russian Federation, the representing approximately 20% of known HIV cases.11 In Ukraine,
registered number of people where 69% of HIV infection is linked to injection drug use,12 it is
estimated that 7% of the prison population is HIV-positive.13 In
living with HIV/AIDS in the
penal system exceeds 36,000. Latvia it is estimated that prisoners comprise a third of the country’s
HIV-positive population, and that a fourth of all HIV-positive persons in Latvia were infected while in prison.14 In Lithuania, in May
2002 the number of new HIV-positive test results among prisoners
found in a two-week period equalled all the cases of HIV identified in the entire country during all of the previous years combined. 15 In total, 284 prisoners (15% of the total Lithuanian
prison population) were diagnosed HIV-positive between May and August 2002.16

Canada
Estimates of HIV prevalence in Canadian federal and provincial prisons range from 2% to
8%17, while studies of HIV prevalence in individual prisons report rates of between 1% and
11.94% .18 Even adopting a conservative approach, these estimates place the HIV prevalence
rate in prisons at 10 times the prevalence rate in the general Canadian population.19
According to preliminary data, 2.01% of all prisoners in Canadian federal prisons were
known to be HIV-positive, with higher rates among women (3.71%).20 Among the five
Correctional Service Canada regions, the rate of reported HIV cases was highest in the
Québec region (2.7%) and lowest in the Ontario region (0.7%).21 A number of HIV prevalence studies have been conducted in federal and provincial prisons, including:
• The first HIV prevalence and risk behaviour study in a Canadian prison was undertaken in a medium-security prison for women in Montréal.22 Of the 321 participants, 23
(7.2%) were HIV-positive and 160 (49.8%) reported injection drug use. Non-sterile

6

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

•

•

•

•

injection drug practices and unprotected sexual activity with a drug user were found to
be the strongest risk factors for HIV infection.
Between 1 October and 31 December 1992 a study of all provincial adult prisons in
British Columbia examined associations between HIV infection and specific demographic and behavioural characteristics. A total of 2482 (91.3%) of 2719 eligible prisoners volunteered for testing. Prisoners who reported a history of injection drug use
were more likely than the others to refuse HIV antibody testing (12.9% versus 6.8%). The 2482 prisoners who were testIn Canada, the HIV prevalence
ed for HIV were similar to the general prison population
rate in prisons is at least 10
with regard to sex, native status, and age group. A total of 28
times higher than in the
prisoners were confirmed to be HIV-positive, for an overall
general population.
prevalence rate in the study population of 1.1%. The prevalence rates were higher among the women than among the
men (3.3% versus 1.0%) and among the prisoners who
reported a history of injection drug use than among those who did not report such a
history (2.4% versus 0.6%). There was no association between HIV status and native
status or age group. The higher prevalence rate among the women is to be explained
by more of the women than of the men reporting a history of injection drug use. The
authors of the study concluded that the overall prevalence rate of 1.1% and the rate
among female prisoners of 3.3% confirm that HIV infection is a reality in prisons and
that the virus has established a clear foothold in prison populations. Further, the
authors suggest that from a public health perspective, the data suggested an urgent
need for access to sterile injection equipment in addition to other preventive measures.23
A study reported in 1995 determined the seroprevalence of HIV infection and hepatitis
C among prisoners of a federal penitentiary for women.24 Of the 130 prisoners available for study, 113 (86.9%) agreed to donate a blood sample. One woman (0.9%) was
HIV-positive; 45 (39.8%) were positive for HCV antibody. The HIV seroprevalence
rate of 0.9% is lower than that found in studies in provincial prisons. However, the high
rate of antibodies to HCV suggests a significant level of risk behaviour, most likely
injection drug use, and suggests the potential for a rapid increase in the rate of HIV
infection should the number of newly admitted HIV-positive prisoners who use injection drugs rise.
In 1998 a Queen’s University team conducted a voluntary, anonymous HIV and HCV
serology screen in a Canadian male medium-security federal penitentiary;25 68% of
520 prisoners volunteered a blood sample and 99% of those giving a blood sample
completed a risk-behaviour questionnaire that was linked numerically to the blood
sample. Compared to previous screenings for HIV (four years earlier) and HCV (three
years earlier26) in the same institution, HIV seroprevalence had risen from 1% to 2%
and HCV seroprevalence from 28% to 33%. The overwhelming risk association for
HCV was with drug use outside prison, although there was a small group of men who
had only ever injected drugs inside prison, over half of whom had been infected with
HCV. The proportion of prisoners who had injected drugs in prison rose from 12% in
1995 to 24% in 1998. The proportion of surveyed individuals sharing injection equipment at some time in prison was 19%.
An HIV prevalence study among 394 women incarcerated in Québec, reported in

HIV and HCV Epidemics in Prison

7

1994, found that 6.9% of all participants, and 13% of women with a history of injection drug use, were HIV-positive.27
• A study released in 2004 of 1617 prisoners in seven provincial institutions in Québec
found an HIV prevalence rate of 2.3 percent among men and 8.8 percent among women.28

Other countries
High rates of HIV infection among prisoners are not limited to European and North
American jurisdictions. Countries in all parts of the world are also struggling to address this
health crisis. In Africa, reports have cited that as many as 41% of the 175,000 people in South
African prisons are living with HIV or AIDS.29 Zambia30 and Nigeria31 have also reported
high rates of HIV in their prisons. In Latin America, studies have shown HIV prevalence
rates of almost 7% in three urban prisons in Honduras (with almost 5% of males aged 16 to
20 testing positive)32 and between 10.9 to 21.5% in a selection of Brazilian prisons.33 In Asia,
numerous studies in Thailand have shown a history of imprisonment to be significantly associated with HIV infection.34 A study of 377 prisoners in three prisons in India found that
6.9% were living with HIV, all of these individuals being originally from Thailand and
Myanmar.35

HCV infection
HCV infection is endemic among prison populations worldwide. In many countries, the high
rates of HIV infection among the prison population are eclipsed by even higher rates of HCV
infection, another bloodborne viral infection that can be transmitted via needle sharing.
Published studies of HCV in the prison setting include those from Australia, Taiwan, India,
Ireland, Denmark, Scotland, Greece, Spain, England, Brazil, the United States, and Canada.
The vast majority of peer-reviewed published studies have found that between 20% and 40%
of prisoners are living with HCV and, within study samples, rates of HCV prevalence among
prisoners who inject drugs are routinely two to three times higher than among prisoners who
have no history of injection drug use.36 It has been suggested that
the concentration of HCV-infected individuals in prisons may be
Between 20% and 40% of
related to a number of factors, including high rates of incarceration
prisoners are living with HCV. among people who inject drugs and among those with previous or
multiple imprisonments; and that imprisonment may be an independent risk factor for contracting HCV infection.37
In Canada, 23.6% of federal prisoners who underwent voluntary HCV testing in 2001
tested positive.38 As with HIV, HCV rates were higher among women prisoners (42.4%) than
among men (23.2%).39 However, the Correctional Service of Canada report that presented
the 2001 data cautions that HCV may be under-reported because “[p]ersons at highest risk
of infection may be less likely to be tested, leading to biased testing patterns and possible
continued transmission of infection.”40 This caution is borne out by a 1996 study of 192 prisoners at a federal men’s institution that revealed that 28% of prisoners were HCV-positive,
with rates significantly higher among people who injected drugs (52%) than those who did
not (3%).41

Drug use in prison
Despite their illegality, the penalties for their use, and the significant amounts of money and
person-hours spent by prison systems to stop their entry, the fact remains that illicit drugs get
into prisons and prisoners consume them. Just as in the community, drugs are present in prisons because there is a market for them and because there is money to be made selling them.

8

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Many prisoners, whether in pretrial custody, awaiting sentencing, or serving a sentence of
incarceration, have a history of drug use or actively use drugs at the time of imprisonment.
Conflict with the law and incarceration are often a result of offences related to the criminalization of certain drugs, offences related to financing drug use (sometimes referred to as
acquisitive crime), or offences related to behaviours brought about by drug use. In many
countries, significant increases in prison populations and consequent prison overcrowding
can be traced in large part to policies of actively pursuing and imprisoning those producing,
trafficking, or consuming illegal substances. In addition to those
people who enter prison with a history of, or active, drug use, a
Just as in the community,
minority of prisoners start using drugs while in prison as a means to
release tensions and to cope with living in an overcrowded and often
drugs are present in prisons
violent environment.42
because there is a market for
Studies conducted in various countries illustrate the degree to
them and because there is
which drug use occurs in prison. In the countries of the European
money to be made selling
Union, for example, the number of prisoners who report ever havthem.
ing used illegal drugs is between 29% and 86%, with most studies
reporting figures of 50% or greater.43 The number of prisoners
actively using drugs during incarceration is between 16% and
54%.44 These EU studies indicate that figures for drug use are even higher among incarcerated women.45 In Canada, a 1995 survey by the Correctional Service of Canada found that
40% of prisoners reported having used drugs since arriving at their current institution.46
Another factor influencing drug-use patterns in prisons is drug testing. Many prison systems, particularly those in the developed world, routinely and/or randomly test prisoners for
illicit drugs, most often by urinalysis. Prisoners who are found to have consumed illicit drugs
can face penalties under criminal laws or administrative/institutional penalties, which can
result in loss of privileges or an increase in the amount of time a prisoner will be incarcerated. Therefore, there is a great incentive for prisoners who use illicit drugs to avoid detection.
Urinalysis can detect the presence of drugs in urine. Some drugs clear the human body in
relatively short order, while other drugs remain detectable, including in urine, for much
longer periods of time. Particularly significant in the context of HIV
and HCV transmission in prisons, smoked cannabis is traceable in
Some prisoners start using
urine for much longer (up to one month) than drugs administered by
drugs while in prison as a
injection, such as heroin and cocaine.47 Therefore, it is logical that
means to release tensions
some prisoners choose to inject drugs (with serious public health
and
to cope with living in an
impacts) rather than risk the penalties associated with smoking
overcrowded and often
cannabis (which has a negligible public health risk). Given the
violent environment.
scarcity of sterile needles and the frequency of needle sharing in
prison, the switch to injecting drugs may have devastating health
consequences for individual prisoners. A number of studies have
determined that urinalysis testing for illicit drugs increases the harms associated with injection drug use, including the potential for transmission of HIV and HCV.48

Injection drug use, shared needles and
risk of HIV and HCV transmission
Sharing needles among intravenous drug users is a high-risk activity for the transmission of
HIV and HCV, due to the presence of blood in needles after injection.49 For people who inject
drugs, imprisonment increases the risk of contracting HIV and HCV infection via needle
sharing. Because it is more difficult to smuggle needles into prisons than it is to smuggle in

HIV and HCV Epidemics in Prison

9

drugs, needles are typically scarce. As a result, prisoners who inject
drugs share and reuse syringes out of necessity. A needle may circulate among (often large) numbers of people who inject drugs, or
be hidden in a commonly accessible location where prisoners can
use it as necessary. A needle may be owned by one prisoner and
rented to others for a fee, or it may be used exclusively by one prisoner, reused again and again over a period of months until it disintegrates.50 Sometimes the equipment used to inject drugs is homemade, with needle substitutes fashioned out of available everyday materials, often resulting
in vein damage, scarring, and injection-site and other infections.

Study after study has
documented the prevalence
of injection drug use in
prisons throughout the
world.

International evidence
Given the legal prohibitions against drug use in most countries, people who inject drugs regularly find themselves coming into conflict with the law. In many cases, this results in periods of incarceration. For example, a national study in the US of 25,000 people who inject
drugs found that approximately 80% had been in prison at some time.51 A 1995 World Health
Organization (WHO) study of HIV risk behaviour among people who inject drugs in 12
cities found that 60% to 90% of respondents had been in prison since commencing injection drug use, most them experiencing incarceration on multiple
occasions.52
One study found that 6 of
Drug users do not necessarily cease using drugs simply because
the 36 people who reported they are incarcerated. In many cases, they continue to use on a reginjecting and sharing syringes ular or occasional basis throughout the course of their sentences. As
stated by UNAIDS in 1997, “long experience has shown that drugs,
when last in prison also
needles and syringes will find their way through the thickest and
reported that this was the
most secure of prison walls,” and study after study has documented
first time they had ever
the prevalence of injection drug use in prisons throughout the
shared syringes.
world.53 In fact, studies have shown that people not only continue to
inject drugs while in prisons but that prisoners actually begin using
injection drugs while incarcerated.
• A 2002 report prepared for the European Union showed that 0.3% to 34% of the
prison population in the European Union and Norway injected while incarcerated. The
report also found that 0.4% to 21% of people who inject drugs started injecting in prison,
and that a high proportion of people who inject drugs in prison share injection equipment. Studies in France and Germany found the incidence of sharing injection equipment among incarcerated women to be even higher than that among incarcerated men.54
• In Australia, studies have found that 31% to 74% of people who inject drugs reported
injecting in prison, and that 60% to 91% reported sharing injection equipment in
prison.55 One study found that 6 of the 36 people who reported injecting and sharing
syringes when last in prison also reported that this was the first time they had ever
shared syringes.56
• In Thailand, the first wave of HIV infections occurred in 1988 among drug injectors.
From a negligible percentage at the beginning of the year, the prevalence rate among
people who inject drugs rose to over 40% by September, fuelled in part by transmission of the virus as people who inject drugs moved in and out of penal institutions.57
More recently, a study concluded that “injecting drug users in Bangkok are at significantly increased risk of HIV infection through sharing needles with multiple partners

10

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

while in holding cells before incarceration.”58
• In Russia, a study of 1087 prisoners found that 43% had injected a drug in their lives,
and that 20% had injected while incarcerated. Of this second group, 64% used injection equipment that had already been used by somebody else, and 13.5% started injecting in prison.59 In the oblast of Nizhni-Novgorod, which has a prisoner population of
28,000, the authorities found that all of the 220 HIV-positive
prisoners had contracted HIV through intravenous drug use.60
A Scottish study in Glenochil
• In Mexico, a study in two jails found rates of injection drug
Prison provided definitive
use of 37% and 24% respectively.61
evidence that outbreaks of
The presence of drugs in prisons, the number of prisoners who enter
HIV infection can occur
prison as active drug users or with histories of drug use, prisoners
among incarcerated
who start using drugs while incarcerated, and the scarcity of needles
populations.
make prisons a high-risk environment for the rapid spread of HIV
and HCV infection. Evidence of HIV transmission within prisons
has been documented since the late 1980s:
• Between 1987 and 1989, Bangkok experienced a major rise in HIV infection among
people who inject drugs in the general population. HIV prevalence rates jumped from
2% to 27% during 1987, and then to 43% by the end of 1988. This significant increase
in HIV infection rates among people who inject drugs in the community paralleled the
amnesty and release of a large number of Thai prisoners. Six studies of HIV infection
among people who inject drugs in Thailand found that a history of imprisonment was
significantly associated with HIV infection.62
• A Scottish study in Glenochil Prison provided definitive evidence that outbreaks of HIV
infection can occur among incarcerated populations. The study investigated an outbreak
of HIV in the prison in 1993. Before the investigation began, 263 of the prisoners who
had been in the institution at the time of the outbreak had been released or transferred to
other prisons. Of the remaining 378 prisoners, 227 were recruited into the study.
Seventy-six people in this group reported a history of injection, and 33 reported injecting
in Glenochil. Twenty-nine of the latter were tested for HIV, with 14 testing positive.
Thirteen had a common strain of HIV, proving that they became infected in the prison.
All the prisoners infected in Glenochil reported extensive periods of syringe sharing.63
• In an Australian prison, epidemiological and genetic evidence was used to connect a
network of people who injected drugs. Twenty-five of the 31 prisoners were identified.
Of these, two tested HIV-negative, seven were deceased, two declined to participate,
and 14 were enrolled in the study. It could be proven that eight of those 14 people
were infected with HIV while in the prison.64
• In Lithuania, during random checks undertaken in 2002 by the state-run AIDS Center,
263 prisoners at Alytus Prison tested positive for HIV. Tests at Lithuania’s other 14
prisons found only 18 cases. Before the tests at Alytus prison, Lithuanian officials had
listed just 300 cases of HIV in the whole country, or less than 0.01% of the population,
the lowest rate in Europe. It has been stated that the outbreak at Alytus is due to sharing of drug injection equipment.65
• Transmission of HCV in prison populations has also been documented in a number of
studies.66 The finding that hepatitis infections occur much more frequently in detention
is supported by a German study conducted in 1996 in the women’s prison in Vechta,
Lower Saxony. The research found that 78% of drug-using women were infected with

HIV and HCV Epidemics in Prison

11

HBV and 74.8% were infected with HCV. Furthermore, the authors found that the
number of seroconversions during detention was considerable. Nearly half the women
who seroconverted (20 of 41) had been infected with hepatitis during incarceration.67

Canadian evidence
Numerous Canadian studies have documented injection drug use and needle sharing in
Canadian prisons:
• In a study reported in 2003, 32% of participants (439 adult males, 158 females) in six
provincial correctional centres in Ontario reported injecting with used needles while
incarcerated.68
• A 2003 study of federally incarcerated women found that 19% reported engaging in
injection drug use while in prison.69
• A 1998 study at Joyceville Penitentiary in Kingston, Ontario, found that 24.3% of prisoners reported using injection drugs in prison. This was an increase from the 12%
found in a similar study at the same prison in 1995.70
• A 1996 survey of prisoners in a federal prison in British Columbia found that 67%
reported injection drug use either in prison or outside, with 17% reporting injection
drug use only in prison.71
• In 1995, the Correctional Service of Canada’s National Inmate Survey found that 11%
of 4285 federal prisoners self-reported having injected since arriving in their current
institution. Injection drug use was particularly high in the Pacific Region, with 23% of
prisoners reporting injection drug use.72
• A 1995 study among provincial prisoners in Montréal found that 73.3% of men and
15% of women reported drug use while incarcerated. Of these, 6.2% of men and 1.5%
of women reported injecting drugs.73
• A 1995 study of provincial prisoners in Québec City found that 12 of 499 prisoners
admitted injecting drugs during imprisonment, 11 of whom had shared needles. Three
were HIV-positive.74

Harm reduction
Traditionally, concerns about disease transmission via injection drug use have been met with
calls to further entrench the philosophy and practice of “zero tolerance” of drug use.
Increased penalties for drug use, tightened security measures to
reduce the supply of drugs, and heightened surveillance of individual drug users are often put forward as “law and order” solutions to
Numerous Canadian studies
public health problems. However, the health risks posed by HIV and
have documented injection
HCV infection through the sharing of needles have prompted many
drug use and needle sharing
countries, including Canada, to recognize the limitations of a strict
in Canadian prisons.
zero-tolerance approach. This has led to the development and
implementation of community health programs that enable people
who inject drugs to reduce their risk of contracting HIV and HCV
while continuing to use illegal drugs. These harm reduction initiatives, including needle
exchange programs and safe injection facilities, have been enacted as pragmatic responses to
injection drug use and the attendant risks that HIV and HCV infection pose, to the individual and to society as a whole.

12

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

While harm-reduction policies do not condone illegal drug use, they do recognize that
reducing the transmission of bloodborne diseases and overdose deaths in society is a more
urgent and achievable goal than is ending illegal drug use. As drug users are often isolated
from health services, harm-reduction initiatives such as needle exchange and methadone
maintenance programs also create important links between health
professionals and these marginalized communities, thus enabling
Harm-reduction policies do
drug users to maintain and improve their overall health status.
not
condone illegal drug use.
Already in 2001, there were over 200 needle exchange sites oper75
ating in communities across Canada.
They recognize that reducing
While many governments have recognized the value of needle
the transmission of
exchange programs and supported their implementation in the
bloodborne diseases and
community, few have made efforts to extend the availability of
overdose deaths is a more
these programs to prisoners. Some jurisdictions, including most
urgent and achievable goal
Canadian jurisdictions, have recognized the risks associated with
than is ending illegal
injection drug use and have implemented limited harm-reduction
drug use.
measures in prisons, such as bleach distribution and/or methadone
76
maintenance treatment.
Unfortunately, most countries continue to fail to act in a pragmatic and decisive manner to protect the health of prisoners who engage in behaviours that
put them at risk of HIV and HCV infection. According to UNAIDS: “Whether the authorities admit it or not – and however much they try to repress it – drugs are introduced and consumed by inmates in many countries…. Denying or ignoring these facts will not help solve
the problem of the continuing spread of HIV.”77 The experience of health services in many
countries, as well as in many prison systems internationally, demonstrates that harm reduction provides the framework for effective action to prevent the transmission of HIV and HCV
in prisons.

HIV and HCV Epidemics in Prison

13

Human Rights and
Legal Standards
Numerous international instruments address the rights of prisoners and prisoners’ access to
health services. These international instruments are relevant in the context of injection drug
use and HIV/AIDS and HCV transmission in prisons. Taken together, these laws, rules,
guidelines, and standards are an expression of the norms that should guide decision-makers,
both legislators and prison authorities. It is important to distinguish between two general categories of instruments that protect rights, as each has different implications for governments.
International human rights law is binding on governments; international rules, standards, and
guidelines are not law, and are therefore not binding on governments.

International human rights law
Human rights are legally guaranteed under existing human rights laws adopted by international bodies. They protect all humans, both groups and individuals, against actions that
interfere with their fundamental freedoms and human dignity. Human rights are primarily
concerned with the relationship between a person or groups of people and the state, and
impose obligations on states to respect, protect, and fulfil certain fundamental rights. The
community of nations has recognized that all human rights are universal, interdependent, and
interrelated.78 States have a duty, regardless of their political, economic, and cultural systems,
to protect and promote human rights.
Numerous international laws, while general in nature, are relevant to the rights of prisoners in the context of HIV/AIDS epidemic:
•
•
•
•

14

International Covenant on Civil and Political Rights79
International Covenant on Economic, Social and Cultural Rights80
African Charter on Human and Peoples’ Rights81
American Convention on Human Rights82

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

• Additional Protocol to the American Convention on Human Rights in the Area of
Economic, Social and Cultural Rights83
• [European] Convention for the Protection of Human Rights and Fundamental
Freedoms84
• European Social Charter85

Since most of these covenants, charters, and conventions are based on the United Nations
Universal Declaration of Human Rights,86 there is a great deal of overlap in the human rights
they guarantee. The Universal Declaration has the status of customary international law87 and
as such is binding on all states. Moreover, states that have ratified or
acceded to any one of the covenants, declarations, or charters set out
Prisoners retain all civil
above have recognized that they are legally bound to respect, protect, and fulfill the following human rights, among others:
rights that are not taken
away expressly or by
• right to equality and non-discrimination
necessary
implication as a
• right to life
result of the loss of liberty
• right to security of the person
• right not to be subjected to torture or to cruel, inhuman, or
flowing from imprisonment.
degrading treatment or punishment
• right to enjoyment of the highest attainable standard of physical and mental health
The international community has generally accepted that prisoners retain all civil rights that
are not taken away expressly or by necessary implication as a result of the loss of liberty
flowing from imprisonment.88 Yet few international laws address explicitly and in detail conditions of imprisonment or the rights of prisoners. International rules, guidelines, principles,
and standards are extremely useful in this regard.

International rules, guidelines, principles, and standards
International rules, guidelines, principles, and standards do not have the force of law and
accordingly are not legally binding on states. Rules, guidelines, principles, and standards are
consensual policy documents that are most often formulated by United Nations bodies, or
other regional governing bodies, with the participation of member states. Although they are
not law, these types of instruments are important for two reasons. First, they provide guidance to states concerning the types of domestic laws and policies that are understood to
respect, protect, and fulfil their human rights obligations. Rules, guidelines, principles, and
standards set out, often in detail, acceptable conditions of imprisonment and treatment of
prisoners. Second, they are “the manifestation of … moral and philosophical standards.”89
Accordingly, it can be argued that states have at the very least an ethical obligation to observe
international rules, guidelines, principles, and standards.
The specific instruments that apply to the situation of prisoners impose both negative and
positive obligations on states regarding prison conditions and the treatment of prisoners:
• Basic Principles for the Treatment of Prisoners90
• Body of Principles for the Protection of All Persons under Any Form of Detention or
Imprisonment91
• Standard Minimum Rules for the Treatment of Prisoners92
• Recommendation No R (98)7 of the Committee of Ministers to Member States
Concerning the Ethical and Organisational Aspects of Health Care in Prison93

Human Rights and Legal Standards

15

Three additional international instruments – one declaration and two sets of guidelines – are
relevant to the situation of prisoners in the context of HIV/AIDS:
• WHO Guidelines on HIV Infection and AIDS in Prisons94
• Declaration of Commitment – United Nations General Assembly Special Session on
HIV/AIDS95
• International Guidelines on HIV/AIDS and Human Rights96

None of these documents have the force of law. All are the result of a consultation or special
session of a United Nations body or bodies. The WHO Guidelines “provide standards – from
a public health perspective – which prison authorities should strive to achieve in their efforts
to prevent HIV transmission in prisons and to provide care to those affected by HIV/AIDS.
It is expected that the guidelines will be adapted by prison authorities to meet their local
needs.”97 The WHO Guidelines outline general principles and cover issues such as HIV testing; prevention measures; management of HIV-infected prisoners; confidentiality; care and
support of HIV-infected prisoners; tuberculosis; women prisoners; juvenile detention; semiliberty, release and early release; community contacts; resources, and evaluation and
research.
The state parties who participated in the UNGASS Declaration did not make any specific commitments in relation to prisoners or prisons, but did commit to taking action on human
rights98 and to reducing vulnerability to HIV infection.99 These sections are generally applicable to the situation of prisoners as a group vulnerable to HIV/AIDS.
The specific relevance of the WHO Guidelines and the International Guidelines on
HIV/AIDS and Human Rights for prison needle exchange programs is reviewed in the
next section.

Prisoners’ right to health and access to sterile needles
Access to sterile needles implicates the right to health, given the great risk of HIV and HCV
transmission associated with needle sharing. Numerous international laws provide that
“Every person has a right to the highest attainable level of physical and mental health.”100 The
right to health imposes a duty on states to promote and protect the health of individuals and
the community, including a duty to ensure quality health care. The right to health in international law should be understood in the context of the broad concept of health set forth in the
WHO constitution, which defines health as a “state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity.”101
Like all persons, prisoners are entitled to enjoy the highest attainable standard of health, as guaranteed under international law. Key
Key international instruments international instruments reveal a general consensus that the standard of health care provided to prisoners must be equivalent to that
reveal a general consensus
available in the general community. Principle 9 of the Basic
that the standard of health
Principles for the Treatment of Prisoners states: “Prisoners shall
care provided to prisoners
have access to the health services available in the country without
must be equivalent to that
discrimination on the grounds of their legal situation.”102 In the conavailable in the general
text of HIV/AIDS, equivalence of “health services” would include
community.
providing prisoners the means to protect themselves from exposure
to HIV and HCV. Support for this proposition is contained in documents emanating from the European Union, the Council of
Europe, and the WHO. Article 35 of the Charter of Fundamental Rights of the European
Union states: “Everyone has the right to access preventive health care and the right to bene-

16

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

fit from medical treatment under the conditions established by national laws and practices.”103 This may be considered to apply to people in prison. Further, Recommendation 10
of Council of Europe Recommendation No R 98(7) states: “Health policy in custody should
be integrated into, and compatible with, national health policy. A
prison health care service should be able to … implement programmes of hygiene and preventive medicine in conditions compaIn 1991, the WHO Regional
rable to those enjoyed by the general public.”104 The WHO
Office for Europe
Guidelines recommend the equivalence of health care, including recommended the provision
preventive measures, and that general policies adopted under
of sterile syringes in prisons
national AIDS programs should apply equally to prisoners and the
as part of a comprehensive
community.105
HIV prevention strategy.
This principle of equivalence of prison health care has been
applied to the issue of HIV/AIDS by the WHO. In 1991, the WHO
Regional Office for Europe recommended the provision of sterile
syringes in prisons as part of a comprehensive HIV prevention strategy.106 Two years later,
the WHO Guidelines were published. Principle 1 of the WHO Guidelines emphasizes that
“All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination … with respect to their legal
status.”107 Principle 2 further states that “general principles adopted by national AIDS programmes should apply equally to prisons and to the general community.”108 The WHO
Guidelines are clear that “In countries where clean syringes and needles are made available
to injecting drug users in the community, consideration should be given to providing clean
injection equipment during detention and on release.”109
The right of people in prison to access adequate standards of HIV/AIDS prevention and
care is also supported by UNAIDS. At the United Nations
Commission on Human Rights, UNAIDS stated that “With regard The International Guidelines
to effective HIV/AIDS prevention and care programmes, prisoners
on HIV/AIDS and Human
have a right to be provided the basic standard of medical care availRights state that prison
able in the community.”110 This would again support the contention
authorities should provide
that where sterile syringes are provided to people who inject drugs
prisoners
with means of HIV
in the community, these same programs must be implemented in
prisons. Furthermore, Guideline 4 of the International Guidelines on
prevention, including clean
HIV/AIDS and Human Rights specifically states that prison authorinjection equipment.
ities should provide prisoners with means of HIV prevention,
including “clean injection equipment.” These Guidelines are intended to promote and protect respect for human rights in the context of
HIV/AIDS, to benefit governments by “outlin[ing] clearly how human rights standards apply
in the area of HIV/AIDS and indicate concrete, specific measures, both in terms of legislation and practice, that should be undertaken” to fulfill state obligations in relation to public
health within their specific contexts.111
International codes of practice governing physicians and other health professionals working in prisons also support the contention that comprehensive HIV and HCV prevention
measures, including needle exchange, must be made available to incarcerated populations.
The Oath of Athens for Prison Health Professionals, adopted in 1979 by the International
Council of Prison Medical Services, “recognize[s] the right of the incarcerated individuals
to receive the best possible health care” and undertakes that “medical judgements be based
on the needs of our patients and take priority over any non-medical matters.”112
International opinion supporting the right of prisoners to health care is not limited to the

Human Rights and Legal Standards

17

documents above. Reports from the European Committee for the Prevention of Torture and
from the Eighth United Nations Congress have expressed similar positions, as have legal
scholars and medical experts within national contexts, for example in the United States and
Australia.113 As has been explored in detail by Jürgens, recommendations on HIV/AIDS in
prisons developed by the international community consistently support “equivalence of treatment of prisoners,” stress the importance of prevention of transmission of HIV in prisons, and
suggest that prevention measures, including sterile syringes, be provided to prisoners.114

Obligations in Canadian law
Among other international human rights laws, Canada has ratified the International
Covenant on Civil and Political Rights and the International Covenant on Economic, Social
and Cultural Rights. Canada is therefore legally bound to respect, protect, and fulfill the
rights guaranteed in these instruments, including the right to the highest attainable standard
of health. Concerning domestic human rights protections, Richard Elliott has argued that
sections 7, 12, and 15 of the Canadian Charter of Rights and Freedoms may provide prisoners with a legal basis on which to seek the implementation of needle exchange programs.115
Section 7 protects the right not be deprived of the right to life, liberty, and security of the person except in accordance with the principles of fundamental justice; section 12 protects
against cruel and unusual punishment; and section 15 guarantees the right to equality before
and under the law and the right to equal protection and benefit of the law without discrimination on the basis of certain personal characteristics.
In addition to the Charter, laws governing prison systems impose
Governments and prison
obligations on governments to safeguard the health and well-being
authorities in Canada may be of prisoners. The federal prison system is governed under the
vulnerable to legal challenges Corrections and Conditional Release Act and the accompanying
for denying prisoners access regulations.116 Under sections 85 to 88 of the CCRA, the
Correctional Service of Canada is mandated to provide every pristo sterile syringes.
oner with essential health care, and reasonable access to non-essential mental health care that will contribute to his or her rehabilitation
and reintegration into the community. The CCRA states that this medical care “shall conform
to professionally accepted standards.”117 It can be argued that since needle exchange is the
accepted standard in the community for preventing the transmission of HIV and HCV via
injection drug use, under the terms of the CCRA these programs must be made available to
prisoners in the federal system.
Professor Ian Malkin has analyzed the application of Canadian tort law within the context
of HIV transmission/prevention in prisons.118 He concludes that governments and prison
authorities in Canada may be vulnerable to legal challenges for denying prisoners access to
sterile syringes if a prisoner can demonstrate that he or she has contracted HIV while incarcerated as a result of sharing needles to inject drugs.

18

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Review of International
Evidence of Prison Needle
Exchange
In many countries, needle exchange programs in the community have become an integral
part of a pragmatic public health response to the risk of HIV transmission among people who
inject drugs and, ultimately, to the general public. Extensive studies on the effectiveness of
these programs have been carried out, providing scientific evidence that syringe exchange is
an appropriate and important preventive health measure. For example, a worldwide survey
found that in cities with needle exchange or distribution programs the HIV prevalence rate
decreased by 5.8% per year; in cities without such programs, it increased by 5.9% per year.119
A 1998 US study analyzed the projected cost to the government of providing access to
syringe exchange, pharmacy sales, and proper syringe disposal for all people who inject
drugs in the country. The study found that “this policy would cost an estimated $34,278 US
per HIV infection averted, a figure well under the estimated lifetime costs of medical care
for a person with HIV infection.”120 A 2002 Australian report concluded that needle exchange
programs in that country had prevented 25,000 cases of HIV over a 10-year period and that
the $150 million spent on the programs had resulted in a savings of $2.4 to 7.7 billion.121
Because of the success of needle exchange programs in the community, calls to make sterile needles available to prisoners have been made in many countries. However, only a handful of countries – Switzerland, Germany, Spain, Moldova, Kyrgyzstan, and Belarus – have
established prison needle exchange programs. Some other countries, including Kazakhstan,
Tajikistan, and Ukraine are reportedly ready to establish such programs in the near future.
This chapter provides a chronological review of the experience of the countries that have
implemented prison needle exchange programs. For each country the review includes, where
available, epidemiological information about HIV and HCV, both in the general population

Review of International Evidence

19

and in prisons; a history of the prison system’s response to HIV and HCV; a review of prison
needle exchange programs, including historical information, evaluations, and lessons
learned; the current situation; and future directions.

Switzerland
Summary
Switzerland has approximately 150 prisons spread across the 26 cantons that comprise the
Swiss federation. Although the penal code is federal, the administration of the prisons is the
responsibility of the government of the canton in whose territory the
institution is located. There are approximately 6000 prisoners in
In 1992 Switzerland became Switzerland. The largest prison has a population of 350, although
the first country to
the majority of prisoners are incarcerated in small institutions with
fewer than 100 prisoners.
introduce a prison needle
In 1992 Switzerland became the first country to introduce a prison
exchange program.
needle exchange program. The initial program was started on an
informal basis by a physician at the Oberschöngrün men’s prison
who, ignoring prison regulations, began distributing sterile syringes
to patients who were known to inject drugs. In 1994 a formal needle exchange pilot project
was established in the Hindelbank women’s prison. After a successful trial and evaluation at
Hindelbank, needle exchange programs have been expanded to a total of seven Swiss prisons.

HIV/AIDS, HCV, and IDU in Switzerland
According to figures released by UNAIDS and the WHO in 2002, there are approximately
19,000 adults (aged 15 to 49) in Switzerland living with HIV or AIDS. This represents an
HIV prevalence rate in the general population of approximately 0.5%. The number of newly
diagnosed HIV infections declined in Switzerland between 1992 and 2000. People who
inject drugs comprised approximately 15% of positive HIV tests in 2000-2001.122
Swiss drug policy began moving toward harm reduction during the late 1980s. During this
time, open injection drug scenes were a significant feature in cities such as Zurich and Berne.
In Needle Park, as it was known, in the Letten district of Zurich, thousands of people who
inject drugs congregated daily to openly purchase and inject heroin. Needle Park received
international media attention and led the Swiss government to adopt significant harm-reduction programs, such as expanded needle exchange access, methadone and heroin maintenance, safe injection facilities, and community health services for drug users. These interventions successfully ended the open drug scenes and resulted in increased health benefits
for users.123

HIV/AIDS, HCV, and IDU in Swiss prisons
Switzerland has not undertaken extensive HIV/AIDS or HCV prevalence research in prisons. However, HIV infection rates have been estimated to be between 2% and 10%.124 As
early as 1985, blood testing among Swiss prisoners detected the presence of HTLV-III antibodies in some prisoners.125 More recently, a 1999 report based on interviews with 234 prisoners at Realta prison found an HIV infection rate of 5.1%, a result acknowledged as being
comparable to rates in other institutions. The same study found that approximately 9% of the
prisoners injected drugs at the time of the study.126

20

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

History of the response to HIV/AIDS, HCV, and IDU in Swiss prisons
Harm-reduction initiatives within the Swiss prison system date back to the mid-1980s. Swiss
prison officials approved the distribution of condoms as early as 1985, a program that over
time expanded to more and more institutions. In 1989, “hygiene kits” containing condoms,
disinfectant, and instructions for cleaning syringes were distributed to prisoners on entry to
Regensdorf penitentiary. Methadone maintenance was begun in a special section of
Regensdorf that same year, and in 1991 was expanded to several other remand prisons in
Basel, Berne, Geneva, and Zurich. In 1990 disinfectants were made
available in the remand prison in Geneva.127 Discussions on prison
Staff have realized that
needle exchange programs began with the first such program, in
distribution of sterile
1992. As of September 2000, condoms were provided in one-third
injection equipment is in
of Swiss prisons, and disinfectants in 8%.128 In addition to syringe
their own interest.
exchange, two Swiss prisons (Oberschöngrün and Realta) have
implemented heroin maintenance programs.

Introduction of needle exchange/distribution programs
The first program
In 1992 the first prison needle exchange program in the world was started in the
Oberschöngrün prison for men, located in the Swiss canton of Solothurn. The program was
initiated by Dr Franz Probst, a part-time physician in the institution. Dr Probst found that
approximately 15 of the 70 prisoners in the institution actively injected drugs. Moreover, he
recognized that the lack of availability of sterile syringes meant that the prisoners were sharing syringes out of necessity. As a physician, Probst felt it was his ethical responsibility to
act to prevent the risk of transmission of bloodborne disease, as well as to minimize the risk
of abscesses and other vein problems resulting from the reuse of old
syringes. He therefore began providing sterile syringes from the prison
medical unit to prisoners who injected drugs.
When the prison warden learned of the syringe distribution program,
rather than stop it, he was instead convinced by Dr Probst’s arguments
about the necessity of the program as a public health intervention. As a
result, the warden sought official approval from prison authorities to
continue the program. 129
The physician distributed approximately 700 syringes annually to
approximately 15 people who injected drugs within the institution.130
While prison staff were initially sceptical of the program, over time
there came to be broad support for it. As explained in 1996 by Peter Fäh,
Warden of Oberschöngrün,
Staff have realized that distribution of sterile injection equipment
is in their own interest. They feel safer now than before the distribution started. Three years ago, they were always afraid of sticking themselves with a hidden needle during cell searches. Now,
inmates are allowed to keep needles, but only in a glass in their
medical cabinet over their sink. No staff has suffered needle-stick
injuries since 1993.131

Automatic syringe
dispensening unit,
Saxerriet Prison, Switzerland

Review of International Evidence

21

Expansion to other prisons
At the same time as these developments were occurring at Oberschöngrün, plans were being
developed for a pilot needle exchange program in the Hindelbank Institutions for Women.132
The Hindelbank project has its foundations in a 1991 survey
of prisoners conducted by the prison physician. This survey of
injection drug use in the institution found that almost all the
people who injected drugs in Hindelbank had shared syringes
while incarcerated. Armed with these findings, the doctor proposed developing a pilot needle exchange program within the
prison. This proposal was supported by the Swiss Federal
Office of Public Health.
The Hindelbank needle exchange pilot project was launched in
1994 as one component of a broader health-promotion and harmreduction initiative that included prevention education, counselling,
and condom distribution. In the short term, the program
Insertion of used syringe in dispensing
sought
to
reduce the harms from drug use and to prevent infection
unit causes a new one to be released.
or
reinfection
by bloodborne pathogens such as HIV and hepatiSaxerriet Prison, Switzerland
tis B and C. In the medium term, the program aimed to reduce the
number of new drug users and of former users who relapse. While
in the Oberschöngrün program syringes were distributed from the medical unit, the Hindelbank
pilot project adopted a new approach. At Hindelbank, syringes could be obtained via automatic dispensing units that were placed in six discreet locations around the institution. These units
operated on a one-for-one basis; inserting a used syringe into the machine would cause a new
one to be released. New prisoners entering Hindelbank were given a “dummy” syringe that
would operate the machine but were not themselves functional. During the first year of the pilot,
5335 syringes were distributed.
In 1996 and 1997, needle exchange programs were established in Champ Dollon prison
(Geneva) and Realta prison (Graubünden) respectively. The Champ Dollon project follows
the Oberschöngrün model of distribution of syringes through the medical unit, while Realta
uses a single dispensing machine. In 1998, prison needle exchange programs were started at
the Witzwil and Thorberg prisons in Berne. Both programs distribute syringes through prison
medical staff. In 2000, the Saxerriet prison in Salez became the seventh Swiss prison to provide sterile needles.133

Evaluation and lessons learned
The Hindelbank pilot project was the subject of an extensive scientific evaluation during its
first year.134 A series of structured interviews were conducted with the prisoners prior to the
launch of the pilot, then again at three-, six-, and 12-month intervals.
Eighty-five percent of the prisoners participated in at least one stage
The evaluation found that
of the evaluation process. The interviews were supplemented with
syringe sharing virtually
voluntary blood testing and information from other correctional
disappeared with the
sources.
The evaluation found that syringe sharing virtually disappeared with
introduction of the pilot
the introduction of the pilot project. At the start of the pilot, eight of
project.
19 women who injected drugs admitted sharing syringes within the
past month in the institution, two of these sharing with more than
one person. At the end of the 12-month pilot, only one woman (who had been imprisoned
just before the interview) admitted sharing a syringe. There was no evidence of an increase

22

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

in drug consumption, and there were no new cases of HIV, HBV, or HCV infection in the
prison population. In addition, there were no reports of syringes being used as weapons
against staff or other prisoners. The prison also experienced a significant decrease in overdoses and in abscesses.135 In terms of drug consumption in prison, there were two interesting
results. First, the evaluation showed that the longer prisoners who had injected heroin and
cocaine before imprisonment stayed in prison, the higher the likelihood they would consume
drugs in prison. Second, the evaluation showed that the longer the harm-reduction project
had been in existence at the time the prisoner entered the institution, the less likely it was that
prisoners who had taken heroin and cocaine before imprisonment would use
drugs in prison.136
The Realta project was also subjected to an evaluation similar in structure
to that done in Hindelbank.137 The Realta project distributed 1389 syringes in
its first 19 months of operation, using dispensing machines. The findings of
the evaluation supported those in Hindelbank. Syringe sharing fell drastically, and was evident in only a few cases. There was no evidence of new HIV,
HBV, or HCV infections in the institution, and there were no instances of
syringes being used improperly (although there was one report of a prisoner
receiving a needle-stick injury from a discarded syringe).
Surveys of staff attitudes at both institutions found that there was a high
level of acceptance of the programs.
The original program at Oberschöngrün has not been evaluated scientifically. However, the physician in charge made a number of observations after
the project’s first three years. Among these were the disappearance of syringe
sharing and abscesses, no increases in deaths or overdoses among people
who inject drugs, and no instances of syringes being used as weapons.138
Any syringe found outside
While urinalysis is practised in the three prisons visited in the course of
its plastic safety box is
preparation of this report (Oberschöngrün, Hindelbank, Saxerriet), none of
considered illegal.
these institutions penalized people for traces of THC in their urine. In some
Hindelbank Prison,
cases the prisons tested for THC but did not penalize for it, while in others
Switzerland.
(photo: Peter Dimakos)
they chose not to test for THC at all. This practice was followed because the
prisons agreed that penalizing people for smoking marijuana or hashish,
which is detectable in urine for much longer than are injection drugs, would
result in many prisoners switching from cannabis use to injection drug use. The prison
authorities wanted to avoid this outcome, due to the significantly increased health risks associated with injecting drugs.
It is also significant that prisoners in institutions with a needle exchange program are permitted to access both methadone maintenance therapy and the needle exchange program.

Current situation
Prison needle exchanges continue to operate without incident in the seven prisons identified
above. Some of these have adapted their programs based upon experience gained over several
years. Hindelbank, for example, will now provide prisoners participating in the program with up
to five additional “points” (needles) to attach to the main body of the
syringe. This is to accommodate people who inject drugs and who may
All syringes must be stored
have trouble injecting due to difficulty finding veins. In such cases, the
in the plastic safety boxes
user may need to make several attempts to inject. With additional
provided
by the health unit.
“points,” the prisoner need not reuse a needle that gets duller with each
attempted injection. This practice has not resulted in any security prob-

Review of International Evidence

23

lems. Oberschöngrün also follows a flexible approach to its syringe exchange program, and does
not adhere to a strict one-for-one policy. Again, this has not resulted in any security or safety
problems.
Hindelbank no longer requires program participants to store their syringes in a visible
place. However, the prison maintains a strict policy that all syringes and extra “points” must
be stored in the plastic safety boxes provided by the health unit. Any syringe found outside
its box is considered illegal, and sanctions are imposed on the prisoner in question. In recent
years, Hindelbank has seen the number of exchanges drop, from a high of over 5000 during
the first year of the program to approximately 350 annually in 2003. Staff attribute this drop
to a combination of factors, including the new practice of providing extra “points” and a general drop in intravenous drug use among younger prisoners, many of whom choose to smoke
or snort rather than inject.
The canton of Berne recently mandated that all prisons under its administrative control
must provide sterile syringes to prisoners. Despite this legislative directive, it was noted by
several people interviewed for this report that this is not happening in an effective manner in
many cantonal prisons. In these cases, prisons that object to syringe exchange have implemented programs in a manner that makes them virtually inaccessible to the vast majority of
people who inject drugs (primarily by using non-confidential methods of distribution). In
doing so, these prisons are able to fulfill the legal requirement of “providing” syringe
exchange programs, yet have created a situation where prisoners will not use the program.
This results in needle exchange programs that exist in name only. This resistance demonstrates the challenge posed by the imposition of needle exchange programs where prison
staff were not involved in the planning and implementation. Such resistance has also been
evident in the experience of Saxerriet prison in the Salez canton, where needle exchange programs were required by order of the cantonal legislature.

Germany
Summary
There are 220 prisons in Germany. Institutions are managed and administered by the state
(Land) in which the institution is located.
In 1996, pilot needle exchange programs were established in three German prisons. In the
women’s prison in Vechta, exchanges were done using one-for-one
syringe dispensing machines. In the men’s prison in Lingen 1 Dept
In 1996, pilot needle
Groß-Hesepe, exchanges were made by staff from the medical unit
exchange programs were
and the drug counselling service. In the open prison Vierlande in
established in three
Hamburg, syringes were distributed by an external organization,
German prisons.
which also provided counselling as well as vocational training for
prison personnel. Following a successful two-year pilot phase and
evaluation, the programs were continued in these three institutions
and were expanded to four others. Over the last two years these programs have come under
increasing attack from political leaders and, despite their effectiveness, six programs have
been cancelled.

HIV/AIDS, HCV, and IDU in Germany
According to figures released by UNAIDS and the WHO in 2002, there are approximately
41,000 adults in Germany living with HIV or AIDS. This represents an HIV/AIDS preva-

24

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

lence rate of approximately 0.1% in the general population.139
There are two sources for AIDS and HIV-related data in Germany. According to the
National Case Report Register for AIDS, the total number of AIDS cases diagnosed up to
the end of 2001 was 21,189, approximately 75% of whom have died. Nearly 16% of AIDS
cases have been diagnosed among people who inject drugs. At the end of 2001 there were
2152 males living with AIDS who reported injecting drugs, 11.6% of all AIDS diagnoses
among men. Among the 2620 women living with AIDS, 43.7% inject or used to inject drugs.
Epidemiological data based on HIV testing is also available. Of the 18,000 laboratory tests
for HIV conducted since 1993, 10.4% of the 1900 positive test results were among people
who currently inject drugs or had a history of injection drug use. Women accounted for 28%
of HIV-infected drug users.140

HIV/AIDS, HCV, and IDU in German prisons
Several studies have estimated the HIV prevalence rate among German prisoners, with
results ranging from 1.1% to 1.9%. These studies found that between 2.1% and 6.3% of prisoners who injected drugs were HIV-positive.141
Another study has indicated a link between incarceration, injecA 1993 study of over 612
tion drug use, and the transmission of bloodborne diseases such as
people
in Berlin who injected
HIV and HCV. A 1993 study of over 612 people in Berlin who injectdrugs concluded that the
ed drugs concluded that the most significant factor for HIV infection
among the group was sharing of needles during incarceration.
most significant factor for
Imprisonment was also found to be the second most common reason
HIV infection among the
cited by the participants for needle sharing. The study concluded that group was sharing of needles
a lack of access to sterile needles was counterproductive to HIV preduring incarceration.
vention measures implemented in the general community.142
Rates of HCV infection among German prisoners are higher. A
1998 study in a Hamburg high-security prison for men found an
HCV prevalence of 25% among all prisoners, and a 96% infection rate among people who
inject drugs. A study at a women’s prison in Lower Saxony found an HCV prevalence rate
of 75%, and identified 20 women who had seroconverted while incarcerated.143 Other studies have found HCV prevalence rates of 77% among prisoners who inject drugs, and 18%
for prisoners who did not inject drugs. A 2001 study of prisoners who had injected drugs
only in prison found a 100% rate of HCV infection.144

History of the response to HIV/AIDS, HBV/HCV,
and IDU in German prisons
The development of the response to HIV/AIDS and hepatitis in German prisons can be
described as a long process toward normalization. In the mid-1980s, when HIV/AIDS was
first identified in the prison setting, there was a debate about separation, isolation of HIVpositive prisoners, and mandatory HIV testing. At this time there was also a lack of knowledge among the prison staff about transmission routes. Voluntary HIV testing is provided,
although the term “voluntary” has been differently interpreted and practised from state to state.
In the early years, some prisons treated all those who refused testing as HIV infected. Due to
different test practices in the 16 Länder, the test rate varied from 10% to more than 90%.
More than 90% of HIV- and/or HBV/HCV-positive prisoners inject drugs or have a history of injection drug use. Injecting is therefore the primary risk factor for HIV and hepatitis transmission in prisons. Despite this fact, the main response to the risks posed by injec-

Review of International Evidence

25

tion drug use in Germany’s criminal justice system continues to be abstinence-based, and
includes counselling and drug-free wings in prisons, and diversion to drug treatment in place
of custodial sentences for minor offences. Condoms are available in all German prisons.
Substitution treatment is provided in most German prisons, although access depends to a
great extent on the state in which the prison is located. While in the northern states substitution treatment is common, it is rare to find it provided in the southern states such as Bavaria
and Baden-Württemberg.145 Methadone is the most frequently used substitution treatment for
detoxification.146 Other harm-reduction measures have only been implemented in a few prisons. The provision of bleach was implemented in a Hamburg prison in the early 1990s, only
to be withdrawn due to lack of access by prisoners. Bleach is currently not available in
German prisons.147 Prison needle exchange programs were piloted in 1996.

Introduction of needle exchange/distribution programs
The first programs
In 1995, the Minister of Justice in the northern German state of Lower Saxony approved a
two-year prison needle exchange pilot project in the women’s prison in Vechta and the men’s
prison in Lingen 1 Dept Groß-Hesepe.148 The success of prison needle exchange programs
in Switzerland, as well as support from various German experts, helped form the basis for
this decision. The pilot projects were initiated in the women’s and men’s prisons in April and
July 1996 respectively.
The Vechta prison houses a population of approximately 200 women (both adults and
youth). Lingen 1 Dept Groß-Hesepe houses approximately 230 adult men. It was estimated
that at least 50% of the prisoners in each institution had a current or
past history of drug use. Each prison opted to explore different methods of needle distribution. In the case of Vechta, five syringe-dispensing machines were placed in various parts of the institution to allow
anonymous access. The men’s prison chose to distribute needles
through staff of the medical and drug counselling service. An external
scientific evaluation of both pilot projects was arranged with
researchers at the university in Oldenburg.
In Vechta, the needle exchange program was one component of a
comprehensive HIV prevention program that also included education
and counselling, harm reduction and safer-sex information, access to
methadone, and involvement of external organizations. Each woman
entering the institution was given information from health-care staff
that included details on participation in the needle exchange program.
Before being approved for the needle exchange program, a prisoner
underwent a medical examination and had her history of drug use documented in her medical file. Young offenders housed in Vechta were
Syringe dispensing machine,
also eligible to participate in the program if parental consent was proLichtenberg Prison, Berlin.
vided. Women participating in the methadone program were not eligible to be part of the needle exchange project.
As in Switzerland, prisoners participating in the program were given a “dummy” needle
that could be inserted into a dispensing machine to release a sterile needle. Following this, a
new needle could be obtained on a one-for-one basis by inserting a used syringe into the
machine. In addition to providing sterile syringes, the machines also dispensed other harmreduction materials necessary to practise safe injection. These included alcohol swabs, ascor-

26

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

bic acid, filters, plaster, and sodium chloride. Each of the dispensing machines was emptied
and refilled daily by health-care staff.
Each prisoner involved in the program was allowed to have only one needle in her possession, and could only carry it on her person when it was being exchanged. Prisoners were
not allowed to lend or sell their needle, and they could not leave the
prison with the needle when transferred to another institution.
Based upon the success of
Possession or distribution of drugs was illegal. One hundred and
the first projects, needle
sixty-nine women participated in the needle exchange program durexchange
programs were
ing the two-year pilot phase, and 16,390 syringes were exchanged,
implemented in several
with 98.9% of them being returned.
In the second pilot project at the men’s prison in Lingen 1 Dept
other German prisons.
Groß-Hesepe, needles were distributed by staff rather than machine.
Workers from the health unit or drug counselling service provided
needle exchange every day in the tea room, a discreet area near the drug counselling centre
that could be accessed from the prison’s recreational area. Exchanges were available during
established hours for any prisoner producing a used needle. Prisoners participating in the
methadone program were not eligible for the needle exchange project. As in Vechta, the needle exchange program in Lingen 1 Dept Groß-Hesepe was one part of a larger comprehensive HIV prevention program including educational interventions, access to methadone, and
involvement of outside organizations. In all, 83 men participated in the program over the
pilot phase, 4517 needles were exchanged, and 98.3% of the syringes distributed were
returned.
In both prisons, consultations and educational programs were provided for staff to make
them aware of the rationale for and objectives of the programs, and to receive their input and
suggestions.

Expansion to other prisons
Based upon the success of the Vechta and Lingen projects, needle exchange programs were implemented in several other
German prisons.
In 1996 a program was started at the Vierlande prison in
Hamburg, which houses over 300 men and approximately 20
women. This prison used both dispensing machines and staff
to distribute sterile syringes. In 1998 needle exchange using
dispensing machines was implemented in Lichtenberg prison
for women and Lehrter Str. prison for men in Berlin.
In Lichtenberg, which has a population of approximately 75
women, every prisoner entering the institution is provided with
a harm-reduction kit as part of the contents of her cell. This kit
Harm reduction kit,
Lichtenberg Prison, Berlin.
consists of a plastic eyeglasses case containing ascorbic acid,
(photo: Peter Dimakos)
alcohol wipes, vein cream, and a “dummy” needle to be used
in the sterile needle dispensing machine. As in other prisons
with needle exchange, syringes stored properly in their plastic
cases are legal. In Lichtenberg, a prisoner found with an improperly stored or hidden needle,
in possession of more than one needle, or with a needle containing a dose of heroin, is subject to penalties.
In early 2000 needle exchange was made available through staff at the Hannöversand women’s
prison and the Am Hasenberge men’s prison in Hamburg (see Current situation, below).

Review of International Evidence

27

Evaluation and lessons learned
An evaluation was conducted of the pilot programs in Vechta and Lingen 1 Dept Groß-Hesepe
after two years. 149 The evaluation yielded results very similar to those found in Switzerland.
The provision of sterile needles did not lead to an increase in drug use, and the amount of
drugs seized within the prison did not change with the availability of needle exchange. In
fact, the number of drug users entering treatment programs actually increased after the
implementation of the pilot, indicating that, as is the case in the outside community, prison needle exchange programs are effective outreach and referral points for people who inject drugs.
There were no instances of syringes being used as weapons against staff or other prisoners, despite the fact that over 20,000 syringes were distributed in the two institutions during
the two-year pilot phase. Observance of the program rules by participants was found to be
high, with only occasional minor infractions occurring in the proper storage of syringes by some prisoners, or the possession of
Since 2001, prison syringe
syringes by some prisoners in the methadone program (who were
exchange programs in
not allowed to also be part of the needle exchange project).
Germany have come under
Staff and prisoners both found the existence of the program nonpolitical attack.
threatening. Staff adapted quickly to the new programs, which came
be seen as a normal part of the institutional routine. There were differences found in the level of acceptance of the programs by prisoners in the two different institutions. The evaluator reported that the women in Vechta had
much more confidence and trust in the program than did the men in Lingen. This was the
result of the differing methods of needle distribution in the two prisons (anonymous dispensing machines in Vechta; hand-to-hand distribution by prison health staff in Lingen). It
was found that many prisoners in Lingen were hesitant to participate in the program, as doing
so would be to identify themselves to staff as injection drug users.
Finally, the evaluator found that there were no new cases of HIV among the participants
who were permanent members of the exchange program. A significant decrease in abscesses was
also identified.
Lichtenberg, which was visited in the preparation of this report, has experienced no incidents of syringes being used as weapons, although one staff member suffered an accidental
needle-stick injury. In this incident, a staff member found a syringe in the prison and stored
it in an envelope. A second staff member was accidentally pricked when picking up the envelope. At the start of the program in Lichtenberg, there were a significant number of
exchanges, although the rate has since declined. Staff attribute this to the fact that many
women participated in the program initially, as they believed that a
high level of participation would ensure the continuation of the
Since the termination of the intervention.
prison needle exchange
program, many prisoners
Current situation
have started to share
Since 2001, prison syringe exchange programs in Germany have
syringes.
come under political attack. In 2002 needle exchange programs
operating in the Hannöversand women’s prison, Am Hasenberge
men’s prison, and the Vierlande open prison (men and women) in
Hamburg were terminated. The decision to terminate the programs was taken by a centreright coalition government formed in September 2001, in the absence of any reports or other
evidence of problems with the programs. It is clear that the termination of the programs was
politically and ideologically motivated. Ignoring six years of evidence of the success of
prison syringe exchange programs in Germany, the governing coalition acted to abolish

28

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

harm-reduction measures and declared drug-free prisons as their main target.150 On 1 June
2003 the needle exchanges in Vechta and in Lingen 1 Dept Groß-Hesepe were also terminated in similar circumstances by a new centre-liberal government in Lower Saxony.
In Berlin, the social-democratic and socialist coalition terminated one of its two needle
exchange programs in early 2004. The stated reason for this action was an alleged lack of
acceptance of the program among staff. The government also
claimed that the prison did not exhibit a lower HIV infection rate
Staff at these prisons are
than another prison without a needle exchange program. However,
among the most vocal critics
there is no epidemiological research to support this claim.
In each of these cases, the decision to terminate the needle of the governments’ decision
to close the needle
exchange programs was made without consulting prison staff, and
exchange program.
without an opportunity to prepare prisoners for the loss of access to
the programs. In the case of Lower Saxony, the government’s
announcement to end needle exchange as of 1 June 2003 was made
three days before it was to take effect and only one day before the start of a holiday weekend. This meant that there was no opportunity to discuss the policy change with the prisoners who accessed the needle exchange, and it essentially created a situation in which,
overnight, prisoners lost access to a program that had provided them with sterile needles for
seven years.
Discussions with prisoners in the Vectha prison in early June 2003 revealed that since the
termination of the program many had started to share syringes and were reverting to the previously unknown practices of borrowing or renting needles from others. In Lingen it was also
reported that syringes now cost €_10 or two packages of cigarettes on the underground market. Before the announcement, syringes were stored safely in plastic boxes in plain sight of
prison staff. They are now being hidden, thus increasing the likelihood of accidental needlestick injuries to staff.
Interestingly, apart from public protests by public health professionals, staff at these prisons are among the most vocal critics of the governments’ decisions. In Vechta prison, for
example, the prison staff have started a petition to lobby the government to reinstate the program. The official staff representative for the prison has written to the government to refute
allegations by the Justice Minister of Lower Saxony that the withdrawal of the program came
as the result of a lack of staff support. In Lichtenberg prison in Berlin, prison staff (85% of
whom opposed the initial introduction of the needle exchange program in 1998) are now the
main actors lobbying the government to keep the program operating. These examples provide
compelling evidence of the benefits of prison needle exchange to staff, and show that strong
staff support can develop for such programs.
Overall, the decision on the part of several state governments in Germany to terminate
prison needle exchange programs clearly illustrates the continuing controversial nature of
such programs, even within jurisdictions where they have a history of successful implementation. The decision to terminate effective needle exchange programs, without any evidence
to justify such decisions, makes no sense from a public health perspective and represents the
triumph of ideology and irrelevant political considerations over sound public health policy.

Spain
Summary
There are 69 prisons in Spain falling under the jurisdiction of the Spanish Ministry of the
Interior. There are also a further 11 prisons that are administered by the government in the
autonomous region of Cataluña.
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29

The first prison needle exchange program was introduced in July 1997 in Basauri prison,
Bilbao, in the Basque region. This was followed by pilot programs in Pamplona prison
(1998) and the Orense and Tenerif prisons (1999). In June 2001 the
Directorate General for Prisons ordered that needle exchange proBy the end of 2003 the
grams be implemented in all prisons. By the end of 2001, syringe
number of Spanish prisons
exchange was provided in 11 Spanish prisons. By the end of 2002
providing needle exchange
the number of prisons providing needle exchange had grown to 27;
had grown to 30.
and by the end of 2003, to 30.151
At present, the mandate to institute needle exchange programs
exists for all 69 prisons under the jurisdiction of Spain’s Ministry of
the Interior, with the exception of psychiatric prisons and one high-security-level prison.
There is also a pilot needle exchange program established in one of the prisons under the
jurisdiction of the government of Cataluña.

HIV/AIDS, HCV, and IDU in Spain
According to figures from UNAIDS and the WHO, there were approximately 130,000 adults
(aged 15 to 49) living with HIV/AIDS in Spain at the end of 2001, and a prevalence rate of
0.5%.152 The HCV prevalence rate in the general community is approximately 3%.153
Although declining in recent years due to the wide implementation of harm-reduction programs such as methadone and needle exchange, the HIV prevalence rate among people who
inject drugs continues to be high at 33.5% in 2000, down from 37.1% in 1996. As of June
2001, the National AIDS Register had identified 39,681 cumulative cases of AIDS in Spain
that were related to injection drug use, 65% of all AIDS cases identified up to that time.154

HIV/AIDS, HCV, and IDU in Spanish prisons
Approximately half of Spanish prisoners have a history of illicit drug use, or are actively
using drugs at the time of incarceration. The vast majority of prisoners seeking drug treatment during incarceration do so for heroin dependence (85%). However, there has been an
increase in injection cocaine use in recent years.155
Rates of both HIV and HCV infection among Spanish prisoners are high. While prisoners represent only 0.01% of the total Spanish population, they account for 7% of AIDS diagnoses.156 Rates of infection are particularly high among those with a history of injection drug
use. In 1989, the first cross-sectional HIV prevalence study found an HIV infection rate
among prisoners of 32%.157 Since that time, rigorous HIV prevention and harm-reduction initiatives in the community and in prisons have achieved significant results. In the early 1990s
the HIV prevalence rate in prisons was approximately 23%.158 In 2000 the HIV prevalence
rate was reported to be 16.6%.159 A 2002 joint report by the Ministry of the Interior and the
Ministry of Health and Consumer Affairs estimated an HIV prevalence rate of 15% and an
HCV prevalence rate of 40%.160 Among incarcerated women, rates of HIV infection are particularly high: in 2001 the HIV prevalence rate among women prisoners was 38%.161
People who inject drugs comprise the majority of AIDS cases among Spanish prisoners.162
Approximately 90% of prisoners living with AIDS in Spain cite injection drug use as a risk
factor.163 Rates of HIV infection among prisoners with a history of injection drug use have
been cited as high as 46.1%.164
Rates of HCV infection are even higher, particularly among people who inject drugs.
According to a 1998 Penitentiary Health Study, 46.1% of prisoners were HCV infected.165 In
2002 the HCV infection rate was cited as being 40%.166 Among prisoners with a history of

30

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

injection drug use, HCV infection rates are as high as 90%. Even among prisoners who have
no IDU history the rate of HCV infection is high, with 20% testing positive.167 Dual infection is also a significant issue. It has been estimated that up to 83.5% of Spanish prisoners
living with HIV/AIDS are also infected with HCV168 and that 31% of all female prisoners
are infected with both HIV and hepatitis.169

History of the response to HIV/AIDS, HCV,
and IDU in Spanish prisons
While the Spanish prison system has developed extensive drug treatment and abstinence programs, including drug-free units in many institutions, there is an official recognition that
“[not] all drug users are candidates for an abstinence based program.”170 Therefore, a multifaceted approach, including significant harm-reduction initiatives, has been implemented.
This approach has been bolstered by various legal and policy instruments that support the
extension of harm-reduction programs to prisoners in Spain. The Spanish Constitution, for
example, establishes that prison sentences and security measures must aim at the re-education and social reintegration of individuals, as well as the protection of their health.171 Article
3.3 of the General Prisons Act also mandates that “the Prison System
shall endeavour to preserve the life, health and integrity of inmates.”
During the course of 2000,
More recently, the National Plan on Drugs 2000-2008 includes speover 23,000 Spanish
cific references to prison health, including a call to “diversify the
prisoners received
available range of harm-reduction programs in prisons through varimethadone treatment.
ous initiatives, such as the extension of needle exchange pro172
grams.”
Methadone maintenance was first introduced into Spanish prisons
in 1992 as a strategy to reduce HIV and HCV transmission in prisons via injection drug use.
By 1998, methadone was available in all but one prison (a very small institution on the island
of Tenerife). During the course of 2000, over 23,000 prisoners received methadone.173
Needle exchange was first piloted in 1997. In November 1998 the Directorate General
for Prisons issued a recommendation that all prisons implement harm-reduction measures,
and recommended that needle exchange programs should be considered.174 In June 2001 the
Directorate General for Prisons issued a directive requiring the implementation of needle
exchange programs in all prisons.

Introduction of needle exchange/distribution programs
The first program
In December 1995 a Basque Parliament green paper recommended that the State Secretariat
for Prison Affairs implement three pilot needle exchange programs in the Basque
Autonomous Community. It was suggested that these pilots could be
used to evaluate the feasibility of introducing syringe exchange proFollowing the positive
grams more broadly within the prison system.175
experience with the first
In January 1996 a planning committee was struck to examine the
prison needle exchange
issue of prison needle exchange programs and make recommendaprojects, the Spanish
tions. The committee’s primary finding was that needle exchange
government made a
programs should be implemented in cooperation with the staff of an
commitment to expand
external, non-governmental organization that was already providing
prison services. Based upon these findings, and following consultatheir availability.
tion and education with prison staff, the first pilot needle exchange

Review of International Evidence

31

was established in July 1997 in the Centro Penitenciario de Basauri in Bilbao, a men’s institution with a population of 250.176 Of the 180 prisoners admitted in 1995, one-third regularly
injected drugs, of whom nearly half were HIV-positive.
In Basauri, exchanges were made by workers from non-governmental organizations for
five hours each day in two discreet areas of the prison. In addition to a sterile needle, the
prisoners also received a harm-reduction kit that contained an alcohol swab, distilled water,
a hard container for carrying the needle, and a condom. The program emphasized the safe
storage of needles in plastic cases so as to minimize the risk of accidental needle-stick
injuries. The needles provided were marked so that they could be distinguished from contraband needles.177
During the first two-and-a-half years of the pilot, over 16,500 syringes were exchanged
by over 600 prisoners using the program. During that time there were no violent incidents
reported involving the use of the syringes.

Expansion to other prisons
In October 1996 the Provincial Criminal Court of Navarra ordered officials at Pamplona
prison to provide sterile needles to prisoners. In 1997, as a result of numerous complaints, the
Office of the Ombudsman also recommended the implementation of
prison needle exchange programs.178 In November 1998 a second
In Spain, needle exchange
prison needle exchange program was started in Pamplona. This was
services are provided by
followed in 1999 by projects in Tenerife, San Sebastián, and Orense.
health-care staff or by
Based upon the experience gained through these programs, the
health-care staff in
National Plan on AIDS and the Directorate General for Prisons
collaboration with external
jointly created the Working Group on Syringe Exchange Programs
in Prisons. The group’s objectives were to “elaborate recommendanon-governmental
tions that seek to standardize as much as possible the conditions for
organizations.
introduction, criteria for action, and indicators for evaluation of
syringe exchange programs in prisons.”179 The Working Group’s
report, Key Elements for the Implementation of Syringe Exchange Programs in Prison, was
published in April 2000. At that time, needle exchange programs were operating in nine prisons in the Basque region, Galicia, Canary Islands, and Navarra. In October 2001 it was
reported that these programs had exchanged 5488 syringes.180 By the end of 2001, syringe
exchange programs had been established in 11 Spanish prisons.181
Following the positive experience of these projects, the Spanish government made a commitment to expand their availability and in March 2001 the parliament approved a green
paper recommending the implementation of needle exchange programs in all prisons.182
From this point, events moved quite rapidly. In June 2001 the Directorate General for Prisons
issued a directive requiring the implementation of needle exchange
programs in all prisons. This was followed in October by a directive
Harm-reduction kits must
from the Subdirectorate General for Prison Health specifying that
by policy include a syringe
needle exchange programs should be introduced in all prisons by
in a hard plastic
January 2002. In March 2002 the Ministry of the Interior and the
transparent case, distilled
Ministry of Health and Consumer Affairs jointly published the document Needle Exchange in Prison: Framework Program, which
water, and an alcohol swab.
provides the prisons with guidelines, policies, and procedures, and
training and evaluation materials for implementing needle exchange
programs.183 By the end of 2002, 12,970 syringes had been distributed in 27 Spanish prisons.184 There is also a pilot needle exchange program established in one of the prisons under

32

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

the jurisdiction of the government of Cataluña. In all prisons,
needle exchange is done exclusively through hand-to-hand
methods (not dispensing machines) in discreet locations within
the prisons. In many cases, particularly in large facilities, sterile needles are available at multiple sites.
Depending upon the institution, needle exchange services
are provided by health-care staff (nurses, physicians), or healthcare staff in collaboration with external non-governmental
organizations. As is the case in other jurisdictions, syringe
exchange is provided as one component of a broader comprehensive approach to drug use, harm reduction, and health promotion that includes other education, counselling, and treatHarm reduction kit,
ment services. Availability of sterile needles varies from two
Soto de Real Prison, Madrid
days per week to every day, depending upon the institution.
(photo: Peter Dimakos)
Times of program operation also vary, although sterile needles
are generally available during a two-to-four-hour period in
either the morning or evening.185
Harm-reduction kits are provided rather than single needles. These kits must by policy
include a syringe in a hard plastic transparent case, distilled water, and an alcohol swab.
Some institutions also provide a cooker and filters in their kits. Two different gauges of
syringes are available to people who inject drugs, depending upon whether the person is
injecting heroin or cocaine. Prisoners participating in the program
are mandated to keep their needle inside the hard plastic case at all
Prisoners participating in
times, whether the syringe is on their person or in their cell. In the
methadone maintenance
case of a search by staff, they must identify that they have the neeare not disqualified from
dle and its location.186 Needles that are not part of the official program are prohibited and are confiscated if found.
accessing the needle
While the tendency of many prison jurisdictions is to elaborate
exchange program.
exhaustive sets of rules and regulations on all issues, the Spanish
guidelines adopt a very progressive and pragmatic approach to the
program. One example of this is seen in their approach to staff safety, as set out in the Framework Program:
It should also be taken into account that [it] is unadvisable to establish a large
number of rules, since an excessive number of rules dilutes the importance of the
basic rules. It is easier to ensure compliance with a minimum number of basic
rules that have real impact on maintaining the safety of the program than to
implement a program with many accessory rules [that] may cause effective preventive measures to be neglected, and therefore lead to an increased risk of accidents.187
There are a number of features of the Spanish policy that are worth
closer examination.
First, the program guidelines do not mandate strict adherence to
one-for-one exchange. While they advise that “the rule should be
exchange, i.e., the previous syringe must be returned before a new
kit is handed out,” they also recognize that “a flexible attitude
should be maintained towards [the one-for-one rule’s] application

Only persons with mental
health issues or those who
are particularly violent may
be excluded from the needle
exchange program.

Review of International Evidence

33

keeping in mind that the primary objective of the program is to prevent shared use of
syringes.”188 The guidelines advise that “The number of kits to be supplied depends on the
frequency of exchange and the user’s consumption habits: it should be sufficient to cover the
inmate’s needs so that he does not have to reuse the syringe before the next day of
exchange.”189
Second, prisoners participating in methadone maintenance are not disqualified from
accessing the needle exchange program. There are three reasons cited for this decision. The
first is a recognition that some drug users on methadone will continue to inject either sporadically or habitually, and that this usually indicates that they are receiving an insufficient
dose of methadone. The second is in recognition that people on methadone may still inject
cocaine. The third is that methadone patients may act as “couriers,” obtaining sterile needles for other people who inject drugs who do not wish to identify themselves to the prison
health unit.190
The guidelines also enable prisoners living in drug-free units or involved in abstinencebased programs to access sterile needles. It is recommended that requests for needles by
these prisoners be “approached from a therapeutic point of view, and appropriate therapeutic measures taken to help him to overcome the relapse, but access
to sterile injection material should never be denied.”191
Correctional officers
The only instances in which participation in the needle exchange
reported very positive
program is restricted are in the cases of persons with mental health
experiences with the needle issues who pose a danger or those classified as particularly violent.
exchange pilot project.
In each of these cases, the guidelines suggest that individuals be
assessed on a case-by-case basis. For example, in the case of violent prisoners, prison officials are encouraged to “regulate the
means of access by especially dangerous inmates, bearing in mind that it is always preferable to adopt special security rules with these inmates than to deny access to sterile
syringes.”192 Involvement in the program can also be denied if an individual uses a needle as
a weapon, or continually violates program rules.193

Evaluation and lessons learned
To evaluate the original Basauri pilot project, a monitoring committee was established to
review and assess the program as it progressed.194 Evaluations that involved consulting prisoners and staff were conducted at zero, three, and six months. A 12-month evaluation was
deemed impossible, as the prison’s high turnover rate meant that
few prisoners remained in the institution from the start of the pilot
Prison needle exchange
until the 12-month point. However, an evaluation with prison and
programs facilitate referral
non-governmental organization staff was done after 22 months.
of users to drug addiction
The prisoners accessing the program experienced no obstruction
treatment programs.
from correctional officers, and supported the fact that the program
was run by the external non-governmental organization. It was noted
that this personalized aspect of the program was preferable to an
anonymous dispensing machine. Furthermore, the evaluation found that drug consumption
among the prisoners had not increased and that there was a reduction in high-risk behaviours.
Correctional officers also reported very positive experiences with the pilot. They reported
no problems or conflicts with prisoners as a result of the program, and there were no instances
of syringes being used as weapons. While they considered the program to be positive, they
expressed a preference that it be run by prison staff rather than by an external organization.
The staff of the non-governmental organization reported no instances of prisoners being

34

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

punished by prison staff for accessing the program, and that the program provided a useful
tool to reach prisoners with health-promotion messages and to refer them to other health programs. They also suggested that some flexibility was necessary in the program, in that a strict
one-for-one exchange policy was not always practical. This issue was debated in the monitoring committee. The non-governmental organization staff argued in favour of flexibility
regarding this policy. Their principle concern was that they did not want to deny a sterile needle to prisoners who injected drugs and who did not have a needle to exchange, since this
would place the prisoner in a situation where he would be forced to share needles. The prison
guards, however, were concerned with security issues. In the end, an 80% return rate was
agreed as an acceptable standard (the program’s return rate was 82%).
Evaluations of the other pilot projects were also positive. In discussing the experience of
nine prison needle exchanges, a 2001 report prepared by the National Plan on Drugs noted
that “[t]hese experiences have shown that these programmes can be reproduced in a penitentiary environment without resulting in any distortion or direct problems.”195 The 2002 document, Needle Exchange in Prison: Framework Program, provided the following conclusions concerning the evaluations of Spanish prison syringe exchange programs:196
• Implementation of a NEP, as in the community outside prisons, is feasible and adaptable to the conditions of execution of the prison sentence.
• NEPs in prison, as in the community outside prisons, produce behavioural changes
that lead to a reduction in the risks associated with injection drug use.
• NEPs in prison facilitate referral of users to drug addiction treatment programs.
• Implementation of a NEP does not generally cause an increase in drug use or, specifically, an increase in parenteral heroin or cocaine use.
• A NEP in prison should operate with a certain degree of flexibility and be tailored to
the individual circumstances of each prisoner, but without forgetting the conditions for implementation established in each
It is always preferable to find
program.
• It is feasible for a NEP and other drug addiction prevention or
a way to provide prisoners
intervention programs to coexist.
who injects drugs with a
sterile needle than force
The Spanish experience of prison syringe exchange has also found
them into a position
that levels of intravenous drug use have remained unchanged, there
where
they will share.
have been no accidental needle-stick injuries, there has been no
increase in conflict among prisoners or between prisoners and staff,
there have been no instances of syringes being used as weapons, and
staff support for the programs has grown with the experience of implementation.197
Now that prison needle exchange has been expanded nationally, guidelines for ongoing
evaluation have been developed as part of the Framework Program. A computer software
package called SANIT is used in each prison to record the number of users of the program,
number of syringes supplied and returned, enrolments/withdrawals from the program, and
reasons for withdrawals. Health status is also included. To maintain the confidentiality of the
program users, a randomly generated number or pseudonym is used to identify each participant. In addition to quantitative data, the evaluation also includes qualitative feedback from
prisoners and staff. Standard anonymous questionnaires for collecting this data are included
within the Framework Program document. It is suggested that evaluations be done on at least an
annual basis, if not more regularly (ie, three-, six-, and 12-month intervals). As a result, ongoing
evaluation and assessment of the programs will be available annually on a national basis.

Review of International Evidence

35

Three lessons emerge from a review of the Spanish experience.
First, those responsible for the administration of the needle exchange programs have
maintained a steadfast commitment to the health objectives and benefits of the program, a
harm-reduction philosophy, and the right to health of people in prison. As a result, the
Spanish prison system has been able to develop very progressive,
pragmatic, and flexible approaches to challenging issues that arise
Prison needle exchange
in the programs. Their solutions to controversial issues such as strict
programs can be quickly
one-for-one syringe exchange, access to needle exchange for prisoners who are supposedly “drug free” (ie, those on methadone
implemented on a national
maintenance or living in drug-free units), and access to syringes for
basis where political will is
violent or psychotic prisoners are all underpinned by the fundacombined with a solid
mental principle that people in prison have a right to protect themimplementation plan.
selves against HIV and HCV infection, that harm-reduction
responses must be adapted to meet individual and unique needs, and
that it is always preferable to find a way to provide prisoners who
injects drugs with a sterile needle than force them into a position where they will share. This
is a valuable lesson for other jurisdictions.
Second, the Spanish example demonstrates the value of providing clear guidelines and
principles for prison syringe exchange programs, yet allowing some flexibility in how each
individual institution implements those guidelines. This is particularly important given that
a one-size-fits-all policy would have been difficult to impose on a system of 69 different prisons of different sizes, regions, security levels, etc. However, providing clear guidelines and
principles on implementation, and clear political instruction that these programs were to be
implemented by a deadline, has allowed institutions to make such programs available within their own unique institutional environments.
Which leads to the final lesson from the Spanish experience. Prison needle exchange programs can be quickly implemented on a national basis where political will is combined with
a solid implementation plan. At the end of 2001, needle exchange programs were in operation in 11 prisons. Just 18 months later, the legislative and policy infrastructure was in place
for implementation in all 69 Spanish prisons, with needle exchange programs up and running in 27 of them.

Current situation
At present, the legislation and policy required for the implementation of needle exchange
programs in all 69 prisons under the jurisdiction of Spain’s Ministry of the Interior exists,
with the exception of psychiatric prisons and one high-security-level prison. By the end of
2002, syringes had been distributed in 27 institutions, increasing to 30 prisons by the end of
2003.198 A pilot needle exchange program has also been established in one of the 11 prisons
under the autonomous jurisdiction of the government of Cataluña. Ongoing annual evaluation and assessment of the programs within the jurisdiction of the Spanish Ministry of the
Interior will be conducted on a national basis.

Moldova
Summary
The first prison needle exchange program in Moldova was initiated in May 1999 in Prison
Colony 18 (PC18) in Branesti. Originally, sterile syringes were provided to prisoners through
the prison health unit. However, after four to five months, the distribution method was

36

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

changed to a peer model, which has been continued.
Based upon the success of the pilot project in PC18, a second syringe exchange program
was initiated in May 2002 in Prison Colony 4 (PC4) in Cricova. The program in PC4 is also
peer based. A third project, in the women’s prison in Rusca, was opened in August 2003.

HIV/AIDS, HCV, and IDU in Moldova
As of September 2002
Prior to 1995, fewer than 10 cases of HIV infection were reported
there were 210 known
annually in Moldova. However, the subsequent epidemic of HIV
prisoners living with
infection among people who inject drugs has driven these figures
significantly higher. According to UNAIDS/WHO, by the end of
HIV/AIDS in Moldovan
2001 there were approximately 1500 adults (aged 15 to 49) in
prisons.
Moldova infected with HIV, the majority becoming infected via
injection drug use. In a 2002 report, UNAIDS/WHO identified
66.7% of AIDS cases within Moldova (73.7% of men, 57.1% of women) as being linked to
injection drug use.199 Physicians working within the country have stated that as many as 83%
of all HIV infections are now linked to injection drug use.200

HIV/AIDS, HCV, and IDU in Moldovan prisons
As of September 2002 there were 210 known prisoners living with HIV/AIDS in Moldovan
prisons, which reflects an HIV/AIDS prevalence rate in the prison system approximately 100
times higher than in the general community.201 Twelve percent of known cases of HIV infection in Moldovan prisons are among incarcerated women. However, these statistics underrepresent the extent of HIV prevalence, since they only include prisoners whose HIV status
is known. There is no universal HIV testing of the prison population, and it is assumed that
the true prevalence of HIV in prisons is higher.202

Known Cases of HIV/AIDS in Moldova
YEAR

1997
1998
1999
2000
2001
to September 2002

GENERAL POPULATION

404
408
155
64
1300
1620

PRISON POPULATION203

38
78
122
134
179
210

History of the response to HIV/AIDS, HCV,
and IDU in Moldovan prisons
The development of harm-reduction initiatives in Moldovan prisons has been led by Health
Reform in Prisons, a non-governmental organization of prison doctors established in 1997
by the former chief of the prison health department. Because the members of Health Reform
in Prisons were themselves current or former prison physicians, the organization was in a
unique position vis-à-vis the prison administration to be able to advocate for the implementation of harm-reduction measures.

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37

Health Reform in Prisons, with the cooperation of the Moldovan
Ministry of Prisons and financial assistance from the Open Society
Institute of the Soros Foundation Network, began delivering HIV
prevention programs in prisons in 1999.204 The organization went on
to provide HIV and harm-reduction programs and services in all 19
prisons in Moldova. These activities include the provision of HIV
prevention education for prisoners and staff, peer education, the creation and dissemination of educational materials, the purchase of
HIV-prevention and harm-reduction tools, the distribution of condoms and disinfectants, and the provision of sterile syringes in two prisons.
Up to September 2002, the project had reached approximately 14,000 prisoners (79% of
all prisoners in Moldova) and 1600 prison staff. The organization distributes condoms, disinfectant, and information in all Moldovan prisons. Since the project was started, over 30,000
items of information have been distributed.205

In May 1999 a pilot prison
syringe exchange program
was established at
Prison Colony 18, a
medium/maximum-security
prison with 1000 prisoners.

Introduction of needle exchange/distribution programs
The first program
In May 1999 a pilot prison syringe exchange program was established.206 The site chosen
was Prison Colony 18 in Branesti. There were several reasons why PC18 was chosen for the
pilot. These included its proximity to the city of Chisinau (the capital of Moldova, where the
NGO coordinating the project is based), the fact that it was the prison with the lowest average age of prisoners (24 to 26 years old), and because at that time it had the highest known
number of prisoners known to be living with HIV/AIDS (18 people).
PC18 is a medium/maximum-security prison with a population of approximately 1000
men. It was originally built in 1950 to house 250 people. The Moldovan prison system is a
military system. Prison staff at PC18 include approximately 200
correctional officers (who are soldiers) and 100 non-military staff.
To make the needle exchange All prisoners in the institution work at one of several prison industries. These include underground stone mining, agricultural and
genuinely anonymous, the
prison medical unit recruited livestock cultivation, grain milling, and baking.
eight prisoners as secondary The Prison Administration of the Ministry of Justice was initially
exchange volunteers to work reluctant to authorize the project due to concerns that the provision
of sterile needles would lead to an increase in drug use. However,
throughout the penal colony. these concerns were assuaged by the results of an anonymous survey of prisoners that demonstrated that as many as eight to 12 prisoners were sharing one needle, and that some people were using
homemade needles, to inject drugs. On 3 December 1999, Order 115 was enacted, authorizing the establishment of the needle exchange in PC18.
The pilot program in PC18 evolved through two stages. During stage one needles were distributed hand-to-hand to prisoners through the prison medical unit. During the four or five
months that this distribution system was in place, between 40 and 50 needles were exchanged.
However, the project team decided that this method of distribution was not satisfactory.
Their most significant concern was that the needle exchange was being accessed by only
25% to 30% of the prisoners known to inject drugs. A number of barriers were identified by
Dr Nicolae Bodrug, head of the prison medical unit, who was responsible for coordinating
the project. These included difficulty in establishing a rapport between the medical staff and

38

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

the prisoners who were injecting, a lack of anonymity and of
confidentiality in the service, and the fact that needle exchange
was only available during office hours. According to Dr
Bodrug, “To make the needle exchange genuinely anonymous,
we recruited eight secondary exchange volunteers to work
throughout the penal colony. The advantage is a much higher
degree of trust and confidentiality.”207 This decision inaugurated stage two of the program.
Under stage two of the program, eight peer volunteers were
trained to provide harm-reduction services in four different
sites in the prison. Two peer volunteers were assigned to work
Harm reduction and
at each site and they are available on a 24-hour basis, as the
HIV-prevention information,
sites are based within the prison living units (barracks-style
Prison Colony 18, Branesti, Moldova.
accommodations, with 70 or more men living and sleeping in
(photo: Elena Vovc)
the same large room). The activities and programs are carried
out in cooperation with the prison physician. The role of the
physician is to act as project supervisor and as a link between
the peer volunteers, prison staff, and Health Reform in Prisons personnel. In the first nine
months of 2002, 65% to 70% of people known to inject drugs in the prison were accessing
the program through the peer volunteers. In 2002, the peer volunteers in PC18 exchanged
7150 syringes.208

Evolution of Syringe Exchange in Prison Colony 18:
Needles Exchanged Annually209
YEAR

SYRINGES EXCHANGED

2000
2001
2002

115
4350
7150

In addition to one-for-one syringe exchange, peer volunteers also distribute condoms, disinfectants, antiseptic pads, and razors for shaving. They also provide harm-reduction and HIVprevention information, including information on safer injecting and post-injection problems. The team of peer volunteers changes every year.

Expansion to other prisons
Based upon the success of the pilot project, on 16 May 2002 Order
52 authorized the implementation of a second needle exchange project in Prison Colony 4, a men’s institution in Cricova housing 1200
prisoners. This program is also peer based and uses three peer volunteers. During the first few months of the project, approximately
40 to 45 prisoners used the exchange. By the end of the year the
number of prisoners accessing the needle exchange program had
increased to approximately 160.210 In PC4, the peer volunteers
exchanged 7555 syringes during 2002.211

Peer volunteers also
distribute condoms,
disinfectants, antiseptic pads,
and razors for shaving.

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39

Distribution of Harm-Reduction Tools in Moldovan Prisons:
2002 System-Wide Figures212
BLEACH KITS
IODINE
SHAVING RAZORS

1,026
211
3,550

SYRINGES

14,705

CONDOMS

100,056

Evaluation and lessons learned
As reported by Dr Nicolae Bodrug, physician in PC18, normalizing the concept of needle
exchange within prisons was a challenge for both staff and prisoners. However, attitudes
changed over time. Says Dr Bodrug, “We emphasized that harm reduction is a practice that
works well in other places and that can protect staff as well as inmates from HIV infection.”213
One significant barrier to the eventual acceptance and success of the program in PC18
was that initially prison guards continued to consider syringes as
contraband, and to search for and confiscate them from prisoners.
The practice of using
While drug possession and distribution remain illegal in the prison,
Dr Bodrug explains: “We eventually got the guards to agree that the
prisoners as volunteers for
project syringes would be ‘legal’ and not confiscated.”214
needle exchange has had
The practice of using prisoners as volunteers for needle exchange
significant positive results in
has had significant positive results in others areas, including
others areas.
decreasing stigmatization and increasing the self-esteem of prisoners living with HIV/AIDS, increasing awareness of HIV transmission among the prison population, and enhancing the credibility of
the health services by creating a more humane image.215 While using prisoners increases the
trust in and anonymity of the program, there is the potential for the quality of the information
disseminated to be less than that provided directly by experienced health-care staff. Therefore,
there must be a commitment to ongoing training and support for the peer volunteers.
The Moldovan projects do not adhere to a strict one-for-one exchange policy. Unlike the
programs in Western Europe, there are also no plastic storage cases provided for the syringes,
nor are there regulations about where they may be stored. Initially, the decision against providing plastic cases was made on economic grounds. Later, it became clear that the programs
were working well and safely without such storage cases and it was therefore decided they
were unnecessary. The Moldovan projects have experienced no instances of syringes being
used as weapons, and no problems with dirty needles.
Of the experience of establishing the first prison needle exchange project in Moldova, Dr
Bodrug says:
It took two years to break the ice of mistrust. We had to learn a lot, say strange
things, and act oddly in front of a [sceptical] majority. But harm reduction
became normal. And with the head of the prison administration in favor of harm
reduction, as well as the minister of justice now, we can look forward confidently to expansion.216

Current situation
A third prison needle exchange was started in the women’s prison in Rusca in August 2003.
In 2003 there were 17 known prisoners living with HIV/AIDS in the women’s institution,
12% of the total population in the institution.217

40

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Kyrgyzstan218
Summary
Kyrgyzstan initiated a pilot prison needle exchange project in October 2002. In early 2003
approval was given to expand needle exchange into all 11 Kyrgyz
prisons. Needle exchanges are now operating in all prisons.
In Kyrgystan, needle
HIV/AIDS, HCV, and IDU in Kyrgyzstan
exchanges are now
operating
in all prisons.
The sharp increase in intravenous drug use, coupled with a difficult
social and economic situation, is creating a serious risk of an escalating HIV epidemic in Kyrgyzstan. As of June 2003 there were 825
known cases of HIV or AIDS in the country, 82% of which were linked to injection drug
use.219 According to a December 2002 report published by UNAIDS and the WHO, a
“[m]ore substantial spread of HIV is now also evident” in Kyrgyzstan.220

HIV/AIDS, HCV, and IDU in Kyrgyz prisons
In the 11 prisons in Kyrgyzstan, the number of identified prisoners living with HIV/AIDS
has been steadily rising in recent years. In 2000 there were only three known cases of HIV
in Kyrgyz prisons. In September 2001 this number had increased to 24, the majority being
people who inject drugs. As of November 2002 there were more than 150 prisoners living
with HIV/AIDS in Kyrgyzstan, 56% of all known cases in the country.221
Injection drug use and needle sharing are highly prevalent in Kyrgyz prisons. A survey
conducted by a Kyrgyz non-governmental organization found that 100% of prison staff
agreed that drugs are being used in the prisons. The survey also found that 90% of drug
users in prisons said they shared needles and did not disinfect them.222

History of the response to HIV/AIDS,
HCV, and IDU in Kyrgyz prisons
HIV prevention programs in prisons started in 1998 before the first case of HIV was identified. Initially, the response consisted of education programs for prisoners and prison staff.
In February 2001 the Main Directorate for Penalty Implementation (MDPI) and its
Department of Correctional Institutions issued a “prikaz” (order) “on prevention of HIV/AIDS
in the prison institutions of Kyrgyzstan” urging prisons to take steps to prevent the spread of
HIV among prisoners. Based on this order, various HIV prevention and harm-reduction initiatives were implemented. These included the provision of condoms and disinfectants, HIV-prevention education for prisoners and staff, peer education, and voluntary HIV testing. Unofficial
needle exchange was also initiated, specifically targeting those living with HIV/AIDS.

Introduction of needle exchange/distribution programs
The first program
In October 2002 a pilot needle exchange project was introduced in Prison IK-47, a maximum-security institution. The project provides services for approximately 50 prisoners
who exchange needles on a daily basis (the project averages approximately 50 exchanges
per day).
It was decided that exchanges should take place in a location where prisoners cannot be
seen by guards; they therefore take place in the medical wards. Syringe exchange is provided in the narcological unit of the central prison hospital, and all prisoners have an opportuReview of International Evidence

41

nity to avail themselves of the program. A prisoner asks to come to the medical unit to
receive medical service and while there he exchanges his syringe. The pilot also provides
secondary exchange using prisoners as peer volunteers, as in the Moldovan model. The project coordinators found that both options for syringe exchange were needed.
At the start of the pilot, everyone was given one syringe. Exchange was made on a onefor-one basis. Only the prisoners involved in the pilot were allowed to access the exchange.
Records were maintained of exchanges, and education is provided for staff.

Expansion to other prisons
In early 2003 an order was issued approving the provision of sterile needles in all Kyrgyz
prisons. As of September 2003 needle exchange programs were operating in six of the 11
prisons in Kyrgyzstan (five men’s prisons and one women’s prison). In February 2004 funding was obtained to expand the programs to all 11 prisons and by April 2004 sterile needles
were available in all prisons.223
In all 11 institutions, needle exchange is done using prisoners trained as peer outreach
workers who work with the medical unit. This model was adopted following concerns that
emerged when the medical unit was the sole point of exchange. Because needles could only
be accessed from the medical unit during the day, and most drug trafficking took place in the
evening, some non–drug using prisoners were accessing sterile needles during the day that
they would later sell at night to prisoners who injected drugs. This problem was rectified by
the implementation of the peer outreach worker model. Since the outreach workers live in
the prison units, they are available to distribute sterile needles 24 hours a day, and the forprofit market for needles was effectively eliminated.
In September 2003 a total of approximately 470 drug users were accessing the six needle
exchange programs then in operation on a daily basis. In April 2004, with programs established in all 11 prisons, this figure was approximately 1000.224 Drug users are provided with
one syringe and three extra needle tips. This allows prisoners who inject drugs to inject more
– up to three times a day without having to reuse a syringe. This also reduces the cost of the
syringe exchange program, since tips cost less than complete needles.
There have been no instances of syringes being used as weapons, and prison medical staff
have identified a reduction in injection-related health problems such as abscesses.

Current situation
Syringe exchange programs are currently operating in all 11 Kyrgyz prisons. There are plans
to pilot test a methadone maintenance treatment program in 2004.

Belarus
Summary
The Republic of Belarus implemented a pilot syringe exchange program in one prison,
Reformatory School 15/1 in Minsk, in April 2003.

HIV/AIDS, HCV, and IDU in Belarus
There were 5165 people known to be living with HIV/AIDS in Belarus as of 1 September
2003.225 HIV and injection drug use are issues of significant concern. In April 2003 there
were approximately 9400 persons officially registered with drug treatment services. The
number of people registered with drug treatment services has experienced an annual growth

42

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

of 20% to 40%. However, these treatment figures are assumed to be a low estimate of the
true circumstances, with the actual number of drug users estimated at 40,000 to 43,000.
Ninety-one percent of drug users in Belarus are people who inject drugs. Injection drug use
is the primary mode of HIV transmission in Belarus, with 75.5% of
people living with HIV/AIDS in the country being infected though
The Republic of Belarus
IDU.226
implemented a pilot syringe
HIV/AIDS, HCV, and IDU in Belarus prisons
exchange program in one
As of May 2003 there were 1131 prisoners in Belarus known to be
prison in April 2003.
living with HIV. This represents 22.5% of all known HIV cases in
the country.227

History of the response to HIV/AIDS,
HCV, and IDU in Belarus prisons
Prisoners in Belarus must undergo mandatory HIV testing when entering detention centres.228 The syringe exchange program is one component of a project that provides education
for staff and prisoners, peer education, provision of information, voluntary HIV testing, and
condom and bleach distribution. The project works with the support of the Committee on
Execution of Penalties of the Ministry of Internal Affairs and with the prison administration.

Introduction of needle exchange/distribution programs
The pilot program was implemented in April 2003 at the Reformatory School 15/1 in Minsk,
a prison with a population of 2000. This site was selected based on the availability of scientific and medical specialists and because the prison also houses the National Hospital, which
provides primary HIV care for all known HIV-positive Belarussian prisoners.229
The pilot is scheduled to run until 2004. There are 28 registered drug users in the prison,
although it is estimated that the actual number of people who inject drugs is approximately
200. Fifteen prisoners are known to be HIV-positive. The program is open to all prisoners in
the institution. The program follows the Moldovan model, and uses 20 volunteers from the
prisoner population to distribute needles to their peers. During the first month over 100 needles were distributed.230

Evaluation and lessons learned
A number of challenges were identified in establishing the program, including the reluctance
of staff, the lack of a legal framework upon which to base a prison needle exchange program,
the short duration of the pilot, and the fact that prisoners using drugs still face penalties if
discovered. There have been no instances of needles being used as weapons. The program
has yet to be evaluated.231

Current situation
The pilot was originally scheduled to run until January 2004. This term was extended until
June 2004. Concurrently, the needle exchange program was extended to two other prisons. The
Ministry of Internal Affairs is prepared to expand prison syringe exchange throughout the
country, although securing funding for such an initiative is a major barrier to realizing this
goal.232 Consideration is also being given to the possibility of initiating methadone treatment.233

Review of International Evidence

43

Analysis of the Evidence
Refuting objections
A number of objections have consistently been made against the implementation of needle
exchange programs in prisons. In many countries, including Canada, these objections have
formed the basis of politicians’ and prison system officials’ rejections of needle exchange
programs. The four principal objections to prison needle exchange programs are:
1. The implementation of prison needle exchange would lead to increased violence and
the use of syringes as weapons against prisoners and staff.
2. The implementation of prison needle exchange would lead to an increased consumption of drugs, and/or an increased use of injection drugs among those who were
previously not injecting.
3. The implementation of prison needle exchange would undermine abstinence-based
messages and programs by condoning drug use.
4. The successful implementation of prison needle exchange programs does not indicate that other jurisdictions will be able to implement successful programs because
existing programs reflect specific and unique institutional environments.

Increased institutional safety
One of the most important lessons to emerge from international experience is that implementing prison needle exchange programs does not necessitate a trade-off between health
and security. In fact, as explained by Stöver and Nelles in a 2003 review of the evaluations
conducted of prison needle exchanges:
In no case had needles and syringes been used as weapons either against personnel or other inmates. This was and is one of the controversial issues facing
prison-based SEPs [syringe exchange programs]. Syringes were not misued and
disposal of syringes did not exhibit any problem. For reasons of safety in the

44

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

working place, it is interesting to note that exchange rates within SEPs are high
(almost 1:1): the return rate for two prisons in Lower Saxony were 98.9% for the
dispensing machine in the women’s prison in Vechta, and 98.3% in the men’s
prison in Lingen, Gross-Hesepe.... Therefore the risk of needle stick injuries by
syringes not properly disposed of is very low.234 [emphasis added]
The safety of these programs has been noted by officials from the Correctional Service of
Canada. In January-February 1999 a delegation from the CSC’s Study Group on Needle
Exchange Programs travelled to Switzerland to observe the syringe exchange initiatives in
three different prisons. Among the findings of the delegation’s report was a note on the safety of these programs.
Inmates involved in the needle exchange program are required
to keep their kit in a pre-determined location in their cells.
This assists the staff when they enter the cell to conduct cell
searches. Because syringes and needles are an approved program, there is no need for the offender to conceal them in their
cells. To date, no injury has been inflicted on staff by a needle.235

In no case have needles and
syringes been used as
weapons either against
personnel or other inmates.

Providing prisoners with access to the means necessary to protect them from contracting
HIV and HCV is in fact compatible with the interests of workplace safety and of the maintenance of safety and order in the institutions.
All the international evidence indicates that there are already
needles present within the prisons of many countries. Therefore, any
The safety of prison needle
suggestion that the implementation of prison needle exchange will
exchange
programs has been
introduce syringes into a “needle-free” environment is demonstranoted by officials from the
bly false. Therefore the question becomes: Which situation is
Correctional Service of
preferable? The status quo – where there are syringes in prisons, the
Canada.
number and location of which are unknown, but these syringes are
most likely contaminated with disease – or the situation in institutions with well-managed needle exchange programs, in which the
number of syringes in circulation is known, the prisoners who have them are known, and the
needles are sterile, or at least used by only one person whose identity is known? From a
workplace health and safety perspective, the second scenario is preferable to the first.
The Spanish Ministry of the Interior and the Ministry of Health and Consumer Affairs, in
their 2002 guidelines on the implementation of prison needle exchange programs, succinctly summarizes the safety benefits of needle exchange:
The start-up of a NEP should not increase the risk, but rather, as previously stated, result in greater safety. First of all, illicit syringes, which are usually hidden
and unprotected, are replaced by program syringes equipped with a rigid protective case. Secondly, in the event of an accident, it is less likely that the syringe
has been used because the inmate can and should exchange it for a new one at
the first opportunity after use. Thirdly, in the event that the syringe has been used,
it is less likely that it has been shared by various inmates, thus reducing the probability of it being infected and enabling the user to be identified with greater cer-

Analysis of the Evidence

45

tainty, which allows preventive actions to be taken if necessary. Finally, in the
long term, reduction of parenterally transmitted diseases will make prisons a
healthier and less risky environment.236

No increase in drug consumption or injecting
The belief that needle exchange programs promote injection drug use has historically been a
barrier to the implementation of this effective harm-reduction measure in both the community
and in prison. However, within prisons this argument is complicated by the fact that many prisoners are incarcerated as a result of drugs or of drug-related offences.
Consequently, providing bleach or sterile needles to prisoners is seen
Reduction of parenterally
to be condoning or promoting behaviour that the prison should be
transmitted diseases will
seeking to eradicate as part of the individual’s “rehabilitation.”
make prisons a healthier and Acknowledging the reality of drug use in prisons is also difficult for
less risky environment.
prison systems because it may be perceived as an admission of the
failure of such systems and their personnel to provide effective drug
programming and to maintain institutional control and security.
In the case of prison syringe exchange, scientific evaluations have consistently found that the
availability of sterile syringes does not result in an increased number of drug injectors, an
increase in overall drug use, or an increase in the amount of drugs in the institutions. In a recent
review of 11 evaluated prison needle exchange programs in Switzerland, Germany, and Spain,
Stöver and Nelles found the following:237

Prison Country
Am Hasenberg

Drug use in
the institution

IDU in the institution

No increase

No increase

No increase

No increase

No increase

No increase

Decrease

No increase

No increase

No increase

No increase

No increase

No increase

No increase

Decrease

No increase

No data

No data

No increase

No increase

No increase

No increase

Germany

Basauri
Basque Country

Hannöversand
Germany

Hindelbank
Switzerland

Lehrter Strasse
Germany

Lichtenberg
Germany

Lingen I
Germany

Realta
Switzerland

Saxerriet
Switzerland

Vechta
Germany

Vierlande
Germany

46

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

These findings demonstrate that the provision of sterile needles to
Scientific evaluations have
prisoners has not resulted in either increased drug consumption or
consistently
found that the
an increase in drug injection among prisoners.
There is evidence in a number of countries, including Canada, availability of sterile syringes
does not result in increased
that many prisoners inject drugs for the first time while in prison.
The argument that a needle exchange program would lead to prisdrug consumption or an
oners begin using injection drugs is therefore undermined by the
increase in drug injection
fact that this behaviour is already the norm in many countries withamong prisoners.
out prison needle exchange programs. In these jurisdictions individuals are forced to share or reuse needles, creating a high risk of HIV
and HCV transmission.
While making sterile needles available to incarcerated drug users has not led to an
increase in drug use, it has led to a decrease in the number of prisoners contracting HIV,
HCV, and other infections.

Part of a continuum of drug-related programming
The provision of sterile needles has not meant condoning the use of illegal drugs in prisons.
The provision of sterile needles in prisons in the six countries examined in this report has not
resulted in prison officials condoning or otherwise permitting the use, possession, or sale of
drugs. In all cases, drugs remain prohibited within institutions where needles exchange is in
place, and security staff is instructed to locate and confiscate all such contraband (including
needles that are not part of the exchange program). In this sense, the policy and practice is
no different than in jurisdictions that do not have needle exchange programs. However, while
possession of illicit drugs remains illegal, possession of needles that
are part of the official needle exchange programs is not.
Needle exchange programs
Needle exchange programs signify that elected and prison offiin prison facilitate referral of
cials take seriously their legal obligation to protect the health of
users to drug addiction
prisoners under their care and control. The recognition that drugs
treatment programs.
are part of the reality of prisons, despite the great expenditure of
resources to eliminate them, underpins this pragmatic response to
the problem of drug use and HIV and HCV infection. When drugs
find their way into the prison and are used by prisoners, the priority must be to protect prisoners’ health by preventing the transmission of HIV and HCV via unsafe injecting practices.
Ideally, needle exchange programs should be one component of a comprehensive drug
service within prisons that includes abstinence-based programs, drug treatment, drug-free
units, and harm-reduction measures. From this perspective, the availability of sterile needles
does not undermine or impede the provision of other programs, but rather offers drug users
more options for improving their health status, and a potentially greater interaction with the
range of health and drug treatment options offered in a particular institution. In the case of
the German pilot programs, the evaluator found that the needle exchange program actually
increased the number of people accessing drug treatment services, demonstrating that needle exchange programs can serve as valuable points of contact and referral for a difficult-toreach drug-using population. This was also the experience in Spain, where the Ministry of the
Interior and the Ministry of Health and Consumer Affairs concluded not only that “[i]t is feasible for a NEP and other drug addiction prevention or intervention programs to coexist,” but
also that “NEPs in prison facilitate referral of users to drug addiction treatment programs.”238
Nonetheless, prison officials and staff often struggle with philosophical and practical
issues related to drug use when implementing needle exchange programs. As was seen in

Analysis of the Evidence

47

Prison Colony 18 in Moldova, and in other jurisdictions, prison staff trained in an ethos of a
zero-tolerance approach to drugs and drug use and an abstinence-based approach to drug
treatment have had to come to terms with confiscating drugs but not injection equipment.
However, as the experience in Germany and Moldova demonstrates,
staff attitudes have changed as staff have learned first-hand about
Refusing to make sterile
the needle exchange programs and the harm-reduction ethos, and as
needles available in prison
they have participated in the implementation and review of needle
systems where injection drug exchange programs. This is the same process that has been observed
use and needle sharing take
in the community, where police attitudes have evolved to accommodate needle exchange programs. Police forces in countries with
place is to condone the
community needle exchange programs have integrated the broader
spread of HIV and HCV.
harm-reduction philosophy into their work without undermining
their mandate to protect and safeguard the populations they serve.
In fact, a harm-reduction approach is consistent with the ultimate aim of protecting and preserving life. As the head of the Merseyside Police Drug Squad has stated:
As police officers, part of our oath is to protect life. In the drugs field that policy must include saving life as well as enforcing the law. Clearly, we must reach
injectors and get them the help they require, but in the meantime we must try and
keep them healthy, for we are their police as well.... People can be cured of drug
addiction, but at the moment they cannot be cured of AIDS.239
This sentiment was echoed by Martin Lachat, the Interim Director of Hindelbank institution
in Switzerland in 1994:
The transmission of HIV or any other serious disease cannot be tolerated. Given
that all we can do is restrict, not suppress, the entry of drugs, we feel it is our
responsibility to at least provide sterile syringes to inmates. The ambiguity of our
mandate leads to a contradiction that we have to live with.240
In prisons in all six countries studied for this report, prison needle exchange programs are
part of larger harm-reduction initiatives. Other harm-reduction measures provided to prisoners include HIV/HCV education, substitution therapy for drug treatment, condom distribution, distribution of bleach or other disinfectants, antiseptic wipes, razors for shaving, and
anonymous HIV and HCV testing.
In reality, the refusal on the part of elected and prisons officials to make sterile needles
available in prison systems where injection drug use and needle sharing take place is to condone the spread of HIV and HCV in the prison population and in the community at large.
Moreover, the provision of sterile needles to prisoners is not incompatible with the goal of
reducing drug use in prisons.

Positive prisoner and public health outcomes
Prison needle exchange programs reduce risk
behaviour and prevent disease transmission
The most important lesson emerging from the international evidence on prison needle
exchange is that these programs are very effective in reducing needle sharing and therefore in
preventing the transmission of HIV and HCV. In a recent review of evaluated prison needle
exchange programs in Switzerland, Germany, and Spain, Stöver and Nelles found that the pro-

48

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

grams strongly reduced syringe sharing (seven of nine prisons) and strongly reduced (two of
five prisons) or resulted in no increase (three of five prisons) in the prevalence of HIV/HCV.241

Prison
Country

Syringe sharing

Prevalence
of HIV/HCV

Am Hasenberg

Strongly reduced

Not investigated

No data

Strongly reduced

Strongly reduced

Strongly reduced

Strongly reduced

No increase

Strongly reduced

Not investigated

Strongly reduced

Not investigated

Strongly reduced

No increase

Single cases

Not investigated

No data

Not investigated

Strongly reduced

No increase

No change

Not investigated

Germany

Basauri
Basque Country

Hannöversand
Germany

Hindelbank
Switzerland

Lehrter Strasse
Germany

Lichtenberg
Germany

Lingen I
Germany

Realta
Switzerland

Saxerriet
Switzerland

Vechta
Germany

Vierlande
Germany

Other positive outcomes on prison health
In addition to the reductions in HIV and HCV transmission detailed in the section above,
international evidence has shown that needle exchange programs result in other positive outcomes for the health of prisoners. Perhaps the most significant positive outcome is the dramatic decrease in fatal and non-fatal heroin overdoses among incarcerated people who inject drugs. For example, the Swiss prison of
Prison needle exchanges
Hindelbank averaged between one and three fatal heroin overdoses
therefore save lives, not only
annually during the years before the needle exchange program was
implemented. Since the program has been in place, Hindelbank has by preventing transmission of
HIV and HCV, but also by
experienced only one fatal heroin overdose in the past nine years.242
preventing overdose deaths.
This experience was also reported in the Swiss prison of
Oberschöngrün, which has a heroin maintenance program in addition to a syringe exchange. Prior to the implementation of needle
exchange, staff at the prison estimated there was approximately one non-fatal overdose a
week and approximately two fatal overdoses annually. Overdoses of any kind are now
extremely rare, and the prison has experienced only one overdose death since 1995.243 Prison
needle exchanges therefore save lives, not only by preventing transmission of HIV and HCV,
but also by preventing overdose deaths.
The prison staff interviewed as part of this report offered two reasons why the provision
Analysis of the Evidence

49

of needle exchange has resulted in such significant decreases in overdoses. The first is that
providing each injection drug user with his/her own personal needle enables the individual
to consume a smaller amount of drug with each injection. In the past, when a syringe was
shared among many prisoners, a person who injected drugs would only have limited access
to it and would be more likely to inject large doses on those rare
occasions when he/she was in possession of the syringe. The second
The other significant health
benefit experienced has been reason cited was that the implementation of needle exchange and
the adoption of a harm-reduction philosophy within the institution
a decrease in abscesses and
fundamentally changed the way that prison health and social work
other injection-related
staff were able to engage in counselling with prisoners. Because
infections.
injection drug use was recognized as a reality by all concerned,
counsellors and health workers and prisoners were able to be much
more open and frank in discussions about drug use and harm reduction. The need for prisoners to pretend to be “drug free” was therefore removed, and honest discussions about risk
behaviour and overdose were able to take place in an atmosphere where prisoners did not
fear sanctions for admitting their drug use.
The other significant health benefit experienced has been a decrease in abscesses and
other injection-related infections. Both Hindelbank and Oberschöngrün reported a near disappearance in abscesses, which had been a major problem before the needle exchange programs were implemented. Staff at Hindelbank noted that this has resulted in significant cost
savings to the prison, as treating abscesses had previously been a significant part of the work
of the prison medical staff.

Effective in a wide range of institutions
Prison officials have sometimes dismissed the evidence of the effectiveness of prison needle
exchange programs by characterizing these programs as “boutique” projects that are in place
only in unusual prison environments (ie, small institutions, women’s prisons, those with
docile prisoner populations, etc). Therefore, this argument goes, the success of these programs has no implication for life in “real” prisons.
While it is true that the initial Swiss pilot projects were conducted
in prisons that are small by most standards (Oberschöngrün has a
The Moldovan and Spanish
population of 75, while Hindelbank has a population of 110), subprisons where needle
sequent programs have been successfully implemented in a wide
exchange programs have
variety of settings in both civilian and military systems. In
proven effective have
Germany, for example, needle exchange programs have been introprisoner populations larger
duced in prisons as small as 50 people (the women’s prison in
Hannöversand) and as large as 500 (Am Hasenberge men’s prison
than any Canadian federal
in Hamburg). In Moldova, syringe exchange programs operate in
institution.
medium/maximum security men’s prisons with populations of 1000
or more. Soto de Real prison in Madrid, which was visited in the
preparation of this report, has a population of approximately 1600 prisoners. Thus, the
Moldovan and Spanish prisons where needle exchange programs have proven effective
have prisoner populations larger than any Canadian federal institution. Indeed, in Spain,
needle exchanges were in place in 30 prisons as of 2002 – prisons of varying sizes and all
security levels.
Needle exchanges have been established in prisons with radically different physical environments. In Western European prisons, programs have proven effective in prisons where
prisoners are housed in ranges of individual cells, each housing one or two prisoners. This is
similar to the Canadian situation. In contrast, in Moldova needle exchange programs have

50

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

proven effective in barracks-style facilities that have
70 or more prisoners living and sleeping in a single
room.
The cases examined also demonstrate that needle
exchange projects can be successfully implemented
in jurisdictions that are relatively well resourced and
financed (Switzerland, Germany, Spain), as well as
in countries in economic transition that operate with
significantly less funding and infrastructural supports (Moldova, Kyrgyzstan, Belarus). However, it
bears mentioning that some of the countries in transition studied for this report have been able to take
advantage of resources from international donors to
Needle exchange programs have proven effective
implement needle exchange programs.
in barracks-style facilities such as
Prison needle exchange programs have been sucPrison Colony 18, Branesti, Moldova.
cessfully implemented by taking into account not
(photo: Elena Vovc)
only institutional size, security level, or structure of
the particular prison in which a program was started, but also the needs of the prisoner population. In the six countries examined for this report,
needle exchange pilot projects have been initiated in response to high rates of HIV prevalence and/or high levels of injection drug use within prisons. Once this need has been recognized, in each jurisdiction examined, prisons have shown flexibility and creativity by
implementing a needle exchange program adapted to the needs of the particular population
and institutional set-up in an institution.

Different methods of needle distribution
have been effective
Among the prison needle exchange programs reviewed above, different countries (and different prisons within a given country) have adopted different methods to distribute (or
exchange) needles. There are important lessons to be learned from the experience of different countries employing different methods of needle distribution. These lessons are particularly important to jurisdictions and prisons planning the implementation of needle exchange
programs in prison. The different methods used by the countries studied for needle distribution were:
• distribution by prison nurses or physicians based in a medical unit or other areas(s) of
the prison
• distribution by prisoners trained as peer outreach workers
• distribution by external non-governmental organizations or
The number of kits
other health professionals who come into the prison for this
to be supplied depends
purpose
on the frequency of
• distribution by one-for-one automated needle-dispensing
exchange and the user’s
machines
consumption habits.
Each distribution method has its own unique opportunities and challenges. It is difficult to simply characterize these as “advantages” or
“disadvantages” of a particular distribution method, since that would require a subjective
assessment based on the philosophy, policies, or physical facility in a given prison system or
prison. An “advantage” from the perspective of one jurisdiction or prison may be a “disadAnalysis of the Evidence

51

vantage” from the perspective of another, depending upon the nature and ethos of the programs themselves.
The issue of requiring a one-for-one needle exchange illustrates this point. While some of
the jurisdictions examined for this report adhere to a strict one-for-one policy, others do not.
Hindelbank, for example, uses dispensing machines that operate on a one-for-one basis, but
also provides hand-to-hand up to five additional “points” or needle tips to program participants who have trouble finding veins to inject into. Spain has also shown flexibility in its
approach. While Spanish guidelines acknowledge that “the rule should be exchange, i.e., the
previous syringe must be returned before a new kit is handed out,” they direct that “a flexible attitude should be maintained towards [the one-for-one rule’s] application keeping in
mind that the primary objective of the program is to prevent shared use of syringes.”244 The
guidelines advise that “[t]he number of kits to be supplied depends on the frequency of
exchange and the user’s consumption habits: it should be sufficient to cover the inmate’s
needs so that he does not have to reuse the syringe before the next day of exchange.”245
While certain features may represent an advantage in one needle exchange program and
a disadvantage in another, the evidence from the six needle exchange programs studied clearly shows that there are distinct features and outcomes associated with each method of distribution. 246 Each method is reviewed in turn.

Hand-to-hand distribution by prison nurse and/or physician
•
•
•
•

Provides personal contact with prisoners and an opportunity for counselling
Can facilitate outreach to and contact with previously unknown drug users
Prison maintains high degree of control over access to syringes
One-for-one exchange or multiple syringe distribution possible (as necessary, and as
reflects individual prison policy)
• Lower degree of anonymity and confidentiality, which may reduce the participation
rate (although high acceptance by prisoners is possible if confidentiality is maintained)
• Access more limited, as syringes are available only during the established hours of the
health service (this is particularly true if the prison follows a strict one-for-one
exchange policy)
• Creates possibility of proxy exchanges by prisoners obtaining syringes on behalf of
those who do not want to participate in person due to lack of trust with staff

Hand-to-hand distribution by peer outreach workers
• High acceptance by prisoners
• High degree of anonymity and trust
• High degree of accessibility (peer outreach workers live in the prison units, and are
available at all hours)
• No direct staff control over distribution, which can lead to increased fears of workplace safety among staff
• One-for-one exchange more difficult to ensure

Hand-to-hand distribution by external non-governmental
organizations or health professionals
• Provides personal contact with prisoners and an opportunity for counselling
• Facilitates outreach to and contact with previously unknown drug users

52

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

• Prison has opportunity to maintain high degree of control over access to syringes
• One-for-one exchange or multiple syringe distribution possible (as necessary, and as
reflects individual prison policy)
• Provides a higher degree of anonymity and confidentiality, as there is no interaction
with prison staff
• Access limited. Syringes available during set hours or set times of the week (this is
particularly true if the program follows a strict one-for-one exchange policy)
• Anonymity and confidentiality may be compromised by policies that require the external agency to provide information on participation to the prison
• There can be mistrust by prison staff of the external services providing syringes
• External workers may experience more barriers in dealing with the prison bureaucracy
than internal prison health staff
• Turnover in staff of non-governmental organization may result in a lack of program
continuity and lack of a consistent “face” for the program for prisoners and prison staff

Automated dispensing machines
• High degree of accessibility (often multiple machines are in various places in the institution, which can be accessed outside the established hours of the medical service)
• High degree of anonymity, as there is no involvement with staff
• High acceptance by prisoners
• Strict one-for-one exchange
• Machines are vulnerable to vandalism and damage by prisoners and staff who are not
in favour of this program
• Technical problems with functioning of the dispensing machines can mean syringes
are unavailable for periods of time, which can decrease prisoner confidence in the program
• Some prisons are not architecturally suited for the use of dispensing machines (ie, lack
of discreet areas freely accessible to prisoners in which machines may be placed)
• Because the machines must be custom designed and individually constructed, the
expense of providing them in sufficient numbers in multiple
prisons can be prohibitive for some prison systems.
It is crucial to have
supportive leaders at the
Common factors in effective prison
highest level to successfully
needle exchange programs
create and implement prison
The evidence from the prison needle exchange programs studied for
needle exchange programs.
this report shows that the actual method of needle distribution is less
important than ensuring that the program responds to the needs of
the institution, the prisoner population, and the prison staff. As detailed above, prison needle
exchange programs have adopted various methods of syringe exchange/distribution. Each of
these methods has proved successful, and has been implemented without jeopardizing the
safety or security of the institution. Despite the differences in the various needle exchange
programs examined for this report, the combined evidence of the programs indicates a number of common factors characterizing effective prison needle exchange programs. These
common factors are reviewed in this section.

Analysis of the Evidence

53

Educational workshops and
consultations with prison
staff have been a key aspect
in the development of prison
needle exchange.

Leadership of prison administration
and support of prison staff

As with other controversial measures, or those measures that apparently run counter to accepted orthodoxy within a system, it is crucial to have supportive leaders at the highest level to successfully
create and implement prison needle exchange programs. Practically,
this may mean leadership by key senior officials responsible for
prison health-care services, or prisons generally, and support by the
head of the prison in which the needle exchange is being established. The support of prison
staff has also been shown to be an integral part of successful programs. In all jurisdictions
visited for this report, educational workshops and consultations with prison staff have been
a key aspect in the development of prison needle exchange.
This is not to say, however, that staff in these institutions have been universally supportive from the start. In several cases, as is evidenced in the evaluations, staff members were
reluctant at the start, yet grew to support the program over time as its benefits were experienced first-hand. The initial reluctance of staff makes the need for committed, informed,
inclusive leaders supporting the implementation of prison needle exchange programs all the
more important. While bottom-up processes that include the involvement and cooperation of
staff have been shown to be successful, there is mixed evidence on the success of top-down
approaches, where the implementation of prison needle exchanges is directed by government. Switzerland has experienced problems when a strictly top-down approach has been
followed. On the other had, the experience in Spain has shown that it is possible for government, including parliament, to take a leading role in setting the agenda for the implementation of needle exchange programs as long as practicality and flexibility at the prison level
are encouraged.

Need for confidentiality and trust
The issue of confidentiality has been a key factor in the creation of successful needle
exchange programs. From the perspective of many prisoners, confidentiality is the most
important factor in establishing trust in the needle exchange program. Inside any prison, absolute confidentiality of prisoners’ personal information may be impossible. However, in the context of
It is crucial to preserve the
prison needle exchange programs, it is crucial to preserve the conconfidentiality of prisoners
fidentiality of prisoners who use drugs and access sterile needles to
who use drugs and access
the greatest extent possible. The successful programs examined in
sterile needles to the
this report have all striven to identify needle distribution methods
greatest extent possible.
that would gain the trust of the prisoner population and thereby
maximize participation in the program.
In some prisons, syringe-dispensing machines located in areas
where prisoners are housed have proved the best mechanism for confidential needle distribution. In those institutions where a person-to-person method of exchange is in place, it has
been shown that identifying a discreet area of the prison in which to conduct the service is a
factor in its success. The importance of confidentiality was demonstrated quite vividly in the
Moldovan experience, where the needle exchange pilot in Prison Colony 18 saw a significant increase in uptake when the physician decided to use peer outreach workers rather than
the medical unit as a point of contact with prisoners who inject drugs. The experience in the
Spanish pilot program in Bilbao, where the evaluations found that prisoners preferred the
program to be administered by an external non-governmental organization rather than prison

54

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

staff, is also an indication of the importance of confidentiality to the program’s users.
Similarly, the evaluation of the two German pilots found that the program that used a handto-hand distribution method through health-care staff enjoyed less trust from prisoners than
did the one using anonymous dispensing machines.
That said, the Bilbao project also indicated that absolute anonymity is perhaps less important to the people who inject drugs than is trust in the person(s) or agency running the program and the quality of the service provided. The Bilbao evaluation found that the prisoners
valued the personal interaction with workers from an external non-governmental organization who conducted the exchanges, and in fact identified this as a preferable distribution
method than anonymous dispensing machines.

Adequate access to needles
In addition to maximizing confidentiality, providing adequate access to the needle exchange
program has also been a key factor in ensuring that programs meet prisoner needs. In some
cases, this has been accomplished by the placement of multiple dispensing machines within
a single institution, as was the case in the Hindelbank pilot. When person-to-person methods
of distribution have been chosen, such as in the Lingen 1 Dept Groß-Hesepe pilot in
Germany or the Bilbao pilot in the Basque region, staff sought to identify areas of the prison
that were both discreet and easily accessible to prisoners. In the Moldovan experience, the
decision to use a peer-based structure allowed for 24-hour access, since the peer outreach
workers lived in the prison units where they distributed needles.

Needle exchange as part of a harm-reduction program
It has also been shown that the goal of reducing HIV and HCV transmission is best accomplished when prison needle exchange is one component of a broader, comprehensive harmreduction strategy. In prisons in all six countries studied for this
report, prison needle exchange programs are part of larger harmThe goal of reducing HIV
reduction initiatives. Other harm-reduction measures provided to
and HCV transmission is
prisoners include HIV/HCV education, substitution therapy for
best accomplished when
drug treatment, condom distribution, distribution of bleach or other
prison needle exchange is
disinfectant, antiseptic wipes, razors for shaving, and anonymous
one component of a
HIV and HCV testing. Although the issue has not been scientifically evaluated, from the primary evidence and experience presented in
broader, comprehensive
this report it appears that prison needle exchange programs and
harm-reduction strategy.
other harm-reduction measures are mutually reinforcing, and that
the (prior) existence of other harm-reduction measures has contributed to the successful implementation of needle exchange programs.
In some prisons, this comprehensive harm-reduction approach includes not screening for
THC (the active ingredient in cannabis) as part of urinalysis drug-testing programs used in
the prison. A number of prisons visited as part of this report have made the decision not to
screen for THC, or not to penalize for the presence of THC, as they believe that doing so
would encourage many prisoners to abandon cannabis use in favour of injecting drugs to
avoid detection.

Importance of evidenced-based decision-making:
evaluating pilot projects
One final common aspect is the use of a well-evaluated pilot project as a first step to expansion. In some countries a single pilot has been used, while others such as Germany imple-

Analysis of the Evidence

55

mented two pilots running in parallel. The outcomes of the pilot program evaluations have
then been used to guide future planning. In some instances (Switzerland, Germany, Spain)
the prisons selected for the initial pilot programs were relatively small institutions and/or
open or half-open institutions with lower security levels. In these cases, programs were tested and evaluated in these prison environments before expanding the programs into larger,
closed prisons with higher security levels. However, in Moldova the pilot needle exchange
was done in a medium/maximum-security prison with a population of approximately 1000
prisoners.
The experience of the six countries studied for this report demonstrates that pilot projects
can be undertaken quickly and do not have to delay broader implementation of needle
exchange programs. For example, in Kyrgyzstan a pilot needle exchange was opened in
October 2002, in early 2003 approval was given to expand the program, as of September
2003 programs were operating in six of 11 prisons, and by April 2004 programs were operating in all 11 prisons. Nor do evaluations have to be fully completed before programs are
expanded to other prisons. For example, in Belarus a program was piloted in one prison
beginning in April 2003, scheduled to run until January of 2004. Although the term of the
pilot was extended to June of 2004, it was also extended to two other prisons, and the
Ministry of Internal Affairs signalled its willingness to expand needle exchange to prisons
throughout the country. It is important to note that in the prison systems presented in this
report, pilot projects have not been relied on as a tactic to delay the broader implementation
of needle exchange programs.
Not only are evaluations important in the expansion of needle exchange programs within
a jurisdiction, but they are also of great use to the broader international community. Rigorous
evaluations of pilot needle exchange programs (and expanded programs) contribute important information to the international literature regarding prison needle exchange programs.
The findings of evaluations provide the evidence for other jurisdictions. With such evidence,
more jurisdictions can demonstrate leadership and generate consensus surrounding the need
for, and implementation of, prison needle exchange programs.

56

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Needle Exchange Programs
Should Be Implemented in
Prisons in Canada
Needle exchange programs recommended since 1992
As presented in detail above, the rate of HIV infection in Canadian prisons is estimated to
be at least 10 times that of the general population, and the rate of HCV infection is approaching 30%. The results of numerous studies clearly indicate the need for programs that reduce
the risk of HIV and HCV transmission among injection-drug-using prisoners. Indeed, the
results of numerous studies indicate rates of HIV and HCV infection and injection drug use
equal to or higher than those in countries that have already implemented prison needle
exchange programs.
In Canada, since 1992 numerous reports have been produced by both governmental and
non-governmental bodies that have explicitly called for the provision of sterile needles to
prisoners in Canadian prisons (federal and provincial/territorial). These include:
• 1992 – HIV/AIDS in Prison Systems: A Comprehensive Strategy, Prisoners’ HIV/AIDS
Support Action Network247
• 1994 – HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS and
Prisons, Expert Committee on AIDS and Prisons, Correctional Service of Canada248
• 1996 – HIV/AIDS and Prisons: Final Report, Canadian HIV/AIDS Legal Network and
the Canadian AIDS Society249
• 1997 – HIV, AIDS, and Injection Drug Use: A National Action Plan, Task Force on
HIV/AIDS and Injection Drug Use250
• 1998 – HIV/AIDS in the Male-to-Female Transsexual/Transgendered Prison

Needle Exchange Programs Should Be Implemented in Prisons in Canada

57

•
•
•
•

Population: A Comprehensive Strategy, Prisoners’ HIV/AIDS Support Action
Network251
1999 – Final Report of the Study Group on Needle Exchange Programs, Study Group
on Needle Exchange Programs, Correctional Service of Canada252
2002 – Action on HIV/AIDS and Prisons: Too Little, Too Late – A Report Card,
Canadian HIV/AIDS Legal Network253
2003 – Unlocking Our Futures: A National Study on Women, Prisons, HIV, and
Hepatitis C, Prisoners’ HIV/AIDS Support Action Network254
2003 – Protecting Their Rights: A Systemic Review of Human Rights in Correctional
Services for Federally Sentenced Women, Canadian Human Rights Commission255

In addition, two reports from House of Commons committees have called for CSC to allow
incarcerated offenders access to harm-reducing interventions in order to reduce the incidence of bloodborne diseases in a manner consistent with the security requirements within
institutions:
• 2002 – Policy for the New Millennium: Working Together to Redefine Canada’s Drug
Strategy, Report of the Special Committee on Non-Medical Use of Drugs256
• 2003 – Strengthening the Canadian Strategy on HIV/AIDS, Report of the House of
Commons Standing Committee on Health257

Taken together, these 11 reports plus this report (Prison Needle Exchange: Lessons from A
Comprehensive Review of International Evidence and Experience) present evidence of the
effectiveness of needle exchange programs and provide ample evidence of the need for such programs in Canadian prisons. In light of
Governments and prison
this body of evidence and informed opinion supporting the introofficials in Canada must take
duction of needle exchange programs in Canadian prisons, it is not
decisive action to reduce the credible for elected and prison officials in Canada to claim that they
harms known to be
are unaware of the health risks associated with injection drug use in
associated with injection
Canadian prisons, or of the existence of a proven-effective means to
reduce those harms – namely, needle exchange programs. Despite
drug use, including HIV and
the support for needle exchange programs from groups and individHCV transmission.
uals who speak with credibility and authority on the issue, governments and prison officials in Canada have failed to take decisive
action to reduce the harms known to be associated with injection drug use, including HIV
and HCV transmission.
All of the above-noted reports are from credible sources and contain important evidence
to support prison needle exchange programs. However, three are exceptionally significant
because of the confluence of processes and people involved in the evidence gathering, production, and publication of each.

Expert Committee on AIDS and Prisons
The 1994 HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS and Prisons
by the Expert Committee on AIDS and Prisons (ECAP) was published by the Correctional
Service of Canada. In 1992 ECAP was established at the direction of the Solicitor General
of Canada to assist the federal government to promote the health of federal prisoners and to
protect CSC staff, and to prevent the transmission of HIV and other infections within federal correctional facilities. Committee members were a clinical immunologist, researcher, and
ethicist; a physician and member of CSC’s Health Care Advisory Committee; a social work

58

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

professor of Aboriginal ancestry; and a former commissioner of CSC. Committee observers
included CSC and Health Canada staff. ECAP reviewed laws and policies, visited correctional facilities, interviewed prisoners, prison staff, and interested and expert individuals and
bodies, and received submissions from 91 Canadian and international agencies and Canadian
governments and governmental agencies. ECAP presented its findings at meetings and conferences and distributed its draft report widely. It received feedback from 50 groups, individuals, and agencies.
ECAP reviewed and assessed the current situation and debate regarding prevention of the
harms associated with injection drug use in prisons. Regarding sterile injection equipment,
ECAP recommended:258
In order to prevent the transmission of infectious diseases, in particular HIV, due
to the sharing of unclean injection equipment, and because injection equipment
may not be effectively or consistently cleaned by bleach, ECAP has concluded
that access to sterile injection equipment by inmates must be addressed by CSC.
Therefore, ECAP recommends that research be undertaken that will identify
ways and develop measures, including access to sterile injection equipment, that
will further reduce the risk of HIV transmission and other harms from injection
drug use in federal correctional institutions. This research should be carried out
with the active involvement of Health Canada and by individuals independent of
but in collaboration with CSC. It should be preceded by consultation with
inmates, staff, community groups and independent experts. It should include one
or more scientifically valid pilot projects, and should be accompanied by planning, communication and education that will expedite making sterile injection
equipment available in the institutions.

Study Group on Needle Exchange Programs
The 1999 Final Report of the Study Group on Needle Exchange Programs was prepared by
the Study Group on Needle Exchange Programs, convened by CSC. The Study Group was
specifically convened to investigate the issue of introducing needle
exchanges into Canadian federal prisons. The Study Group includCSC’s own Study Group
ed Dr Peter Ford, an internal medicine specialist in infectious disrecognized
in 1999 that a
ease, physician contracted to CSC to provide care to HIV-positive
needle exchange project
prisoners in several institutions in Ontario, and co-author of four
would advance the
epidemiological studies on HIV and HCV prevalence in Canadian
prisons. Other members of the Study Group included CSC staff
government’s promise of
(security, health services, and women-offenders representatives),
building safer communities
health and community organizations, Health Canada, prisoners, and
and reinforce the Solicitor
the public. The project included a CSC task force of health service
General’s commitment to
and security representatives that visited three Swiss prisons to learn
more about harm-reduction strategies, and more specifically needle public safety and protection.
exchange programs.
In the Final Report of the Study Group on Needle Exchange
Programs, the Study Group recognized that a needle exchange project:259
• would advance the government’s promise of building safer communities and reinforce
the Solicitor General’s commitment to public safety and protection

Needle Exchange Programs Should Be Implemented in Prisons in Canada

59

• can reach offenders who are at relatively high risk for HIV and HCV infection and act
as a gateway that links them to other appropriate health-care services, drug treatment
programs, and counselling and social services, encouraging reintegration of offenders
back into the community
• is not and cannot be a stand-alone program, and must be offered as part of comprehensive prevention and treatment programs such as methadone maintenance, substance
abuse and addictions programs, and counselling

The Study Group issued a consensus recommendation that the CSC do the following: 260
To obtain ministerial approval in principle for a multi-site NEP [needle exchange
program] pilot program in men and women’s federal correctional institutions,
including the development and planning of the program model; and the implementation and evaluation of the pilot program.

Standing Committee on Health
In June 2003 the House of Commons Standing Committee on Health issued its report,
Strengthening the Canadian Strategy on HIV/AIDS. The Committee is made up of members
of Parliament from all political parties sitting in the House of Commons. It heard oral testimony and accepted written evidence from numerous groups, organizations, and individuals,
including Health Canada, Correctional Services Canada, the Canadian HIV/AIDS Legal
Network, and the Canadian Association for HIV Research. Despite the fact that the focus of
the Committee’s examination and resulting recommendations was on funding levels for the
Canadian Strategy on HIV/AIDS, the Committee recommended with respect to harm reduction in federal prisons that:261
Correctional Service Canada provide harm reduction strategies for prevention of
HIV/AIDS amongst intravenous drug users in correctional facilities based on eligibility criteria similar to those used in the outside community (as per the recommendation of the December 2002 report of the Special Committee on NonMedical Use of Drugs).
The Special Committee on Non-Medical Use of Drugs recommended that “Correctional
Service Canada allow incarcerated offenders access to harm-reducing interventions, in order
to reduce the incidence of blood-borne diseases, in a manner consistent with the security
requirements within institutions.”262
In her response to the Standing Committee’s report, the Minister of Health did not directly address this recommendation.263

Canadian prisons (both
federal and provincial/
territorial) have a legal
obligation to provide
prisoners with access to
sterile needles.

60

Legal obligation to respect, protect,
and fulfill prisoners’ right to health
As examined above (see the chapter on Human Rights and Legal
Standards Relevant to Injection Drug Use, HIV, and Hepatitis C in
Prisons) there are numerous international as well as Canadian
instruments that detail the legal and ethical responsibility of
Canadian governments to provide health care, including HIV and
HCV prevention measures, to prisoners. Based on the guarantees

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

contained and standards presented in these instruments, it can be argued that Canadian prisons (both federal and provincial/territorial) have a legal obligation to provide prisoners with
access to sterile needles. Further, it can be argued that prisoners who have suffered damage
or harm as a result of the failure on the part of prison authorities to provide access to sterile
needles might have a successful legal cause of action against such authorities. Such an action
could be based on the Charter and the common law (for exemple, an action in negligence).

Inadequacy of bleach
In Canada, bleach is available as a harm-reduction measure in many prisons.264 Bleach is an
important harm-reduction option for injection-drug-using prisoners who do not have access
to sterile needles. However, it is not a substitute for sterile needles among people who risk
HIV and HCV infection as a result of injection drug use.
The efficacy of using bleach to eliminate HIV in syringes has been well established,265 but
bleach is not fully effective in reducing HCV transmission.266 As well, previous studies indicate that many injection drug users have trouble remembering how to properly disinfect
syringes using bleach.267 In numerous studies, half or more of injection drug users do not
know or do not practise the proper method of using bleach for disinfecting needles.268
Therefore, bleach is not regarded as the gold standard for preventing the transmission of
infectious diseases among injection drug users. Further, and specific to harm-reduction measures in the prison environment, evidence from Australia indicates that a substantial proportion of prisoners do not avail themselves of bleach even when it is made available.269 The
probability of effective decontamination of needles using bleach is further decreased in
prison because cleaning is a time-consuming procedure and some prisoners may be reticent
to engage in any activity that increases the risk that prison staff will be alerted to their illicit
drug use.
While providing bleach to prisoners is a positive measure, problems with program uptake,
as well as the limited effectiveness of bleach in preventing HCV transmission, suggest that
this intervention alone is clearly an inadequate response to drug-related harm in prisons. It
has even been suggested that the reuse of an HIV-contaminated syringe cleaned with bleach
may actually increase the risk of HIV transmission.270 Many studies promoting the value of
bleach as a harm-reduction measure still conclude that access to sterile syringes is preferable
to disinfecting previously used needles.271
The experience of the needle exchange programs studied for this report indicates a number of other health benefits associated with needle exchange for prisoners, benefits that cannot be realized with bleach. These benefits include a significant reduction in abscesses and
other vein problems that result from reusing dull or damaged needles, and a significant
decrease in fatal and non-fatal overdoses in some institutions.
Needle exchange programs have also improved staff safety by reducing or eliminating the
risk to prison staff of accidental needle-stick injuries from concealed syringes during cell and
personal searches. The provision of bleach does not offer this benefit to prison staff, as needles are still considered contraband within the institutions and are therefore hidden rather
than stored safely in visible areas.
That bleach is a suboptimal public health measure is true not only in the Canadian context, but also in all prison systems throughout the world that provide bleach or other disinfectants, but not access to sterile needles. According to UNAIDS, the provision of fullstrength bleach to prisoners as a harm-reduction measure has been adopted in prisons in
Europe, Australia, Africa, and Central America.272 Elected and prison officials in jurisdictions
where prisoners have been provided with bleach in the absence of sterile needle distribution

Needle Exchange Programs Should Be Implemented in Prisons in Canada

61

could significantly improve the health and safety of prisoners, prison staff, and the community by instituting needle exchange programs.

Methadone maintenance therapy
a partial solution to the harms of IDU
Methadone is a crucial element of a comprehensive harm-reduction strategy, both in prisons
and in the community, as it provides an important option for injection-drug-using prisoners
who wish to stop injecting heroin. Taken orally, methadone is successful in blocking the
effects of opiate withdrawal symptoms.273 As a result, methadone
maintenance therapy (MMT) is effective in reducing major risks,
Methadone is a crucial
harms, and costs associated with untreated opiate addiction among
element of a comprehensive patients attracted into and successfully retained in MMT.274 MMT is
harm-reduction strategy,
associated with reduced HIV and viral hepatitis transmission
rates.275 Worldwide, an increasing number of correctional systems
both in prisons and
are offering MMT to prisoners.276 Evaluations of MMT programs in
in the community.
prisons have indicated positive results.277 For example, results from
a prison in New South Wales, Australia, indicated lower rates of
heroin use, injection drug use, and syringe sharing among those
enrolled in MMT compared with prisoners in a control group.278
In Canada, in May 2002 CSC expanded access to MMT.279 Under the new policy, prisoners on methadone maintenance at the time of incarceration may continue methadone, and
prisoners who meet the expanded access criteria may apply to initiate MMT while incarcerated. The expansion of access criteria for MMT was based in part on evaluations undertaken by CSC demonstrating that MMT has a positive impact on release outcome and on institutional behaviour.280 Access to MMT in provincial and territorial prisons varies widely.281
Despite its value, there are several reasons why providing methadone maintenance in the
absence of needle exchange is an insufficient response to the risk of HIV and HCV transmission in prisons via injection drug use. The primary reason is that MMT, as a form of drug
treatment for heroin dependence, does not benefit prisoners who do not access the treatment
program. There are at least four potential circumstances in which prisoners will not access,
or not have access to, MMT. First, prisoners who inject heroin may choose not to access
MMT. Second, despite an addiction to heroin, prisoners may not meet all of the criteria for
admission to the MMT program or may fail to meet ongoing eligibility criteria once on
MMT. Third, under current CSC policy, limits have been placed on the number of prisoners
enrolled in MMT at any one time, based on the capacity to administer the program within
each institution. The issue of lack of capacity and resources is not unique to CSC and is likely shared by a number of Canadian provincial/territorial systems. Fourth, it takes time to
process an application for MMT and to initiate MMT once a prisoner is accepted into the
program. Therefore, there will be numerous situations where prisoners with a heroin addition will continue to inject heroin and potentially engage in high-risk behaviours, despite the
existence of MMT programs within the prison.
Additionally, under accepted guidelines, MMT is only for drug users who are physically
dependent upon opiates according to standard criteria (usually those set out in the Diagnostic
and Statistical Manual of Mental Disorders, published by the American Psychiatric
Association). Therefore, MMT is not medically indicated for people who are occasional or
recreational users who inject opiates, who again will likely continue to inject and to share
syringes where needle exchange is not provided. Within prisons, barriers often exist to the
optimal provision of methadone. As a medical therapy, a methadone program requires the
involvement of a prison physician who is both trained in methadone provision and philo-

62

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

sophically supportive of the use of substitution treatment. In Canada and internationally, such
physicians may not be present in all prisons.
Similarly, prisoners may continue to inject illicit drugs, including drugs other than heroin, even during MMT treatment. This reality has been recognized by the Spanish government
and is cited as one of the reasons for allowing prisoners on methadone programs to also
access needle exchange.282 Ongoing injection of heroin might occur where prisoners do not
receive a methadone dose sufficient to address withdrawal symptoms, or where prisoners
inject narcotics to self-treat pain associated with chronic illness.
Finally, methadone is only a useful treatment for opiate dependency. It is not a harmreduction option for those who inject non-opiates such as cocaine. Therefore, MMT does not
address the unsafe injecting practices of these drug users.
To summarize, while MMT is an essential element of a harm-reduction strategy, alone or
even in combination with bleach distribution, it is not a sufficient response to the risk of disease transmission via injection drug use in prisons. Furthermore, for reasons similar to those
set out in the preceding section on the inadequacy of bleach, the implementation of needle
exchange programs in prisons has achieved other important benefits in the areas of prisoner
health and staff safety that cannot be replicated by MMT alone or in combination with bleach.

Opinions of prison staff
Part of the reluctance of Canadian federal and provincial/territorial governments to introduce
needle exchange programs is attributable to the real and expected objections of staff. In 1999
the Union of Solicitor General Employees, representing correctional officers, opposed needle exchange programs in federal institu- A recent review of studies of
tions.283 However, the evidence regarding the attitudes of individual
needle exchange programs in
prison staff with respect to needle exchange programs is inconcluSwitzerland, Germany, and
sive. For example, when researchers from the Expert Committee on
Spain
found that staff were
AIDS and Prisons surveyed CSC staff attitudes toward HIV pregenerally supportive of the
vention initiatives, 15% of correctional officers and 31% of healthcare staff were in favour of making syringe exchange programs
programs.
available to prisoners.284 The survey was conducted 10 years ago.
Since that time there has been new evidence of significant increases in HIV and HCV infection rates among prisoners, of the successful and safe implementation of prison needle exchange programs in other jurisdictions, of the implementation and
subsequent expansion of MMT in federal prisons, and of updated HIV/AIDS education programs. Attitudes and opinions can change. This change can result from knowledge and information gained through first-hand or through workplace education programs. Therefore, it is
reasonable to expect that the number of staff supporting the implementation of needle
exchange programs would be higher today.
Canadian elected and prison officials should be aware of the evidence of staff attitudes in
other jurisdictions. A recent review of studies of needle exchange programs in Switzerland,
Germany, and Spain found that staff were generally supportive of the programs, although
survey response rates varied.285 And as noted in this report, particularly in relation to the situation in Germany and Moldova, staff attitudes have changed as staff have learned first-hand
about the needle exchange programs and the harm-reduction ethos, and as they have participated in the implementation and review of needle exchange programs.
It is important to highlight that Canadian jurisdictions have safely and successfully introduced harm-reduction measures such as condoms and bleach in prisons in recent years
despite the initially controversial nature of such measures. The implementation of these programs has demonstrated that despite initial concerns in some quarters, harm-reduction meaNeedle Exchange Programs Should Be Implemented in Prisons in Canada

63

sures have not “sent the wrong message” or led to increased drug use and smuggling, violence against staff and between prisoners, and vandalism. This history, combined with the
lessons learned from needle exchange programs in other jurisdictions, should be remembered in response to staff concerns that the implementation of needle exchange programs in
prisons would lead to similar negative consequences.

Cost-effectiveness of prison needle exchange programs
There is no direct evidence of the cost-effectiveness of prison needle exchange programs.
There is evidence of the cost-effectiveness of community needle exchange programs. A recent
Australian report concluded that money invested in community needle exchange programs in
that country had resulted in a greater than fifteen-fold return in savings resulting from infections prevented over a 10-year period.286 A mathematical cost-effectiveness model using the
United States as an example determined that the economic benefits of needle exchange and
disposal programs are substantial.287 An analysis of needle exchange programs in New York
State demonstrated both cost-effectiveness and cost-saving from a societal perspective.288
Even in the absence of prison-specific economic analysis, there is a strong argument that
prison needle exchange programs are cost-effective on a societal level. Arguably, the results
of studies that have measured the cost-effectiveness of community-based needle exchange
programs are valid indicators of the potential cost savings attributable to prison-based programs. If for no other reason, because the majority of prisoners return to the community and
access health and social services there, most of the costs of HIV and HCV infection will
eventually fall to the community. Therefore, an examination of the cost-effectiveness of needle exchange programs should not be limited to the cost savings for the budgets of prison
system. This is especially the case in a country such as Canada, where both the federal government and provincial/territorial governments significantly fund the health care and prescription drugs in the community (and entirely fund these services in prisons). So any economic analysis must take into account the overall savings in government expenditures.
At a case-by-case level, the cost savings associated with preventing HIV and HCV transmission are substantial. With respect to HIV, a recent Canadian study showed that the mean
direct cost of providing medical care (including pharmaceutical, inpatient, outpatient, and
homecare costs) for one patient for one month in Alberta in 1997-1998 was $1036, adjusted
to 2001 dollars.289 Therefore, on an annual basis, every case of HIV prevented would result
in a savings of $12,432 measured in 2001 dollars. To put this amount in perspective, the cost
of one automated syringe-dispensing machine is approximately €_3000,290 the equivalent of
approximately $4700 Canadian. Even assuming that needle exchange programs prevent relatively few cases of HIV or HCV transmission among prisoners who inject drugs, needle
exchange programs would pay for themselves many times over. They would also likely
reduce the health-care resources currently dedicated to treating other health problems associated with injection drug use, such as injection-site and other infections.

Time for elected officials and
prison authorities in Canada to act
Canadian prisons should implement needle exchange programs without delay. Non-governmental and governmental organizations, study groups and committees have called on
Canadian prisons to do so since 1992. The experience and evidence from all six countries
where prison needle exchange programs exist demonstrate that such programs:
• do not endanger staff or prisoner safety, and in fact make prisons safer places to live
and work

64

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

•
•
•
•
•

do not increase drug consumption or injecting
reduce risk behaviour and disease (including HIV and HCV) transmission
have other positive outcomes for the health of prisoners
have been effective in a wide range of prisons in six countries
have successfully employed different methods of needle distribution to meet the needs
of staff and prisoners in a range of prisons

Not only are needle exchanges a proven effective public health measure for reducing the
harms associated with injection drug use, including HIV and HCV transmission; federal and
provincial/territorial governments in Canada have a legal obligation to respect, protect, and
fulfill prisoners’ right to health. This right is recognized in international law, and includes the right to preventive health-care measures.
Canadian prisons should
In the context of the HIV/AIDS epidemic, needle exchange proimplement needle exchange
grams have been proved an effective preventive health measure for
those at risk of HIV infection. Given the persistence of illicit drug
programs without delay.
use in prison, and the evidence of needle sharing among prisoners
who inject drugs, prison needle exchange programs are crucial to
the right to health for prisoners who inject drugs.
In addition, there are sound reasons to believe that prison needle exchange programs are
cost-effective and would even result in cost savings for Canadian governments.
Canadian governments should make important public health decisions based on the evidence and their legal obligations, not on public opinion or political expediency. Nor should
elected or prison officials make a decision about prison needle exchange programs by ignoring the evidence and their legal obligations, as has been the case for too long in Canada.
Leadership from elected officials and prison authorities is required. Leadership is also
required from individual prison staff, both correctional staff and health service staff, and
from outside physicians who work in prisons. Governments in Canada, and in particular
CSC, have been among the leaders in introducing harm-reduction measures in prisons.
Individual prison systems in Canada have already introduced condom and bleach distribution and MMT, and provide HIV education to prisoners and staff – although work needs to
be done to ensure that prisoners throughout Canada have reliable access to such measures.
Despite the debate and resistance that surrounded the introduction and implementation of
harm-reduction measures, they are now widely accepted as part of the prisons systems’
responsibility to prisoners and have not compromised institutional security and good order
in Canadian prisons. The existence of these measures and the experience of their implementation, along with international experience of and evidence from prison needle exchange programs, represent the building blocks for the introduction of needle exchanges in Canadian
prisons.

Recommendation
Both federal and provincial/territorial correctional services in Canada should immediately
take steps to implement multi-site pilot needle exchange programs.

Needle Exchange Programs Should Be Implemented in Prisons in Canada

65

Conclusion: A call for
leadership on prison needle
exchange programs
Although the number of countries that have implemented prison syringe exchange is relatively small, programs have been successfully implemented in a wide range of prison settings. Prison needle exchange programs can be found in countries of Western Europe,
Eastern Europe, and Central Asia. They are operating in well-funded prison systems and
severely underfunded prison systems. They are operating in civilian prison systems and military prison systems, and in institutions with drastically different physical arrangements for
the housing of prisoners. They are operating in men’s and women’s institutions, and in prisons of all security classifications and all sizes. They are operating as individual pilot projects,
and as integrated components of overall prison policy. They utilize various methods for distributing syringes.
While these prison syringe exchange programs have been implemented in diverse environments and under differing circumstances, the results of the programs have been remarkably consistent. Improved prisoner health and reduction of needle sharing have been
achieved. Fears of violence, increased drug consumption, and other negative consequences
have not materialized. Based on the evidence and experience presented in this report, it can
be concluded unequivocally that prison needle exchange programs effectively and successfully address the interrelated issue of injecting drug use, HIV, and HCV in prisons.
However, when it comes to the issue of needle exchange in prison, objective evidence has
often proved secondary to political and ideological considerations, and public apathy toward
issues faced by prisoners, prison staff, and prison systems. Many countries that exhibit significant rates of HIV, HCV, and injection drug use in prisons refuse to consider needle
exchange programs despite the evidence of their effectiveness and safety. This has even been

66

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

the case in countries, including Canada, that have acted to implement other harm-reduction
measures to address injection drug use, HIV, and HCV in prisons. Yet, as has been explored
in this report, a harm-reduction strategy that does not include sterile needle exchange is not
only a suboptimal public health measure; it is in contravention of international norms related to prison health, and fails to meet best practice.
Given the report’s goal, among the lessons learned from the research conducted for this
report, two stand out in encouraging prison systems with HIV and HCV epidemics driven
by injection drug use to implement needle exchange programs.
The first lesson is that prison needle exchange is a pragmatic and necessary health
response to the problems of HIV, HCV, and injection drug use that has been proven to be
effective and safe. Needle exchange has been available in some prisons for as long as 10
years, and it is an approach that has been rigorously evaluated everywhere it has been enacted. Prison systems and governments can no longer avoid their responsibilities to provide for
the health of prisoners by dismissing prison needle exchange programs as something new or
untested. They are neither.
The second lesson that emerges is that no matter how effective in practice, prison harmreduction initiatives remain controversial. Decisions about prison conditions, or the failure
to make decisions, are often unrelated to the evidence, to the detriment of the health of prisoners, prison staff, and the general public. For some people, prisons become a focal point for
expressions of political ideology, with little regard for the evidence about measures that in
fact promote the health and safety of prisoners, prison staff, and the general public. This was
demonstrated in the case of Germany, where long-term successful needle exchange programs were terminated by newly elected governments.
These two lessons point to the need for leadership from elected officials and prison
authorities on the issue of prison needle exchange programs. Leadership is also required
from individual prison staff (both correctional staff and health service staff) and from outside physicians who work in prisons. In the context of needle exchange programs in prisons,
leadership implies a number of attributes. First, leadership implies an understanding of the
legal obligations of prison systems to respect, protect, and fulfill prisoners’ right to health.
Second, leadership implies knowledge of the experience of and evidence from existing
prison needle exchange programs. This report is a comprehensive resource for such knowledge. Third, leadership implies a willingness and commitment to make prison needle
exchange programs responsive to the needs of prisoners and prison staff (both health care
and correctional). This means involving prisoners and prison staff in the design and implementation of programs.

Conclusion: A Call for Leadership

67

Notes
1

J Nelles,T Harding. Preventing HIV transmission in prison: a tale of medical disobedience and Swiss pragmatism. Lancet 1995; 346:
1507.

2 TM
3

Hammett. AIDS in Correctional Facilities: Issues and Options. 3rd ed. Washington, DC: US Department of Justice, 1988, at 26.

US National Commission on AIDS. Report: HIV Disease in Correctional Facilities. Washington, DC:The Commission, 1991, at 10.

4

Spanish Focal Point. National Report 2001 for the European Monitoring Centre for Drugs and Drug Addiction. Madrid: Government
Delegation for the National Plan on Drugs, October 2001, at 84, with reference.
5 T Harding, G Schaller. HIV/AIDS Policy for Prisons or for Prisoners? In: J Mann, D Tarantola,T Netter (eds). AIDS in the World.
Cambridge, MA: Harvard University Press, 1992, 761-769, at 762; with reference to T Harding. AIDS in prison. Lancet 1987; 2:12601263.
6

H Heilpern, S Egger. AIDS in Australian Prisons - Issues and Policy Options. Canberra: Department of Community Services and
Health, 1989 at 21.

7T

Harding, G Schaller. HIV/AIDS and Prisons: Updating and Policy Review. A survey covering 55 prison systems in 31 countries.
Geneva: WHO Global Programme on AIDS, 1992, at 20.

8

Heilpern & Egger, supra, note 6.

9 TM

Hammett, MP Harmon, W Rhodes.The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health 2002; 92: 1789-1794.

10 Bureau of Justice Statistics Bulletin. HIV in Prisons, 2001. Washington: US Department of Justice, Office of Justice Programs, January
2004 (NCJ 202293).
11

A Bobrik. Health and health-related factors at the penal system of Russia. January 2004 (unpublished).

12

Central and Eastern Europe Harm Reduction Network. Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and
Eastern Europe and the Former Soviet Union.Vilnius:The Network, July 2002, at 5.
13

International Harm Reduction Development. Drugs, AIDS, and Harm Reduction: How to Slow the HIV Epidemic in Eastern Europe and
the Former Soviet Union. New York: Open Society Institute, 2001, at 14 with reference.

14

M Schonteich. Latvia: exploring alternatives to pre-trial detention. Open Society Justice initiative, 2003. Available at
www.justiceinitiative.org/publications/justiceinitiatives/2003/schoenteich0603.

68

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

15

Central and Eastern Europe Harm Reduction Network, supra, note 12 at 5 with references.

16

Joint United Nations Programme on HIV/AIDS and World Health Organization (UNAIDS/WHO). AIDS Epidemic Update: December
2002. Geneva: UNAIDS/WHO, 2002, at 15.
17

Ibid at notes 8 to 15.

18 Seroprevalence data is from Correctional Service of Canada (CSC). HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS
and Prisons. Ottawa: CSC, 1994, at 15-19; CSC. HIV/AIDS in Prisons: Background Materials. Ottawa: CSC, 1994, at 47-79; Jürgens, infra,
note 47 at Appendix 2, with references; R Lines. Action on HIV/AIDS in Prisons: Too Little, Too Late – A Report Card. Montréal: Canadian
HIV/AIDS Legal Network, 2002, at 3-4.
19 Centre for Infectious Disease Prevention and Control, Health Canada, and Correctional Service of Canada. Infectious Disease
Prevention and Control in Canadian Federal Penitentiaries 2000-01. Ottawa: CSC, 2003, at 6.
20 HIV/AIDS and hepatitis C in prison: the facts. Montréal: Canadian HIV/AIDS Legal Network, 2004 (revised, updated version of info
sheet one in the series of info sheets on HIV/AIDS in prisons. More detailed information is available for 2001. See supra, note 19.
21

Supra, note 19.

22

C Hankins et al. HIV-1 infection in a medium security prison for women – Quebec. Canada Diseases Weekly Report 1989; 15(33):
168-170.

23 DA Rothon, RG Mathias, MT Schechter. Prevalence of HIV infection in provincial prisons in British Columbia. Canadian Medical
Association Journal 1994; 151(6): 781-787.
24 P Ford, C White, H Kaufmann et al. Voluntary anonymous linked study of the prevalence of HIV infection and hepatitis C among
inmates in a Canadian federal penitentiary for women. Canadian Medical Association Journal 1995; 153: 1605-1609.
25 PM Ford, M Pearson, P Sankar-Mistry,T Stevenson, D Bell, J Austin. HIV, hepatitis C and risk behaviour in a Canadian medium-security
federal penitentiary. QJM 2000; 93(2): 113-119.
26

M Pearson, PS Mistry, PM Ford. Voluntary screening for hepatitis C in a Canadian federal penitentiary for men. Canada Communicable
Disease Report 1995; 21: 134-136.

27 CA Hankins, S Gendron, MA Handley, C Richard, MT Tung, M O’Shaughnessy. HIV infection among women in prison: an assessment
of risk factors using a nonnominal methodology. American Journal of Public Health 1994; 84(10): 1637-1640.
28

S Landry et al. Étude de prévalence du VIH et du VHC chez les personnes incarcérées au Québec et pistes pour l’intervention.
Canadian Journal of Infectious Diseases 2004; 15(Suppl A): 50A (abstract 306).
29

Reuters Health, 18 February 2003. Available at www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=16138.

30

Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(2): 20.

31

A Raufu. Nigerian prison authorities free HIV positive inmates. AIDS Analysis Africa 2001; 12(1): 15.

32

UNAIDS/WHO, supra, note 16 at 23.

33

NM Osti et al. Human immunodeficiency virus seroprevalence among inmates of the penitentiary complex of the region of
Campinas, state of São Paulo, Brazil. Memórias do Instituto Oswaldo Cruz 1999; 94(4): 479-483. Also M Burattini et al. Correlation
between HIV and HCV in Brazilian prisoners: evidence for parenteral transmission inside prison. Revista de Saúde Pública 2000; 34(5):
431-436; L Strazza, RS Azevedo, HB Carvalho, E Massad.The vulnerability of Brazilian female prisoners to HIV infection. Brazilian Journal
of Medical and Biological Research 2004; 37(5): 771-776.
34

K Dolan et al. Prison-based syringe exchange programmes: a review of international research and development. Addiction 2003; 98:
153-158, with reference.
35

B Pal, A Acharya, K Satyanarayana. Seroprevalence of HIV infection among jail inmates in Orissa. Indian Journal of Medical Research
1999; 109: 199-201.
36

See generally, GE Macalino, JC Hou, MS Kumar, LE Taylor, IG Sumantera, JD Rich. Hepatitis C infection and incarcerated populations.
International Journal of Drug Policy 2004; 15: 103-114; K Dolan. The Epidemiology of Hepatitis C Infection in Prison Populations. University of
New South Wales: National Drug and Alcohol Research Centre, 1999, at 12, with many references.
37

Macalino et al, supra, note 36 at 111.

38

CSC, supra, note 19 at 14.

39

Ibid.

40

Ibid at 20.

41

S Black. Springhill Project Report. Ottawa: Correctional Service of Canada, 1999.

Notes

69

42

For example, see A Taylor et al. Outbreak of HIV Infection in a Scottish Prison. British Medical Journal 1995; 310: 289-292.

43

European Monitoring Centre for Drugs and Drug Addiction. Annual report on the state of the drugs problem in the European Union
and Norway. Luxembourg: Office for Official Publications of the European Communities, 2002, at 46.

44

Ibid.

45

Ibid at 47.

46

Correctional Service of Canada. 1995 National Inmate Survey: Final Report. Ottawa:The Service (Correctional Research and
Development), 1996, No SR-02.

47 R Jürgens. HIV/AIDS in Prisons: Final Report. Montréal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society, 1996, at 23, with
notes.
48 With

respect to the public health impacts of urinalysis testing for illicit drugs in prison, see generally: SM Gore, AG Bird, AJ Ross.
Prison rights: mandatory drugs tests and performance indicators for prisons. British Medical Journal 1996; 312(7043): 1411-1413.

49 See, for example, SM Shah, P Shapshak, JE Rivers, RV Stewart, NL Weatherby, KQ Xin, JB Page, DD Chitwood, DC Mash, D Vlahov, CB
McCoy. Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a preliminary laboratory report. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1996; 11(3): 301-306; P Shapshak, RK Fujimura, JB
Page, D Segal, JE Rivers, J Yang, SM Shah, G Graham, L Metsch, N Weatherby, DD Chitwood, CB McCoy. HIV-1 RNA load in
needles/syringes from shooting galleries in Miami: a preliminary laboratory report. Journal of Drug and Alcohol Dependency 2000; 58(1-2):
153-157; RH Needle, S Coyle, H Cesari, R Trotter, M Clatts, S Koester, L Price, E McLellan, A Finlinson, RN Bluthenthal,T Pierce, J
Johnson,TS Jones, M Williams. HIV risk behaviors associated with the injection process: multiperson use of drug injection equipment and
paraphernalia in injection drug user networks. Substance Use & Misuse 1998; 33(12): 2403-2423; B Jose, SR Friedman, A Neaigus, R
Curtis, JP Grund, MF Goldstein,TP Ward, DC Des Jarlais. Syringe-mediated drug-sharing (backloading): a new risk factor for HIV among
injecting drug users. AIDS 1993; 7(12): 1653-1660, erratum in AIDS 1994; 8(1): following 4.
50

R Lines. Pros & Cons: A Guide to Creating Successful Community-Based HIV/AIDS Programs for Prisoners.Toronto: Prisoners’ HIV/AIDS
Support Action Network, 2002, at 67.

51

Supra, note 36.

52

A Ball et al. Multi-centre Study on Drug Injecting and Risk of HIV Infection: a report prepared on behalf of the international collaborative group for the World Health Organization Programme on Substance Abuse. Geneva: World Health Organization, 1995.

53

Joint United Nations Programme on HIV/AIDS (UNAIDS). Prisons and AIDS: UNAIDS Point of View. Geneva: UNAIDS Information
Centre, April 1997, at 6.

54

Supra, note 43 at 46-47.

55

Dolan, supra, note 36 at 6.

56

Ibid, with reference.

57

Jürgens, supra, note 47, with reference.

58

A Buavirat et al. Risk of prevalent HIV infection associated with incarceration among injecting drug users in Bangkok,Thailand: casecontrol study. British Medical Journal 2003; 326(7384): 308.

59 Medecins Sans Frontières. Health Promotion Program in the Russian Prison System: Prisoner Survey 2000. Cited in: International
Harm Reduction Development, supra, note 13. See also R Jürgens, MB Bijl. Risk behaviours in penal institutions. In P Bollini (ed). HIV in
Prison. A Manual for the Newly Independent States. MSF, WHO, and Prison Reform International, 2002.
60

Ibid.

61

C Magis-Rodriguez et al. Injecting drug use and HIV/AIDS in two jails of the North border of Mexico. Abstract for the XIII
International AIDS Conference, 2000.
62

Dolan, supra, note 34 at 153, with references.

63

Jürgens, supra, note 47 at 40, with references.

64

K Dolan, W Hall, A Wodak, M Gaughwin. Evidence of HIV transmission in an Australian prison. Medical Journal of Australia 1994;
160(11): 734; K Dolan et al. A network of HIV infections among Australian inmates. XI International Conference on AIDS,Vancouver, 711 July 1996, Abstract We.D.3655.

65 R Jürgens. HIV/AIDS in prisons: recent developments. Canadian HIV/AIDS Policy & Law Review 2002; 7(2/3): 13-20, at 19, with reference to L Dapkus. Prison’s rate of HIV frightens a nation. Associated Press 29 September 2002.

70

66

Dolan, supra, note 36.

67

R Keppler, F Nolte, H Stöver.Transmission of infectious diseases in prisons – results of a study for women in Vechta, Lower Saxony,

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

Germany. Sucht 1996; 42: 98-107 at 104.
68 LM Calzavara, AN Burchell, J Schlossberg,T Myers, M Escobar, E Wallace, C Major, C Strike, M Millson. Prior opiate injection and incarceration history predict injection drug use among inmates. Addiction 2003; 98(9): 1257-1265.
69

A DiCenso et al. Unlocking Our Futures: A National Study on Women, Prisons, HIV, and Hepatitis C.Toronto: Prisoners’ HIV/AIDS Support
Action Network, 2003.
70

PM Ford et al. HIV and hep C seroprevalence and associated risk behaviours in a Canadian prison. Canadian HIV/AIDS Policy & Law
Newsletter 1999; 4(2/3): 52-54.

71 T

Nichol. Bleach Pilot Project. Second unpublished account of the introduction of bleach at Matsqui Institution, dated 28 March 1996.
Cited in Jürgens, supra, note 47.

72

1995 National Inmate Survey, supra, note 46.

73

C Hankins et al. Prior risk factors for HIV infection and current risk behaviours among incarcerated men and women in mediumsecurity correctional institutions – Montreal. Canadian Journal of Infectious Diseases 1995; 6(Suppl B): 31B. Cited in Jürgens, supra, note
47.
74 A Dufour et al. HIV prevalence among inmates of a provincial prison in Quebec City. Canadian Journal of Infectious Diseases 1995;
6(Suppl B): 31B. Cited in Jürgens, supra, note 47.
75 E Single. Harm reduction as the basis for hepatitis C policy and programming. Presentation at First Canadian Conference on Hepatitis
C, Montréal, Canada, 4 May 2001.
76

Lines, supra, note 18.

77

Joint United Nations Programme on HIV/AIDS (UNAIDS). Prisons and AIDS: UNAIDS Technical Update. Geneva: UNAIDS, April 1997,
at 3. Available online via www.unaids.org.

78 Vienna

Declaration and Programme of Action, adopted 25 June 1993. World Conference on Human Rights. UN GA Doc
A/CONF/137/23.

79 International Covenant on Civil and Political Rights. UN GA res 2200A (XXI), 21 UN GAOR Supp (No 16) at 52, UN Doc A/6316
(1966), 999 UNTS 171, entered into force 23 March 1976.
80 International Covenant on Economic, Social and Cultural Rights. UN GA res 2200A (XXI), 21 UN GAOR Supp (No 16) at 49, UN
Doc A/6316 (1966), 993 UNTS 3, entered into force 3 January 1976.
81

African Charter on Human and Peoples’ Rights. OAU Doc CAB/LEG/67/3 rev 5, 21 ILM 58 (1982), adopted 27 June 1981, entered
into force 21 October 1986.

82

American Convention on Human Rights. OAS Treaty Series No 36, 1144 UNTS 123, entered into force 18 July 1978.

83

Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights. OAS Treaty
Series No 69 (1988), signed 17 November 1988.

84 [European] Convention for the Protection of Human Rights and Fundamental Freedoms. ETS 5, 213 UNTS 222, entered into force 3
September 1953, as amended by Protocols Nos 3, 5, and 8, which entered into force on 21 September 1970, 20 December 1971, and
1 January 1990 respectively.
85

European Social Charter. ETS 35, 529 UNTS 89, entered into force 26 February 1965.

86

Universal Declaration of Human Rights. UN GA res 217A (III), UN Doc A/810 at 71 (1948).

87

According to the principle of customary international law, the standards and norms contained in declarations are acknowledged
among the community of nations as establishing binding law.The question of what is included in customary international law is a question of fact and usage. Customary international law is law that becomes binding on states out of custom when enough states have
begun to behave as though something is law, and does not require the laws to be written.

88 See generally Jürgens, supra, note 47 at 85-86. Specifically, Principle 5 of the UN Basic Principles for the Treatment of Prisoners states
that “Except for those limitations that are demonstrably necessitated by the fact of incarceration, all prisoners shall retain the human
rights and fundamental freedoms set out in the Universal Declaration of Human Rights, and … the International Covenant on Economic,
Social and Cultural Rights, and the International Covenant on Civil and Political Rights … as well as such other rights as are set out in other
United Nations covenants.” Adopted by General Assembly Resolution 45/111, annex, 45 UN GAOR Supp (No 49A) at 200, UN Doc
A/45/49 (1990).
89

S Shaw. Prisoners’ Rights. In: P Seighart (ed). Human Rights in the United Kingdom. London: Pinter Publishers, 1988, at 42.

90

Basic Principles, supra, note 88.

91

Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment. UN GA res 43/173, annex, 43
UN GAOR Supp (No 49) at 298, UN Doc A/43/49 (1988).

Notes

71

92 Standard Minimum Rules for the Treatment of Prisoners. Adopted 30 August 1955 by the First United Nations Congress on the
Prevention of Crime and the Treatment of Offenders. UN Doc A/CONF/611, annex I, ESC res 663C, 24 UN ESCOR Supp (No 1) at
11, UN Doc E/3048 (1957), amended ESC res 2076, 62 UN ESCOR Supp (No 1) at 35, UN Doc E/5988 (1977).
93 Recommendation No R (98)7 of the Committee of Ministers to Member States Concerning the Ethical and Organisational Aspects
of Health Care in Prison. Adopted by the Committee of Ministers on 8 April 1998 at the 627th Meeting of the Ministers’ Deputies
[hereinafter Council of Europe Recommendation No R 98(7)].
94 WHO

Guidelines on HIV Infection and AIDS in Prisons. Geneva: WHO, 1993 [hereinafter WHO Guidelines].

95

Declaration of Commitment – United Nations General Assembly Special Session on HIV/AIDS. UN GA Res/S-26/2, 27 June 2001
[hereinafter UNGASS Declaration].
96

International Guidelines on HIV/AIDS and Human Rights. UNCHR res 1997/33, UN Doc E/CN.4/1997/150 (1997).

97 WHO

Guidelines, supra, note 94 at Art 4.

98

UNGASS Declaration, supra, note 95 at Art 58.

99

Ibid at Arts 62, 64.

100

See, for example, Universal Declaration of Human Rights, supra, note 86 at Art 25; International Covenant on Social, Economic and
Cultural Rights, supra, note 80 at Art 12; European Social Charter, supra, note 85 at Art 11; African Charter on Human and Peoples’
Rights, supra, note 81 at Art 16.
101

Constitution of the World Health Organization. In: Basic Documents, 39th ed. Geneva: WHO, 1992. See generally:V Leary.The right to
health in international human rights law. Health and Human Rights 1994; 1(1): 24-56.

102

Basic Principles, supra, note 88.

103

Charter of Fundamental Rights of the European Union, Art 35.

104

Council of Europe Recommendation No R 98(7), supra, note 93.

105 WHO

Guidelines, supra, note 94 at guidelines 1, 2, 4.

106 H Stöver. Drugs and HIV/AIDS Services in European Prisons. Oldenburg, Germany: Carl von Ossietzky Universität Oldenburg, 2002, at
127-128.
107 WHO

Guidelines, supra, note 94 at 4.

108

Ibid.

109

Ibid at 6.

110

Joint United Nations Programme on HIV/AIDS (UNAIDS). Statement on HIV/AIDS in Prisons to the United Nations Commission
on Human Rights at its Fifty-second session, April 1996.
111

International Guidelines on HIV/AIDS and Human Rights, supra, note 96 at paras 2, 15(d).

112 International Council of Prison Medical Services. Oath of Athens for Prison Health Professionals. Adopted 10 September 1979,
Athens.
113

See Jürgens, supra, note 47 at 81-88.

114

Ibid.

115

R Elliott. Prisoners’ Constitutional Right to Sterile Needles and Bleach. Appendix 2 in Jürgens, supra, note 47.

116

Corrections and Conditional Release Act, SC 1992, c 20 [hereinafter CCRA]; SOR/92-620.

117

CCRA, s 86(2).

118

I Malkin.The Role of the Law of Negligence in Preventing Prisoners’ Exposure to HIV While in Custody. Appendix 1 in Jürgens,
supra, note 47.
119

SF Hurley, DJ Jolley, JM Kaldor. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet 1997;
349(9068): 1797-1800.

120 DR Holtgrave, SD Pinkerton,TS Jones, P Lurie, D Vlahov. Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology
1998; 18(Suppl 1): S133-138.
121

Australian National Council on Drugs, Australian National Council of AIDS and Hepatitis Related Diseases. National Council backs
investment on needle programs. Media release dated 22 October 2002, Australian National Council on Drugs.

72

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

122 Joint United Nations Programme on HIV/AIDS and World Health Organization (UNAIDS/WHO). Switzerland: Epidemiological Fact
Sheets on HIV/AIDS and Sexually Transmitted Infections – 2002 Update. Geneva: UNAIDS/WHO Working Group on Global
HIV/AIDS, 2002.
123

Swiss Federal Office of Public Health. Swiss Drugs Policy. Berne:The Office, September 2000, at 8-11.

124

C Berger, A Uchtenhagen. Prevention of Infectious Diseases and Health Promotion in Penal Institutions: Summary of a final report
for the Swiss Federal Office of Public Health. Zurich:The Office, April 2001, at 1.
125

J Nelles, A Fuhrer, HP Hirsbrunner,TW Harding. Provision of syringes: the cutting edge of harm reduction in prison? British Medical
Journal 1998; 317; 270-273.

126 J Nelles, A Fuhrer, I Vincenz. Prevention of drug use and infectious diseases in the Realta Cantonal Men’s Prison: Summary of the
evaluation. Berne: University Psychiatric Services, 1999.
127

J Nelles.The contradictory position of HIV prevention in prison: Swiss experiences. International Journal of Drug Policy 1997; 1: 2-4.

128

Swiss Federal Office of Public Health. Swiss Drugs Policy: Harm Reduction Fact Sheet. Berne:The Office, September 2000.

129

Described in Nelles & Harding, supra, note 1.

130

J Nelles, A Dobler-Mikola, B Kaufmann. Provision of syringes and prescription of heroin in prison:The Swiss experience in the prisons
of Hindelbank and Oberschöngrün. In: J Nelles, A Fuhrer (eds). Harm Reduction in Prison. Berne: Peter Lang, 1997, at 239–262. Cited in
Dolan et al, supra, note 34.
131 Personal communication with P Fäh, Warden of Oberschöngrün, on 1 March 1996. Cited in R Jürgens. Needle exchange in prisons:
an overview. Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(4): 1, 40-42.
132 Description of the Hindelbank program is amalgamated from two sources. R Jürgens. HIV prevention taken seriously: provision of
syringes in a Swiss prison. Canadian HIV/AIDS Policy & Law Newsletter 1994; 1(1): 1-3; Nelles et al, supra, note 125.
133

Stöver, supra, note 106 at 135-136.

134

Information on the Hindelbank evaluation is taken from Nelles et al, supra, note 125; Dolan et al, supra, note 34.

135

D DeSantis, Hindelbank Institution, 2 June 2003. Interview with Rick Lines.

136

J Nelles, A Fuhrer, HP Hirsbrunner,TW Harding. How does syringe distribution in prison affect consumption of illegal drugs by prisoners? Drug and Alcohol Review 1999;18: 133-138.
137

Nelles et al, supra, note 126.

138

Nelles et al, supra, note 130.

139

Joint United Nations Programme on HIV/AIDS and World Health Organization (UNAIDS/WHO). Germany: Epidemiological Fact
Sheets on HIV/AIDS and Sexually Transmitted Infections – 2002 Update. Geneva: UNAIDS/WHO Working Group on Global
HIV/AIDS, 2002.
140 U Marcus. HIV/AIDS und Drogenkonsum in Deutschland – Epidemiologische Entwicklungen und Erklärungen. In: J Klee; H Stöver
(eds). AIDS und Drogen – Ein Beratungsführer. 3rd edition, 2003 (in press).
141

R Simon, E Hoch, R Hüllinghorst, G Nöcker, M David-Spickermann. Report on the Drug Situation in Germany 2001. German Reference
Centre for the European Monitoring Centre for Drugs and Drug Addiction, 2001, at 145, with reference.

142 R Muller, K Stark, I Guggenmoos-Holzmann, D Wirth, U Bienzle. Imprisonment: a risk factor for HIV infection counteracting education and prevention programmes for intravenous drug users. AIDS 1995; 9(2): 183-190.
143

A Thiel. Hepatitis C in prison – the underestimated problem. Conference presentation at 7th International Conference on Hepatitis
C, Edinburgh, June 12-13, 2003.

144

Simon et al, supra, note 141.

145

European Monitoring Centre on Drugs and Drug Addiction, supra, note 43 at 50. See also Keppler et al, supra, note 67.

146

Other drugs used in substitution therapy include levomethadone, buprenorphine, dihydrocodeine, and codeine. Personal correspondence with Heino Stöver.
147

Personal correspondence with Heino Stöver, dated 8 September 2004.

148

All information on the German prison needle exchange projects is taken from Stöver, supra, note 106 at 128-131, unless otherwise
noted.

149

Information on the evaluation is summarized from H Stöver. Evaluation of needle exhange pilot projects show positive results.
Canadian HIV/AIDS Policy & Law Newsletter 2000; 5(2/3): 60-64.

Notes

73

150 H Stöver, J Nelles.Ten years of experience with needle and syringe exchange programmes in European prisons. International Journal
of Drug Policy 2003; 14(5/6) (in press).
151 J Sanz Sanz, P Hernando Briongos, JA López Blanco. Syringes Exchange Programs in Spanish Prisons. Presentation at the conference
of the European Network of Drug Services in Prison, Rome, 22-24 May 2003; and J Sanz Sanz. Subdirección General de Sanidad
Penitenciaria, Dirección General de Instituciones Penitenciarias, Ministerio Del Interior. Private correspondence dated 20 April 2004.
152 Joint United Nations Programme on HIV/AIDS and World Health Organization (UNAIDS/WHO). Spain: Epidemiological Fact
Sheets on HIV/AIDS and Sexually Transmitted Infections – 2002 Update. Geneva: UNAIDS/WHO Working Group on Global
HIV/AIDS, 2002 at 2.
153

Spanish Focal Point, supra, note 4 at 75.

154

Ibid at 25.

155

Delegación del Gobierno para el Plan Nacional sobre Drogas, Ministerio Del Interior. Plan Nacional Sobre Drogas: Memoria 2000.
Madrid: Ministerio Del Interior, 2001, at 54.
156

Ministerio Del Interior/Ministerio De Sanidad y Consumo. Needle Exchange in Prison: Framework Program. Madrid: Ministerio Del
Interior/Ministerio De Sanidad y Consumo, October 2002, at 4.

157

Ibid.

158

Sanz Sanz et al, supra, note 151.

159

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 53.

160

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 4.

161

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 55.

162

Spanish Focal Point, supra, note 4 at 75.

163

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 4.

164

Sanz Sanz et al, supra, note 151.

165

Drogas, supra, note 155 at 53.

166

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 4.

167

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 53.

168

Sanz Sanz et al, supra, note 151.

169

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 55.

170

Ibid at 58.Translated from original Spanish.

171

Spanish Focal Point, supra, note 4 at 75-76.

172

AL Sánchez Iglesias. Instruction 101/2002 on Criteria of Action in Connection with the Implementation in a Number of Prisons of
the Needle Exchange Program (NEP) for Injecting Drug Users (IDUs). Madrid: Directorate General for Prisons, 23 August 2002, at 7.
Reprinted in Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156.

173

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 58.

174

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 6.

175

Ibid.

176

Information on the pilot project is from C Menoyo, D Zulaica, F Parras. 2000. Needle exchange programs in prisons in Spain.
Canadian HIV/AIDS Policy & Law Review 2000; 5(4): 20-21, unless otherwise noted.
177

Dolan et al, supra, note 34 at 157.

178

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 6.

179

Grupo De Trabajo Sobre Programas De Intercambio De Jeringuillas En Prisones (April 2000). Elementos Clave para la Implantación
de Programas de Intercambio de Jeringuillas en Prisión. Secretaría del Plan Nacional Sobre el SIDA/Dirección General de Instituciones
Penitenciarias, at 2.Translated from the original Spanish.

74

180

Delegación del Gobierno para el Plan Nacional sobre Drogas, supra, note 155 at 58.

181

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 5.

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

182

Ibid at 6.

183

Ibid at 6-7.

184

Sanz Sanz et al, supra, note 151.

185

J Sanz Sanz, P Hernando Briongos, JA López Blanco. Syringe-exchange programmes in Spanish prisons. In Connections: The Newsletter
of the European Network Drug Services in Prison & Central and Eastern European Network of Drug Services in Prison 2003; 13: 9-12.

186

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 11.

187

Ibid at 16-17.

188

Ibid at 11.

189

Ibid at 14.

190

Recomendaciones sobre los Programas de Intercombio de Jeringuillas (PIJ). Obtained from the Prisión Soto de Real, Madrid. Copy on

file.
191

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 10.

192

Ibid.

193

Ibid at 12.

194

Information on the Bilbao evaluation is summarized from Menoyo et al, supra, note 176.

195

Spanish Focal Point, supra, note 4 at 60.

196

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 5.

197

Sanz Sanz et al, supra, note 185. Officials from the Spanish prison service and the National Plan on Drugs interviewed for the
preparation of this report also confirmed that there have been no instances of program syringes being misused or used as weapons.
198

Sanz Sanz, supra, note 151.

199 Joint United Nations Programme on HIV/AIDS and World Health Organization (UNAIDS/WHO). Republic of Moldova:
Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections – 2002 Update at 2, 6.
200

Figure provided by Health Reform in Prisons, November 2002.

201 There
202

are 20 prisons in Moldova incarcerating approximately 10,500 people.

Figures provided by Health Reform in Prisons, November 2002.

203 The

numbers in this column represent known HIV/AIDS cases identified at any point during the calendar year.The number of
HIV/AIDS cases during the year was not necessarily constant, given the turnover in the prison population, and accounting for deaths.

204 For more information about the Open Society Institute and its International Harm Reduction Development Program, see
www.soros.org/initiatives/ihrd.
205

Figures provided by Health Reform in Prisons, November 2002.

206 Much of the information on the two Moldovan projects comes from conference presentations by Dr Larisa Pintelli and Dr Nicolae
Bodrug of Health Reform in Prisons. International Harm Reduction Development Prison Grantees Conference, Chisinau, Moldova, May
2002.
207

N Bodrug. A pilot project breaks down resistance. In Harm Reduction News: Newsletter of the International Harm Reduction
Development Program of the Open Society Institute 2002; 3(2).

208

Dr Larisa Pintelli of Health Reform in Prisons, Moldova. Private correspondence dated 13 May 2003.

209 Dr Larisa Pintelli of Health Reform in Prisons, Moldova. Conference presentation, November 2002, and private correspondence
dated 13 May 2003.
210

Pintelli, private correspondence dated 19 May 2002.

211

Pintelli, private correspondence, supra, note 208.

212

Pintelli, private correspondence, supra, note 210.

213

Bodrug, supra, note 207 at 11.

214

Ibid at 11.

Notes

75

215

Ibid.

216

Ibid.

217

Pintelli, private correspondence, supra, note 208.

218

All information on HIV/AIDS, injection drug use, and harm reduction in Kyrgyz prisons – and the needle exchange pilot – was provided by Dr Raushan Abdyldaeyva, and by Elvira Muratalieva of the Open Society Institute, unless otherwise noted.

219

E Subata. Accepting maintenance treatment. Harm Reduction News: Newsletter of the International Harm Reduction Development
Programme of the Open Society Institute 2003; 4(2): 6.

220

AIDS Epidemic Update, supra, note 16 at 14.

221

Figures presented by Kyrgyzstan delegation to Prison Grantees Workshop, International Harm Reduction Development Conference,
Chisinau, Moldova, November 2002.
222

Dr Raushan Abdyldaeyva, private correspondence, May 2003.

223

Elvira Muratalieva, Open Society Institute, Kyrgyzstan, private correspondence dated April 9, 2004.

224

Ibid.

225

Dr Larisa Savishcheva. Project “Prevention of HIV in Penitentiary Institutions in the Republic of Belarus.” Presentation at the
International Harm Reduction Development Conference, Warsaw, Poland, 8 September 2003.
226 Figures taken from Nathalia Karzhaeva. Drug Using and Harm Reduction Programme in Belarus. Presentation at Effective Advocacy
for Health in the NIS conference,Tbilisi, Georgia, 18 September 2003.
227

Dr Larisa Savischeva, Project Manager in Belarus, private communication, September 2003.

228

L Savischeva. Needle exchange in Belarussian prisons: A joint UNDP-UNAIDS pilot project. In Connections: The Newsletter of the
European Network Drug Services in Prison & Central and Eastern European Network of Drug Services in Prison 2003; 13: 8.

229

Ibid.

230

Dr Larisa Savischeva, Project Manager in Belarus, private correspondence dated 30 September 2003.

231

Ibid.

232

Dr Larisa Savischeva, Project Manager in Belarus, private correspondence dated 8 April 2004.

233

Savischeva, supra, note 230.

234

Stöver & Nelles, supra, note 150.

235 W

Headrick. Report on the Needle Exchange Program in Switzerland Prisons, 9 April 1999. Copy on file.

236

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 16.

237

Stöver & Nelles, supra, note 150 at 15.

238

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 5.

239 Cited in D Riley. Drug Use in Prisons. In: Correctional Service of Canada. HIV/AIDS in Prisons: Background Materials. Ottawa: CSC,
1994, at 156.
240 M Lachat. Account of a pilot project for HIV prevention in the Hindelbank Penitentiaries for Women – Press conference, 16 May
1994. Berne: Information and Public Relations Bureau of the Canton.
241

Stöver & Nelles, supra, note 150 at 15.

242

DeSantis, supra, note 135.

243

H Stutz, U Weibel. Obershöngrün Institution, 4 June 2003. Interview with Rick Lines.

244

Ministerio Del Interior/Ministerio De Sanidad y Consumo, supra, note 156 at 11.

245

Ibid at 14.

246 This

analysis is adapted and expanded from that found in Stöver & Nelles, supra, note 150 at 14.

247

Prisoners’ HIV/AIDS Support Action Network (PASAN). HIV/AIDS in Prison Systems: A Comprehensive Strategy.Toronto: PASAN, June
1992.
248

76

CSC, Final Report, supra, note 18.

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience

249

Jürgens, supra, note 47.

250 Task

Force on HIV/AIDS and Injection Drug Use. HIV, AIDS, and Injection Drug Use: A National Action Plan. Ottawa: Canadian Centre
on Substance Abuse and Canadian Public Health Association, 1997.

251

A Scott, R Lines. HIV/AIDS in the Male-to-Female Transsexual/Transgendered Prison Population: A Comprehensive Strategy.Toronto:
Prisoners’ HIV/AIDS Support Action Network, 1998.
252 Study Group on Needle Exchange Programs. Final Report of the Study Group on Needle Exchange Programs. Ottawa: Correctional
Service of Canada, October 1999. Copy on file.
253

Lines, supra, note 18.

254

DiCenso et al, supra, note 69.

255

Canadian Human Rights Commission. Protecting Their Rights: A Systemic Review of Human Rights in Correctional Services for
Federally Sentenced Women. Ottawa: Canadian Human Rights Commission, December 2003.
256 Special Committee on Non-Medical Use of Drugs. Policy for the New Millennium: Working Together to Redefine Canada’s Drug Strategy.
Ottawa: House of Commons, 2002. Recommendation 32 of the report reads: “The Committee recommends that Correctional Service
Canada allow incarcerated offenders access to harm-reducing interventions, in order to reduce the incidence of blood-borne diseases,
in a manner consistent with the security requirements within institutions.” In Supplementary Reports, the Canadian Alliance soundly
rejected the idea of prison needle exchange as “preposterous” (at 171); the Bloc Québecois did not comment on the issue; and the
NDP “would place greater emphasis on adopting harm reducing measures, such as needle exchanges and widespread access to treatment, as a more practical solution [to deal with the reality of drugs in our prisons]” (at 181).
257

House of Commons, Standing Committee on Health. Strengthening the Canadian Strategy on HIV/AIDS. Ottawa: House of Commons,
2003 (available at www.parl.gc.ca/InfoComDoc/37/2/HEAL/Studies/Reports/healrp03-e.htm).
258

CSC, Final Report, supra, note 18 at 78-79.

259

Final Report of the Study Group, supra, note 252, at 1-2.

260

Ibid.

261

Standing Committee on Health, supra, note 257, recommendation 4(d).

262

Special Committee on Non-Medical Use of Drugs, supra, note 256 at 106.

263

Government response to the Third Report of the Standing Committee on Health, Strengthening the Canadian Strategy on HIV/AIDS.
Available at www.parl.gc.ca/InfoCom/PubDocument.asp?FileID=65688&Language=E.
264

Lines, supra, note 18.

265

N Abdala, AA Gleghorn, JM Carney, R Heimer. Can HIV-1-contaminated syringes be disinfected? Implications for transmission among
injection drug users. Journal of Acquired Immune Deficiency Syndromes 2001; 28(5): 487-494.
266 H Hagan, H Thiede. Does bleach disinfection of syringes help prevent hepatitis C virus transmission? Epidemiology 2003; 14(5): 628629; author reply on 629.
267 CB McCoy, JE Rivers, HV McCoy et al. Compliance to bleach disinfection protocols among injecting drug users in Miami. Journal of
Acquired Immune Deficiency Syndromes 1994; 7(7): 773-776.
268 See RG Carlson, J Wang, HA Siegal, RS Falck. A preliminary evaluation of a modified needle-cleaning intervention using bleach
among injection drug users. AIDS Education and Prevention 1998; 10(6): 523-532; McCoy et al, supra, note 267; AA Gleghorn, MC
Doherty, D Vlahov, DD Celentano,TS Jones. Inadequate bleach contact times during syringe cleaning among injection drug users. Journal
of Acquired Immune Deficiency Syndromes 1994; 7(7): 767-772.
269 KA Dolan, AD Wodak, WD Hall. A bleach program for inmates in NSW: an HIV prevention strategy. Australian and New Zealand
Journal of Public Health 1998; 22(7): 838-840.
270 In a syringe sterilized with bleach, traces of bleach are likely to remain present even after flushing with water. Bleach contains free
chlorine, a known oxidant, and in vitro laboratory studies have shown that low concentrations of oxidants can lead to both tissue
inflammation and HIV-1 replication.Therefore, although not statistically proven, “Hypothetically, oxidant effects of the residual bleach in
the bleach-sterilized syringes could enhance the possibility of infection by remaining HIV-1 contained in a contaminated syringe.” C
Contoreggi, S Jones, P Simpson, WR Lange, WA Meyer. Effects of varying concentrations of bleach on in vitro HIV-1 replication and the
relevance to injection drug use. Intervirology 2000; 43(1): 1-5.
271 F Kapadia, D Vlahov, DC Des Jarlais, SA Strathdee, L Ouellet, P Kerndt, EV Morse, I Williams, RS Garfein, S Richard, for the Second
Collaborative Injection Drug User Study (CIDUS-II) Group. Does bleach disinfection of syringes protect against hepatitis C infection
among young adult injection drug users? Epidemiology 2002; 13(6): 738-741. See also N Flynn, S Jain, EM Keddie, JR Carlson, MB
Jennings, HW Haverkos, N Nassar, R Anderson, S Cohen, D Goldberg. In vitro activity of readily available household materials against

Notes

77

HIV-1: is bleach enough? Journal of Acquired Immune Deficiency Syndromes 1994; 7(7): 747-753.
272

UNAIDS, Prisons and AIDS: UNAIDS Technical Update, supra, note 77, at 6.

273

E Senay, A Uchtenhagen. Methadone in the treatment of opioid dependence: A review of world literature. In: J Westermeyer (ed).
Methadone Maintenance in the Management of Opioid Dependence. New York: Prager, 1990.
274

G Bertschy. Methadone maintenance treatment: an update. European Archives of Psychiatry and Clinical Neuroscience 1995; 245(2):
114-124; M Rosenbaum, A Washburn, K Knight, M Kelley, J Irwin.Treatment as harm reduction, defunding as harm maximization: the case
of methadone maintenance. Journal of Psychoactive Drugs 1996; 28(3): 241-249.

275 DR Gibson, NM Flynn, JJ McCarthy. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion
among injecting drug users. AIDS 1999; 13(14): 1807-1818; DM Hartel, EE Schoenbaum. Methadone treatment protects against HIV
infection: two decades of experience in the Bronx, New York City. Public Health Reports 1998; 113(Suppl 1): 107-115; KA Dolan, J
Shearer, M MacDonald, RP Mattick, W Hall, AD Wodak. A randomised controlled trial of methadone maintenance treatment versus wait
list control in an Australian prison system. Drug and Alcohol Dependence 2003; 72(1): 59-65.
276 A Byrne, K Dolan. Methadone treatment is widely accepted in prisons in New South Wales. British Medical Journal 1998; 316(7146):
1744-1745; D Goldberg, A Taylor, J McGregor, B Davis, J Wrench, L Gruer: A lasting public health response to an outbreak of HIV infection in a Scottish prison? International Journal of STD & AIDS 1998; 9(1): 25-30.
277

K Dolan, Hall W, Wodak A: Methadone maintenance reduces injecting in prison. British Medical Journal 1996; 312(7039): 1162; Dolan
et al, supra, note 275.

278

Ibid.

279

Commissioner’s Directive 800-1. Methadone Treatment Guidelines (2 May 2002); Policy Bulletin 127, 2 May 2002. See generally R
Jürgens. HIV/AIDS in prisons: more new developments. Canadian HIV/AIDS Policy & Law Review 2002: 7(1); 15-17.
280

B Sibbald. Methadone maintenance expands inside federal prisons. Canadian Medical Association Journal 2002; 167(10): 1154.

281

See Lines, supra, note 18; N Whitling. New policy on methadone maintenance treatment in prisons established in Alberta. Canadian
HIV/AIDS Policy & Law Review 2003; 8(3): 45-47.
282

See the analysis of needle exchange in Spanish prisons, above.

283

Final Report of the Study Group, supra, note 252.

284

CSC, HIV/AIDS in Prisons: Background Materials, supra, note 18 at 94.

285

Dolan et al, supra, note 34.

286

Australian National Council on Drugs, supra, note 121.

287

Holtgrave et al, supra, note 120.

288

FN Laufer. Cost-effectiveness of syringe exchange as an HIV prevention strategy. Journal of Acquired Immune Deficiency Syndromes
2001; 28(3): 273-278.
289 HB Krentz, MC Auld, MJ Gill.The changing direct costs of medical care for patients with HIV/AIDS, 1995-2001. Canadian Medical
Association Journal 2003; 169(2): 106-110.
290

78

Personal correspondence with Heino Stöver.

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About the Authors
Rick Lines is the Executive Director of the Irish Penal Reform Trust in Dublin. He has
worked on HIV/AIDS and harm reduction in prisons since 1993 for several organizations,
including the Canadian HIV/AIDS Legal Network. He may be contacted at rlines@iprt.ie.
Ralf Jürgens is the Executive Director of the Canadian HIV/AIDS Legal Network in
Montréal. From 1992 to 1994, he was the Coordinator of the Expert Committee on AIDS
and Prisons of Correctional Service Canada. He may be contacted at ralfj@aidslaw.ca.
Glenn Betteridge is a Senior Policy Analyst at the Canadian HIV/AIDS Legal Network.
Before joining the Network, he worked as a staff lawyer at the HIV/AIDS Legal Clinic of
Ontario. He may be contacted at gbetteridge@aidslaw.ca.
Heino Stöver, PhD, is a social scientist working at the Bremen Institute for Drug
Research in Germany. He may be contacted at heino.stoever@uni-bremen.de.
Dr Dumitru Laticevschi has been involved in with the Moldovan NGO, Health Reform in
Prisons, since 1999 and was involved in implementing two prison needle exchange projects
in the country. He may be contacted at dlaticevschi@ucimp.mdl.net.
Dr Joachim Nelles initiated the first scientifically evaluated syringe exchange program in
Hindelbank prison in Berne, Switzerland, and since that time has headed scientific evaluations of syringe exchange programs in various Swiss prisons. He may be contacted at
joachim.nelles@solnet.ch.

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