It’s time: a case for trialling a needle and syringe program in Australian prisons

The profound and lasting impact of NSPs has resulted in Australia having one the lowest rates of HIV among people who inject drugs (PWID) in the world.¹ Between 2000 and 2009 alone, NSPs were estimated to have directly averted 32,050 new cases of HIV and 96,667 cases of hepatitis C.²

These results have had an immeasurable impact on the lives of individuals, as well as an immense economic benefit, saving approximately $1.28 billion in healthcare costs.³

Australia’s strategic response to illicit drug use is founded on three pillars of harm minimisation: reducing drug supply through law enforcement; reducing drug demand through dependence treatment programs; and reducing drug harms through harm reduction interventions.

Although the majority of Australia government spending focuses on the first of these areas, bolstering law enforcement responses⁴ – a strategy proven to be far less cost effective than treatment⁵ – our broad, three-pronged harm minimisation approach has placed Australia in a demonstrably better position than countries that rely almost exclusively on law enforcement.

In the US for example, where a ban on federal funding for NSPs by Congress in 1989 (in accordance with a drug war ideology)⁶ was only recently lifted, the estimated prevalence of HIV among people who inject drugs (PWID) is ten times higher than in Australia⁷.

This correlation between NSP coverage (or lack of it) has been observed in relation to divergent HIV epidemics among PWID globally.⁸

Prison-based NSPs: the missing piece of the puzzle

The public health case for prison-based NSPs is incontrovertible. The ongoing criminalisation of drug use and the routine incarceration of people for drug-related crime means that PWID are grossly over-represented in Australian prison populations. PWID are the primary hepatitis C risk population in Australia⁹, and are also at elevated risk of acquiring HIV compared to the general population¹⁰.

While NSPs are readily accessible in the community, inmates within correctional facilities are denied access to clean needles and syringes. This key gap in Australia’s NSP coverage amounts to a significant deficit in harm reduction policy and practice, which continues to undermine Australia’s response to blood borne viruses, both in and outside of the prison system.

Despite drug interdiction strategies and a generally restrictive environment, injecting drug use continues to occur in prison.^{11, 12}It is little wonder that a lack of access to sterile injecting equipment in prison contributes to significant rates of intraprison hepatitis C transmission.¹³

Aside from the clear public health imperatives of providing prison-based NSPs, incarcerating people with drug dependence in environments with high rates of BBVs and where injectable drugs are available, but prohibiting access to clean injecting equipment represents a fundamental breach of basic human rights.

This approach contravenes international law stating that prisoners must be able to access the same standard of health care as available in the wider community.¹⁴

Prison NSPs are endorsed by major Australian health and medical peak bodies, including the Australian Medical Association, Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), the Public Health Association Australia (PHAA), the Royal Australasian College of Physicians, and the Australian Ministerial Advisory Committee on Blood-Borne Viruses.

Prison NSPs are also endorsed by major global bodies like the United Nations General Assembly, World Health Organization (WHO), UNAIDS (the Joint United Nations Programme on HIV/AIDS) and the United Nations Office on Drugs and Crime (UNODC).

Despite these endorsements and a strong disease prevention and harm reduction rationale, Australia is not alone in its reluctance to implement and maintain prison NSPs. The first (albeit informal) prison NSP commenced in Switzerland in 1992, followed by pilot programs in Germany in 1996 and Spain in 1997.

Only 13 countries have established prison NSPs, often as pilots operating for a limited time and across a limited number of sites. Currently, only eight countries maintain prison NSPs¹⁵, while 90 operate community-based NSPs¹⁶.

Arguments against

So what are the key concerns that prevent prison NSP implementation?

An overriding concern driving Australian debates has been that prison NSPs present an occupational health and safety risk to prison staff. This issue has been flagged repeatedly by the Community and Public Sector Union (CPSU) as justification for their opposition to the long proposed prison-based NSP at the Alexander Maconochie Centre in Canberra.^{17, 18}

While the safety of prison staff is a legitimate concern, international experience has shown that introducing prison NSPs does not in fact increase occupational risk.

Careful consideration of prison operational environments and appropriate systems to control and monitor the location of injecting equipment has meant that, across nearly 25 years of international experience, prison NSPs have not been associated with increased attacks on prison staff or other prisoners.

Furthermore, there have been no safety problems reported that relate to syringe disposal.¹⁹ Strategies to enhance occupational safety have revolved primarily around one-for-one exchange (whereby used injecting equipment must be returned in exchange for new equipment) and implementing strategies that ensure prison management and staff know who is in possession of injecting equipment, and where injecting equipment is located.

Conditions for accessing prison NSPs have included directives that equipment may only be stored in specific locations when not being used, and that prisoners must disclose the location of injecting equipment (including if they are carrying injecting equipment on their person).²⁰

In addition to learning from the successful management of occupational health and safety risks in international prison NSP models, it is important to acknowledge the risks posed by current circumstances in which injecting drug use occurs in Australian prisons.

In the absence of NSPs, uncontrolled and clandestine exchange of reused injecting equipment between prisoners is the norm. In this situation, officers carrying out searches are at a clear risk of a needlestick injury.

A survey of Australian prison officers conducted in 2006 reported that two-thirds had ever found needles and syringes during prison searches and that seven percent (n=17) had experienced a needlestick injury, most commonly during searches.²¹

Relative to the status quo, controlling the number and location of needles and syringes in prison through a formal prison NSP program is highly likely to enhance the occupational safety environment in Australian prisons.

Another commonly cited objection to prison NSPs is that such programs sanction, or even encourage continued drug use and may therefore undermine the effectiveness of prison drug treatment programs.

The notion that NSPs cannot co-exist with prison treatment services, or align with longer-term abstinence goals, ignores the fact that NSP and drug treatment services are already well integrated in the community, and that the typical trajectory for people using drugs involves changing patterns of drug use, including periods of self-imposed cessation.

Furthermore, evaluations of international prison NSPs have found no evidence of increased drug use or the amount of drugs entering correctional settings. On the contrary, some evaluations have found that a prison NSP can increase demand for drug treatment due to contact with NSP staff and services.^{22, 23}

Meanwhile, the argument that financial investments required for prison NSPs would be better spent on drug treatment programs ignores the fact that current responses to drug use in Australia’s correctional system overwhelmingly favour treatment programs and strategies that reduce demand and supply.

The almost total absence of evidence-based harm reduction interventions in prison is therefore at complete odds with Australia’s long-standing harm minimisation strategy.

It is also important to note that none of these arguments have been evoked to oppose the operation of NSPs in the wider community.

It’s time for an honest dialogue on prison-based NSPs

One of the few drug harm reduction interventions currently in place within Australia’s prisons is the provision of bleach to clean used needles and syringes, which is available to prisoners in all correctional facilities. Ironically, the suggestion by those opposed to prison NSPs that they condone drug use in prison also logically applies to bleach programs.

Unfortunately this duplicity leaves prisoners relying on an only partially efficacious approach to preventing blood borne virus transmission.²⁴ In Australia, the workplace and programmatic concerns about prison NSPs have been largely prosecuted by the CPSU. But sitting above this resistance is the reality that prison NSPs are highly unlikely to be a political winner for any government.

To implement a prison NSP, governments must be willing to either push through on the basis of public and prevention health evidence (as the ACT government has tried to do over recent years) or engage in a longer-term strategy of engaging in an honest dialogue with the community about drugs in prison.

Such a discussion would need to include the overarching issues associated with the ongoing criminalisation of drug use and the incarceration of people for drug-related offences. No Australian government has yet embarked on this endeavour in any meaningful way.

During the 2010 International AIDS Conference in Vienna, Mercedes Gallizo Llamas, the General Secretariat of Penitentiary Institutions in Spain, was asked about strategies that were successful in gaining political support for prison NSPs.²⁵

Her response was simple. Politicians need to be made aware that no prison system in the world is drug-free and that drugs in their prisons are therefore not their political failure. Recognition that drugs in prison are an inevitable product of criminalising drug use and incarcerating drug users is a precondition to engaging in a mature conversation about how to reduce drug harms in prison.

While a full and frank political debate about drugs in Australia’s prisons is yet to emerge, the one Australian jurisdictional government that has at least shown leadership on prison NSPs from a public health and prevention perspective is the ACT government.

A long process that emerged from the public support for a prison NSP trial at the Alexander Maconochie Centre (AMC) from successive ACT Chief Ministers, Jon Stanhope and Katy Gallagher, is now drawing to a close. As part of a Deed of Agreement that brought to an end a long-running enterprise bargaining agreement (EBA) stalemate between the ACT government and the CPSU that centred on the prison NSP trial²⁶, a process is now underway to develop a prison NSP model that can be feasibly implemented at the AMC.

A NSP Working Group has been tasked with developing a NSP model to be voted on by AMC staff, with majority support needed for the trial to proceed (in according to the Deed of Agreement). The Working Group has sought and received submissions detailing the potential operations of a prison NSP that pays due consideration to legal and operational issues as well as the health, safety and welfare needs of staff and detainees.

The features of the successful prison NSP models implemented internationally can be brought to bear on the process underway in the ACT. International experiences indicate clearly and unambiguously that an effective balance can be reached to deliver a program that is effective in reducing injecting drug-related harms, maintains the good working order of a prison and protects the health and safety of staff and prisoners.²⁷

With only a limited number of international jurisdictions currently operating prison NSPs, the ACT is now in a position to show genuine international leadership by becoming the first jurisdiction in the English-speaking world to introduce a prison NSP.

This would be the first significant innovation in drug harm reduction policy and practice in Australia for well over a decade, invoking memories of a time when Australia once led the world in drug harm reduction policy and practice.

References

1 Mathers, B., Degenhardt, L., Phillips, B., Wiessing, L., Hickman, M., Strathdee, S., et al. (2008). Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet, 372(9651), 1733–1745. doi: 10.1016/S0140-6736(08)61311-2

2 Wilson, D., Kwon, A., Anderson, J., Thein, H., Law, M., Maher, L., et al. (2009). Return on investment 2: evaluating the cost-effectiveness of needle and syringe programs in Australia 2009. Australian Government Department of Health and Ageing, Canberra.

3 ibid.

4 Ritter, A., McLeod, R., Shanahan, M. (2013, June). Monograph No. 24: Government drug policy expenditure in Australia – 2009/10. DPMP Monograph Series. National Drug and Alcohol Research Centre, Sydney.

5 Moore, T., Ritter. A., Caulkins. J. (2007). A cost effectiveness comparison of three policy options for reducing heroin dependency. Drug and Alcohol Review, 26(4), 369–378.

6 Clark, P., Fadus, M. (2010). Federal funding for needle exchange programs. Medical Science Monitor, 16(1), PH1–13.

7 Mathers, B. et al. (2008). op. cit.

8 Clark, P. et al. (2005). op. cit.

9 Department of Health (DoH). (2014). Fourth National Hepatitis C Strategy 2014–2017. Commonwealth of Australia.

10 DoH. (2014). Seventh National HIV Strategy 2014–2017. Commonwealth of Australia, Canberra.

11 Corrections Research Evaluation and Statistics. (2013). Drug use in the inmate population – prevalence, nature and context. Corrective Services, Sydney.

12 Fetherston, J., Carruthers, S., Butler, T., Wilson, D., Sindicich, N. (2013). Rates of injection in prison in a sample of Australian-injecting drug users. Journal of Substance Use,18(1), 65–73. doi: 10.3109/14659891.2012.760008

13 Luciani, F., Bretaña, N., Teutsch, S., Amin, J., Topp, L., Dore, G., et al. (2014). A prospective study of hepatitis C incidence in Australian prisoners. Addiction, 109(10), 1695–1706. doi: 10.1111/add.12643

14 United Nations General Assembly. (1990). Principle 9 of the Basic principles for the treatment of prisoners, United Nations General Assembly. A/RES/45/111. Retrieved from: www.un.org

15 United Nations Office on Drugs and Crime (UNODC). (2014). A handbook for starting and managing needle and syringe programmes in prisons and other closed settings. UNODC, Vienna.

16 Harm Reduction International (HRI). (2014). The Global State of Harm Reduction. HRI, London.

17 Westcott, B. (2012, 18 October). Breaking the syringe economy: prison union fights ACT plan. www.crikey.com.au. Retrieved from: www.crikey.com.au

18 McIlroy, T. (2014, 17 September). Stalemate over needle exchange hampering prison officers’ pay talks. The Canberra Times. Retrieved from: www.canberratimes.com.au

19 UNODC. (2014). op. cit.

20 ibid.

21 Larney, S., Dolan, K. (2008). An exploratory study of needlestick injuries among Australian prison officers. International Journal of Prison Health, 4(3), 164–168. doi: 10.1080/17449200802264720

22 Stöver H., Nelles, J. (2003). Ten years of experience with needle and syringe exchange programmes in European Prisons. International Journal of Drug Policy, 14(5), 437–444.

23 Lines, R., Jürgens, R., Betteridge, G., Laticevschi, D., Nelles, J., Stöver, H. (2006). Prison needle exchange: lessons from a comprehensive review of international evidence and experience.Canadian HIV/AIDS Legal Network, Canada.

24 Hagan, H., Pouget, E., Des Jarlais, D. (2011). A Systematic Review and Meta-Analysis of Interventions to Prevent Hepatitis C Virus Infection in People Who Inject Drugs. Journal of Infectious Diseases. 204(1), 74–83.

25 Hernández-Fernández, T., Arroyo-Cobo, J. (2010). Results from the Spanish experience: A comprehensive approach to HIV and HCV in prisons. Rev Esp Sanid Penit, 12(3), 86–90. Retrieved from: http://scielo.isciii.es

26 Rattenbury, S. (2015, 1 April). Progress on Corrective Services EBA. Media release. ACT Government, Canberra. Retrieved from: www.cmd.act.gov.au

27 UNODC. (2014). op. cit.

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Associate Professor Mark Stoové is Head of the HIV Research Program and the Justice Health Research Program in the Centre for Population Health at the Burnet Institute.