The neglected drug users in European prisons
Michel Rotily and Caren Weilandt
HIV infection and hepatitis in the setting of prisons.
INSERM U 379, Epidemiology and Social science applied to medical innovations,
Marseille, France [email protected]
European Network for Prevention of AIDS and Hepatitis in Prisons
All the European studies have shown that prison populations are much more likely to be contaminated by AIDS and hepatitis than the population at large. But public health systems have tended to overlook this issue.
The period immediately following release from detainment appears to be especially risky for drug users.
The total number of people currently detained in prisons in the European Union's fifteen member States is estimated to be 350,000, or 94 per 100,000 inhabitants (as compared to 940 in the United States). This number has been increasing considerably over the past twenty years. Changes in prosecution policies and the stringent regulations on drug use have both contributed to this increase (Raynal, 1998). The hard-drug users account for variable proportions of the prison populations, depending on the country, ranging between 15% and 65%, according to the estimates available. In France, it has been estimated that 40-45% of all hard drug users have already served a prison sentence (Facy, 1993), and 60% of all injecting drug users (IDUs) serving a prison sentence at any given time have already served a previous sentence (Rotily, 1994). The IDUs in Berlin have been imprisoned 2.7 times on average since they started using drugs (Klelber and Pant, 1996). It has also been established that HIV seroprevalence is higher at prisons than in the population at large (Gore et al., 1997; Bird et al., 1997; Rotily et al., 1994). A study carried out in prison, 13-85% of all convicted drug users inject drugs and 50-100% of them share injecting material. The results agree, whatever the methods used (direct interviews or filling. out questionnaires) and the responden populations (at detention centres, penitentiaries, prisoners and former prisoners) studied. The period immediately following their releas appears to be especially risky for drug use (Dye and Isaacs, 1991). It has been established recently that during the first few weeks following release from prison, the death rates, especially from overdoses, are very high in Scotland (Seaman et al., 1998). The treatment programmes available for drug users in prison vary depending on the country involved. In Sweden, for example, methadone is not prescribed at all during detention, whereas in Italy and Greece, it is available for inmates who have already undergone treatment before being imprisoned.
There are no syringe exchange programmes operating in European prisons.
Many countries are running short drug withdrawal programmes, in which no maintenance treatment is provided, or only for HIV-positive subjects undergoing highly active anti-retroviral therapy (HAART). In Denmark, France, Scotland, Spain and the Netherlands, withdrawal and maintenance programmes are theoretically available to a large number of users. In fact, more often than not, these measures have not yet been properly assessed, and it is impossible to state whether all drug users serving prison sentences have access to programmes of this kind as easily as drug users at large.
There are no syringe exchange programmes in European prisons. This is because many prison detainees are there in the first place because they were using drugs: since drug use is forbidden, the prison authorities consider programmes of this kind to be inappropriate for prisons. To make measures of this kind more acceptable, the programmes will have to be designed in co-operation with the administrative and medical teams working at individual establishments. They will also have to be thoroughly assessed. Now that the first pilot project in Switzerland has proved to be feasible and effective in small prisons (Nelles, 1995), others are being tested in Spain (Basque Region) and Northern Germany, and the initial results obtained have been encouraging.
Since 1993, bleach tablets have been distributed in all Scottish prisons along with video cassettes giving instructions as to how they should be used, especially for sterilising injection equipment. The effectiveness of these measures is questionable, however, given the precarious practical conditions usually existing in prison circles, which crack down heavily on drug use. Bleach is made available in the prisons of most of the European Union countries, but often without any specific instructions as to how it should be used to sterilise injection and tattooing needles. The resistance met by the idea of distributing practical instructions along with the bleach is akin to the resistance met by projects to introduce needle exchange programmes. There are people who still believe that needle exchange amounts to explicitly accepting drug use inside prisons, and who feel that this is incompatible with providing drug users with treatment, as well as being against the regulations.
Access to harm reduction services in European prisons is lagging far behind the actual needs and behind the World Health Organisation's 1993 recommendations. In addition, the prevalence of hepatitis C is much higher than that of HIV infection, and recent data indicate that hepatitis C is becoming an extremely frequent cause of death among drug users.
There is an urgent need to reinforce harm reduction strategies inside prisons.
When it comes to explaining why it is impossible to set up real harm reduction strategies inside prisons, the argument most often put forward is that it is so difficult for the administrative and medical staff to acknowledge the reality of forbidden practices in a place where law and order are supposed to reign. In fact, the players need to be more pragmatic and recognise that the main objective of imprisonment is social rehabilitation. And that involves improving the prisoners' state of mental and physical health.
There is an urgent need to reinforce harm reduction strategies in prison environments and to set up experimental projects that have been well tried and tested elsewhere. These projects should be adapted to the cultural specificities of each country. They also need to be adapted to the organisational constraints and to the current policies applying to the population at large, particularly as regards substitution treatment, needle exchange programmes, family visiting units, and drug-free units. The implementation of these projects must involve truly effective collaboration among the teams responsible for providing inmates with their medical, social, and educational needs.
Since prisoners are an integral part of the community, overall public health policies must also take prison settings into consideration. At this stage in the HIV and hepatitis epidemics, we should remember that priority must be given to the actions targeting the most disadvantaged populations, since those in detention often originate from these particular populations.