Drug policy and harm reduction SANCO/2006/C4/02

Final Report on Prevention, Treatment, and Harm Reduction Services in Prison, on Reintegration Services on Release from Prison and Methods to Monitor/Analyse Drug use among Prisoners

April 2008

WIAD

Wissenschaftliches Institut der Centre for Interdisciplinary Ärzte Deutschlands gem. e.V. Addiction Research (CIAR)

Neither the European Commission nor any person acting on its behalf is responsible for the use which might be made of the information contained herein.

H. Stöver1, C. Weilandt3, H. Zurhold2, C. Hartwig1, K. Thane1,2

1 Bremen Institute for Drug Research (BISDRO), University of Bremen 2 Centre for Interdisciplinary Addiction Research (CIAR), University of Hamburg 3 Scientific Institute of the German Medical Association (WIAD gem. e.V.), Bonn

Corresponding address:

WIAD Ubierstrasse 78 D-53173 Bonn Germany tel 49 228 8104 182 fax +49 228 8104 1736 home www.wiad.de

1. Status-quo of prevention, treatment and harm reduction services for people in prisons, reintegration services for persons on release from prisons

The main objective of this work package was to analyse the status-quo of prevention, treatment and harm reduction services for people in prisons and in reintegration services for persons on release from prisons. The report is based on data on health interventions targeting imprisoned drug users as well as on relevant information included in the national action plans on social inclusion prepared by the Member States within the context of the open method of coordination on social protection and social inclusion.

A key result of this work package is that there is a need for more systematic research on the effectiveness of treatment for drug users in prison, as there is hardly any high-quality research in this field, especially in the EU. Although there exist a range of interventions for drug using inmates, the implementation is often sporadic and not sufficient to meet the needs.

To promote and secure health in prison, testing for infectious diseases and vaccination is a major opportunity, and does have an impact on the health of the incarcerated, the correctional employees and the communities to which the inmates return. Vaccination for Hepatitis B and A is highly recommended for prisoners. Drug testing on the other hand, in particular mandatory drug testing in prison can have adverse effects, e.g. encourage people to switch from smoking drugs like Cannabis to injecting drugs like heroin, in order to avoid detection. It has been observed that mandatory drug testing is rather expensive and can be counterproductive, due to an increasing tension in the prison. Treatment for prisoners involves the treatment for drug dependency and infectious diseases. Upon entering the prison, prisoners with AIDS should be offered treatment with highly active anti-retroviral therapy (HAART), which is an effective treatment. Hence existing HAART should not be discontinued and prisoners not yet receiving HAART should be encouraged to start HAART. Similar to AIDS, treatment for HCV is safe and feasible.

Although the establishment of prison-based substitution treatment proved to be as effective in reducing mortality, crime and re-incarceration rates and HCV as in the community, the implementation of prison-based substitution treatment is still not equally well accepted and realized. Concerning harm reduction measures in prison the implementation is fragmentary and often problematic, despite existing research on the topic. Evidence for the effectiveness of prison needle exchange programmes (PNEP) has been gathered in a number of very different prison settings: PNEP reduces needle sharing very effectively, can increase uptake of drug treatment as well as the safety in the prison, and can reduce abscesses and fatal overdoses. It does not increase injecting drug use, nor has it shown any other negative effects. No research was found explicitly evaluating the distribution of sterile tattooing equipment. Still this measure should be recommended to reduce the risk of transmitting diseases, as tattooing often occurs in prison. Condoms are likely to be the most effective method for preventing sexually transmitted diseases (STDs). No serious negative effects of condom distribution in prisons have been found, and the free availability of condoms seems feasible in a wide range of prison settings.

The full report is attached (Annex 1: Final report [WP 4]. The status-quo of prevention, treatment and harm reduction services for people in prisons and in reintegration services for persons on release from prisons).

2. Report on current approaches to monitor/analyse drug use among prisoners

The main objective of this work package was directed to report on current approaches to monitor/analyse drug use among prisoners, based on data and methods available from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the World Health Organization (WHO) and the European Network on Drugs and Infections Prevention in Prison (ENDIPP) and current literature, assessing the data quality and analysing ways to improve availability and reliability of such information.

Many countries are reporting an increase in the use of illicit drugs in prisons, but national routine data on drug use in prison is rare. Prison related data collected by the EMCDDA come from a range of sources, which are often not comparable in terms of the methods used. Variations across countries and across surveys make comparisons between and within countries difficult and are related to issues such as sampling strategy, sample size, geographical coverage, population selection, and methods of measurement of drug use (selfreport, medical assessment). Moreover, studies in different countries use different measures of prevalence (lifetime or last year or month prevalence), and frequency of drug use.

Compared to the data on the prevalence and dynamics of drug use inside prisons, the data on the availability of harm reduction services and facilities collected by EMCDDA are more comprehensive and of a higher quality. However, information on the accessibility, coverage rates, quality and the utilisation of such facilities, with a particular focus on at-risk populations, need to be improved in order to obtain an overview of the situation in the different countries with clear indications on coverage as a core-element in policy evaluation.

In 2006, the Health in Prison Project (HIPP) of the World Health Organization Regional Office for Europe (WHO) has launched a Prison Health Database, which has been developed in collaboration with the EMCDDA and the Scientific Institute of the German Medical association (WIAD). The development and implementation of this database has been cofunded by the European Commission under the framework of the Public Health Programme 2003-2008. This prison health database was developed in order to increase the knowledge of drug related problems inside prisons, trends in prison health and their importance for public health. The indicators of this database cover four subjects: Penal Statistics, General Population Epidemiology, Interventions Monitoring and Penal Epidemiology. However up to now the data reported from Member States to the WHO Health in prison database is quite limited.

Overall, there is an obvious lack of systematic monitoring and research on drugs and health issues in European prisons. There are some valuable starting points in gathering information, which could support health planning and policy making, but these systems have to be improved and need strong support from national authorities. It is a future challenge to develop and implement an EU standard protocol to collect data on drug use, infectious diseases and risk behaviours in prison population that could then be used by countries to assess these issues in prison. Such a protocol would have to include a standard questionnaire but also methodological and ethical recommendations about how to implement a prison survey on health and drug-related issues.

The full report is attached (Annex 2: Final report [WP 5]. Current approaches to monitor/analyse drug use among prisoners).

Annex 1

Drug policy and harm reduction

SANCO/2006/C4/02

Final report (WP 4)

The status-quo of prevention, treatment and harm reduction services for people in prisons and in reintegration services for persons on release from prisons

April 2008

WIAD

Wissenschaftliches Institut der Centre for Interdisciplinary Ärzte Deutschlands gem. e.V. Addiction Research (CIAR)

Heino Stöver1, Caren Weilandt2, Heike Zurhold3, Christine Hartwig1, Katja Thane1, 3

1 Bremen Institute for Drug Research (BISDRO), University of Bremen 2 Scientific Institute of the German Medical Association (WIAD gem. e.V.), Bonn 3 Centre for Interdisciplinary Addiction Research (CIAR), University of Hamburg

Corresponding addresses:

Institute for Drug Research Bremen (BISDRO) University of Bremen FB 06 Postbox 330 440 D-28334 Bremen

tel +49 421 218 3173 fax +49 421 218 3684 e-Mail: [email protected]

Scientific Institute of the German Medical Association (WIAD gem. e.V.) Ubierstraße 78 D-53173 Bonn

tel +49 228 8104-182 fax +49 228 8104-1736 e-Mail: [email protected]

Contents

Executive Summary........................................................................................................ 8

1. Introduction .......................................................................................................... 10

2. Methodology and definitions ............................................................................... 12

2.1. Methodology.................................................................................................... 12

2.2. Definitions ....................................................................................................... 14

2.2.1. Prison ..................................................................................................... 14

2.2.2. Drugs ...................................................................................................... 14

2.2.3. Problematic Drug Use............................................................................ 14

2.2.4. Drug free interventions........................................................................... 15

2.2.5. Harm Reduction...................................................................................... 15

3. Background Information on prison systems in the EU..................................... 17

3.1. General ............................................................................................................ 18

3.2. Demographics.................................................................................................. 19

3.3. Capacity........................................................................................................... 24

3.4. Legal aspects, degree of penalty...................................................................... 25

3.5. Flow of entries, length of imprisonment, suicides and deaths ........................ 29

3.6. Occupation, education and professional training in prison ............................. 35

3.7. Prison Staff ...................................................................................................... 35

4. Epidemiological aspects of drugs and infectious diseases in prison................. 39

4.1. Excursus I: Consequences of drug use for the prison system.......................... 42

4.2. Infectious diseases in the community and in prisons ...................................... 44

4.3. Excursus II: Social and health problems of female drug using offenders....... 49

5. Analysis of the actual situation............................................................................ 52

5.1. Nature of drug use and related risks in prison................................................. 52

5.2. Prevalence of risk behaviour related to transmission of blood-borne viral infections ......................................................................................................... 58

5.2.1. Unprotected sex in prisons ..................................................................... 58

5.2.2. Tattooing and body piercing .................................................................. 60

5.2.3. Injecting drug use and communicable diseases ..................................... 61

5.3. Environmental and institutional risks.............................................................. 63

5.3.1. Overcrowding and the over-representation of risk groups .................... 66

6. Prevention, treatment, care and support of drug users in prisons .................. 68

6.1. Testing of infectious diseases and vaccination................................................ 69

6.2. Drug testing ..................................................................................................... 72

6.3. Health education and promotion for prisoners ................................................ 76

6.4. Healthcare for prisoners with AIDS and Hepatitis.......................................... 78

6.5. Abstinence-oriented programmes.................................................................... 82

6.6. Detoxification .................................................................................................. 85

6.7. Substitution treatment...................................................................................... 86

6.8. Harm reduction in prisons ............................................................................... 90

6.9. Prison needle exchange programme................................................................ 93

6.10. Provision of bleach and disinfectants .............................................................. 97

6.11. Provision of sterile tattooing equipment.......................................................... 99

6.12. Provision of condoms, dental dams, and water-based lubricants.................... 99

6.13. Pre and post release programmes .................................................................. 102

6.14. Training and information of prison staff ....................................................... 104

7. Formulation of service gaps and recommendations........................................ 110

8. References ........................................................................................................... 114

Annexes: Country reports

Index of Tables

Table 1: Database search strategy............................................................................13 Table 2: Literature grading......................................................................................14 Table 3: Prevalence of hepatitis C und HIV among female prisoners.....................51 Table 4: HIV testing and vaccination......................................................................72 Table 5: Drug testing ...............................................................................................75 Table 6: Provision of HAART and treatment of Hepatits C....................................82 Table 7: Example studies on abstinence-based treatment in prison ........................84 Table 8: Detoxification treatment............................................................................86 Table 9: Example studies on substitution treatment................................................90 Table 10: Prevalence of needle exchange programmes.............................................93 Table 11: Example studies on PNEP.........................................................................97 Table 12: Example studies on bleach provision ........................................................99 Table 13: Example studies on provision of condoms..............................................102

Index of Figures

Figure 1: Prison population rate per 100 000 inhabitants.........................................19 Figure 2: Female prisoners in percent.......................................................................20 Figure 3: Foreign prisoners in percent......................................................................21 Figure 4: Prisoners under 18 years of age in percent................................................22 Figure 5: Prisoners from 18 to less than 21 years in percent....................................23 Figure 6: Prison density per 100 places ...................................................................24 Figure 7: Sentenced prisoners in percent..................................................................25 Figure 8: Sentenced prisoners rate per 100 000 inhabitants .....................................26 Figure 9: Sentenced prisoners by length of sentence: Less than 1 year in

percent .......................................................................................................27 Figure 10: Sentenced prisoners by length of sentence: 5 years and over and

life imprisonment in percent......................................................................28 Figure 11: Entries to penal institutions rate per 100 000 inhabitants..........................29 Figure 12: Entries before final sentence in percent.....................................................30 Figure 13: Average length of imprisonment in months..............................................31 Figure 14: Mortality rate per 10000 prisoners ............................................................32 Figure 15: Suicides as a percentage of total deaths.....................................................33 Figure 16: Suicide rate per 10000 prisoners ...............................................................34 Figure 17: Staff employed by the prison authorities according to professional

categories in percent..................................................................................36 Figure 18: Supervision rate of prisoners by custodial staff.........................................37 Figure 19: Supervision rate of prisoners by treatment staff........................................38 Figure 20: Sentenced prisoners by main offence: drug offences in %........................40 Figure 21: Studies of lifetime prevalence of use of various drugs among

prisoners, 1999 to 2004 in some EU countries .........................................41 Figure 22: Newly diagnosed HIV infection rate per million population in 2005.......45 Figure 23: IDUs among newly diagnosed HIV infections in 2005 in percent............46 Figure 24: IDUs among cumulative totals of newly diagnosed HIV

infections in percent...................................................................................47 Figure 25: HIV prevalence (percentage infected) among injecting drug

users; studies with national and subnational coverage, 2003-2004...........48 Figure 26: Harm reduction services available in prison (R2.8)..................................92

Executive Summary

Within the scope of this project an extensive literature research was performed gathering the evidence for prevention, treatment and harm reduction programs for prisoners. This study offers insight into the status quo of scientific research for the three headlines. Besides the evidence, it allows a deep insight into the prison population by providing ample penal statistics.

The literature research revealed that testing for infectious diseases and vaccination is a major opportunity to promote and secure health in prison. Tremendous opportunities exist that have an impact on the health of the incarcerated, the correctional employees and the communities to which the inmates return. Vaccination for Hepatitis B and A is highly recommended for prisoners. Similar to testing for infectious diseases, drug testing plays an important part in prison. It can have very different aims and methods. Mandatory drug testing in prison can encourage people to switch from smoking “soft” drugs (i.e. Cannabis) to injecting “hard” drugs (i.e. heroin) for the latter is not as long detectable. It has been observed that mandatory drug testing is rather expensive and can be counterproductive, due to an increasing tension in the prison.

Testing for infectious diseases, vaccination and drug testing play a decisive role in prevention of communicable diseases and illegal drug consumption.

Treatment for prisoners involves the treatment for drug dependency and infectious diseases, e.g. AIDS and Hepatitis. The provision of healthcare for prisoners suffering from AIDS and Hepatitis is not only a human right, but also an effective and safe intervention. Upon entering the prison, prisoners with AIDS should be offered treatment with highly active anti-retroviral therapy (HAART). Existing HAART should not be discontinued and prisoners not yet receiving HAART should be encouraged to start HAART. Similar to AIDS, treatment for HCV is safe and feasible. This has been proven for problematic drug users (PDUs) in the general population, and recently there have been promising results from trials inside the prison.

Regarding treatment for drug dependency, detoxification with adequate medication is rarely available throughout Europe. There is a lack of evidence for detoxification programs in prisons, with only two studies published. Substitution therapy has been widely recognized as an effective treatment for opioid dependence in the general population. The establishment of prison-based substitution treatment proved to be as effective in reducing mortality, crime and re-incarceration rates and HCV. But still the implementation of prison-based substitution treatment is not equally well accepted and realized.

A harm reduction approach in prison recognises that a valid aim of drug interventions is to reduce the relative risks associated with drug use. In this work we assessed the impact of prison-based needle exchanges programs (PNEP), provision of disinfectants, distribution of sterile tattoo equipment and provision of condoms. Evidence for the effectiveness of PNEP has been gathered in a number of very different prison settings. PNEP reduces needle sharing very effectively, can increase uptake of drug treatment as well as the safety in the prison, and can reduce abscesses and fatal overdoses. It does not increase injecting drug use, nor has it shown any other negative effects. Regarding disinfecting injecting equipment with bleach is rather too complicated to be effective; it should be used as a “second” measure only, where PNEP is not provided yet.

No research was found explicitly evaluating the distribution of sterile tattooing equipment. Still this measure should be recommended to reduce the risk of transmitting diseases, as tattooing often occurs in prison.

Condoms are likely to be the most effective method for preventing STDs. No serious negative effects of condom provision in prisons have been found, and the provision of condoms seems feasible in a wide range of prison settings.

Although there exist a range of interventions for drug using inmates, the implementation is often sporadic and not sufficient to meet the needs. Furthermore, structured and more high-ranking research, which at present is conducted almost exclusively outside Europe, is required to assess the effectiveness of different treatment approaches.

1. Introduction

The negative health effects arising from imprisonment include the impact on mental health, the risk of suicide and self-harm, the risk of drug overdose on release, the risk of acquiring blood-borne-infections and the harm resulting from inappropriate imprisonment of people requiring facilities unavailable in prison or in overcrowded prisons.

Guidelines developed by the Worls health Organization (WHO) Health in Prisons Project1 and the Pompidou Group of the Council of Europe principles for the provision of healthcare services in prisons (2001) state that:

‘There should be health services in prisons which are broadly equivalent to health services in the wider community.’ (WHO Europe 2001)

They also recommend that services are based on clearly assessed needs of prisoners, who are often from socially deprived groups and present additional problems. This will include identifying problematic drug users and those with communicable diseases such as HIV and hepatitis who need additional support as well as healthcare. A key element of this process should be to consult with prisoners themselves and allow them to take some responsibility in planning their treatment. These guidelines are not only in place to assist prisoners but also the prison and healthcare services on a wider scale by preventing the spread of communicable diseases, promoting healthy lifestyles and reducing the personal and environmental harm resulting from high-risk behaviours. However a study into healthcare services in prison systems in the EU revealed that due to staff shortages and limited budgets, this was often difficult to achieve, despite the implications for the human rights of prisoners (MacDonald 2005; Hayton and Boyington 2006). In addition, further guidelines have emphasised the need for healthcare in prison to be at least equivalent to community provisions, and in recognition of the additional needs often presented by prisoners and also of the lack of provision available for some groups in the community, to in fact be better than community healthcare.

Due to the increased risk behaviours associated with drug use in prison (as explored in chapter 5.2.), and the fact that custodial settings form a risk of their own (overcrowding, often poor sanitary and hygiene conditions, limited space for every prisoner) there are many arguments against the systematic use of imprisonment for those who are involved in crime and drug use. Prison generally does not have a rehabilitative effect on those it contains. There are many harmful consequences of drug use in prisons described in the literature, and learning to be drug-free in prison does little to prepare drug-using

1 http://www.euro.who.int/prisons

offenders for being drug-free on their return to the community. The spatial and methodical range of action for implementing remedial measures in prisons is very limited. Prisons may exacerbate harms caused by drug use, and this harm may then be translated to the community outside of prisons (Turnbull and Webster 1998). In view of the increase in drug consumption in many prison systems, it is imperative to provide adequate and equivalent helping services that meet the needs of drug users and are based on their abilities and resources. The prevention, care, treatment and support measures taken must be balanced with the requirements for security and good order, and be consistent with human rights norms and standards. The goals pursued should also be pragmatic, not only with respect to the prison system but also with respect to the prisoners. Therefore, the reduction of harmful drug use and risk behaviours should be the guiding philosophy behind the measures. However, the implementation of harm reduction programmes in European prisons is still quite heterogeneous. In a report of the implementation of the Council Recommendation (of 18 June 20032) on the prevention and reduction of health-related harm associated with drug dependence3 it is said that a policy to provide drug users in prisons with services that are similar to those available to drug users outside prisons exists in 20 Member States and is about to be introduced in four countries. However, the coverage, availability and accessibility of harm reduction services is varying significantly in European countries and even within the countries from region to region (see chapter 6.8).

2 http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_165/l_16520030703en00310033.pdf 3 http://eur-lex.europa.eu/LexUriServ/site/en/com/2007/com2007_0199en01.pdf

2. Methodology and definitions

2.1. Methodology

A systematic review of international literature on evidence of effectiveness of interventions such as prevention, treatment, and harm reduction measures in prisons has been carried out in order to set the foundation for an evidence-based approach. The decision for undertaking a systematic review rather than a traditional review was based on the development that not only for clinical decision a systematic approach is needed. Basic data have been collected to describe the profile of drug using population (drugs used before, while and after imprisonment, drug using patterns, risk behaviour, drug related death after release etc.), living conditions of drug users in European prisons (data on demographic, sex, age, institutions etc.), and of prevention, treatment and harm reduction services in prisons. Special emphasis will be put on the evidence of the prevalence of infectious diseases (HIV, HBV, HCV, and TB etc.) and risk behaviours in prisons.

Published studies concerning the topics mentioned above were identified through manual and computerised searches of relevant databases. As it is known that the sensitivity of Medline search is, even with excellent search strategies, not perfect (Wilczynski et al. 2004), the search was extended to other relevant clinical and sociological databases (see below). To isolate the research question in advance of the systematic review the focus was settled on existing literature and data from well-known and established institutes.

This review has some limitations: Only publications in English and German were included, as well as some in French and Spanish, other languages were not included; and not all papers (mostly ‘grey literature’) could be obtained within the time limit.

Regarding the search in detail the following workflows were made:

1. Manual and electronic search for the existing data

y in databases, publications, expertises, monographs, standards and guidelines of the EMCDDA

y in the national reports of the National focal points of the REITOX-Network

y in activities and information of the WHO Europe, Pompidou-Group and other international bodies working in the field (e.g. UNAIDS, UNODC)

y through contacts to national and international experts in the field.

    1. A database search was conducted using a systematic search strategy (see below) for published literature and primary research studies in specific and general electronic databases (Cochrane, Dare, Medline, Embase, Psycinfo, Social Science).
    2. Additionally reference lists of publications in relevant scientific journals as well as in the retrieved publications have been hand searched.
  1. Compilation of electronic reference lists using EndnoteX.
  2. Analysis of the retrieved literature.
  3. Identification of possible lacks of information.

Table 1: Database search strategy

1 Substance-related disorder/ or exp opioid-related disorder/ or amphetamine-related disorder/ or cocaine-related disorder.mp. or cannabis-related disorder.mp.*
2 (abuse$ or depend$ or addict$ or substance abuse or withdrawal).mp.
3 (heroin$ or opiate$ or opioid$ or morphium or morphin$).mp. or exp morphinans/ or methadone.mp. or inhalant$.mp. or cocaine.mp. or crack.mp. or amphetamine$.mp. or exp amphetamine/ or cannabis.mp. or marijuana.mp.
4 1 or 2
5 3 and 4
6 drug therapy.fs. or drug treatment.mp. or drug therapy.mp. or minnesota.mp. or 12-step.mp. or drug intervention.mp. or drug services.mp. or drug awareness.mp. or drug training.mp. or drug-related problem$.mp. or drug demand programmes.mp. or drug demand reduction.mp. or detoxification.mp. or therapeutic communit$.mp. or TC.mp. or cognitive treatment.mp.
7 (harm reduction or syringe exchange or needle exchange or condom$ or lubricant$ or disinfect$ or NEP or PNESP).mp.
8 (substitution$ or methadone or subutex or buprenorphine or heroin$ or codeine$ or heroin-assisted maintenance or substitution treatment).mp.
9 (drug-related infectious diseases or HIV or HCV or HBC or hepatitis or TB or tuberculosis).mp. or exp HIV infections/ or hepacivirus.mp.
10 (pre-release programme or aftercare programme or throughcare programme or drug release programme or aftercare or release).mp.
11 (prison health or health care service or drug education).mp.
12 or/6-11
13 (prison$ or detainee$ or correctional facilit$ or correctional institution$ or remand$ or carceral$ or jail$ or inmate$ or convict$ or gaol$ or penitent$ or custod$).mp.
14 5 and 13
15 12 and 14

*

mp=title, original title, abstract, name of substance word, subject heading word

The included literature was graded according to the following table (adapted from (Kleber et al. 2006):

Table 2: Literature grading

A Randomized clinical trial. A study of an intervention in which subjects are prospectively followed over time; there are treatment and control groups; subjects are randomly assigned to the two groups
B Clinical trial. A prospective study in which an intervention is made and the results of that intervention are tracked longitudinally; study does not meet standards for a randomized clinical trial.
C Cohort or longitudinal study. A study in which subjects are prospectively followed over time without any specific intervention.
D Case-control study. A study in which a group of patients is identified in the present and information about them is pursued retrospectively or backward in time.
E Review with secondary data analysis. A structured analytic review of existing data, e.g., a meta-analysis or a decision analysis.
F Review. A qualitative review and discussion of previously published literature without a quantitative synthesis of the data.
G Other. Textbooks, expert opinion, case reports, and other reports not included above.

2.2. Definitions

2.2.1. Prison

In this report, the term “prison” is used for all places of detention, no matter if the person is in police detention, pre-trial/remand prisons, or is already sentenced.

2.2.2. Drugs

This report is focusing on illicit drug use and especially “problematic drug use use” (see next chapter) in prisons.

2.2.3. Problematic Drug Use

Problematic drug use (PDU) is defined as “injecting drug use or long duration/regular use of heroin/cocaine and/or amphetamines” (EMCDDA 2006a). This definition can also include other opioids such as methadone. Furthermore, drug consumption is deemed to be problematic, if this behaviour is joined with other risk behaviour, causes damage to other persons or produces negative socials consequences (EMCDDA 2005). The latter is not clearly defined. Although no clear definition of negative consequences can be found in the literature, it can be said, that negative social consequences are frequently linked to offending, be it a direct cause such as theft to found drugs or a contributory factor such as violent crime fuelled by excessive alcohol use. In most countries PDU is understood as distinct from recreational or experimental use, in that it often led to harmful consequences. Polydrug use needs to be distinguished from PDU, because it describes the “…frequent use of more than one substance over a minimum of specified time period…” (EMCDDA 2006a, p. 92). Recently there has been a debate about this topic, due to the spread of polydrug users and the therewith involved problems within the monitoring system. (EMCDDA 2006a).

2.2.4. Drug free interventions

The importance of drug problems in prisons has been widely recognised internationally. In the ‘Declaration on the guiding principles of drug demand reduction’, which accompanied the UN General Assembly Special Session on Drugs (UNGASS) in 1998, prisoners were explicitly identified as an important group for demand-reduction activities (see United Nations 1998).

Turnbull states that:

“One of the main reasons why this approach has been adopted within prisons is the perception that prison culture often works against other types of treatment and education programmes.” (Turnbull and McSweeney 2000, p. 47F))

Another reason is that abstinence is compatible with, and reinforces, the aim of custody in general, and is seen to enable prisoners to lead a life without committing criminal offences after release. Within prisons, the use of illegal drugs is a criminal offence, and therefore abstinence-based interventions are generally viewed as compatible with the goal of many prison systems to seek to eradicate drug us inside prison.

2.2.5. Harm Reduction

In their broadest sense, harm reduction policies, programmes, services and actions work to reduce the health, social and economic harms to individuals, communities and society that are associated with the use of drugs4. A “harm reduction approach” recognises that a valid aim of drug interventions is to reduce the relative risks associated with drug misuse, from reducing the sharing of injecting equipment, through to stopping injecting, substitution on opioid drugs for heroin users and abstinence from illegal drugs. Most harm reduction interventions specifically aim to prevent blood-borne diseases (most particularly HIV and hepatitis infections) and other drug-related harm, including overdose and drug related death. All drug treatment services, residential or community-based, should provide a distinct harm reduction element to reduce the spread of blood borne viruses and risk of drug-related deaths in the treatment they provide. Specific harm reduction interventions to reduce the spread of blood-borne viruses and reduce overdose include:

UK Harm Reduction Alliance website at http://www.ukhra.org

  • Needle exchange services i.e. the provision and disposal of needles and syringes and other clean injecting equipment (e.g. spoons, filters, citric acid) in a variety of settings
  • Advice and support on safer injection and reducing injecting and reducing initiation of others into injecting
  • Advice and information to prevent transmission of BBVs (particularly hepatitis A, B and C and HIV) and other drug misuse-related infections
  • Hepatitis B vaccination
  • Access to testing and treatment for hepatitis B, C and HIV infection
  • Counselling relating to HIV testing (pre and post test)
  • Advice and support on preventing risk of overdose
  • Risk assessment and referral to other treatment services.

Harm reduction interventions such as needle exchange, advice and information on safer injecting, reducing injecting and preventing overdose should also be available as open-access services in each local area. Needle exchange services often have contact with problematic drug users who are not in touch with structured drug treatment services. Harm reduction interventions should be integrated into all drug treatment service specifications via contracts or service level agreements. Harm reduction interventions should also be integrated into structured drug treatment according to an individual client’s needs and should be incorporated into a care plan agreed with the client (National Treatment Agency for Substance Misuse 2005, p. 41).

A Status paper on prisons, drugs and harm reduction (WHO 2005b) defined harm reduction measures in prisons:

“In public health relating to prisons, harm reduction describes a concept aiming to prevent or reduce negative health effects associated with certain types of behaviour (such as drug injecting) and with imprisonment and overcrowding as well as adverse effects on mental health” (WHO Europe 2005b).

Harm reduction acknowledges that many drug users cannot totally abstain from using drugs in the short term and aims to help them reduce the potential harm from drug use, including by assisting them in stopping or reducing the sharing of injecting equipment in order to prevent HIV transmission that, in many ways, is an even greater harm than drug use. In addition, the definition WHO adopted acknowledges the negative health effects imprisonment can have. These include the impact on mental health, the risk of suicide and self-harm, the need to reduce the risk of drug overdose on release and the harm resulting from inappropriate imprisonment of people requiring facilities unavailable in prison or in overcrowded prisons.

3. Background Information on prison systems in the EU

The source of data used for this chapter is the Council of Europe Annual Penal Statistics: SPACE I. For most of the countries, we could refer to the recent surveys (2004), with prison population figures (stock) relating to the situation at 1st September 2004, and flow of entries, total number of days spent in penal institutions, and incidents (escapes, deaths and suicides) relating to the year 2003.

However, seven member states of the European Union (Austria, Belgium, Czech Republic, Greece, Ireland, Malta and Portugal) did not answer to the SPACE I 2004 Survey. In these cases, we used the 2003 and 2002 surveys.

In all charts of this chapter the following own calculations were included:

  • Totals for Spain and the United Kingdom, whenever possible. In the SPACE tables, data for these countries were never presented as a whole, but according to the different national structures. In order to calculate the measures of central tendency, as well as the “EU average” mentioned below, we only used totals.
  • Total for all 25 EU Member States or for all the data supplied for these countries (without Bulgaria and Romania): “EU total”. Regarding the items where percentages or rates had to be calculated for the total, we only used the absolute numbers available for the same countries in all concerned items. We named this total rate: “EU average”, as it takes into account the demographical weighting of the countries involved (i.e. is strongly determined by Germany, France, the United Kingdom, Italy, Spain and Poland, which have the highest (prison) population numbers).
  • Additionally, an “EU-mainstream“ is described, which is defined as a (relative) majority of the data-providing EU-member states around the “EU-average”.
  • Measures of central tendency (mean, median, minimum, maximum) to describe the distribution of data supplied by the EU member states (without Bulgaria and Romania). For Spain and the United Kingdom, only the totals were used. These measures do not take into account the demographical weighting of the countries involved (other than the “EU average”).

The answers to the partly revised SPACE I survey 2004 suggested that “cross-national comparisons of prison population rates must be conducted cautiously as the categories included in the total number of prisoners vary from country to country. The same is true for cross-national comparisons of deaths and suicides in penal institutions as well as of staff working in penal institutions.” The sometimes significant differences between the member states indicate different forms of social control regarding crime or the social definition of crime, respectively. These differences must result in differently composed prison populations and consequently have an impact on epidemiological structures and the distribution of risk groups and behaviour. The policy on drug consumption and its penalisation, for example, will influence the structure of a country´s prison population as well as the social control of prostitution (which female IDU can use to finance their drug consumption) might affect the prevalence of STD in prison.

The following chapter covers general prison population statistics, demographical aspects of the prison population (i.e. gender, nationality, age), capacity of prisons, legal aspects of the prison population (i.e. legal status, length of sentences), movements in prison population (i.e. flow of entries, length of imprisonment, suicides, deaths), occupation and education in prison and, at last, statistics on prison staff.

3.1. General

The absolute numbers of prisoners in Europe at a given day can give an impression of the quantitative dimension of prison issues. The prison population in the member states of the European Union comprises 558 025 prisoners (including pre-trial prisoners) on 1st September 2004, while 40 085 persons in Romania and 10 935 persons in Bulgaria, the two future member states, are in prison at that time. Therefore, issues of prison and health in prison in particular affect directly more than half a million people at an appointed date and even more during a period of time because of the constant changes in the prison population. In each of the six biggest countries of the European Union more than 50 000 persons are in prison at the appointed date: 82 668 in the United Kingdom, 79 676 in Germany, 79 344 in Poland, 59 224 in Spain, 56 271 in France and 56 090 in Italy, i.e. almost three of four prisoners (413 273) in the European Community are to be found in a prison of one of the six biggest member states.

These figures might help to assess the weight and importance of the following data, which are in general rates per country in order to make it possible to compare the states despite their very different population size. Moreover, the “EU average” used in almost all descriptions has always been calculated on the basis of the absolute numbers in all member states of the European Union (without Bulgaria and Romania) for which data were available (i.e. not always the 25 member states), and consequently takes into account the demographical weighting of the countries involved. Therefore, the “EU average” is strongly determined by the United Kingdom, Germany, Poland, Spain, France and Italy, which have the biggest prison population numbers. But it is also necessary to keep in mind the quite different ways how different countries define and construct their prison population in general. Additionally, all following comparisons can only be regarded as approximations because of various differences and irregularities in the national statistics explained in notes.

Within these limits of comparability, there is a significant variation of the prison population rate per 100 000 inhabitants between Slovenia – with a very low rate of 56,4

– and Finland, Denmark and Malta (66,0 to 71,9) on the one hand, and Estonia and Latvia – with extreme values of 337,9 and 333,3 respectively – on the other hand. Lithuania (227,1) as the third Baltic State and Poland (207,8) show a very high level as well compared to the “EU average” of 121,6 (Figure 1). 14 countries plus Bulgaria show figures between approx. 160 and 80. In comparison with the other EU members, almost all eastern states (with the exception of Slovenia) and Romania show higher prison population rates of more than 160. Additionally, Bulgaria has a rate comparable to the highest western rate shown by Spain, which is visibly higher than the “EU average” as well as the figure for the United Kingdom.

Figure 1: Prison population rate per 100 000 inhabitants

0,0 50,0 100,0 150,0 200,0 250,0 300,0 350,0 400,0

Estonia

Latvia

Lithuania

Poland

Czech Republic

Slovakia

Hungary

Spain

United Kingdom

Portugal

Netherlands

Luxembourg

Austria

Italy

Germany

France

Belgium

Greece

Sweden

Ireland

Malta

Denmark

Cyprus

Finland

Slovenia

"EU average"

Bulgaria

Romania

Source: Council of Europe 2004

Concerning changes of the prison population rates between 2003 and 2004, an increase of more than 5% took place in the Netherlands, Bulgaria, Luxembourg, Sweden and the Slovak Republic (9,6 to 7,6%). It cannot be determined, whether the extreme value of 51,0% for Cyprus is caused by changes in statistical methodology or by real developments. A remarkable decrease took place in Lithuania (-21,0%) and in Romania as well (-11,3%).

3.2. Demographics

According to a recent survey among the Ministries of Justice of the European Member States eight countries reported that 10-30 % of the female prisoners have a drug problem (Zurhold and Haasen 2005). The same number of countries specified 40-60% of the female prisoners as drug users.

These findings are in line with other research results. A review of studies on the prevalence of drug dependence in prisoners reveals a substantial heterogeneity in the history of drug use but underlines as well the higher proportion of drug problems among female inmates (Fazel et al. 2006). The review of 13 studies with a total of 7563 prisoners shows a drug dependence that varied from 10 to 48 % in male prisoners and 30 to 60 % in female prisoners.

As Figure 2 shows, there is only little variation of the percentage of female prisoners between Poland, Ireland and Bulgaria (2,8 to 3,1%), but also Lithuania, Estonia, Luxembourg and Cyprus, on the one hand, and Spain and Portugal (7,6 and 8,0% respectively) on the other hand. While the “EU average” is 5%, a majority of 17 countries and Romania are situated between approx 4 and 6%.

Figure 2: Female prisoners in percent

0,0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 8,0 9,0

PortugalSpainSweden HungaryAustria United KingdomFinland Latvia Netherlands GermanyGreece Denmark ItalySlovakia Slovenia BelgiumCzech RepublicFrance Malta CyprusLuxembourgEstonia Lithuania Ireland Poland "EU average"BulgariaRomania

Source: Council of Europe 2004

At the same time there is a wide range of percentages of foreign prisoners (Figure 3), which is first of all indicated by a difference of almost 8 to 35% in a large middle group of 16 EU Member States. Furthermore, the discrepancies in European prisons are expressed by an extreme rate in Luxembourg (74,6%) and very high values in Cyprus, Greece and Belgium (48,4 to 40,9%), while in Latvia, Lithuania, Romania, Poland, Bulgaria, the Slovak Republic and Hungary (0,5 to 3,9 %), detainees from foreign origin are only a small group, compared to the “EU average” of 18,6%. Moreover, with

the exception of Estonia5, all eastern countries are below this value, which indicate that strong structural differences between European eastern and western societies still exist.

Figure 3: Foreign prisoners in percent

Source: Council of Europe 2004

Concerning the age structure of the prison population, data are not available for all countries. Considering rates of prisoners under 18 years of age (Figure 4) there are no great, but visible differences between the Scandinavian countries Finland, Sweden and Denmark and also the Netherlands with low percentages (0,3 to 0,6%) on the one hand, which might indicate a more liberal attitude to young offenders, and Latvia (2,7%) and the UK (3,0%) on the other hand. Bulgaria and Romania and a majority of 13 from 19 member states range between 1,1 and 2,3%, while the „EU average“ is 1,8%.

It is not possible to determine, if the high value for Estonia is caused by the large Russian minority in this country as a result of the Soviet era, a group which can hardly be compared to the ethnic minorities and migrants in western countries. In this case, all eastern states would differ from the western member states.

Figure 4: Prisoners under 18 years of age in percent

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5

Source: Council of Europe 2004

The percentages of prisoners from 18 to less than 21 years vary more distinctively (Figure 5): low rates can be found in Italy, Malta and Spain as well as in Finland (2,4 to 2,8%) compared to very high figures for Ireland (13,3%) and the UK (11,3%), which could express a tougher Anglo-Saxon handling of juvenile delinquency. But also Estonia and Austria (9,5 and 9,4% respectively) show relatively high values compared to the „EU average“ of 5,3 %, while Bulgaria and Romania are situated in the European mainstream together with a majority of 14 of 22 member states which are situated between more than 3 and 8%.

Figure 5: Prisoners from 18 to less than 21 years in percent

Source: Council of Europe 2004

3.3. Capacity

A majority of 16 countries plus Bulgaria and Romania show a prison density per 100 places between around 90 and about 120. The highest rates can be found in Cyprus, Greece and Hungary (160,6 to 144,9) and the lowest in Malta (62,6) (Figure 6). The “EU average” is 109,6, indicating a general tendency of overcrowding in the prisons throughout the European Community.

Figure 6: Prison density per 100 places

Source: Council of Europe 2004

3.4. Legal aspects, degree of penalty

Regarding the legal status of the prison population, in the category “percentage of sentenced prisoners” (Figure 7), Belgium, the Netherlands and Luxembourg are showing the lowest percentages (54,7% to 41,6%), i.e. the proportion of untried prisoners is relatively high in these countries. The EU member states Finland and Ireland and Romania (87,9% to 85,0%) show high values compared to the “EU average” of 73,8%, while 20 member states and Bulgaria range between about 60 and approx. 80%.

Figure 7: Sentenced prisoners in percent

0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 100,0
Finland 87,9
Ireland 85,5
Cyprus 82,4
United Kingdom 81,4
Czech Republic 80,6
Lithuania 79,8
Poland 79,6
Germany 79,5
Sweden 78,0
Spain 76,9
Estonia 76,0
Hungary 75,3
Greece 71,5
Denmark 70,2
Portugal 69,5
Slovakia 67,7
Malta 66,9
Slovenia 65,5
France 64,8
Latvia 64,1
Austria 63,9
Italy 62,6
Belgium 54,7
Netherlands 48,7
Luxembourg 41,6
"EU average" 73,8
Bulgaria 82,4
Romania 85,0

Source: Council of Europe 2004

The eastern EU member states Estonia, Latvia, Lithuania and Poland show remarkably high rates of sentenced prisoners per 100 000 inhabitants (Figure 8): from 256,8 to 165,4. The figures for the eastern countries Czech Republic, Hungary, Slovak Republic, Romania and Bulgaria are also higher in comparison to the western EU member states. On the other hand, the new member state Slovenia shows the lowest value with 36,9. While the “EU average” is 88,7, 14 member states and Bulgaria are situated in a wide range from 55 to about 120.

Figure 8: Sentenced prisoners rate per 100 000 inhabitants

0,0 50,0 100,0 150,0 200,0 250,0 300,0
Estonia Latvia Lithuania Poland Czech RepublicHungarySlovakia United SpainPortugalGermanySweden Ireland Austria ItalyFinland France Greece CyprusLuxembourgDenmark Netherlands Malta BelgiumSlovenia "EU average"BulgariaRomania

Source: Council of Europe 2004

There are also great differences in the length of sentences. While Germany, the Netherlands, Finland, Denmark (42,6% to 35,4%) belong to the countries which can be characterised by sentences predominantly shorter than 1 year, Portugal, Latvia, Belgium (4,5% to 3,7%) and Romania (3,7%) on the other hand show the lowest proportions for short sentences. The “EU average” in this category “rates of sentences shorter than one year” (Figure 9) is of 16,1%, while 13 of 22 countries range between approx. 9% and 20%. Bulgaria shows quite a high percentage (30,9%) of sentenced prisoners with sentences shorter than on year. For Cyprus, Poland and Spain, there are no data available.

Figure 9: Sentenced prisoners by length of sentence: Less than 1 year in percent

0 5 10 15 20 25 30 35 40 45
GermanyNetherlands Finland Denmark Sweden Austria Slovenia Slovakia HungaryIreland Czech RepublicFrance United KingdomLuxembourgEstonia Malta Lithuania Greece ItalyPortugalLatvia Belgium"EU average"BulgariaRomania 4,5 3,9 3,7 3,7 20,1 18,5 16,6 16,4 16,1 15,7 13,9 13,2 12,3 10,8 10,3 8,8 8,7 16,1 24,1 27,7 30,9 42,6 40,4 37,8 35,4

Source: Council of Europe 2004

In the category “rates of sentences of 5 years and over” and respectively “life imprisonment” (Figure 10), Greece achieves with 72,7% the maximum, more than twice as much as the “EU average” of 32,4%. High shares are to be found in Malta, Italy, Latvia, Luxembourg, France (49,5% to 42,7%) and Romania (45,9%) as well. As expected, Denmark, Finland, the Netherlands and Germany (19,4% to 12,8%), which have the most prisoners sentenced to less than 1 year, are bottom in this category. The mainstream (12 of 23 countries and Bulgaria) ranges between approx. 23% and 41%. Regarding this issue, there are no information on Cyprus, Poland and Spain.

Figure 10: Sentenced prisoners by length of sentence: 5 years and over and life imprisonment in percent

0 10 20 30 40 50 60 70 80
Greece Malta ItalyLatvia LuxembourgFrance PortugalUnited Estonia Ireland BelgiumLithuania HungarySlovenia Czech RepublicSlovakia Sweden Austria Denmark Finland Netherlands Germany"EU average"BulgariaRomania 49,5 47,2 44,4 43,8 42,7 40,8 39,9 39,7 38,5 36,7 35,7 30,6 30,5 30,1 25,8 23,2 22,8 19,4 18,2 16,6 12,8 32,4 23,2 45,9 72,7

Source: Council of Europe 2004

3.5. Flow of entries, length of imprisonment, suicides and deaths

There is a remarkable variation in the rate of entries to penal institutions per 100 000 inhabitants between the single EU member states (Figure 11). While Estonia achieved the maximum rate (406,2), Lithuania and Denmark (346,7 and 343,3) show high figures as well. On the opposite, Portugal (69,8) has the lowest rate, followed by Bulgaria (81,1). Around the “EU average” (171,4), a mainstream of 16 (out of 22) countries and Romania can be identified, ranging between approx. 95 and 255 entries per 100 000 inhabitants. Data are missing for Greece, Latvia and Sweden.

Figure 11: Entries to penal institutions rate per 100 000 inhabitants

0 50 100 150 200 250 300 350 400 450
Estonia Lithuania Denmark Ireland United KingdomLuxembourgPoland Netherlands HungarySlovakia Slovenia Austria GermanyCyprusBelgiumItalyCzech RepublicFrance Finland Malta SpainPortugal"EU average"BulgariaRomania 255,1 236,9 232,2 202,8 185,1 181,6 172,6 163,6 160,5 151,4 141,3 135,1 131,7 110,0 103,1 96,4 69,8 171,4 81,1 112 299,2 297,7 346,7 343,3 406,2

Source: Council of Europe 2004

As Figure 12 shows, Portugal and Italy (88% to 87,5%) achieve high shares of entries before final sentence. Slovenia, Hungary and Finland (24,1% to 33,3%) show the lowest figures in this context. Around the “EU average” (60,4%), a mainstream of 10 (out of 20) countries can be identified, ranging between approx. 50% and 70%. Bulgaria with 47% remains below the „EU average“. For Denmark, Greece, Latvia, Spain, Sweden and Romania, there are no data provided.

Figure 12: Entries before final sentence in percent

Source: Council of Europe 2004

The indicator of average length of imprisonment (in month) – based on the total number of prisoners on 1st Sept. 2003 - differs significantly among the member states (Figure 13). This indicator is at the highest in Portugal (22,7 months), closely followed by Romania (22,4 months) and Bulgaria (19,1 months), and at the lowest in Denmark, Ireland, Cyprus and Slovenia (from 2,3 to 3,6 months). Around the “EU average” of 8,1 months, a mainstream of 15 countries (out of 22) ranges from approx. 5 to 11 months, as an average length of imprisonment. Data are missing here for Greece, Latvia and for Sweden.

Figure 13: Average length of imprisonment in months

0 5 10152025

SpainCzech RepublicPoland Slovakia Estonia HungaryLithuania Malta France ItalyFinland BelgiumGermanyAustria Netherlands United KingdomLuxembourgSlovenia CyprusIreland Denmark "EU average"BulgariaRomania

Source: Council of Europe 2004

Regarding the total number of deaths in penal institutions, the highest values are achieved by the big European member states France, Germany, Italy, Poland and Spain. United Kingdom would likely belong to this cluster, if data were available. Besides Romania which is close to these countries, Portugal shows a large number of deaths in penal institution, too. This high absolute figure is reflected in the following mortality rate.

As Figure 14 shows, the maximum in the category mortality rate per 10 000 prisoners in penal institutions (suicides included) is achieved by Portugal with 70,6. The lowest rates are to be found in Cyprus and Malta (both 0,0) and the Czech Republic (8,3). A large group of countries (16 out of 22) as well as Romania are ranging around the “EU average” of 27,3 (from approx. 16 to 40). Bulgaria shows quite a high rate (43,8). Data are missing for Luxemburg, the Netherlands and the United Kingdom.

Figure 14: Mortality rate per 10000 prisoners

Source: Council of Europe 2004

Another picture can be drawn from the suicides as a percentage of total deaths (Figure 15): the Czech Republic (92,9%) is at the top, closely followed by Belgium and Slovenia (80% to 75%). In this case, it is difficult to identify a real mainstream around the “EU average” of 36,9, since the variations are very important: 16 of 20 countries range from a quite low 18,0% to a quite high 57,1%.The lowest rates can be found in Greece with 3,3% as well as in Romania and Bulgaria (5,6% and 6,8%). Data are based on small numbers only, and need to be dealt with carefully. Data for Cyprus, Luxemburg, Malta, the Netherlands and the United Kingdom are missing.

Figure 15: Suicides as a percentage of total deaths

0 10 20 30 40 50 60 70 80 90 100
Czech Republic Belgium Slovenia Ireland Germany Sweden France Lithuania Italy Denmark Estonia Finland Poland Slovakia Austria Spain Portugal Latvia Hungary Greece "EU average" Bulgaria Romania 3,3 6,8 5,6 42,4 36,3 31,6 30,0 30,0 29,1 26,7 22,5 20,7 19,6 19,4 18,0 36,9 57,1 53,3 53,3 52,2 80,0 75,0 92,9

Source: Council of Europe 2004

Slovenia (27,3), followed by Belgium and France (21,6 and 20,9) are at the top as regards the suicide rate per 10 000 prisoners in penal institutions (Figure 16). On the opposite, there are Cyprus and Malta (both 0,0), closely followed by Greece (1,2), as well as Romania and Bulgaria (1,5 and 3,0). While the “EU average” is 9,9, there are 13 out of 23 member states which range from approx. 6 to 14. Data are missing for Luxemburg and the United Kingdom.

Figure 16: Suicide rate per 10000 prisoners

0 5 10 15 20 25 30
Slovenia BelgiumFrance Denmark Lithuania PortugalIreland Austria Sweden GermanyItalyFinland Czech RepublicLatvia Netherlands SpainEstonia HungaryPoland Slovakia Greece CyprusMalta "EU average"BulgariaRomania 14,1 13,8 13,2 12,0 11,8 10,1 10,0 8,7 7,7 7,4 7,1 6,5 6,3 5,3 4,6 4,5 1,2 0,0 0,0 9,9 3,0 1,5 16,8 21,6 20,9 27,3

Source: Council of Europe 2004

3.6. Occupation, education and professional training in prison

Data on occupation, education and professional training in prison were to be found in the WHO Prison Health Database (see Country Profiles and Data Analyser), but correspond to the data collected in 2005 during the WIAD survey in the 10 new member states, which were already very incomplete at that time. Only 3 to 8 countries answered the corresponding questions, more or less completely: in some cases, the subgroups of prisoners did not sum up to the total number of sentenced prisoners in the respective countries, so that the calculation of percentage rates presented in the HIP Data Analyser is to be interpreted very cautiously.

As far as data are provided by the countries, it seems that a majority of sentenced prisoners was not working, with the exceptions of Hungary, Malta and Slovakia: here, more than 50% of the sentenced prisoners were working, whereas only approx. one third did so in the other responding countries. Within the very limited data provided, most of the sentenced prisoners did not attend any basic education courses. The data on sentenced prisoners attending vocational professional training might have not been understood and show significant variations between the respondents: in the Czech Republic, Estonia, Hungary, Slovakia and Romania, there seem to be high proportions of sentenced prisoners attending such training, whereas in other responding countries, these rates seem to be very low.

3.7. Prison Staff

The SPACE statistics classify the staff employed by the prison authorities in six categories: Management, Custodial, Treatment, Workshops, Administrative and Other Staff.

For our study on health issues, we concentrated on the following categories: Treatment staff (including medical staff, psychologists, social workers, teachers/educators, etc.) and Custodial staff. However, respondents to SPACE were asked to exclude staff working in penal institutions but not employed by the prison authorities (in some countries – i.e. France and Italy, this applies to doctors, teachers, etc.). As a consequence, the data on treatment staff is not always complete. Within these limits of comparability, the following information can be highlighted in Figure 17 on the distribution (in percentage) of staff employed by the prison authorities according to the professional categories “Treatment, Custodial and Other staff”: The share of treatment staff is at highest in the Czech Republic, Lithuania and Poland (16,7 to 16,1%) and at lowest in Cyprus and Greece (0,9 and 2,1%). Around the “EU average” of 7,8%, 17 countries plus Bulgaria and Romania are ranging between approx. 3 and 12%. As for the share of custodial staff, it is at highest in Ireland, Italy and Cyprus (87,9 to 86,9%) and at lowest in Hungary (45,8%). Around the “EU average” (72%), 15 countries plus Bulgaria and Romania are ranging from 63 to 82,6%.

Figure 17: Staff employed by the prison authorities according to professional categories in percent

Source: Council of Europe 2004

There are significant differences of the rate of supervision of prisoners by custodial staff (number of prisoners per custodian) in Figure 18: In Poland, Hungary, Bulgaria and Romania (5,9 to 5), the custodial staff has to supervise five to six times more prisoners than in Ireland (1). 11 countries are ranging from 2,2 to 3,2, around the “EU average” of 2,7 prisoners per custodian.

Figure 18: Supervision rate of prisoners by custodial staff

Source: Council of Europe 2004

The rate of supervision of prisoners by treatment staff (number of prisoners per treatment staff) (Figure 19) shows strong variations as well: one “treatment person” in Cyprian prisons has to care for the most prisoners (182), followed by Greece with 110,5 prisoners per treatment staff. At the other end, one treatment person in Finish prisons only has to care for 8,5 prisoners. 16 countries, as well as Bulgaria and Romania, are ranging from 19 to 33, around the “EU average” of 24,6 prisoners per treatment person.

Figure 19: Supervision rate of prisoners by treatment staff

0 20 40 60 80 100 120 140 160 180 200

Cyprus

182,0

110,5

Greece

United Kingdom

39,9

33,3

Italy

31,2

France

29,4

Ireland*

Germany

29,2

Portugal*

27,1

Sweden

26,7

24,0

Netherlands

23,0

Hungary

Poland

20,8

Belgium*

20,7

Estonia

20,3

Latvia

20,2

20,3

Spain

19,6

Slovakia

Luxembourg

18,9

Austria*

18,8

Slovenia

13,6

13,5

Lithuania

12,1

Denmark

Czech Republic*

10,7

Malta*

10,5

Finland

8,5

"EU average"

24,6

28,6

Bulgaria

29,1

Romania

Source: Council of Europe 2004

4. Epidemiological aspects of drugs and infectious diseases inprison

The use of illicit drugs is a century old phenomenon and it is widespread throughout the world. It is a major public health problem, which is also common in prisons.

To obtain reliable data of the magnitude of drug users is a complicated undertaking. Before 1998 no overall pictures of the EU could be drawn, due to missing data of Member States. The estimates of the extent of drug users are usually drawn from multiple data sources, e.g. cohort or case studies, demographic models, extrapolation from treatment data (Kraus et al. 2003).The prevalence of PDUs range from 1 to 8 per 1000 persons aged 15 to 64 in Europe. Among high-prevalence (5 to 8 cases per 1000 persons) countries Italy, Luxembourg, Ireland, Malta and Austria are ranked. As low-prevalence countries the Czech Republic, Greek, Germany, Lativa and the Netherlands can be regarded.

Epidemiological data on injecting drug users (IDU) are provided by only a few countries. Data on IDUs can similar to data on PDUs is derived from different data sources, e.g. fatal overdoses or treatment demand. It is estimated that 60% of PDUs use drugs intravenously.

Despite the fact that heroin is still the most prominent drug illicitly used, cocaine use has been rising in most European countries, with the highest prevalence in the Italy (4.6%), United Kingdom (6.1%) and Spain (5.9%). Use of cocaine alone is seldom, while co-use of cocaine and heroin is common among PDUs. Other important subgroups of cocaine users are the group of opiate dependent persons in MMT. Patterns of cocaine use differ between subgroups, with PDUs showing a high rate of cocaine injecting (Haasen et al. 2004).

Drawing a detailed picture of the extent and nature of drug use in prisons in a country is often difficult because it is an activity that occurs in extreme secrecy. Therefore one has to get a hold of surrogate data. These can be the discovery of needles, positive drug tests among prisoners and/or official statistics of known and sentenced drugs user. But these factors are only indicators reflecting only a part of the actual situation.

Scientifically acquired data such as prevalence studies, while useful, may reflect the situation in no more than one single prison. Due to the changing nature of the population from one prison to another and from region to region within a country, these isolated cross-sectional studies cannot be taken as representative of the situation as a whole.

However, despite the challenges in collecting data, it is generally accepted that drug use is a common activity in prisons around the world. 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 (UNAIDS 1997, p. 3).”

EMCDDA estimates that at least half of the EU’s prison population has a history of drug use, many with problematic and/or injecting drug use (EMCDDA 2003b). This is demonstrated in figure 20.

Figure 20: Sentenced prisoners by main offence: drug offence in %

Source: Council of Europe 2004

This figure shows great differences in the composition of the prison population with regard to drug offences: In Portugal (41,5%) and Greece (38,1%), but also in Italy and Malta, drug offenders are an important group, while in Hungary (1,7%) and Romania (1,6%), but also in the Slovak Republic, the Czech Republic, Estonia and Lithuania, these crimes are of little importance. Data on the percentage of drug offences among main offences are not available for Austria, Belgium, Poland and Bulgaria. While the “EU average” is 18,5%, 11 from 22 member states range between about 15 and 23%. At the same time, all New EU Member States including Romania show figures clearly below 10% (plus Slovenia with 11%). Of course, figure 4 can also only serve as a surrogate, because drug-using inmates cannot be solely found within the prison population of drug-related offences.

National routine information on drug use and patterns of use among prisoners is rare. Most of the data available in the EU come from ad hoc studies among prisoners carried out at local level with samples that vary considerably in size and they are often not representative of the whole prison system. This makes extrapolation to a national figure for the prison system very difficult. Furthermore, the lack of repeated surveys impedes trend analysis in most of the EU countries (EMCDDA 2003b; EMCDDA 2006a).

The data reported to the EMCDDA come from a range of sources, which are often not comparable in terms of the methods used. Variations across countries and across surveys make comparisons between and within countries difficult and are related to issues such as: sampling strategy; sample size; geographical coverage; population selection (for example convicted/remanded, male/female); method of measurement of drug use (self-report, medical assessment). Moreover, studies in different countries use different measures of prevalence (lifetime or last year or month prevalence), and frequency of drug use.

The EMCDDA states in the annual report of 2006 that drug users are overrepresented in prisons. Data derived from national data sources reveal that one third or less of the prisoners in Hungary and Bulgaria reported ever using an illicit drug, in The Netherlands, the United Kingdom and Norway two thirds or more of the prisoners reported ever using an illicit drug, whereas in the remaining countries the statement of prevalence remains vague, with estimates of 50% lifetime prevalence of illicit drug use (EMCDDA 2006a).

Drug consumption in prison also has major implications for the penal system: drugs become the central medium and currency in prison subcultures. Many routine activities for inmates focus on the acquisition, smuggling, consumption, sale and financing of drugs. If the acquisition and use of drugs dominate the life of prison inmates, prison directors and staff have to make increased efforts to safeguard a regular course of prison sentences accomplishment. This is the primary goal to be achieved. Solving the problem of drug addiction in detention is secondary.

Figure 21: Studies of lifetime prevalence of use of various drugs among prisoners, 1999 to 2004 in some EU countries

Source: EMCDDA 2006b

Only limited data are available about the exact percentage of injecting drug users in European prisons (see figure 21). As already informed, the EMCDDA estimated in 2006 that the life time prevalence of injecting drug use among prisoners in Europe is between 7 % and 38 %, which shows that the spread of problematic drug use is varying widely throughout the countries, as well as the prevalence of intravenous drug use in prison between 1-15% and differs even within the country from one prison to the other. Drug use is seen as one of the main problems of the current prison system that threatens security measures, is dominating the relationships between prisoners and staff and leads to violence and bullying for both prisoners and often their spouses and friends in the community (Restellini 2007).

4.1. Excursus I: Consequences of drug use for the prison system

Prison management is faced with increased public pressure to keep prisons drug-free. This affects all forms of detention for men and women: punitive detention, pre-trial detention, detention of juveniles. Only a small number of prison managers talk frankly about the issue in public, establish adequate drug services and develop new drug strategies. Frequently, however, confessing that drug use also appears in prison is to be mistaken for failing to maintain security in prisons: the prison system which is supposed to be impenetrable for drug trafficking, has turned out to be penetrable. The number of prison managers who deny or ignore drug use in prison for political reasons is still great. Additionally, many prison doctors believe that they cure the inmates drug problem, when an inmate is temporarily obliged to stop using drugs. Against this background, it becomes obvious why dealing with addicts in detention is difficult: on the one hand the goal to achieve the inmates rehabilitation must be pursued; on the other hand prison management in many countries faces rising drug consumption among inmates and with political and economic restrictions that make it even more difficult to solve the drug problem.

In prison the drug use patterns change. On one hand drug use can become more risky in terms of injecting and needle sharing, on the other hand the frequency and prevalence of drug use decrease during imprisonment. A Survey from England reveal that the rates of drug use in prison were significantly lower than in the previous year (Ramsay 2003a); 45 % of the female prisoners had used a drug while in prison, compared with 72% in the year before prison. Once in prison there is also a tendency to use depressants rather than stimulants. In the survey of Ramsay (2003) 27 % had used heroin and 21 % had used cannabis. Similar results are presented by the Home Office (2003). The main drugs which women reported using in prison were heroin (27 %), followed by cannabis (21 %) and tranquillisers (17 %). However, 30 % of the women said they were no longer using drugs at all in prison. These findings are supported by a European study on 185 female drug users in prison (Zurhold et al. 2005). While all women used drugs prior to their imprisonment this number declines gradually to 60 % and to down to 30 to 50 % the longer the time they spend in prison.

In most countries, a differentiated system of sanctions and incentives has been developed in prisons in order to punish drug-using behaviour or to reward those who remain abstinent within a unit or a treatment programme. Sanctions can include:

  • additional days of imprisonment for positive urine tests
  • forfeitures of privileges
  • stoppage of earnings
  • no home leaves

no visits Incentives are designed to encourage good behaviour of prisoners and may include:

  • transfer to a drug-free wing
  • single cell
  • home leave
  • holiday
  • in-cell television

Evaluations of such programmes have also yielded some promising results with respect to high-risk behaviour among drug-dependent prisoners (WHO et al. 2004).

4.2. Infectious diseases in the community and in prisons

It is estimated that approximately 180 million people, accounting for 3% of the world´s population are currently infected with HCV. Of those 180 million infected people 130 million are chronic carriers of HCV and are therefore at an elevated risk of liver cirrhosis and cancer. The HCV epidemic is described by the WHO as a “viral time bomb” (WHO et al. 2007b). Estimated 250.000 people die annually of HCV-related causes. Present and past injecting drug use account for 90% of those individuals with chronic HCV infection.

HCV infection is still extremely prevalent in IDUs across the EU. The infection spreads rapidly among IDUs due to the high infectivity of virus. Besides of the transmission of HCV via needle/syringe sharing, also other injecting equipment (e.g. water, cotton, etc), can carry infected blood particles and therefore account for HVC infections.

Antibody levels of over 60% among IDU samples tested in 2003–2004 are reported from Belgium, Denmark, Germany, Greece, Spain, Ireland, Italy, Poland, Portugal, the United Kingdom, Romania and Norway. The highest prevalence (over 40%) among IDUs under age 25 was found during 2003–2004 in samples from Belgium, Greece, Austria, Poland, Portugal, Slovakia and the United Kingdom. The highest prevalence among new IDUs (over 40%) was found in samples from Greece, Poland, the United Kingdom and Turkey (EMCDDA 2006a). In Eastern Europe (Estonia, Lithunia, Russia and Ukraine) very high rates of HCV infections are reported, with rates ranges from 70% to over 90% (CEEHRN 2007).

The prevalence of HBV infection markers varies even more than for HCV, which may be due to differences in vaccination levels. The most complete data are for the antibody to the hepatitis core antigen (anti-HBC), which indicates a history of infection. In 2003– 2004, prevalence rates of over 60% among IDU samples were reported only from Italy and Poland, suggesting low levels of vaccination coverage in earlier years.

Figure 22 shows a shows in a decreasing order the newly diagnosed HIV infection rates per million population in the EU member states in 2005. Acutally in all New EU Member States low rates are to be found with the exception of two Baltic States with a very high rate (129.6) for Lativa and an extremely high rate (467) for Estonia. The “EU average” seems quite low: 71.7. This can be explained by the fact that data for Spain and parts of Italy are missing. A further explanation is that some other countries with a strong demographical weight (i.e. Germany, Poland) have relatively low rates. 14 of 24 member states are ranging from approx. 26 to 102 newly diagnosed infections per million population around the “EU average”.

Figure 22: Newly diagnosed HIV infection rate per million population in 2005

0,0 50,0 100,0 150,0 200,0 250,0 300,0 350,0 400,0 450,0 500,0

Estonia PortugalUnited KingdomLuxembourgLatvia BelgiumFrance Ireland Netherlands ItalyAustria Denmark CyprusGreece Malta Sweden Lithuania Germany Finland Slovenia Poland Hungary Czech Republic Slovakia "EU average"BulgariaRomania

Source: Council of Europe 2004

The proportion of intravenous drug users (IDUs) among newly diagnosed HIV infections in 2005 (Figure 23) is at highest in Lithuania (70,8%), followed by Latvia (37,1%) and Portugal (32,5%). The lowest shares are to be found in Cyprus, Malta, Slovakia and Slovenia (0%), followed by Romania (1%) and Belgium (1,1%). Again, the “EU average” seems quite low: 7,6%. This time, the relatively low shares in the United Kingdom, France and Germany – and the missing data for Italy and Spain-, all countries with a strong demographical weight, are driving down the “EU average”. 12 of 22 countries (data are missing for Austria, Estonia, Spain and parts of Italy) are ranging from approx. 2% to 13%, around the “EU average” (7,6%). Bulgaria has a share of IDUs among newly diagnosed HIV infections (15,7%) above this mainstream.

Figure 23: IDUs among newly diagnosed HIV infections in 2005 in percent

Source: EuroHIV 2005

The cumulative totals of newly diagnosed HIV infections since the start of reporting in the EU member states are difficult to compare because several countries started a new HIV reporting system just a few years ago (i.e. France in 2003, the Netherlands in 2002). However, this restraint disappears when building a rate, as in Figure 24 on the proportion of IDUs among newly diagnosed HIV infections. As expected, Figure 24 follows a similar course than in Figure 23, but at a higher level for most countries, indicating that the share of IDUs among newly diagnosed HIV infections has been reduced during the last years in the majority of states (the “EU average share” is divided by two in 2005, compared to the whole time period since the start of reporting), with the exception of Portugal and first of all Bulgaria who have a higher share in 2005 than during the time period since the start of reporting, and, on a lower absolute level, Romania, Hungary and France.

As in Figure 23, the higher shares in Figure 24 are to be found in Lithuania (78,7%) and Latvia (67,7%), followed this time by Poland (54,5%). At the other end, Romania (0,2%) as well as Cyprus (1,0%), Slovakia and Hungary (both 1,3%) have the lower shares of IDUs among newly diagnosed HIV infections. The “EU average share” is almost twice as high as in 2005 (13,8% to 7,6%), and 14 of 22 countries plus Bulgaria are ranging from approx. 3% to 17% around this average. As in Figure 22, data are missing for Austria, Estonia, Spain and parts of Italy.

Figure 24: IDUs among cumulative totals of newly diagnosed HIV infections in percent

0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0
Lithuania Latvia Poland Ireland PortugalFinland ItalyLuxembourgSweden GermanyDenmark United KingdomMalta Netherlands Czech RepublicSlovenia BelgiumGreece France HungarySlovakia Cyprus"EU average"BulgariaRomania

Source: EuroHIV 2005

According to the most recent national/regional HIV prevalence studies (see figure 25) and diagnostic testing among injecting drug users in the 27 EU member states, there are very high shares of HIV cases among IDU tested in Spain (Catalonia: 33%), followed by France (regional: 23%). Studies in Portugal (16% HIV+ among IDU tested), Italy (14,7%) and the Netherlands (Rotterdam: 10,2%) also show rates above 10%. Studies in Poland, Latvia and Estonia found shares ranging around 6,5%. Shares of HIV cases among IDU tested below 1% were found in Hungary, Slovakia, Slovenia, the Czech Republic, Greece, Finland and the United Kingdom.

Figure 25: HIV prevalence (percentage infected) among injecting drug users; studies with national and subnational coverage, 2003-20046

Source: EMCDDA 2006a

6 Notes: Figures represent the (range in) percentage infected among national and [subnational] samples of IDUs. Colour indicates the midpoint of national data, or if unavailable, of subnational data. Data for Italy and Portugal include non-IDUs and are likely to underestimate prevalence in IDUs.

* Data in part or totally before 2003 (Spain 2002-03; France 2002-03; Latvia 2002-03; Netherlands 2002) and from 2005 in case of Estonia.

4.3. Excursus II: Social and health problems of female drug using offenders

In the international literature there is a congruent finding that most of the women offenders suffer from multiple problems and experienced stressful events. For this reason the Anti-Discrimination Commission in Queensland, Australia (2006) came to the conclusion:

“Females entering prison commonly have combined disadvantages. These include low levels of education, limited employment skills and opportunities, poor housing, inadequate income and often backgrounds of childhood trauma and abuse.”

The Commission found 43 % of the women prisoners who reported being the victim of non-consensual sexual activity before the age of 16. Other reports found even higher rates of child and/or adult sexual and physical abuse with the majority of the women being victims of multiple forms of abuse. An Australian study on 470 women prisoners (Johnson 2004a) showed that

y 87 % were victims of sexual, physical or emotional abuse in either childhood (63 %) or adulthood (78 %),
y 60 % had mental health problems while growing up, and 62 % of these women said these problems significantly interfered with their lives,
y 44 % grew up in families with alcohol problems, and 26 % in families with drug problems.

Similar the report of the Home Office (2003) in London revealed that among 301 female prisoners 71°% reported to have been physically assaulted and 54 % said that family members or friends violated them.

According to Johnson (2004b) sexual and physical abuse, poor mental health conditions and a history of family problems are common risk factors which influence both the drug use and the criminal career among women. But even the prison environment itself is often not a safe place for survivors of assaults. In a European study 75 % of the female study participants reported becoming victims of assaults during their imprisonment (Dünkel et al. 2005). Against this background it is no surprise that women prisoners experience prison as particularly brutal and traumatising.

Several studies indicate that the vast majority of women is sentenced to prison for nonviolent offences (Commission on Women and the Criminal Justice System 2004; Johnson 2004b; Walsh 2004; Anti-Discrimination Commission Queensland 2006). Most of the women prisoners have been incarcerated for regular drug offences such as buying or selling drug and for property offences such as burglary, stealing without break-in, and trading in stolen goods (Walsh 2004). Due to their regular offending up to 75 % of the women had been previously in prison (Zurhold et al. 2005).

The imprisonment itself often has a damaging effect on social relationships and the mental and physical well-being of women prisoners. According to estimations more than half and up to 70 % of the women prisoners have children which are separated from their mother by imprisonment (Johnson 2004a; Anti-Discrimination Commission Queensland 2006).

In addition research findings agree that mental health problems are higher among prisoners compared with the general population and that female prisoners have a much higher incidence of mental health problems than male prisoners (Andersen 2004; Butler et al. 2005; Anti-Discrimination Commission Queensland 2006). Most of the recent literature on mental health disorders derives from Australia and New Zealand. A study in New South Wales shows that 61 % of the female prisoners were diagnosed to suffer from psychiatric morbidity compared to 39 % of the male prisoners (Butler et al. 2005). In Queensland 57 % of the female prisoners have been diagnosed with a specific mental illness, the most common being depression (Anti-Discrimination Commission Queensland 2006). The study from Tye & Mullen (2006) screened women in two Victoria prisons for the 12-month prevalence rates of ICD-10 mental disorders. Among the screened female prisoners the most prevalent mental health disorders were drug dependence (57 %), major depression (44 %) and posttraumatic stress disorder (36 %).

In general, the prevalence of reported mental health problems is lower in European than Australian prisons. According to a European study between 11 % (Denmark) and 44 % (Greece) of the female prisoners are found to suffer from a severe depression (Dünkel et al. 2005). The report on the situation of female prisoners in England and Wales (Home Office 2003) document that almost half the women (45 %) had received medication in the 12 months before entering prison, usually for depression. Furthermore a number of women felt more anxious when in prison than outside. The anxiety levels appear higher for drug-dependent women and those with harmful levels of drinking.

The research results are unique in their findings that the most frequent mental health problems of women prisoners consist in drug dependence, depression and anxiety. However, it can be assumed that there is a significant population of mentally ill prisoners being both insufficiently detected and treated. Given the high prevalence of mental illness identified in several studies, it is essential that prison mental health services be adequately resourced to meet the needs of this population and to ensure that mental health does not deteriorate during incarceration. In fact, the prison administration has a particular responsibility for health as the loss of liberty disempowers individuals to take care for their health themselves.

Mental health disorders are closely associated with self-harm outside and in prison. The Home Office report (2003) stresses that about half of the female prisoners act out self-harm at some time in their lives and 47 % said that they had made a suicide attempt in their lifetime. Another report found 40 % of the women who perform self-harm in prison (Commission on Women and the Criminal Justice System 2004). Finally the European study identified every 9th to 10th female prisoner being at high risk of self-harm in prison (Dünkel et al. 2005).

Several studies indicate that the prevalence of HCV and as well of HIV is particularly high among female prisoners in specific countries (see table 1). These findings emphasize the need for effective harm reduction programs that provide an appropriate response to the problem of drug related heath risks among women prisoners.

Table 3: Prevalence of hepatitis C und HIV among female prisoners

Hepatitis C HIV Source
Ireland 56% 10% Donoghoe 2006
Nine European countries 44% 12% Dünkel et al. 2005 (N=159 women with drug problems)
Barcelona 74% 62% Zurhold et al. 2005 (N=185 female drug users)
Glasgow 11% 3%
Hamburg 65% 5%
Vienna 78% 6%
Warsaw 35% 30%
Queensland (AUS) 40% n.s. Anti-Discrimination Commission Queensland March 2006

5. Analysis of the actual situation

The following chapter reflects the actual situation of drug users and non-drug users in the prison setting. After the individual risks which derive from drug consumption and “way of life” in prison, we also focus on the institutional risks. Firstly we describe the specific nature of drug use in prison, secondly the prevalence of risk behaviour related to transmission of BBV, followed by drug-related diseases and other drug-related problems. Finally, issues of staff, knowledge and attitudes are presented and various institutional risks of the prison setting.

5.1. Nature of drug use and related risks in prison

With the entrance into prison, prisoners are faced with a severe change in their life and for many of them this is accompanied with a change in drug use patterns, frequency of use and the kind of drug used.

There are numerous studies which demonstrate that prisons and secure settings are facing increasing problems with drug use and other high risk behaviours which can have serious health consequences (Polonsky et al. 1994; Pallas et al. 1999; Stöver 2002a; Lines et al. 2004a; MacDonald 2005). In addition, PDUs are among the most vulnerable prisoners, and are over-represented within the prison population, often due to a growing trend towards the criminalization of drug use and possession and the use of custodial sentences for drug-related crime throughout the EU (EMCDDA 2003a).

Drawing a detailed picture of drug use in prisons is difficult in a particular country, and even more so in all European countries. Drug use in prison takes place in extreme secrecy, and drug seizure statistics, the confiscation of needles and syringes and positive urine test rates only indicate some of the full story of drug use behind bars. The patterns of drug use vary considerably between different groups in the prison population. For instance, drug use among women differs significantly from that among men, with different levels and types of misuse and different motivations and behavioural consequences.

The following list summarizes some key information about drug use in European prisons (see overview for the following data: Stöver 2002b):

y The use of illegal drugs in prisons seems to be a longstanding phenomenon dating back to the late 1970s. Needle-sharing at that time was extremely widespread;
y Substances available outside prison can also be found inside prisons, with the same regional variation in patterns of use. The quality of these drugs is often poor compared with that of drugs in the community;

y The prevalence of drug use varies depending on the institution. Some studies have shown that drug use is more prevalent in large institutions, short-stay prisons, women’s prisons and prisons close to a large urban centre. There is less drug use in remand prisons because of the lack of organized trafficking networks;

y In many prisons, the most commonly used drug besides nicotine is cannabis, which is used for relaxation purposes. Some studies have shown that more than 50% of the prisoners use cannabis while in prison. A much smaller percentage reports injecting drugs in prison;

y Several empirical studies indicate that the frequency of use usually declines after imprisonment. This may be due to the reduced supply of drugs or it may reflect the ability of drug-using inmates to reduce or stop drug use while in prison. A minority of prisoners uses drugs daily;

y Imprisonment per se does not seem to motivate individuals to reduce or stop drug use. Reduced drug use appears to be a consequence of the reduced availability of drugs, lack of resources to procure drugs or the fear of detection;

y Some prisoners use drugs in prison to fight boredom and to help them deal with the hardships of prison life or to overcome a crisis situation, such as bad news, conviction and sentencing or violence. Imprisonment thus sometimes seems to provide reasons for taking drugs or continuing the habit or causes relapse after a period of withdrawal;

y In some countries, alcohol and tobacco are the most commonly used drugs among people admitted to prison or already in prison. In France, one third of new admissions say that they have harmful drinking patterns;

y Many countries report changes in the patterns of drug use (volume and type of drug) when the preferred drugs are scarce. Studies and observations of prison officers indicate that switching to alternative drugs (such as from opiates to cannabis) or to any substitute drugs with psychotropic effects no matter how damaging this would be (illegal drugs and/or medicine) is widespread. Due to a lack of access to the preferred drug or because of controls (such as mandatory drug testing), some prisoners seem to switch from cannabis to heroin, even if on an experimental basis, because cannabis is deposed within fatty tissue and may be detected in urine up to 30 days after consumption;

y Some prisoners use the prison as an opportunity to “take a break”, to “recover physically” or to stop using drugs in prison. This time of abstinence is often accompanied by stabilization of general health status (including an increase in weight). Further, many drug users in prisons come from the more disadvantaged groups in society, with a high prevalence of low educational attainment, unemployment, physical or sexual abuse, relationship breakdown or mental disorder. Many of these prisoners never had access to health care and health promotion services before imprisonment. The health care services therefore offer an opportunity to improve their health and personal well-being;

y According to various studies undertaken in Europe, between 16% and 60% of people who injected on the outside continue to inject in prison;

y Needle-sharing and drug-sharing are widespread among prisoners who continue injecting. Although injecting drug users are less likely to inject while in prison, those who do are more likely to share injecting equipment and with a greater number of people. Many were accustomed to easy and anonymous access to sterile injecting equipment outside prisons and start sharing injecting equipment in prison because they lack access to equipment in prison. In the first documented outbreak of HIV within a prison population in 1993, 43% of inmates reported injecting within the prison – and all but one of these individuals had shared injecting equipment within the prison (Taylor and Goldberg 1996);

y Figures from a European study and some national and prison-based surveys indicate that between 7% and 24% of prisoners who inject say that they started to inject while in prison;

y Some prisoners may also discover new substances while in prison (medicines or tablets) or develop habits of mixing certain drugs they did not mix outside;

y Although smoking heroin (“chasing the dragon”) instead of injecting plays an increasing and significant role all over Europe, this route of administration is not widespread in prison because drugs are so expensive in prisons and injecting maximizes the effect of a minimal amount of drugs;

y There is a high risk of acquiring communicable diseases (especially HIV infection and hepatitis) in prison for those who continue to inject drugs and share equipment. Several studies conducted outside penal institutions reveal a strong correlation between previous detention and the spread of infectious diseases. Although injecting drug use in prison seems to be less frequent than in the community, each episode of injecting is far more dangerous than outside due to the lack of sterile injecting equipment, the high prevalence of sharing and already-widespread infectious diseases. Prisons are high-risk environments for the transmission of HIV and other infections for several reasons, including:

- a disproportionate number of inmates coming from and returning to backgrounds where the prevalence of HIV infection is high;

- authorities not officially acknowledging HIV, thus hindering education efforts;

- activities such as injecting drug use and unsafe sexual practices (consensual or otherwise) continuing to occur in prison, with clean injecting equipment and condoms rarely being provided to prisoners;

- tattooing using non-sterile equipment being prevalent in many prisons; and

- Epidemics of other sexually transmitted infections such as syphilis, coupled with their inadequate treatment, leading to a higher risk of transmitting HIV through sexual activity.

y A study carried out in 25 European prisons in 1996–1998 (Rotily and Weilandt 1999) found an overall prevalence of HIV infection of 5.7%, with substantially higher rates in prisons in Portugal (19.7%) and Spain (12.9%). The proportion of prisoners living with HIV is many times higher than the proportion in the general population (for example, 25 times higher in Germany). Rates of hepatitis B virus and hepatitis C virus infection and TB in inmate populations are also generally many times higher than in the population as a whole. Where HIV coexists with TB infection, the annual risk of developing TB disease is between 5% and 15% versus the estimated 10% lifetime risk for those not infected with HIV

y Prisoners often regard certain drugs (especially cannabis and benzodiazepines) as serving a useful function or as helping to alleviate the experience of incarceration. Inmates seem to regard cannabis as essentially harmless. Alongside these attitudes, inmates recognise a need for treatment among those with serious drug problems and were aware of some of the health implications of injecting. They also displayed a possibly exaggerated concern about the problems of drug withdrawal. In the same study, prison officer staff shared many of these attitudes, some commenting on the uses of drugs as palliatives and the relative harmlessness of benzodiazepines and cannabis. Others were concerned about the development of a black market in drugs. In general, staff were acutely aware that the problem of drug misuse in prisons reflected a similar problem in the community;

y Many drug users in prison had no previous contact with drug services before imprisonment despite the severity of their drug problems; and

y After release, many injecting drug users continue with their habit. A study (Turnbull et al. 1991) indicates that 63% of those who injected before prison inject again in the first three months after release. Prison therefore cannot be seen as providing a short- or longer-term solution to individuals’ problems with drugs

Despite many control efforts illicit drugs get into prisons and prisoners consume them. Just as in the community, drugs are present in prisons because there is a demand and a market for them and because there is money to be made selling them. Many prisoners have a history of drug use or are actively using drugs at the time of incarceration. As such, drug users form a particularly over-represented group in the prison population in many countries (Kingma and Goos 1997). A typical profile for the group of drug users finally ending up in prison would include the following characteristics: socially deprived, poly-drug users with several stays in prison, having experienced several treatment attempts with a high incidence of relapse and with severe health problems, including incurable infectious diseases and mental illness (Stöver 2001).

The number of drug-law offences in most EU countries has consistently risen over the past 15 years. As a result, the number of drug users in prisons has increased substantially (Stöver 2001). In addition to those people who enter prison with a history of, or active, drug use, a substantial proportion of prisoners start using drugs while in prison as a means to release tensions and to cope with living in an overcrowded and often violent environment (Taylor and Goldberg 1996).

For many prisoners, the first two weeks following release from prison is particularly dangerous, as many prisoners resume (higher levels of) drug use and are at very high risk of drug overdose. In the week following release, prisoners are about 40 times more likely to die than the general population. In this period, immediately post-release, most of these deaths (over 90%) were associated with drug - related causes (Singleton et al. 2003). Prisoners who have not taken drugs frequently during detention often have difficulty in adapting to the new situation after release. They return to old habits and consume drugs in the same quantity and quality as before prison. The transition from life inside prison to the situation in the community is an extremely sensitive period. The longer a drug user stays in prison, the more difficult adapting to life outside prison will be. Even a prison sentence of only several weeks, during which no drugs are consumed, poses a considerable risk to released drug users: because of a reduced tolerance for opiates, even small quantities can be life-threatening (Stöver and Weilandt 2007).

“In the countries of the European Union, for example, the number of prisoners who report ever having used illegal drugs is between 29% and 86%, with most studies reporting figures of 50% or greater. The number of prisoners actively using drugs during incarceration is between 16% and 54%. These EU studies indicate that figures for drug use are even higher among incarcerated women. 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” (Lines et al. 2006, p. 9).

The health threats prison health care services are facing also affect public health, because drug using inmates are often serving short term sentences and then return to society, to their partners, their children and their families and may transmit blood borne infections into the wider community (WHO et al. 2001a). The following problems are arising from the above described situation:

y High risk behaviour (e.g. sharing of injection equipment, unprotected sexual contacts; and tattooing/piercing) is widespread as needles and syringes are contraband and thus scarce in the prison setting; sexual relationships are a taboo.
y Blood borne infections (e.g. HIV, Hepatitis B and C) that are transmitted among drug users by unsafe injections, sexual practices, tattooing and piercing are massively over represented in prisons compared to the community (CEEHRN 2007; Laticevschi 2007; Lines 2007).

y The prevalence of drug use and sharing injection equipment among incarcerated women is higher than that among incarcerated men (Stöver and Lines 2006).

y Juveniles and migrants are at particular risk to acquire infectious diseases, as they often have a poor understanding of the nature and character and the dynamics of infectious diseases in closed settings (EMCDDA 2003a).

y A substantial number of drug users report having first started to inject while in prison Studies of drug users in prison suggest that between 3-26% first used drugs while they were incarcerated and up to 21% of injectors initiated injecting whilst in prison (EMCDDA 2003a).

y Drug related deaths in prisons and shortly after release as well as suicide attempts, self harm and several other drug use related diseases (mental illnesses, STIs, TB, etc ) are higher than outside prisons walls (Bird and Hutchinson 2003; Bird et al. 2003; Christensen et al. 2006).

y Prison staff is at risk to get infected with blood borne diseases while searching cells or by accidental needle stick injuries (Bögemann 2007).

y The opportunities for treating drug abuse and dependence and the related diseases (such as anti-retroviral and antiviral treatment) are limited in comparison to services in the community. Often only organisational measures are taken (drug free wings/zones) in order to allow prisoners to be separated from drug using inmates.

y Prevention strategies (e.g. vaccination) are often not pro-actively offered to the inmates in most of the countries. In many countries education and information towards drug use is reduced to the transfer of knowledge. Approaches successfully applied and widespread in the community such as harm reduction

(e.g. provision of condoms and sterile needles and syringes) are not implemented in most prison settings and are discussed controversially (WHO Europe 2005b).

y Health services in most countries are under the responsibility of the Ministry of Justice and are organisationally separated from the health service in the communities. This leads to problems in cooperation and communication among services (see Moscow Declaration: WHO 2003).

y Drug-related diseases, injuries and violence are causing costs to society in the health, welfare, employment and criminal justice sectors in EU 27 but the cost figure cannot be calculated.

y Several studies show that effective aftercare for drug using prisoners is essential to maintain gains made in prison-based treatment. Despite this widely acknowledged fact, prisoners often have difficulties in accessing treatment on release under community care arrangements.

y There is an obvious lack of systematic documentation and research on health
issues in European prisons. Health reporting systems are not systematically
applied in prisons. There are only few reliable data and information available on
prevalence and incidence of infectious diseases, patterns and frequency of drug
use, risk behaviour, and accessibility of prevention and care efforts and efficacy
and efficiency of services used.
y Prisons and prison staff tend to understand illicit and non-prescribed drug use as
a delinquent act to be punished. Any attempts to reduce the risks of continued use
are viewed as supporting a prohibited behaviour and therefore unwelcome. Strict
prohibition and rigid controls are regarded as the only acceptable prevention, and
abstinence as an enforceable behaviour (Uchtenhagen 2006).

The promotion of health in prisons can make a major contribution to national strategies for tackling the problems of drugs in society (WHO and Council of Europe 2001, p. 1).

In 1988, the WHO Regional Office for Europe (1990) developed recommendations for managing health problems of drug users in prisons. Since then, other efforts to address problems related to drug use in prisons have been undertaken, including efforts to tackle drug users’ health problems in juvenile (MacDonald et al. 2006) and adult prisons and the whole criminal justice system (WHO et al. 2001b). Starting in 1995, the WHO Health in Prisons Project (WHO) has addressed issues related to drug use in prisons.

5.2. Prevalence of risk behaviour related to transmission of blood-borne viral infections

Independent of drug use there is a number of behavioural patterns which comprises high risks of transmitting BBVs. This includes unprotected sex, tattooing, piercing, and other possible contacts with body fluids. As these risk behaviours can be in particular associated with vulnerable group of drug users, this adds to their existing risk behaviour.

5.2.1. Unprotected sex in prisons

Unprotected sexual contacts between prisoners pose a risk for the sexual transmission of HIV, Hepatitis and other sexually transmitted diseases. Within penal institutions, sexual contacts occur in different ways, and in varying frequencies. Sex may be consensual, or it may be forced or coercive. Sex may also be used as a form of currency within the prison and exchanged for money, protection, property, or drugs. Violent forms of unprotected sexual anal or vaginal intercourse, including rape, carry the highest risk for transmission HIV, particularly for the receptive partner who is more likely to suffer damage or tears in the membranes of the anus or vagina (Betteridge 2004).

Same-sex sexual activities are the most common forms of sexual contacts in prisons. Although homosexuality has been decriminalised in many countries, significant stigma is still attached to same-sex sexual activities (particularly male homosexuality) in many societies and in many prison systems. This stigma can lead to discrimination by other prisoners and staff members. Men having sex with other men in particular may be subject to violence, discrimination, and social exclusion. These negative consequences can make sexually active male prisoners even more vulnerable to HIV infection by deterring them from accessing safer sex measures such as condoms (in prisons that provide them) for fear of identifying themselves as sexually active. Many prison systems maintain prohibitions against any sexual activity (whether consensual or non-consensual) that can also create barriers to prisoners accessing safer sex measures such as condoms.

The prevalence of sexual activity in prison is influenced by factors such as whether the accommodation is single-cell or dormitory, the duration of the sentence, the security classification, and the extent to which conjugal visits are permitted. Given the stigma in most societies against same-sex sexual relationships, levels of sexual activity among prisoners are difficult to estimate with any accuracy as these relationships (whether consensual or forced) generally occur in secrecy. Risk behaviour studies within prisons may also under-record the true amount of sexual activity, as many prisoners may be reluctant to disclose same-sex sexual behaviours to researchers. Dumond (2006) found that only a small minority of victims reports rapes to prison authorities (96 of 2,000 rapes reported): “In some ways, the victim is in a no-win situation” (Dumond and et al. 2006, p. 5). Only a few percent of correctional officers charged with direct supervision believed that rape was a rare occurrence. Staff may respond poorly or blame the victim (Jürgens 2007).

That said, several studies have provided evidence that significant rates of risky sexual behaviour occur in correctional settings. Studies of high – risk behaviour show widely varying estimations of the proportion of male inmates who have sex with other men (see Okie 2007). They range from 2 to 65% and estimations of the proportion of those who are sexually assaulted range from 0 to 40% (Krebs 2006). A study conducted among 373 male prisoners at all of South Australia’s prisons (Gaughwin et al. 1991) concluded that 12% engaged in anal intercourse at least once. Another study in South Australia (Douglas and al. 1989) reported that prison officers and prisoners estimated that between 14% and 34% of prisoners engaged in ‘occasional anal intercourse’. The European Network on HIV/AIDS and Hepatitis Prevention in Prison found rates for sexual intercourse among men in prison of between 0.4% (Sweden), 1.4% (Austria) and 5% (Spain). The rates of condom use for the last intercourse were between 0% (Belgium) and 30% for Spain (Rotily and Weilandt 1999). In the Austrian contribution to that Network study (Spirig and et al. 1999) it was found that 2.8% of the men stated that they were raped in prison, 1.4% stated that they had sexual intercourse with another man in prison, no one stated they had accepted payment for sexual intercourse, and no one stated they had used a condom. The nature of the prison’s physical environment (i.e., individual cells, shared cells, shared living units, dormitories, and barracks) can have particular impact on levels of coerced sexual activity, sexual abuse, and rape. Prison policy that allows children and young people to be housed with adults can also increase the vulnerability of young prisoners to sexual abuse. Staffing levels and levels of supervision of prisoner living areas can also have an impact on levels of sexual activity, both consensual and coerced. Although most sexual contacts in prisons are same-sex activities, heterosexual contacts may also take place. These may occur between prisoners and prison staff (which may be coercive in nature, particularly for female prisoners) or during prison visits (whether or not such visits are officially “conjugal” in intent).

5.2.2. Tattooing and body piercing

Tattooing amongst prisoners is a common practice in many countries. Research has revealed high levels of tattooing among prisoners in countries including Australia (Dolan et al. 1999), Canada (Correctional Service Canada 1996), Ireland (Long and et al. 2000), Spain and the United States (Dolan 1999).

Because tattooing involves breaking the skin with a needle, it is an activity that poses a risk of transmission of blood-borne diseases though the sharing and reuse of tattooing equipment such as needles and inks – both of which come into contact with large amounts of blood during the tattooing process7. Tattooing and the possession of tattooing equipment are prohibited by prison authorities in many countries, and those found to be engaging in tattooing are subject to punitive sanctions. As a result, tattooing is an activity that takes place secretively, often in unhygienic environments, using homemade equipment and inks, and as quickly as possible so as to minimize the risk of detection by prison staff. All of these factors increase the risk of negative health consequences via tattooing in penal institutions (Bammann and Stöver 2006).

Conclusive clinical evidence of HCV or HIV transmission via tattooing is elusive. One of the barriers to demonstrating a clear causal relationship between the transmission of blood-borne disease and tattooing, particularly among prison populations, is the very high level of injecting drug use history among this group. It therefore becomes difficult to identify conclusively whether the source of infection was tattooing or syringe sharing. However, despite a lack of definitive evidence, there is significant anecdotal evidence of blood borne disease transmission through tattooing (inside and outside prisons), as well as a body of scientific opinion identifying the potential health risk when tattooing occurs in a non-sterile environment. Several studies of prison populations have found evidence linking tattooing to the transmission of blood-borne

7 See also Resolution ResAP(2003)2 on tattoos and permanent make-up/ COUNCIL OF EUROPE COMMITTEE OF MINISTERS (https://wcd.coe.int/ViewDoc.jsp?id=45869) - (Adopted by the Committee of Ministers on 19 June 2003 at the 844th meeting of the Ministers' Deputies)

diseases in prisons (Estebanez Estebanez et al. 1990; Holsen et al. 1993; Thompson and et al. 1996; Post and al. 2001; Samuel et al. 2001).

On the related issue of body piercing, a review of various studies on the relationship between piercing and hepatitis transmission concluded that eight of twelve studies identified percutaneous exposure, including body piercing and ear piercing, as a risk factor for viral hepatitis. Six of the studies found that hepatitis seropositivity was significantly associated with ear piercing (Hayes and Harkness 2001).

There are still other risks for transmitting infections in prison; Exposure to human blood and body fluids (if infected with HIV/HCV) has the potential for transmitting infections. Within prisons, both prisoners and prison staff may be exposed to human blood or other body fluids as a result of

y assaults and fights (which can lead to open wounds and bleeding)
y accidental needle stick injuries from hidden or concealed syringes
y carrying out professional duties (as is the case with medical staff)
y providing first aid.

5.2.3. Injecting drug use and communicable diseases

In Europe the HIV prevalence among prisoners is primarily related to the sharing of injecting equipment inside and outside of prisons. Sharing syringes among intravenous drug users is a high-risk activity for the transmission of HIV due to the residual presence of blood in the syringe after injecting (Shah et al. 1996; Shapshak et al. 2000). Given the secure environment of penal institutions, it is often more difficult to smuggle syringes into prisons than it is to smuggle in drugs (Lines 2002b; Lines 2002a). As a result, syringes are typically scarce, and prisoners who inject drugs share and reuse syringes out of necessity (WHO 2004a). For people who inject drugs, imprisonment therefore increases the risk of contracting blood-borne infections such as HIV, through sharing needles.

In a prison, a syringe 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, is rendered totally unusable or is confiscated by prison staff (Lines 2002b; Lines 2002a). Sometimes the equipment used to inject drugs is homemade, with syringe substitutes fashioned out of available everyday materials, often resulting in additional vein damage, scarring, and injecting-site and other infections.

Injecting drug users (IDUs) in prisons are a far from homogeneous population, but one that comprises various subgroups that can benefit from targeted interventions:

y those who inject on the outside but not in prison; There are obvious risk differences among these groups, especially for infection through contaminated equipment; for example, the renters are clearly at higher risk than the independent injectors. Moreover, all these groups will also contain both HIV-positive and HIV negative people, whose needs will often be different. HIV prevention programmes need to adjust their messages accordingly.

y those with no previous history of injecting (approximately 5–10% of all IDUs start injecting while in prison);
y those who smoked drugs like heroin in the community but inject in prison, mostly for reasons of economy and efficiency;
y those who have a history of injecting in prison but no longer do so, having identified and resisted high-risk behaviour (similar to the first group);
y occasional injectors, for whom the behaviour may be opportunistic, recreational or impulsive;
y independent injectors, who are disciplined about risk reduction and have their own injecting equipment that they will not share or lend;
y closed-circle injectors, who share equipment only within their own group, whether to reduce risk or to avoid detection by prison officers;
y renters, who rent injecting equipment from others for money, drugs or favours; and
y hirers, who own injecting equipment and rent it out for a fee or service (Shewan et al. 2005).

The high rates of injecting drug use, if coupled with lack of access to prevention measures, can result in frighteningly rapid spread of HIV. There were early indications that HIV could be transmitted extensively in prisons. In Thailand, the first epidemic outbreak of HIV in the country probably began among injecting drug users in the Bangkok prison system in 1988. Six studies in Thailand found that a history of imprisonment was associated significantly with HIV infection. HIV outbreaks in prison have been documented in a number of countries, including in Australia, Lithuania, the Russian Federation and Scotland (Stöver et al. 2007).

Studies conducted in various countries illustrate the degree to which drug use occurs in prison.

A national study in the US of 25,000 people who inject drugs found that approximately 80% had been in prison at some time (Dolan and et al. 1999). A 1995 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 injecting drug use, with the majority experiencing incarceration on multiple occasions (Ball and al. 1995).

This is not to say, however, that prison has no effect on patterns of drug injecting. In fact, research has demonstrated that incarceration affects patterns of injecting and decisions about injecting in various ways, often with the result of increasing the risk of transmission of HIV and other blood-borne diseases. For example, while people who inject drugs typically inject less frequently in prisons (Shewan and al. 1996), studies have found that injecting tends to take place in a more “high-risk” fashion than injecting outside of prisons (Darke et al. 1998; Malliori et al. 1998). Drug users often choose to inject in prison when they would not normally inject outside prison, and networks of drug users who share injecting equipment can be larger in prisons than outside prisons (Long 2003; see for overview: Lines et al. 2006, p. 10). As stated by UNAIDS:

“Long experience has shown that drugs, needles and syringes will find their way through the thickest and most secure of prison walls,” (UNAIDS 1997, p. 6)

Research has revealed a number of factors that encourage drug injecting among prisoners, or the switch to injecting among non-injectors. The inconsistent or scarce supply of drugs such as heroin is one. Because injecting is a more efficient means of drug consumption, resulting in less waste, it has been shown that some heroin smokers will elect to inject heroin rather than smoke it while incarcerated. The prison economy may also prove a factor, and provide an incentive for prisoners who “own” a syringe to rent it or trade it to others in exchange for drugs (Long 2003).

In addition to the extensive evidence of high risk behaviours among prisoners in many countries, there is also documented evidence of the transmission of HIV, as well as blood-borne infections such as HCV, within prisons (see with more details Stöver and Lines 2006).

And there are still other drug-related problems occurring in prisons, which are not the topic of this report, such as

y overdose
y drug related death after release
y suicide
y self-harm
y tuberculosis.
5.3. Environmental and institutional risks

There is a range of risks occurring in prison because of the special secluded and secured environment. All these risks can affect the health and/or social situation of the prisoners.

y overcrowding

y discontinuity of care and treatment (post and pre)

y psychiatric co-morbidity

y drug free orientation

y discrimination

y violence (against minorities)
y mothers and children
y sexual violence (US-Act)
y food and sport

Worldwide over 9.25 million people are held in penal institutions – almost half of these in the US, Russia or China (Walmsley 2006). In the 27 European Member States more than 600.000 people are incarcerated in prisons on a given day. The prison population in the member states of the European Union comprises 558.025 prisoners (including pretrial prisoners) on 1st September 2004, while 40.085 persons in Romania and 10.935 persons in Bulgaria, were in prison at that time (Council of Europe 2004). The turn over rate is estimated to be at least threefold, which means that around 2 Mio people pass EU-custodial institutions annually. In average, the prison population rate per 100.000 inhabitants in the European union is 121,6 (with large variations between 56,4 in Slovenia and 337,9 in Estonia). In average, more than 5% of the prison population are female prisoners (for details see chapter 3).

Prison conditions are integrally linked to the physical health and mental well-being of prisoners. Poor living conditions can contribute to an increased risk of HIV transmission in prisons and a decline in the health of prisoners living with HIV/AIDS. First, substandard conditions can increase the risk of HIV transmission by promoting and encouraging drug use, (which usually involve unsafe injecting practices) to escape boredom or stress. They can also contribute to the increased risk of prison violence, sexual coercion and rape. Secondly, among prisoners living with HIV/AIDS, poor conditions can increase vulnerability to a decline in health by exposing them to contagious diseases and opportunistic infections; placing them at risk for dual infection with either TB or hepatitis; housing them in unhygienic and unsanitary environments; confining them in spaces that do not meet basic needs for size, natural lighting, and ventilation; failing to provide them with proper diet, nutrition and/or clean drinking water; and housing them in overcrowded, high-stress environments. Minimum standards for the housing and treatment of prisoners are defined by international agreement, yet many prison systems in Europe – whether in high-income countries or countries in economic transition – fail to meet these standards, due to strained financial resources and/or a lack of political and public interest in the well-being of prisoners. Failure to improve such confinement conditions can undermine the effectiveness of HIV/AIDS programmes and strategies (Lines et al. 2004a; MacDonald 2005).

The discrepancy between treatment need and receiving of treatment is an issue underlined in several studies. Most details on treatment assessments are provided by the report of the Home Office (Home Office 2003). 40 % of the total sample received help for drugs in prisons mainly detoxification and counselling. In addition 42 % of the women sought help for emotional or mental health problems by a prison doctor or psychiatrist. Not even half of those women in need received treatment and a number of those who did were not satisfied with the help they got. The most common cause of dissatisfaction was the length of time to see the doctor or to receive treatment. In the European study of Dünkel, Kestermann et al. (Dünkel et al. 2005) did 17 % to 29 % of the women prisoners undergo drug treatment. The need for this kind of treatment reported 20 % to 35 % of the women. This gap is even more alarming regarding psychological treatment needs. Only 11-20 % of the women received psychological treatment although 14-37 % of the women said to be in need for this treatment. Women with drug problems and severe depression showed an even higher need for psychological treatment which was up to 56 %.

The results clearly demonstrate that treating of mental illness is inadequate as psychiatric services do not meet the extent of the women’s need.

International literature shows that the number of ex-prisoners relapsing after release and becoming re-imprisoned is high and even increasing. Most studies found gender differences in terms of fewer women than men who re-offend after release but evidence suggests that reconviction rates for women tend to be the same proportion as adult males (Commission on Women and the Criminal Justice System 2004).

As regards gender differences a study from Finland reveals that of 30.000 individuals 59 % returned to prison during five years after release. Men re-offended more often (59 %) than women (45 %) (Hypén 2003). Similar recidivism rates for men and women are reported from Queensland, Australia (Walsh 2006).

Re-offending rates seems especially high for drug using prisoners. A review of seven studies on imprisoned drug users found that levels of re-offending post-release were significantly higher for drug users (62 %) than for abstainers (36 %) (Ramsay 2003b).

International research identified several reasons for the consistent fact that a majority of the prisoners re-offend after release. When summarising the main given reasons, relapses after release are related to

y substantial minorities of drug-using prisoners that received treatment (Ramsay 2003b),
y an insufficient preparation for release and the lack of someone who meets the prisoner at the gate upon release (Walsh 2006) and
y a persistent drug problem and a low self-efficacy to remain abstinent in high-risk situations(Pelissier and Jones 2006).

In addition deprived living conditions increase the likelihood to relapse after release. According to a recent study on gender differences in predictors of criminal recidivism (Benda 2005) childhood and recent abuses, living with a criminal partner, selling drugs, stress, depression, fearfulness, and suicidal thoughts are stronger positive predictors of recidivism for women than for men.

The findings highlight the importance of a health and social policy addressing the women’s lives by providing drug treatment, mental health care, welfare benefits, housing, education, and employment. Addressing the realities of women prisoners through gender-sensitive programmes is fundamental to prevent relapses and to improve their resettlement in community (Bloom and al. 2004).

Last not least the destructive impact of imprisoning mothers underline the need for new pathways in handling female offenders (Zurhold et al. 2005).

5.3.1. Overcrowding and the over-representation of risk groups

Despite several attempts to improve the situation, nearly all prison services in the EU Member States are reporting overcrowding (Walmsley 2003; Walmsley 2006). A majority of 16 countries plus Bulgaria and Romania show a prison density per 100 places between around 90 and about 120. The highest rates can be found in Cyprus, Greece and Hungary (160,6 to 144,9) and the lowest in Malta (62,6). The EU average prison density is 109,6, indicating a general tendency of overcrowding in the prisons throughout the European Community (Council of Europe 2004). This represents institutional/environmental risk factors for prisoners.

Prisoners are a vulnerable group coming from vulnerable sectors of society with high unemployment rates, low levels of education and poor health (Møller et al. 2007). Generally in many countries the number of prisoners has dramatically increased over the two last decades (Stöver and Weilandt 2007). The EMCDDA estimates that at least half of the EU’s prison population has a history of drug use, many with problematic and/or injecting drug use (EMCDDA 2003b). Only limited data are available about the exact percentage of injecting drug users. As already informed, the EMCDDA estimated in 2006 that the prevalence of injecting drug use among prisoners in Europe is between 7 % and 38 %, which shows that the spread of problematic drug use is varying widely throughout the countries and differs even within the country from one prison to the other. Drug use is seen as one of the main problems of the current prison system that threatens security measures, is dominating the relationships between prisoners and staff and leads to violence and bullying for both prisoners and often their spouses and friends in the community (Restellini 2007).

Research has demonstrated the detrimental impact of overcrowding in prisons, in relations to security issues and also on prisoners’ health and access to other services such as education, work and visits from family members and other external organisations. With regards to prisoner health, overcrowding presents additional risks for prisoners with HIV or other infectious diseases, as they often experience poor nutrition, limited access to treatment and are also often engaged in high risk behaviours such as injecting drug use, sexual activity and tattooing (Tkachuk and Walmsley 2001; Lines et al. 2004a; WHO 2005b). Overcrowding in prisons has also been shown as a key factor in increasing levels of self-harming and suicide among prisoners, higher prevalence of mental illness among prisoners and also as having a detrimental impact on resettlement and rehabilitation strategies (Howard League for Penal Reform 2001).

6. Prevention, treatment, care and support of drug users in prisons

In this chapter interventions for drug users in prison are described. These interventions can bee seen under three big headlines: prevention, treatment and harm reduction. They correspond to the three levels of prevention in a public health context. In which prevention in a prison setting can be referred to primary prevention (chapter 6.1 to 6.3), treatment to secondary prevention (chapter 6.4. to 6.7) and harm reduction (chapter 6.8 to 6.13) to tertiary prevention. Furthermore in the last two chapters 6.14 and 6.15 we focus on pre-and post release programmes and training of prison staff.

Within this chapter we aimed at giving information on the evidence of effectiveness. As there is hardly any research which meets the criteria of high-ranking evidence (RCT) we included all kinds of studies into this review. Whenever a review on a special topic was undertaken already, we usually did not review the cited studies again but relied on the existing reviews.

Generally speaking, the research situation on treatment effectiveness for drug users in prison varies greatly. The studies included on the evidence of effectiveness come from all available countries. A rather huge number of studies come from the US and also from Australia, in particular higher-ranked research. In the field of testing for infectious diseases and vaccination, and care for prisoners with HIV/AIDS and Hepatitis as well as pre- and post-release programmes the main research comes from the US. Whereas programmes on harm reduction measures as well as on drug testing are predominantly from European Studies. The origin of studies is indicated within the individual chapters.

Generally the interventions for drug and alcohol dependence vary greatly throughout Europe and ranges from 12 Steps programmes to acupuncture, therapeutic communities and methadone provision, cognitive-behavioural methods and educational programmes (Harrison et al. 2003; Merino 2003). In order to survey drug programmes in the criminal justice system in the EU, 36 programmes had been analysed by Merino (2003). As regards the objectives of prison-based programmes the analyses reveals that crime reduction along with early intervention is most common (24 %; 23 %). These objectives are followed by harm reduction (19%) and social integration (14%). In addition drug-free programmes, psychotherapy, drug-free areas and counselling are key services for crime and demand reduction. At least for the USA there are less often evidence-based practices offered in prison than in the community, which might be similar for Europe, as there is not much research on the evidence of effectiveness (Friedmann et al. 2007).

However, it is important to accommodate those prisoners who are not motivated or able to stop using drugs, but do need to better understand how to reduce the harms associated with drug use. Research has highlighted the need for treatment providers, in any setting, to identify the needs of clients and their goals, whether this be maintenance or abstinence, and provide support in accordance with this (Marlatt et al. 2001; Stöver et al. 2004). All in all it can be stated that “Positive experience from in-prison treatment helps inmates to continue treatment after release, reduce relapse rates and related health risks, and also reduce delinquency recidivism” (Uchtenhagen 2006).

In the UK the Department of Health has published a guide on clinical management of drug dependence in the prison setting, which should be developed accordingly (Department of Health 2006).

6.1. Testing of infectious diseases and vaccination

Testing of infectious diseases and vaccination in a prison setting is significant factor to ensure the prisoners health during incarceration and to ensure the health of their families and friends after discharge. Therefore not only the individual risk but the public health aspect has to be put in the fore hold. Besides, the knowledge of an infectious disease is a prerequisite to organize and receive the appropriate care (WHO et al. 2007b)

According to the WHO database on disease in prison elaborated by the WHO disease testing mostly takes place on admission rather on release, with the exceptions of Estonia, Finland and Lithuania where HIV is tested both on admission and on release. In Lativa, Luxembourg and Belgium half of the prisoners are tested for infectious diseases (WHO). If there is mandatory HIV testing in prison, the patient confidentially needs to be addressed cautiously. This is from particular importance if the test revealed a positive result (MacDonald et al. 2006).

As it has been stated earlier prisoners are a high-risk group for acquiring infectious diseases. In several European countries (e.g. the United Kingdom, Germany, the Czech Republic) vaccination for prisoners is recommended. Vaccination of HBV takes more often place than vaccination for HAV. This seems to be the case for central and eastern European countries (CEEHRN 2007) and for western European countries.

From the available literature there is no indication for other vaccinations in European prisons such as tetanus vaccine, live measles, mumps and rubella vaccine or influenza.

prisons. Due to the high turn over rates, screening and vaccination for HAV and HBV often remain incomplete. As Hepatitis B infection may constitute a severe co-infection to HIV/AIDS the risk of acquiring an infection in prisons may be reduced by a vaccination both for prisoners and for staff.

Similar to drug testing (see following chapter) testing for infectious diseases in prisons is rarely evaluated. Testing for infectious diseases includes testing for blood-borne diseases such HIV, HCV, HBC and HAV, but also for TB and for STD such as syphilis (Bick 2007).

The consciousness of HIV status is essential for receiving the adequate care, treatment and support. There are major differences upon access to voluntary HIV testing. Also there are still differences in the way HIV tests are offered: voluntary or mandatory.

It has been shown, that offering HIV test voluntary resulted in a large number of prisoners accepting HIV testing and counselling. Liddicoat and colleagues (Liddicoat et al. 2006) showed that offering HIV test upon incarceration combined with a brief group counselling and a private informed consent significantly increased HIV testing rates compared to a historical cohort. In the intervention group 73,1% accepted HIV testing, whereas in the control group only 18% accepted (73,1% vs. 18%; p<0,0001).

This result was also shown in an earlier study undertaken in Wisconsin, USA, were in three consecutive years a blinded sample followed by a voluntary sample were assessed. The emphasis of this study was laid on possible bias that persons at risks systematically deterred from voluntary testing. This hypothesis could be refuted, because the total number of IDU did not increase (Hoxie and al. 1990).

It is known, that mandatory HIV testing and segregation are counterproductive (Jacobs 1995). Besides testing in an environment in which a great number of persons at high risk are assumed fails to reach a sizeable number of HIV-infected individuals [Jenkins, CDC].

One way to encourage voluntary testing, as proposed by Bausermann et al (2003), is offering oral tests to inmates.

The majority of the European countries perform HIV tests on admission. From those countries the majority performs voluntary test. But there also countries in which HIV testing is mandatory (The Netherlands (since 2006) for all risk groups, Cyprus (since 2006)(WHO).

Testing for infectious diseases does not only apply to testing for HIV also for Hepatitis and for sexual transmitted diseases. The entrance in the prison poses a good opportunity to test prisoners for Hepatitis. There are various forms in which this is done, upon request, testing only prisoners at risk or routinely testing all prisoners. All viral hepatitis forms present a major challenge to the prison health systems (Spaulding et al. 2006), therefore screening and vaccination are ways to face and handle this problem.

Hepatitis B vaccination has been widely integrated and evaluated in the Scottish and England prison system. It has been shown, that with the implementation of a HBV vaccination program in the Scottish prison service in 1999, the uptake of at least one dose of HBV vaccine had more than tripled (16% to 52%) compared to recent initiates to injecting drug users.

In England two large HBV vaccination campaigns were launched in 2001: 41 jails participated to target the large number of individuals that pass through the prison system. To expand the effectiveness of the program the campaign was extended to all prison sites including female and young offenders’ prisons (Gilbert et al. 2004a). The overall aim of this vaccination program was to increase the coverage of HBV vaccination within the group of IDUs by 20%. It was shown that the proportion of self-reported vaccine uptake rose between 1998 and 2004 from 27% to 59% (adjusted OR=3,7; 95% CI: 3,2-4,3). In an attendant survey it was revealed that the greatest proportion of the IDUs received the vaccination in prison. The authors concluded that achievement of an increase of 20% coverage of HBV was highly attributed by prisons (Hope et al. 2007). Although it had been stated that HBV vaccination in prison can have an affect on the prevalence of HBV in the general population (Sutton et al. 2006), this has not been shown yet. Nevertheless various studies has been shown, that the prison setting is good opportunity to prevent HBV infection by vaccination (Hammett 2003; Kuo et al. 2004; Weinbaum et al. 2005).

Similar to HBV every prisoner should know their hepatitis A status and should be offered vaccination (Bick 2007).The risk of acquiring HAV is not as high as for HBV and the complication risk is low. There is only one HAV epidemic in prison described in the literature, which occurred in Queensland, Australia (Whiteman et al. 1998).

After an increase of HAV cases was observed in South Yorkshire, again in England a community-based HAV vaccination program was set up and hereupon expanded into the prisons system. This step showed a significant impact on the incidence of HAV in the community (Gilbert et al. 2004b).

To sum up, vaccination against HAV should be offered to prisoners at risk (Neff 2003) (Whiteman et al. 1998) whereas HBC vaccine (Kuo et al. 2004; Sutton et al. 2006) should be made available for all prisoners.

Screening for TB can be done in three different ways: systematic screening latent or active tuberculosis with the Mantoux test, systematic screening of all jail inmates by x-ray or systematic screening with skin tests. Whereas the sensitivity of the latter is rather low with 10-15% false-positive results. Regardless of what kind of test used, it is important to screen incoming inmates with active signs of TB (Niveau 2006)

Table 4: HIV testing and vaccination

Study Quality Main results
Liddicoat et al, 2007 C In this evaluation study carried out in Boston, MA., USA, 1,004 inmates were offered routine, voluntary HIV testing. 734 (73.1%) accepted; 2 (0.3%) were HIV positive. The testing rate of 73.1% was significantly increased from the rate of the control period (p<0.001).
Hoxie et al, 1989 C From 1986 to 88 voluntary and blinded HIV testing was conducted among Wisconsin, US, male prison entrants. HIV seroprevalce was 0.30% in 1986, 0.53% in 1987, and 0.56% in 1988.Voluntary HIV testing was accepted by 71% of male prisoners.
Hope et al, 2007 C Hepatitis B immunization among IDUs is strongely recommend. In England, the Department of Health, aims to expand the coverage by 20%. Therefore a in 2001 a vaccination programme for prison inmates in England was instigated. A significant rose from self-reported vaccine uptake from 27% in 1998 to 59% in 2004 (OR=3.7; 95%CI:3.2-4.3). In a following, aiming at locating the source of the received vaccine, prisons were the most common sources followed by drugs services and general practioners.
Gilbert et al, 2007 C In South Yorkshire an increase in cases of hepatitis A was observerd. A community-based vaccination programm did not yield at any success. By implementation of the vaccination campaign in the local prison, vaccinating 1,236 prisoners, the notification of cases of hepatitis A from South Yorkshire ceased.

6.2. Drug testing

Drug testing is the testing of individuals for their drug use. The aim of drug testing is to deter drug use in the prison, to identify drug users and to provide information on the level of drug use and the type of drugs used (MacDonald 1997). The testing in prison is usually done by urinalysis, other possibilities would be hair or blood analysis. The frequency as well as the mode of testing can vary considerably: on admission and/or release, before/after holidays or weekend leaves, by suspicion of drug consumption, per random routine, mandatory for all prisoners or only subgroups (Dean 2005).

Drug testing is conducted in virtually all European countries, but the mode and frequency of testing as well as the aims associated with it varies greatly. For example in Cyprus and Malta random drug testing is done in all prisons as well as on admission, by suspicion, and before holiday leave. In some countries, mandatory drug testing is conducted in a few prisons, e.g. in Ireland, while in Latvia drug tests are mainly conducted by suspicion. Other countries like Belgium and Poland only use drug tests in a few prisons or only in medical services when needed (see for details country reports in Annex). In England, Wales and Scotland, mandatory random drug testing has been introduced in 1995 and was discontinued in Scotland in 2005, while giving additional days for positive tests was discontinued already in 2002 (Dean 2005).

Drug testing is very rarely evaluated. The most discussed form of testing is the mandatory drug testing. Some research has been done on the programme of mandatory drug testing in England, Wales and in Scotland. A pilot trial was conducted in 1994/95 in eight prisons and continued afterwards in all prisons in the country.

Mandatory drug testing is one factor found to influence drug-use patterns in prisons. It may decrease or alter drug use due to the fear of detection and sanctioning (Edgar and O'Donnell 1998; Prendergast et al. 2004a; Scottish Prison Service 2000, cited in Dean 2005). But mandatory testing can also have unintended outcomes; In the English pilot trial the percentage of positive tests for opiates and benzodiazepines rose from 4.1% to 7.4% (Gore et al. 1996). A survey among prisoners and staff concluded mandatory drug testing to be counterproductive, especially without adequate follow-up like treatment and counselling programmes. It can also increase the tension inside prison and deflects attention from other important issues (MacDonald 1997), as shown by the number of assaults increased by 20% from 1993 to 1995 (Gore et al. 1996). For this programme also a cost analysis was conducted. Although some forms of drug testing can give a good estimation on the prevalence of drug use (Gore et al. 1999; Fraser and Zamecnik 2002; Harrell and Kleiman 2002), even if not all users will be detected (Edgar and O'Donnell 1998), other studies claim that mandatory drug testing seriously underestimates the prisoners need for harm reduction (Bird et al. 1997). Rather high costs especially for punishment of refusals and for cannabis testing were found. Costs of a compulsory drug testing would be twice as much as a rehabilitation and drug reduction programme at the time of the study, and less beneficial (Gore and Bird 1996). The additional days given as punishment for drug offences in England and Wales in 1997 amounted to an extra 360 prisoners places per year (HM Prison Service 2003).The cost for this additional time to the prison sentence was estimated at seven million £ in 1998 (Edgar and O'Donnell 1998).

Prisoners with a positive test result 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, in England up to 28 additional days in prison (Hughes 2000a), only seldom treatment and rehabilitation are offered to those tested positive (Dean 2005). Therefore, there is a great incentive for prisoners who use illicit drugs to avoid detection. While urinalysis can detect the presence of drugs in urine, some drugs clear the human body in relatively short order

(e.g. heroin in about three days), while other drugs remain detectable for much longer periods of time (e.g. cannabis for up to 28 days), so this is a particularly significant factor in the context of the transmission of blood-borne diseases in prisons (e.g. MacDonald 1997; Jürgens 2002; Lines et al. 2006, p. 9). Therefore, it is logical that some prisoners choose to inject drugs (with serious public health impacts) rather than risk the penalties associated with smoking cannabis (which has a negligible public health risk) simply to minimise the risk of detection and punishment. Anyway, given the scarcity of sterile needles and the frequency of needle sharing in prison, the switch to injecting drugs surely has devastating health consequences for individual prisoners, as almost every injection is infection relevant. Such a conversion from soft drugs to hard drugs has been found in Zurich, Switzerland (according to Gore et al. 1996) as well as in the above-mentioned pilot trial in England and Wales (Edgar and O'Donnell 1998). As the difficulties of mandatory drug testing can be serious, not only regarding the transmission of diseases but also the tension inside the institution, such programmes, if needed at all, should always be linked with adequate treatment and counselling programmes (MacDonald 1997), but to this inmates might fear sanctioning and therefore don’t approach staff (Hughes 2000a). The form and mode of drug testing should be carefully considered and research recommends that resources should be shifted from mandatory testing to other interventions (e.g. Gore and Bird 1996; Dean 2005).

Table 5: Drug testing

Study Quality Main results
Dean 2005 F Scottish research on MDT: Especially suspicion testing leads to resentment among prisoners. Provision of Mandatory drug testing will not combat the problem of drug misuse. Results of drug testing in 2004/05: 22% with random testing positive, 46% on suspicion, 50% on liberation. 21% of all prisoners tested positive while in custody but estimated 71% of arrestees are drug users. On admission drug use has decreased as a result of testing.
Edgar and O’Donnell 1998 survey 148 prisoners and 146 staff in England interviewed. Prevalence of drug use in prison changed because of fear of detection and sanctioning. Switching from cannabis to heroin occurred but not persisted. Not all users were detected by MTD. Additional costs by additional time as sanction likely to be 360 places per year.
Gore, Bird et al. 1996 G Pilot study on English Mandatory drug testing 1995 in 8 prisons: positive tests for opiates and benzodiazepines rose from 4.1% to 7.4%. Number of assaults increased by 20% from 1993 to 1995.
Gore and Bird 1996 G England/Wales: If testing all inmates, costs were twice as much as running a rehabilitation and drug reduction programme and about half the total healthcare expenditure for a prison. More than 50% of the costs would be for cannabis testing. 5% of all IDUs are in prison, so 5% of prevention and treatment costs should be directed there. no evidence for effectiveness of compulsory drug testing.
Hughes 2000 G 17 qualitative inmates interviews in England found MDT to be received as unfair. Switching was reported. Treatment was not offered for those tested positive, and inmates reluctant to approach the staff with drug problems because of fear of sanctioning.
MacDonald 1997 survey Interviewed staff in England thought, that testing would decrease drug use a little, prisoners not. Both stated it would shift the use from soft to hard drugs. Prisoners viewed process as unfair and punishments as unreasonable. Insufficient following rehabilitative programmes for positive tested users. Evidence that mandatory drug testing encourages users to switch from "soft" drugs to less long-term detectable "hard" drugs. Testing process is counterproductive, increases tension in prison, deflects attention from other crucial areas. Money could better be spent on treatment and counselling follow-up.
Prendergas t et al. 2004 150 inmates per week were tested from the eligible inmate general population in two US prisons, results supported the effectiveness of systematic random urine testing in reducing prison substance use, as measured by the number of inmates refusing to test or testing positive for illicit substances.

6.3. Health education and promotion for prisoners

Health promotion means by definition: Health promotion is the process of enabling people to increase control over, and to improve their health (WHO 1998). This definition serves as a catalyst for providing health education and promotion in prisons.

Providing information and education on HIV transmission, transmission routes, and prevention strategies is typically the first approach in developing an HIV programme in prisons. Developments in several countries have shown that the justice system is an important setting for the education of groups or individuals who are potentially at risk of becoming infected with HIV, or other blood-borne or sexually transmitted infections. Individuals arrested, detained or incarcerated, in police stations, pre-trial detention centres or penal institutions, can be informed, trained, and provided with the means to protect themselves. Often they are in contact with help facilities for the first time in their life, even though they may have been drug users for a fairly long period of time. Prison-based services should include the same range and quality of education programmes offered in the community (see e.g. UNAIDS), and provide accurate information in a non-judgemental fashion. Prison-based educational programmes on HIV/AIDS, drug use, and sex work can be more successful when they reflect an integrated approach between prison and community health services, bringing prison health and public health services closer together (see WHO 2003). Information about HIV/AIDS is generally regarded as a prerequisite for effective HIV prevention programmes, and there is no evidence to show that education is sufficient on its own.

In developing educational initiatives, the following targets should be met:

y To raise awareness of health problems connected to drug use, drug-related infectious diseases, drug injecting, sexually transmitted infections and tattooing and piercing.
y To initiate and support a discussion about risk reduction as response to these health problems
y To increase the knowledge and skills of both prisoners and staff with regard to drug use, drug related infectious diseases, drug injecting, STIs, tattooing and piercing as health problems
y To encourage a positive attitude towards risk reduction activities by both prisoners and staff.
y To disseminate accurate and non-judgemental information relevant for HIV prevention and health promotion by a range of means.
y To stimulate and support the realisation of risk reduction activities for prisoners as well as for staff members.

Education strategies should include (see Stöver and Trautmann 2001):

y Accurate and non-judgemental HIV/HBV/HCV information must be widely available and in the relevant languages.
y Prison and community-based programmes should be integrated/connected and offered on an ongoing basis.
y Demand reduction efforts should be undertaken to support and motivate prisoners to abstain from drugs during imprisonment.
y Safer drug use information to avoid HIV transmission and other health damage related to intravenous drug use and the sharing of injecting equipment.
y Safer sex information adjusted to specific life settings (i.e., private relations, sex work).
y The methods applied should reflect the growing need for interactive learning (Stichting Mainline 1999).
y Peer-education initiatives and materials should be encouraged and supported.
y Relapse prevention programmes (how to avoid recidivism and overdose after release).
y Services must meet needs and individual resources of the concerned.
y Delays and barriers to access support and counselling must be minimised
y Consistent availability of services and support.
y Safer drug use, safer sex and safer work (re sex work) seminars should be offered

Education on HIV/AIDS for both prisoners and prison staff is usually provided at the beginning, when a person first enters prison or begins new employment. Ongoing refresher courses and seminars should be used to sustain and reinforce the HIV/AIDS related health messages.

Modern educational methods, peer education initiatives, and visual aids are now well-established outside prison and should be encouraged and supported. Information should be delivered through a variety of channels, including:

y General awareness campaigns, including general education sessions by prison staff, posters, pamphlets, and other materials.

y The provision of targeted information through health and social services frequented by injecting drug users or sex workers.

y Peer education and outreach, particularly to drug users and other marginalised populations within the prisons.

y Involvement of civil society and other health professionals from outside the prison.

y Face to face communication, particularly to support drug users and sex workers to turn information into actual behaviour change through a process of clarification and reinforcement.

Harm reduction services, the embedding of educational programmes into comprehensive prevention, and treatment and support packages for injecting drug users and sex workers can be crucial for their success. Psycho-social support is known to add a major additional help to such programmes. Information and/or training before release to prepare prisoners with experience of drug use and/or sex work for the risks faced after release (information about enhanced overdose risk after release, safer injecting, safer sex etc.) is a service available in only a few prisons, and should also be developed.

6.4. Healthcare for prisoners with AIDS and Hepatitis

Whether a person living with HIV/AIDS lives in prison or in the outside community, they have very similar medical care, treatment, and support needs. However, within many prison systems, lack of funding and medical infrastructure, lack of properly trained medical staff, lack of access to antiretroviral therapies (ARVs) and other HIV treatments, and inappropriate prison policies and practices mean that HIV-positive prisoners often live in conditions that increase their vulnerability to medical neglect, opportunistic infections, needless suffering, and untimely death8.

As it had been stated earlier, the WHO´s Guidelines on HIV Infection and AIDS in Prison pronounce that prisoners have the right to receive health care “equivalent to that available in the community without discrimination”. Those recommendations also state in detail aspects related to care and support for HIV-positive prisoners. In a latter recommendations (2006) the United Nations Office of Drugs and Crime (UNODC), joined with WHO and UNAIDS emphasized the equivalence principle of receiving ART for prisoners. In nearly all European countries ART is available in all prisons.

The treatment of HIV and AIDS with highly highly active anti-retroviral therapy (HAARTI has been scientifically evaluated and can be said that it is effective in the

Guiding questions for scrutinizing the prison health care services come from the CPT and are extremely helpful Council of Europe (1999). Health care services in prisons. Strasbourg..

suppression of HIV viral load, the preservation of immunologic function, the improvement of quality of life and the reduction of HIV-related mortality and morbidity (Pontali 2005). With the adoption of HAART HIV has lost the life-threatening aspects and has changed into a treatable, chronic disease (WHO 2007)

The deliverance of HIV care in correctional institutes is despite different opinions of correctional healthcare providers less comprehensive than in community settings (De Groot 2000; Bernard et al. 2007).Treating HIV-infected prisoners with ART will not only have an affect on the individual health but also an impact of public health outside of the prison. It has been emphasized that the deliverance of HAART in a prison where the medical care is provided by the correctional institution and not by public health authorities is regarded as rather problematic. If that is the case the implementation of HIV-care in a prison setting can rely on proper resources (Pontali 2005).

The cohort of persons entering prisons consists of persons already lacking access to proper medical resources. Therefore the correctional institution in which structural barriers to health care are removed and the prisoner is capable should offer HAART to all HIV-infected prisoners.

There has been evidence that often treatment is initiated in prison. Altice and Mostashari (2001,1998) reports that up to 67% of HIV-positive prisoners first received HAART while in prison (Mostashari et al. 1998; Altice et al. 2001)

The success of a therapeutic intervention is revealed by the adherence to the program. Especially dealing with (HAART this is a matter of great concern. Because the highest benefit can only be achieved when there is full adherence several methods needs to be undertaken to ensure that the prisoner takes the medication. The complex issue of drug resistance is the consequence of improperly or inconsistently taken HIV medication.

This was revealed in a study conducted in Spain where the prevalence of genotypic resistance among HIV-positive incarcerated was analyzed. It was differentiated between primary resistance and drug resistance. 127 drug-naïve subjects were recognized in 13% in 1999 versus 15% in 2001. Whereas drug resistance was found in 35% and 59% of 182 pre-treated subjects in 1999 and 2001. Resistance was seen in drugs with low genetic barrier, such as lamivudien and nonnucleoside reverse transcriptase inhibitors (Wohl et al. 2003).

There are also studies which report good or excellent adherence of HAART in prisons. Another Spanish study carried out by Soto Blanco and colleagues (2005) showed that the adherence to HAART was higher than in the wider community. 117 HIV-infected were asked to fill out a questionnaire concerning their adherence to the therapeutic regimen. 24.3% were non-adherent. Predictors of non-compliance were for instance poor or lack of ability to follow the prescribed treatment regimen, no visits in a months, difficulties in taken the medication or methadone maintenance treatment (Soto Blanco et al. 2005).

An excellent adherence of 94% was observed in the study by Kirkland et al (Kirkland et al. 2002). The primary goal of this randomized controlled trial was to evaluate a compact regimen with one daily tablet administered twice daily. Both therapeutic regimens were well tolerated and only 4 patients dropped out of because of adverse events (AE).The occurrence and the severity of AEs are a predictive factor in the adherence of HAART. This was demonstrated in a study carried out in Connecticut were the most predictive factor associated with nonadherence in the multivariate analysis was the composite variable “side-effects”. An even greater impact on the adherence to HAART had social isolation (12-fold increase versus 11-fold increase)(Altice et al. 2001).

Furthermore it had been evaluated that attitudes related to trust in medications and the health system have a significant impact on the adherence to HAART. The prisoner’s view of the person who is dispending the medication will have a probably undeterminable effect of the adherence of HAART (Mostashari et al. 1998).

Besides of the factors that have an impact on the adherence of HART the modalities of administration differ and therefore influence the adherence. In general three different modalities are differentiated: Directly observed therapy (DOT), modified DOT and keep on person (KOP) (Pontali 2005).DOT refers to a system in which the prisoners goes to the medical unit or pharmacy and swallows the medication under sight check. During this routine visits the medical staff can record possible side effects, give brief counseling to the patient and react quickly to signs of discomfort of the patient. It can be said that the adherence within is the greatest compared to KOP, but it should kept in mind, that the routine visits of the patient involves the loss the confidentially as the prisoners fear to get “discovered” by other inmates. The difference in a modified DOT is that here the patient receives the daily doses in one package. It is up to the nurse to watch the patient swallow. So the medical staff gets in contact with the patient every day, but the inmate is fully responsible. KOP (sometimes called self-administered therapy (SAT) is the system that allows the inmates to keep a monthly or weekly rationale of medication in their cells and take them independently. Here the confidentially and privacy rights of the patients are fully secured (Pontali 2005).

The literature is inconsistent about the evidence about which modality to prefer. Babudieri et al (2000) reported that DOT compared to modified DOT was associated with a better virological and immunological response (Babudieri and al. 2000). Contrarily it was reported that the degree of adherence was similar in all three regimens. But selection bias needs to be considered, that only highly motivated patients tend to choose KOP.

The treatment for HCV has improved substantially over the last decade and it has been show to be efficient. Depending on the genotype either a 24- to 48-week combination therapy of pegylated interferon and ribavirin is given. This combination achieves an overall sustained virologic response (SVR) of 50% to 80%. Whereat the genotype 2 and 3 have a higher success rate, with a SVR at about 76-80%, than genotype 1 with SVR for 46-54% (Fried et al. 2002)

It has been show that treatment for HCV is also feasible and successful for marginalized groups such as IDUs. Although a very high proportion of HCV infected IDUs circle through the correctional system for a large proportion no therapeutic approach is being made.

Only four studies were identified which evaluated a prison-based treatment of HCV. The newest study was undertaken in France, where 37 medical units’ French jails participated. In this prospective cohort study 217 patients were included. They were treated with a combination of pegylated interferon alpha and ribavirin. Six months after the completion of treatment 200 patients were analysed regarding their SVR. Ninety-five patients (47.5%) experienced a SVR. Data was missing data for 61 patients and 24 patients were non-responders (Remy et al. 2006).

A Canadian study designed as a retrospective analysis of medical charts from 10 federal correctional facilities included 114 inmates. Analysis was performed for 80 treatment subjects. 66.3% of this treatment sample achieved SVR. Those with Genotype 2 and 3, injecting drug use and completion of treatment were significantly more likely to achieve SVR (Farley and al. 2005; Farley et al. 2005).

Two small observational studies were carried in the United States (Allen et al. 2003; Sterling et al. 2004). In the study conducted by Allen et al, 93 incarcerated patients were treated with interferon alpha and ribavirin. SVR were achieved by 46% (26 out of 53) after 6 months of treatment.

The second study revealed a response of 34 out of 59 (58%) patients and a SVR was seen in 21 patients. Predictors of SVR were being Caucasian and being infected with genotype 2 or 3. Besides the treatment of HCV, for this study telemedicine, which allowed the use of electronic information and communication technologies was deployed and it the acceptance off the prisoners´ staff was fine.

Although there are only very few studies published on the topic of Hepatitis C treatment, the evidence seems to be clear. Treatment in infected inmates is feasible and safe. By reducing the HCV prevalence among inmates in prisons the prevalence of HCV in the general population is also reduced. Therefore, especially from a public-health point of view the implementation of HCV treatment in prison and the access to care for all infected prisoners needs to be provoked.

Table 6: Provision of HAART and treatment of Hepatits C

Study Quality Main results
Wohl,et al C Prisoners under HAART revealed a higher rate of virological failure in conjunction with an unexpected lower rate of drug resistance.
Soto Blanco et al F Cross-sectional study with 117 HIV infected prisoners out of two Spanish prisons. 24.3% were not adherent to therapeutic regimen.
Farley et al E Retrospective review of medical charts of 114 inmates treated for HCV from Canadian prisons. 4 out 5 completed treatment (78.8%); 66.3% achieved SVR.
Remy et al E Analysis of 200 treated patients for HCV in French prisons revealed an SVR for 95 (45.5%) patients.
Allen et al F 93 patients were treated for HCV in Rhode Island, USA for HCV.63% (50 of 79) of patients achieved viral clearance after 6 months of therapy and 46% (26 of 57) achieved SVR 6 months after treatment.
Sterling et al F 59 consecutive enrolled HCV positive patients were treated with interferon and ribavirin. SVR was achieved by 21 patients. Additionally it was asked, whether there racial differences between Caucasian and African Americans.

6.5. Abstinence-oriented programmes

This kind of programmes refers to different approaches of psychosocial interventions aiming at abstinence by providing rehabilitation and social reintegration. Another term used is “demand reduction”, which describes

“policies or programmes directed towards reducing the consumer demand for narcotic drugs and psychotropic substances covered by the international drug convention control conventions” (United Nations 1998).

The goal of these programmes is to support prisoners in leading a drug-free life in response to an awareness of risks associated with the use of drugs especially in the prison setting. The most common approaches include therapeutic communities, drug free wings, and cognitive-behavioural programmes. Access to these programmes is voluntary under certain conditions, sometimes even with contracts for behavioural change. The central objective is abstinence. Therefore urine testing plays a major role to ensure the drug-free status. These programmes are mostly run in separate sections of the prison with no direct contact with other prisoners and a high control standard.

Therapeutic communities offer support for prisoners suffering from ‘emotional disturbance’ in a group setting and are based on principles of a ‘collaborative, democratic and de-institutionalised approach to staff-patient interaction’ (see Association of Therapeutic Communities 2007). As prisoners are effectively a captive audience, this offers some advantages to prison based therapeutic communities, however, the regime can also impede such programmes effectiveness, due to strict regulations impact on group and individuals’ decisions regarding treatment.

Drug free units are formed on separate sections within prisons, offering support to those prisoners who wish to cease all types of drug use (often including smoking). Prisoners are routinely tested, attend regular and often intensive counselling programmes and group activities, which might include cognitive behavioural programmes. They focus on ceasing drug use during the sentence and also may provide after care services once prisoners are released (Hough 1996).

Cognitive-Behavioural programmes are structured psychosocial interventions aiming at modifying cognition and behaviour. It usually includes some kind of skills training and practice to deal with craving as well as relapse prevention. Different modifications and

The provision of abstinence-based treatment programmes in prison varies considerably throughout the EU. According to Turnbull, by 1997 80% of all Council of Europe countries had abstinence-based programmes, but the extent varies greatly (Turnbull and Webster 1998). Some countries show an increase of drug-free areas since the mid-nineties of 300-400% (Turnbull and McSweeney 2000, p. 48). Therapeutic communities and other rehabilitative programmes are available in most European countries, but not sufficient data for the new member states are available. Drug-free units are available in Austria, Denmark, England/Wales, Finland, Germany, Ireland, Luxembourg, Netherlands, Norway, Portugal, Scotland, Spain, and Sweden, mostly in only parts of the prison system, and no drug-free wings exist in Belgium and France, whereas there were no data for the new EU-member states (Merino 2005).

Not many studies have been conducted on the effectiveness of psychosocial interventions in the prison setting (Strang et al. 2007), and a need for more studies on effectiveness of treatment programmes was identified (Costall et al. 2006). Studies indicate that it is important for prison systems to develop particular strategies for prison drug treatment rather than simply just reflecting those strategies that exist in the community (Turnbull and Sweeney 1999). Generally there is a growing consensus that drug treatment programmes in prison can be effective if they are based on the needs and resources of prisoners and are of sufficient length and quality (Ramsay 2003b).

The effectiveness of TC on recidivism for incarcerated drug users was shown (Pearson and Lipton 1999), other treatment approaches including cognitive-behavioural interventions and 12-step programmes were declared as promising but there was not enough studies to evaluate (Pearson and Lipton 1999). Two RCTs (Wexler et al. 1999; Sacks et al. 2004) were identified on TC in prison, both from the USA. TC in prison was associated with reductions in criminal activity, recidivism, and relapse, compared to a prison control group. For the reincarceration rate no significant difference was found at 12 months but at five years (Smith et al. 2006; Strang et al. 2007). No effectiveness of boot-camps (a military-style scheme) for young offenders was demonstrated in two US studies, as the treatment group did not differ from the control group (Strang et al. 2007). For incarcerated women case management, skills training, and TCs are especially recommended (Lewis and Lewis 2006).

On drug-free units a German study found significant lower criminal recidivism in regular programme completers than in drop-outs (Heinemann et al. 2002). There are some indicators that drug-free units reduce drug use, and some conflicting evidence on recidivism (WHO et al. 2007b). Counselling programmes in prison seem to be effective in reducing re-offending but not drug use, and voluntary programmes seem to be more effective than other programmes, but the study quality on these issues is not good (WHO et al. 2007b).

Abstinence-based treatment programmes provide a good opportunity for those prisoners who are motivated and capable to cease using drugs.

Table 7: Example studies on abstinence-based treatment in prison 6.6. Detoxification

Study Quality Results
Costall et al. 2006 survey Interventions in nine European countries are presented. The effectiveness needs to be studied, and models of interventions should be evaluated.
Heinemann et al. 2002 survey 408 prisoners in two drug-free units in Hamburg/Germany were followed. Those who finished the programme regularly had significant lower criminal recidivism than drop-outs. Drop-out during first 100 days predicted worst outcome.
Persaon and Lipton 1999 E TC is effective on reducing recidivism; boot camps and drug-focused counselling are not. ST, 12-step, cognitive-behavioural approaches, and substance abuse education are all promising but too few studies to evaluate.
Rosen et al. 2004 D 220 inmates in substance abuse treatment compared to 441 not in treatment. Treatment motivation was evaluated; increased focus on internal motivation may lead to more effective treatment.
Smith et al. 2006 F This Cochrane review found two RCTs on TC in prison; participants had significantly fewer re-incarcerations criminal activity, alcohol and drug offences after 12 months, compared to Mental Health treatment group.
Strang et al. 2007 F Two RCTs on TC, same as Smith et al. Two studies on bootcamps did find no difference between treatment and control group in a traditional juvenile camp.
Turnbull and Webster 1998 survey Extend of drug demand programmes varies widely between countries. Most common interventions are to provide information and to encourage treatment contact.

Detoxification describes the process of discontinuation of a consumed substance under medical supervision. In the course of an addiction therapy detoxification plays an important role. Complications e.g. seizures and delirium should be avoided to help the patient tackle this difficult phase. For the treatment of opiate addiction a detoxification without medical assistance is not reasonable. The symptoms of an opiate withdrawal symptom according to ICD-10:

y Craving
y Rhinorrhea
y Lacrimation
y Muscle pain
y Abdominal pain and spasm
y Nausea and vomiting
y Diarrhea
y Sleeping disorder

In generell, detoxification is possible with methadone, buprenorphine, clonidin and opiate antagonist, for example naltrexone.

According to the WHO prison data base detoxification without medication is available in Belgium, Finland, Lativa, Portugal and Malta. No detoxification without medication is available in Cyprus, Czech Republic, Estonia, Hungary, Netherlands and Slovakia (WHO). This double negotiation means that prisoners must undergo detoxification by themselves (“cold turkey”).

Detoxification with medication is available in Belgium, Czech Republic, Estonia, Finland, Hungary and in Lativa. Agonist treatment is available in Belgium, Finland, Lativa and in Portugal (WHO). Due to missing data no statement for other EU countries can be made.

The literature search for prison-based opiate detoxification retrieved only two relevant studes. In a Southern England all-male prison a RCT for opioid detoxification was conducted. The study employed a randomised double-blind, two-group comparison design to compare the relative efficacy, side effect profiles and participant acceptability of opioid detoxification. The used medications were methadone and lofexidine. Seventy-six patients could be included in the trial. Due to withdrawal of patients and errorly detoxification, only 68 patients commenced the treatment. Thirty-two patients received lofexidine and 36 patients, respcectively, methadone. The socio-demographic and patterns of opioid use were comparable. Twenty-one patients were loss-to-follow up due to various reasons. Withdrawal scores showed very similar patterns and derived withdrawal scores indices showed no significant differences between treatment groups (Howells et al. 2002).

In an Australian prison the introduction of naltrexone was evaluated. Participants were recruited from 14 prisons. Data were analysed from two subsets drawn from 204 male inmates who participated in a former unsuccessful randomised trial. Patients received either naltrexone (n=68) (first sub-sample) or in the second sub-sample naltrexone (n=14), methadone (n=21) or buprenorphine (n=21) over 24 months.

Only nine of 68 subjects actually started naltrexone treatment. The main reason for refusing naltrexone was failure in detoxification for methadone or buprenorphin. Retention rates were analysed for subjects in the second sub-sample. Retention in methadone was significantly higher in methadone compared to naltrexone (log rank statistic = 11.52, df=1, p=0.007). The evaluation of this study yieled at a negative result for naltrexone for prisoners (Shearer et al. 2007).

One promising study has been set up in the UK: the Leeds Evaluation of Efficacy of Detoxification Study (LEEDS). The study protocol has been published in January 2007. This study will take place in a prison in Leeds with a sample size of 120 (Sheard et al. 2007).

Table 8: Detoxification treatment

Study Quality Results
Howells et al A 74 opioid dependent male inmates at a Southern England prison were randomised to receive either methadone or lofexidine. No significant differences in the severity of withdrawal symptoms
Shearer et al A 68 + 47 participants were randomised to naltrexone, methadone or buprenorphine treatment. 13% of the sample started naltrexone, with 7% remained in treatment after six months. Six-month retention was significantly lower in naltrexone compared to methadone (p=0.007)

6.7. Substitution treatment

One major approach to aim at both harm reduction and social integration represents the substitution maintenance treatment. The term “substitution treatment” (ST) refers to the medically supervised treatment of individuals with opioid dependency, based on the prescription of opioid agonists (Thomas 2001). These can include methadone, buprenorphine, codeine, morphine, and diamorphine. The treatment options include the management of withdrawal on admission as a gradual detoxification (proceeding to abstinence-oriented treatment) or the long-term substitution maintenance.

In countries that provide methadone in prisons, it is most commonly used for short-term detoxification, and less frequently as a maintenance treatment. In some countries, such as Austria and Spain, substitution treatment is provided as standard therapy to all prisoners who began treatment in the community and are deemed likely to continue it after release (Stöver et al. 2004). In others, including Greece and Sweden, it is not available in prisons at all. A recent study on practice and policies of in-prison substitution treatment in 18 European countries (Stöver et al. 2006) concludes that there are heterogeneous and inconsistent regulations and treatment modalities throughout Europe. Even though the scope of substitution treatment has extended considerably across Europe, there remains a treatment gap between prisoners requiring substitution maintenance treatment and those receiving it. Most countries use methadone for the substitution treatment, like in the community, but e.g. in France buprenorphine is by far the most common medicine for substitution, as well inside and outside prison (Michel 2005).

The long-term impact of ST has been investigated in imprisoned male heroin users by Dolan et al. (2003). 382 individuals participated in a randomized controlled trial of prison-based ST and had been followed-up. The results show that retention in ST is associated with reduced hepatitis C infection, re-incarceration rates and mortality. For instance the re-incarceration risk was lowest during ST episodes of eight months or longer. ST periods of two months or less were associated with greatest risk of re-incarceration. An increased risk of hepatitis C seroconversion was significantly associated with prison sentences of less than two months and ST episodes less than five months.

Evidence shows that methadone maintenance treatment can reduce injecting risk behaviour in penal institutions such as reduced frequency of illicit drug use in prison and reduced involvement in the prison drug trade (Dolan et al. 1998). The frequency of injecting was reduced in prisoners enrolled in ST for the entire duration of imprisonment (Lenton 2003). An Australian Study found reduced crime rates (officially recorded offending rates) for participants in ST, and this was true for a number of different offences, e.g. robbery, motor vehicle thefts, break and enters (Lind et al. 2004), so ST is an effective crime prevention measure. Studies have also demonstrated that methadone maintenance treatment provision in a prison healthcare setting was effective in reducing heroin use, drug injection and syringe sharing among incarcerated heroin users (Dolan et al. 2002). A sufficiently high dosage also seems to be important for an increase in the retention rate, which then can be used for additional health care services, a sufficient dosage seems to be at least 60 mg methadone (WHO et al. 2007b). There is evidence that continued MMT in prison has a beneficial impact on transferring prisoners into drug treatment after release. The initiation of MMT in prisons also contributes to a significant reduction in serious drug charges and in behaviour related to activities in the drug subculture (WHO et al. 2007b). In addition, ST can increase the uptake of antiretroviral and other therapies (WHO et al. 2007b), and does reduce the mortality (Dolan et al. 2005), which is especially important on release (WHO et al. 2007b). A 2001 evaluative study of the methadone programme of the Correctional Service of Canada concluded that participation in methadone programmes had positive post-release outcomes. The study found that opiate users accessing ST during their incarceration were less likely to be readmitted to prison following their release – and were less likely to have committed new offences – than were those not accessing methadone. The study further concluded that:

An important implication of these findings is that CSC may spend less money on these offenders in the long term. The cost of the institutional MMT program may be offset by the cost savings of offenders successfully remaining in the community for a longer period of time than equivalent offenders not receiving MMT. In addition, health related costs such as treatment for HIV or Hepatitis C infection would be affected by MMT availability in prisons (Correctional Service of Canada 2001).

Research into the subjective experiences of prisoners participating in substitution programmes reveals the heterogeneity of prescription practices in prisons. In particular, short courses of methadone detoxifications were frequently experienced as insufficient and inadequate. Most striking was the inconsistency in substitution treatment inside prison compared to the community (Hughes 2000b). Forty years after the introduction of substitution treatment for opioid dependent persons its implementation is often far from adequate in prison settings. Here the availability, the implementation, clinical management, and the evaluation of substitution treatment is often deficient (Stöver et al. 2004). The practice and policy of substitution treatment differs not only from country to country, but also from state to state, and from prison to prison (Michel and Maguet 2003; Michels et al. 2007). Notably, the disruption of treatment when entering the institution often leads to physical and psychological problems and increases the risk of intravenous drug use and sharing of injection equipment (Stöver et al. 2004). There was also an impact of prison-based ST found on post-release drug use (WHO et al. 2007b).

Although substitution therapy has been widely recognized as an effective treatment for opioid dependence in the general community (Farrell et al. 2001; WHO 2004b, see also Work Package 1), having crime reducing effects (Lind et al. 2004) and though methadone and buprenorphine have just been added to WHO’s Model List of Essential Medicines (WHO 2005a), it remains highly controversial for prisons, particularly in Eastern Europe, where substitution treatment is still prohibited in the community (Trimbos Instituut 2006), it still misses standards of substitution treatment in community as regards access and continuity. Despite the controversy, experience has clearly shown the benefits of this treatment in prisons (Heimer and al. 2005; WHO et al. 2007b). The WHO states:

“The advantages of using substitution therapy are very great. These include reducing suicide and self-harm during withdrawal, improving regimen management problems during withdrawal and reducing the risk of fatal overdose following release from prison. The high-level endorsement by international organizations and the growing appreciation that this does work, and cost-effectively, indicates that the priority in the immediate future is to develop the clinical and other standards urgently required” (WHO 2005b, p. 15).

Acknowledgement that the benefits of substitution treatment in the community might also apply to the prison setting has taken years. The source of the controversy – and the slow and patchy manner of the intervention’s implementation thus far – can be traced to the prison ethos of coercion, which usually manifests itself in a strict abstinence-based approach to drug use. Therefore, while opioid-dependent individuals in the community may be treated as patients and receive substitution treatment, in prison they continue to be treated as prisoners who are supposed to remain drug free. This double standard leads to frequent interruptions in treatment and inconsistency in dosages, especially as many opioid users spend periods of time incarcerated.

Several studies on the effects of the divergent practices of substitute prescribing in penal institutions reflect the development of substitution treatment in prisons (Stöver et al. 2004):

y Substitution treatment has become more widespread in many countries,
y Prison policy and administration are looking for standards and protocols and are
reviewing the progress,
y Access and treatment modalities have changed substantially,
y Additional substitution drugs are prescribed (e.g. buprenorphine).

In 1995, prisoners in Oberschöngrün prison in Switzerland were enrolled in a heroin maintenance trial that coincided with a community trial (Kaufmann et al. 1997). The prescription of heroin in prison was found to be feasible and does takes place in two Swiss prisons. Although there has been heroin trials in other countries (The Netherlands, Germany, Spain (Andalusia and Catalonia), Canada and the United Kingdom), which all showed that heroin maintenance is a safe and feasible maintenance therapy for severly opiate addicts, no other heroin-assisted treatment was integrated into a prison setting.

Clear protocols and guidelines are needed to regulate entry into and conduction of substitution programmes in prison (Palmer 2003). This is also necessary for exiting and transferring patients to community based programmes (NSW Health Department 1999).

Finally substitution treatment is offering a daily contact between health care service in prison and patient, a relationship that can serve as baseline for raising further health issues and a linkage with other HIV/AIDS preventive strategy matters. It is also a central topic in preventing relapse the high mortality of drug users after release.

Table 9: Example studies on substitution treatment

Study Quality Results
Dolan et al. 2003 A 191 each in ST and control group. Heroin use was significantly lower at 5-months follow-up. Lower levels of drug use were reported. No difference in HIV or HCV incidence.
Levasseur et al. 2002 D 420 dossiers of opiate addicts from 9 French prisons included. ST both with methadone and buprenorphine reduces re-incarceration rate after 3.5 years.
Lind et al. 2004 This Australian study analysed court and imprisonment data in connection with ST data. Reduction in crime rates were found for participants in ST.
Stallwitz and Stöver 2007 F Literature review concerning the effectiveness of prison-based ST. Results indicated that PMMT is the primary used MT. PMMT found to be effective in contributing to health and social stabilisation if a sufficiently high methadone dose (at least 60 mg) is dispensed.
Stöver, Casselmann et al. 2006 F ST is very likely to be discontinued in prison, treatment provision is often not enough.
WHO2007 F Prison-based ST appears to be effective in reducing the frequency of injecting drug use, when long-term in a sufficient dosage provided. Positive effect on prison safety as drug-seeking behaviour decreased. Health benefits are likely, re-incarceration is reduced. No security or safety problems were found. ST increases access to help for antiretroviral therapies.

6.8. Harm reduction in prisons

Harm reduction programs aim to limit as far as possible drug-use related health risks to individuals, the community and society. The theme of these harm reduction programs is: ‘If you use drugs in prisons, do it as ‘safely as possible!’ and ‘Behave yourself as if everybody is positive’ (Stöver and Trautmann 2001). The practical support for users matches the individual needs and resources of the drug users.

Harm reduction is an important public health measure because reusing and sharing needles or other equipment for preparing and injecting drugs represent a highly efficient method of transmitting HIV and hepatitis C. In the absence of harm reduction activities, HIV prevalence among injecting drug users can rise to 40% or more within one or two years after the virus is introduced in their communities. Worldwide, more than 114 countries now report HIV epidemics associated with injecting drug use (Aceijas et al. 2006).

Harm reduction measures are highly politically loaded, cannot be introduced due to resistance of staff, or are perceived as inappropriate for the prison setting (e.g. needle exchange). The introduction of harm reduction measures is relatively new to prison systems and is often perceived as threatening to the traditional abstinence-oriented drug policy in prisons. The goal of abstinence which is the ultimate goal is presupposed to be achieved in prisons and abstinence is seen as covered with the goal of the sentence (to lead a life without committing crime). Various harm reduction measures are generally seen as undermining the security measures of the prison system. This is different due to different measures. Substitution treatment for instance is more and more seen as a medically supervised adequate treatment of opioid dependent inmates. The benefit for the whole system in keeping the institution ‘calm’ is more and more seen as a benefit arising from prescribing the substance (see Stallwitz and Stöver in press). This is different when it comes to prison needle exchange projects, which are perceived as undermining the goal of abstinence and needles are symbolized as ‘giving up’ – a failure to control drug traffic within the institution as well. Furthermore they are seen as instrument to threaten staff and inmates. However, it is recognised that these concerns are often the result of failing to see harm reduction as more effective treatment and care for prisoners with special needs. The positive aspects and results from scientific work have not been communicated as it is needed. An important aspect of the thinking behind harm reduction is to add another valuable element to the health care of drug-dependent prisoners and to reduce the health risks to personnel.

Despite the problems inherent in implementing harm reduction measures, many aspects of harm reduction are now widely accepted and applied throughout Europe. An analysis of prison-based programmes contained in the EMCDDA information system Exchange on Drug Demand Reduction Action (EDDRA) (Merino 2003) found that about one fifth of the prison interventions had reducing drug-related harm as their main objective. Prison systems in Europe are often especially reluctant to support the introduction of needle- and syringe-exchange schemes because they feel it might lead to an increase in injecting drug use, accidental needle pricks and conflicts among prisoners or between prisoners and staff and the risk that syringes or needles would be used as weapons.

Evidence shows that schemes have been introduced in prisons in Spain and in five other European countries without these problems arising (Stöver and Nelles 2003; Lines et al. 2004b). Nevertheless, harm reduction in prisons involves much more than needle-exchange schemes. Useful harm reduction programmes can still be established where such schemes are currently not being considered.

The implementation of harm reduction programmes is quite heterogeneous in European prisons. In a report of the implementation of the Council Recommendation (of 18 June 20039) on the prevention and reduction of health-related harm associated with drug dependence10 (Commission of the European Communities 2007) it is said that a policy to provide drug users in prisons with services that are similar to those available to drug users outside prisons exists in 20 Member States and is about to be introduced in four

9 http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_165/l_16520030703en00310033.pdf 10 http://ec.europa.eu/health/ph_determinants/life_style/drug/drug_rec_en.htm

countries (see Figure 26). The distribution of drug paraphernalia is not a common practice in the prisons (11 countries only). Three countries in the European Union (Spain, Luxembourg, Germany) provide needle and syringe exchange in prisons.

In view of the increased spread of needle/syringe sharing and drug use in European prisons, it is necessary to raise the issue of infection risks and protection possibilities in every penal institution out of damage limitation considerations. This does not necessarily mean that syringes have to be provided or that syringe vending machines must be installed in every prison. The type of individual measures necessary for infection prevention or the choice of how syringe provision takes place (hand-to-hand or vending machine) can be made according to the needs, the structure of the prison, the prison’s spatial conditions and staff capacity as well as the prisoners’ culture of drug use. For instance, intravenous opiate use in parts of England, but particularly in The Netherlands, is traditionally far less widespread than, say, inhaling or smoking. Consequently the subject of infection prophylaxis in prison must be discussed first and foremost. The decision taken by a prison depends on this discussion and an inventory of drug use, risk behaviour, etc. If syringe provision is opted for, then great demands must be made on the smooth running of any scheme.

Figure 26: Harm reduction services available in prison (R2.8)

Source: Commission of the European Communities 2007

6.9. Prison needle exchange programme

Needle exchange is one of the important measures of harm reduction. The term refers to all kind of injecting equipment distribution to people who inject drugs. Prison needle exchange programmes (PNEP), also called needle and syringe programmes or syringe exchange programmes, are often accompanied by counselling or other services (WHO et al. 2007a). Usually the exchange of needles and syringes is done on a one-to-one base: One used needle is exchanged for one new. There exist different methods of exchange; hand-to-hand by medical prison staff, or by external organizations, or by peer workers, or exchange by automated exchange machines (Lines et al. 2006). The aims of PNEP are to reduce the risk of transmitting blood-borne diseases by needle sharing, especially HIV and HCV and other injecting-related harm.

Outside prison, needle exchange exists in many European countries and is usually a widespread and accepted harm reduction measure. In prisons, syringe exchange/distribution programmes have been operating for more than 15 years. The first prison syringe exchange programme was established in 1992 in Switzerland. By 2003 PNEP was provided in 46 prisons (Stöver and Nelles 2003), and at present, there are programmes operating in more than 60 prisons (see table below), but of the 27 European countries only five countries provide PNEP. In some countries, syringe exchange is available in only a few prisons, while in Spain and Kyrgyzstan syringe exchange is authorised in all prisons.

Table 2: Prevalence of needle exchange programmes

Country Start of programme Number of prisons with PNEP remarks
Armenia 2004 3
Belarus 2003 1 In 2004
Germany 1996 1 6 others were closed because of political reasons
Iran 2005 ? programmes expected to open in 2006
Kyrgyz Republic 2002 11
Luxembourg 2005 1
Moldova 1999 7
Portugal 2008 implementation planned by 2008
Scotland 2007 A study planned for 2007
Spain 1997 38
Switzerland 1992 7
Ukraine 2007 2 expected to start in 2007

Source: adapted from WHO et al. 2007a

Syringe 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; hand-tohand distribution by prison physicians/health-care staff or by external community health workers; and programs using prisoners trained as peer outreach workers, each model having advantages and disadvantages (Stöver 2002b; Stöver and Nelles 2003). Prison syringe exchange programmes 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).

The question remains unanswered as to why, despite the numerous positive results from different projects, syringe provision in prison settings is still so controversial, and that syringe provision has only been introduced in four European countries to date, and even there only in specific penal institutions in aid of infection prophylaxis and harm limitation in relation to the use of illegal drugs. The answer cannot be based on logic. In fact there is sufficient fundamental experience in, and knowledge about, syringe provision in penal institutions to justify an extensive introduction of these measures. Measures for syringe provision cannot be imposed, as the experience in Switzerland has shown, where despite an official order a number of prisons rejected them. Firstly, one must work on translating these measures into reality: all-encompassing political decisions and support to the penal institutions in practical, individual questions (legal, communicative and technical aspects) are required, to help obtain the necessary breakthrough as regards effective harm reduction in prisons.

A Position Paper of the United Nations System identifies syringe exchange as one component of “a comprehensive package for HIV prevention among drug abusers”, stating that

“Several reviews of the effectiveness of needle and syringe exchange programmes have shown reductions in needle risk behaviours and HIV transmission and no evidence of increase into injection drug use or other public health dangers in the communities served. Furthermore, such programmes have shown to serve as points of contact between drug abusers and service providers, including drug abuse treatment programmes” (United Nations 2002).

Since then, a further number of reviews on PNEPs have been undertaken, and gathered evidence for the effectiveness of PNEP (Rutter et al. 2001; Stöver and Nelles 2003; Lines et al. 2005; Lines et al. 2006; WHO et al. 2007a), so a further discussion on the implementation is needed (Hughes 2000c), as evidence indicates that the implementation of such measures is possible and feasible with no security problems

(e.g. Kerr et al. 2004).

One of the most important results is the massive decline of needle sharing; a German project in Berlin found 71% of needle sharing before the start of the PNEP, decreasing to 11% at four-month follow up and to almost zero afterwards (Stark et al. 2006). Another outcome from a Swiss evaluation is the decrease over time of injecting drug use after implementing a harm-reduction programme including needle exchange in a female prison (Nelles et al. 1999). Other evidence from those countries where prison needle exchange programs exist demonstrates that such programs 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. A drastic reduction in overdoses is reported in some prisons and also increased referral to drug treatment programmes. PNEP has successfully cohabited in prisons with other drug addiction prevention and treatment programmes (Meyenberg et al. 1999; Nelles and Stöver 2002). The method of distribution needs to be considered, as machines may be unreliable (Heinemann and Gross 2001), and on the other hand a personal distribution won’t be anonymous; there are advantages and disadvantages for both (Stöver and Nelles 2003).

Another international review on PNEP evaluation found 6 evaluations on PNEP and all were in favour of the programme due to the fact that needle sharing decreased dramatically, no new cases of transmission of BBV were reported, and no serious negative events occurred (Dolan et al. 2003). A further more recent literature review and additional interviews on six countries with PNEP (Germany, Switzerland, Spain, Moldova, Belarus, Kyrgyzstan) found similar outcomes in very different prison settings: large and small institutions, for men and women, single cell and dorm, needle distribution by machines, peers or hand to hand from medical staff:

y No injuries of staff were reported in evaluation reports,
y syringes were not used as weapons,
y drug use or injecting did not increase (only one out of twelve studies found that it
did in some cases)
y PNEP can increase uptake of drug treatment services
y PNEP is very effective to decrease needle sharing (only one study found small
decrease)
y Abscesses and fatal overdoses decreased in some prisons (Lines et al. 2005; Lines et
al. 2006).

The acceptance of PNEP by prison staff has been surveyed and was usually but not always in favour of PNEP, as fear of needle accidents or use as a weapon were expressed (e.g. Heinemann and Gross 2001; Dolan et al. 2003). This emphasizes the importance of adequate staff training on issues of harm reduction. PNEP should be accompanied by accompanying measures like information, and counselling. A Dutch study then found hardly any injecting drug use in prison and therefore no need for a needle exchange programme (van Haastrecht et al. 1997), so the need of PNEP in each prison should be carefully monitored and evaluated, as the drug use behaviour of prisoners might change over time.

Evidence of research is all in favour of PNEP, as well as the numerous overviews and reviews on the topic. Important international organisations like WHO and the Council of Europe strongly recommend the implementation of PNEP (Rutter et al. 2001) as an effective measure of HIV and HCV prevention, to reduce the risk of infectious diseases and other harms connected with injecting drug use. Needle exchange programmes have proven to be an effective HIV prevention measure that reduces needle sharing, and therefore the risk of HIV and HCV transmission, among people who inject drugs and their sexual partners. Despite the success of these programs in the community, only a small number of countries have extended syringe exchange programmes into prisons. Those countries that have initiated syringe exchange in prisons have been met with remarkable success.

Table 11: Example studies on PNEP

Study Quality Results
Dolan et al. 2003 F 6 evaluations identified: drug use decreased or remained stable, needle sharing declined dramatically, no new transmission of BBV reported, no serious unintended effects, staff attitude varied.
Heineman n and Gross 2001 cross-sectional investigation No seroconversions of HIV, HBV, HCV during a German needle exchange programme. More than 12 000 needles changed in 12 months. Dispensing machines were unreliable, needle sharing still occurred. Acceptance of the programme was rising among IDUs but not among non-drug users and staff.
Lines, Jürgens et al. 2006 F 12 studies included. PNEP increased safety, no injuries of staff reported, did not increased drug use (only one study found single cases). PNEP can increase uptake of treatment services, very effective in decreasing needle sharing and therefore HIV/HCV infections, decreased fatal overdoses and abscesses in some prisons. Prison settings with PNEP very different.
Stark et al. 2006 follow-up N=174 IDUs in 2 German prisons. PNEP since 1998: Level of needle sharing declined from 71% to 11% during 4-month follow-up and almost zero afterwards. Baseline seroprevalence for HIV, HBV, HCV: 18, 53, 82%. No HIV and HBV seroconversions but four HCV seroconversions occurred.
WHO 2007 F 9 evaluations of PNEP identified. PNEP is feasible in many different prison settings. It reduces needle sharing, is accepted by prisoners and staff, and there is no evidence for serious unintended negative effects.

6.10. Provision of bleach and disinfectants

The provision of bleach and disinfectants in order to clean injecting equipment and also tattooing equipment and therefore reduce the risk of infectious diseases is an important harm reduction measure. Different methods are used and different disinfectants are provided for the purpose of disinfect injection equipment. Before 1993, guidelines for syringe cleaning stipulated a method known as the `2x2x2' method. This method involved flushing injecting equipment twice with water, twice with bleach and twice with water. Newer cleaning guidelines recommended that injecting equipment should be soaked in fresh full strength bleach (5% sodium hypochlorite) for a minimum of 30 seconds (Shapshak and al. 1993). More time is needed for decontamination if diluted concentrations of bleach are used. For example, injecting equipment needs to be immersed in bleach for two hours in order to be disinfected.

By August 2001, bleach was provided in 11 of 23 pre-expansion EU prison systems (Stöver et al. 2004). Still bleach is not provided in every European prison system; Bulgaria, Cyprus, Czech Republic, Hungary, Latvia, Malta, Romania, and Slovakia don’t provide bleach, while in Slovenia there are financial problems in practically providing, and some countries don’t have data on bleach provision. In Ireland, Lithuania, Netherlands and Poland, bleach is distributed in some prisons, and in Belgium, Estonia, Scotland and Spain bleach is made available in every prison (see tables in Annex) , but the method may vary, e.g. in some places prisoners have to ask for it, while in others it is made available discreetly and anonymously. Many prison systems internationally have adopted programmes that provide disinfectants such as bleach to prisoners who inject drugs as a means to disinfect injecting equipment before re-using it. According to UNAIDS in 1997, the provision of full-strength bleach to prisoners as a measure had also been successfully adopted in prisons, Australia, Africa, and Central America (UNAIDS 1997), and is also implemented now in Indonesia as an important HIV prevention measure (Winarso et al. 2006).

Disinfection as a means of HIV prevention is of varying efficiency, and is regarded only as a secondary strategy to syringe exchange programmes (WHO Europe 2005a). The effectiveness of disinfection procedures is also largely dependent upon the method used. Research in 1993 raised doubts about the effectiveness of the’2x2x2’ method in the decontamination of used injecting equipment (Shapshak and al. 1993). Scottish research on the effectiveness of bleach provision in a Scottish long-term prison found the measure being suboptimal (Champion et al. 2004), but together with other harm reduction interventions (substitution treatment, HBV vaccination, staff training and counselling) there was no evidence for new HIV infections after 12 months of the programme, whereas before there was a massive HIV-outbreak in one Scottish prison (Goldberg and al. 1998). A new review by the WHO recommends bleach only as a second-line strategy after PNEP, as there is no evidence of effectiveness in the community and therefore less likely in prison, due to the rather complicated decontamination process (WHO et al. 2007a). The WHO reported that concerns that bleach might be used as a weapon proved unfounded, and that this “has not happened in any prison where bleach distribution has been tried.” (UNAIDS 1997, p 6).

The effective use of bleach and disinfectants in prisons is complicated, where fear of detection by prison staff often means that drug use happens quickly, and that prisoners will often not take the time to practice optimal disinfection techniques (WHO et al. 2004). Furthermore bleach is effective in killing the HIV virus, but not 100% the hepatitis C virus. This then can lead to a false security feeling of having equipment cleaned efficiently. However, despite the limitations, provision of disinfectants to prisoners is an important option to reduce the risk of HIV transmission, particularly where access to sterile syringes is not available. The provision of bleach as one part of harm reduction measures should therefore be available to all prisoners also from a public health and human rights perspective (Kerr et al. 2004; Jürgens and Betteridge 2005).

Table 12: Example studies on bleach provision

Study Quality Results
Champion et al. 2004 C In a Scottish harm reduction programme including bleach distribution the effectiveness of bleach was found suboptimal.
Goldberg et al. 1998 Follow-up After initiation of a harm reduction programme including bleach provision in Scotland no evidence for further HIV-spread after 12 months.
WHO et al. 2007 F Bleach distribution is feasible but because there is hardly evidence for the effectiveness, it is only recommended as second-line strategy to PNEP.

6.11. Provision of sterile tattooing equipment

Tattooing is a common practice in many prisons (see chapter 5.2.2.), and because of the possibility of transmission of BBVs the provision of sterile tattooing equipment is an important harm reduction measure. As tattooing in prison is rather popular, it is a high risk behaviour

Tattooing equipment is provided in a number of European prisons in England/Wales, France, Netherlands, Norway, and Catalonia, no data on the new member states (Merino 2005). In Canada tattooing pilot projects in prison were set up as a trial in 2004 (Jürgens 2004).

Despite numerous evidence of the transmission of BBVs by tattooing in prison, no research on the evidence of provision of tattooing equipment was found. An overview found providing sterile equipment as well as training to reduce tattooing-related HCV-transmission (Lenton 2003). To reduce tattooing (and other risk behaviours) in prison, a peer educational programme was evaluated in a Russian prison, which seemed to be effective in decreasing the prevalence of tattooing (Dolan et al. 2004)

The provision of sterile tattooing equipment seems nevertheless an effective HIV/HCV prevention measure and should therefore be available for prisoners.

6.12. Provision of condoms, dental dams, and water-based lubricants

The provision of condoms aims at preventing STDs by sexual contacts (see chapter

5.2.1. of this report). Condom use is internationally accepted as the most effective method for reducing the risk of the sexual transmission of HIV and other BBVs (WHO and UNAIDS 2001). Water-based lubricants reduce the probability of condom breakage and dental dams reduce the risk of STD transmission during oral sex (WHO et al. 2007c).

Many prisons across the world provide condoms to prisoners as part of their institutional health policies. As early as 1991, a WHO study found that 23 of 52 prison systems surveyed provided condoms to prisoners (Canadian HIV/AIDS Legal Network 2002). By August 2001, 18 of the 23 prison systems in the pre-expansion EU were distributing condoms (Stöver and Trautmann 2001). This is in keeping with the recommendation of the WHO Guidelines on HIV Infection and AIDS in Prisons recommends that:

Since penetrative sexual intercourse occurs in prison, even when prohibited, condoms should be made available to prisoners throughout their period of detention. They should also be made available prior to any form of leave or release (WHO 1993, p. 20).

Most European prison systems provide condoms to the inmates, but the mode varies; sometimes they are distributed by medical or other staff and the prisoner has to ask for condoms or buy them in the prison shop; in other prisons condoms are available anonymously in different places of the prison. In Lithuania they are only available for long-term visits; and in Bulgaria, Cyprus, Hungary, Ireland, Malta, Netherlands, and Romania, condoms are not available in prisons (see country tables in Annex), and for some countries there is no data. For the prevalence of provision of dental dams and lubricants there is only occasional data. In Scotland, Italy and Ireland, sexual relations are prohibited in prison and condoms or lubricants are not available for prisoners. They are partly handed out for home leavers and/or as part of the release pack (Merino 2005). In many Esatern European countries condoms are available in theory but often with limited access and confidentiality (MacDonald 2004).

Although there is a body of research on sexual activity in prison, there are not many studies evaluating the distribution of condoms in prison. Perkins (1998) examined the accessibility of condoms in European prisons and found a wide range of different policies “...on a continuum spanning endorsement of free distribution within prison to total prohibition” Nine of the fifteen EU countries had clear official policies allowing free access to condoms for prisoners, in line with the WHO Guidelines. The other six occupied different positions on the road towards allowing such access, from the extreme of prohibition based on lack of recognition of the problem.

In 1995 in Australia, 50 prisoners launched a legal action against the state of New South Wales for non-provision of condoms, arguing that “[i]t is no proper part of the punishment of prisoners that their access to preventative means to protect their health is impeded” (Jürgens 2007). Since then, at least in part because of the legal action, the New South Wales government has decided to make condoms available. Other Australian systems have also made condoms available.

No negative consequences have been reported from those prison systems where condoms are available and the provision seems feasible in a wide range of prison settings (Jürgens 2006). The provision did not compromise prison security and safety, and there was no increase in sexual activity found (WHO et al. 2007c). Another study found decreased risk behaviour after the initiation of condom distribution and high levels of condom use among prisoners (WHO et al. 2007c).

Condoms need to be easily and discreetly accessible, as prisoners often might fear to be detected as gay (WHO et al. 2007c). The fieldwork indicates the importance of a clear and committing policy in developing best practice in this regard. “Implementation begins with clear messages from the top about policy commitment. The message needs to be reiterated through various levels of organisation.” (Perkins 1998, p. 34). One example is the Austrian policy on that matter. In July 1994 the Ministry of Justice of Austria issued the following ruling that “...condoms have to be provided in such a way that unobserved taking out of a container is ensured” (Bundesministerium für Justiz/Republik Österreich 1994, p. 2). Access to condoms should be easy, and in varying anonymous locations of the prison (WHO et al. 2007c).

Despite the availability of condoms, barriers exist to their use in many prisons, and there is often poor knowledge among prisoners of sexual risk behaviour and individual risk prevention (Todts and al. 1997; WHO et al. 2007c). These barriers include the fact that homosexuality is not accepted by most of the prison population and prisons do not offer enough privacy for the occurrence of this behaviour. Furthermore there is evidence that condoms, dental dams, and water-based lubricants are not easily and discreetly available, or are not available on a 24-hour basis. In many prisons, consensual sex is also prohibited, which can result in prisoners being reluctant to access safer sex measures for fear of identifying themselves as engaged in such activities. In order to maximise HIV prevention efforts in prison, and reduce the risk of transmission via unsafe sex, condoms, dental dams, and water-based lubricants should be easily and discreetly available through a variety of distribution channels. Experience has shown that discreet areas such as toilets, waiting rooms, workshops, or day rooms are options that increase the confidentiality of prisoners accessing condoms.

Other important measures alongside with condom provision are educational and informational activities for prisoners and staff on topics of STDs and the provision of condoms (WHO et al. 2007c).

Table 3: Example studies on provision of condoms

Study Quality Results
WHO et al. 2007 F Condom provision is feasible in different prison settings. Acceptance rises among prisoners and staff after implementation of the programme. No study has determined if infections have prevented due to condoms, but there is evidence that prisoners use condoms to prevent infections.

6.13. Pre and post release programmes

The time before and after release from prison has very important impact on future criminal activity, re-incarceration, and relapse (WHO et al. 2007b). The time just after release from prison is especially difficult and needs to be considered separately. The risk of opiate overdose is especially high in the two weeks after release. There is a twenty to fifty fold increase of drug related deaths in the first week after release, this drops by 50% per week and plateaus at 4 weeks (Farrell 2005). Pre- and post-release treatments as well as throughcare programmes constitute important features of treatment.

Continuity of treatment provision is an important factor, particularly as aftercare following release and this is linked to re-offending rates (Porporino et al. 2002).

The prevention of relapses after release and the reduction of recidivism among inmates is one of the major concerns of a penal system bound to rehabilitation. Nevertheless in Europe, there is not much evidence for efforts to provide relapse prevention programmes or to evaluate the effects of those treatments provided. If one wants to know what works, you have to look for findings from Northern-America. Here, a number of specific treatment programmes combined with aftercare had been established in several state prisons. Most of these programmes base upon in-prison therapeutic communities (TC) - often for drug dependents - which are followed by gradually release programmes and participation in aftercare treatment. The most famous programmes are the Californian “Forever Free” in-prison, residential, substance abuse treatment program designed for women (Hall et al. 2004), the “Amity” TC program (Prendergast et al. 2004b), and the corrections-based drug treatment “Key-Crest” in Delaware (Butzin et al. 2005). In addition there are evaluations of prison-based TC’s from New York (Metraux and Culhane 2004; Turley et al. 2004). These studies have been done by tracking the same cohort of inmates over time to assess the impact of treatment on recidivism.

One of the Californian studies was conducted among 4.155 participants of in prison-based TC treatment (Burdon et al. 2004). The results highlight the importance of duration of time spent in treatment. Increased time spent in prison-based treatment predicted increased participation in aftercare and decreased the 12-month recidivism. The “Forever Free” assessment based upon a 1-year follow up of a treatment (N=101) and a comparison group (N=79) (Hall et al. 2004). According to the findings did those women with more lifetime arrests show a significantly increased risk of re-incarceration. Treated women had significantly fewer arrests, less drug use, and greater employment. Similar results are to be found in the “Amity” 5-year post release follow-up (Prendergast et al. 2004b). Again the treatment group had significantly lower rates of re-incarceration than the control group. Those who attended also aftercare had even lower levels of re-incarceration and higher levels of employment. Another 5-year follow-up study examined the effects of post-release transitional therapeutic community treatment in Delaware corrections system (Butzin et al. 2005). The comparison between the treatment and control group showed substantial and persistent benefits for the treatment group even for those with extensive criminal history, low rates of marital bonds, and substantial unemployment. About 32 % of the treatment participants were drug-free compared to 10 % of non-treated. The time to relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. The impact of prison-based treatment and aftercare programmes in reducing the rates of re-incarceration significantly are as well underlined by two studies from New York (Metraux and Culhane 2004; Turley et al. 2004).

In English prisons the drug treatment programme provided by RAPt (Rehabilitation of Addicted Prisoners Trust) has been assessed (Ramsay 2003b). This programme for male prisoners aims at a total abstinence from drugs and alcohol. After a 2-year follow up period the reconviction rate was significantly lower for the treatment group than for untreated prisoners (40 % vs. 50 %. The main finding was that good-quality treatment can be effective in reducing drug use and re-offending. To be effective treatment needs

to be
y tailored to individual needs,
y of sufficient duration,
y followed up by high-quality aftercare, both in prison and on release.

Another study from UK evaluated the effectiveness of different types of treatment for drug dependent prisoners (Harrison et al. 2003). According to the results the strongest evidence for effectiveness have first behavioural skills training and second cognitivebehavioural therapies and Motivational Interviewing. Relapse prevention as a cognitive behavioural approach is proofed to be generally effective to prolong the intervals between relapses and to reduce the severity of relapses. Methadone maintenance has been found to reduce injecting risk behaviour in prison and to decrease crime rates. However, the authors concluded that the success of prison-based treatment is closely connected with the provision of throughcare and aftercare arrangements.

Apart from treatment needs prisoners often have several inter-related resettlement requirements (accommodation, employment, training, health issues) when leaving prison. For this reason Crow (2006) underlined the “importance of multi-modal action addressing the full range of offenders’ needs”. Agencies can play a part in encouraging and reinforcing ex-prisoners’ own efforts and to support these efforts good linkage between agencies is essential. Psychological impairment (Messina et al. 2006) and the situation that there is nothing in place at the time of release increase the likelihood to return to drug uses and related offending.

Because of the high risk of overdose after release, a linkage to immediate substitution treatment is recommended (Rich et al. 2005).

The importance of continued and integrated interventions in the different stages (incarceration until aftercare) are highlightened by Inciardi (1996).

One release programme operating since 1992 is Antenne Toxicomanie, an intensive prerelease course, which decreases the reincarceration rate: 39% of participants returned to prison within one year, compared to 63% in a control group (Turnbull and Webster 1998).

“Especially good-quality aftercare that covers the vulnerable period from release until the first months of re-entry into the community has been proofed to be vital to the success of treatment programmes in prison.” (Zurhold et al. 2005).

6.14. Training and information of prison staff

Prison staff should to be involved and informed on varies issues of drug dependence and treatment, especially in the area of harm reduction.

Harm reduction measures are often perceived as threatening to the traditional abstinence oriented drug policy. Harm reduction often is highly politically loaded, cannot be introduced due to resistance of staff, or are perceived as inadequate for the prison setting (i.e. needle exchange, condom provision).

Prison staff are often particularly reluctant to support the introduction of harm reduction measures, because they feel it would contribute to a wrong message or a double bind situation (drug free orientation as major goal and at the same time providing instruments from continuing habits which are not allowed or even risky or life threatening).

Regarding substitution treatment in prisons it is said both by prisoners and staff that the prison setting is supposed to be drug free. Substitution drugs are seen not a therapeutics but as street drugs, prisoners often experience with buying or selling these drugs in their street drug career. The perspective of prison as a drug free environment is taken by both staff and prisoners (Stöver et al. 2004).

Regarding needle/syringe exchange schemes objections are that they will lead to an increase in intravenous drug use, an increase of accidental needle stick injuries, an increase in conflicts between prisoners or between prisoners and staff, and the risk that syringes/needles would be used as weapons or as goods within the prison economy. There is now evidence that schemes have been introduced in prisons, for example in Switzerland, Spain and Germany, without these problems arising (see Stöver and Nelles 2003).

Regarding the provision of condoms it is often said that condoms are misused for drug trafficking purposes, and that the provision of condoms is difficult to transmit for partners and families outside, because it suggests that sex is a common behaviour in prisons.

HIV/AIDS is not only an issue affecting the health of prisoners. It also has significant implications for the workplace health and safety of staff, and on their duties and professional responsibilities. Therefore it is essential that all prison staff receive regular training and education on HIV/AIDS/HCV prevention, infection control in the workplace, harm reduction and the needs of prisoners living with HIV/AIDS.

According to the International Labour Office’s Code (ILO) of Practice on HIV/AIDS and the World of Work:

“Workplace information and education programmes are essential to combat the spread of the epidemic and to foster greater tolerance for workers with HIV/AIDS. Effective education can contribute to the capacity of workers to protect themselves against HIV infection. It can significantly reduce HIV-related anxiety and stigmatization, minimize disruption in the workplace, and bring about attitudinal and behavioural change.” (International Labour Office 2002, p. 13)

Therefore, training and education of prison staff on HIV/AIDS as well as on broader themes of harm reduction should include information to enable them to protect themselves against HIV infection though their own personal risk behaviours, education to combat HIV-related stigma and discrimination, and specific strategies related to managing HIV/AIDS in the workplace. Prison staff should also be trained in the importance of confidentiality and the privacy of medical information.

Training on the use of universal precautions and protective equipment as part of infection control should be provided for all employees who may come into contact with human blood or body fluids, whether as a consequence of their professional responsibilities, their working environment, or through administering first aid. The ILO further recommends that “Training [on HIV/AIDS] should be targeted at, and adapted to, the different groups being trained.” (International Labour Office 2002, p. 16)

Therefore different training should be provided for different categories of prison staff depending upon their duties (i.e., security staff, medical staff, etc.). Specific training should be provided to prison medical staff to ensure that their knowledge and skills are kept current with emerging medical treatments, prevention strategies and research.

Training and education on harm reduction measures should form a compulsory component of initial training for all new staff, and thereafter HIV/AIDS should be included as a component of the annual training plan in the workplace (International Labour Office 2002). This should include education and training on existing prison policy and legislation related to HIV/AIDS, the rationales behind those laws and policies, and the duties and responsibilities of prison staff to follow them. Furthermore training should focus on the practice and philosophy of harm reduction, as this often is seen as opposing the goals of the prison sentence. Experiences have shown that participative methods are suitable and appropriate to relieve staff’s anxiety11.

The ILO recommends that training may be provided by “external support from national AIDS programmes or other relevant stakeholders” and also encourages the development of peer education initiatives, noting that “The best trainers are often staff themselves.”12

How can this be done practically? Training seminars for prison / drug service staff

Especially important issues for training seminars for prison staff include:

11 Personal Communication Mónica Suárez (Ministerio de Sanidad y Consumo) about the experiences in Spain when introducing

needle exchange projects in prisons, February 2005 12

Ibid.

y Seminars that help prison staff to identify themselves with and support the
objective of preventing infections (emotional level)
y Seminars in which prison staff acquire basic knowledge about drugs, drug use,
infectious diseases and other drug use related health risks
y Seminars in which individual and collective needs for
y safety are discussed and agreed upon. Again the focus of these seminars cannot
only be on knowledge but should also focus on:
y Skills, e.g. in the field of counselling;
y Raising awareness about the staff’s attitude towards drug use, sexual behaviour,
etc.

The training seminars should focus on adequate behaviour patterns as part of measures initiated to prevent the spread of infections in prison. A single training on behaviour change, however, will not be efficient without accompanying structural changes in the prison setting. According to interviews with prison staff, the three following goals need to be met (Stöver and Trautmann 2001):

Identification with the goal of preventing infections:

Prison staff and management can only personally identify with the objective of preventing infections if they accept that infections are a threat for everybody, both in and even outside prisons and therefore should be fought. They need to understand that they have a vital role in doing so successfully. Using print media as leaflets is not enough. These are only suited to complementing other preventive measures such as personal counselling and other services but they cannot replace such measures. Implementation of preventive measures is frequently jeopardized by individual attitudes and prejudice of prison staff (“Inmates know exactly what they are doing; they are grown-ups and they are responsible for themselves”).

Moreover, prison staff often considers drug consumption a weakness of character (“Addiction can be overcome if the will is strong enough. Quitting is the only solution!”) or religious reasons are given for why earthly means are hardly suitable for combating risks of infection (“AIDS is the well-deserved punishment imposed by a higher power!”). Such attitudes and beliefs are deeply rooted in people. They cannot be changed easily. Hence training offered to prison staff should aim at familiarizing them cautiously with new attitudes and at sensitising staff towards the situation of drug-using inmates and of course, allaying the fears of colleagues.

Acquiring basic medical knowledge:

The use of illegal drugs and the use of medical services and medication are often related to each other. However, frequently, drug-using inmates are reluctant to seek help concerning their use of illegal drugs directly from medical services. The situation is getting more complicated by the taboo under which drug use (in prison) operates. Therefore it is crucial that prison staff learn basics of medical knowledge in order to:

y Avoid infections, especially viral infections often associated with drug use,

y Allow prevention and early treatment of health damage related to drug use.

Accepting and meeting individual and collective needs for safety:

This is an important issue when training prison staff, as it has been shown that fear, insecurity and the wish to separate oneself from others have a negative effect on the atmosphere and on interactions and relations between staff and inmates. Although separation from others can be considered a method of protecting oneself against supposed or real threats, it should be overcome in order to establish a closer relationship between prison staff and inmates. This is a prerequisite for successful risk reduction activities, such as discussing safer behaviour. A closer relationship can only be established if the prison staff´s need for safety is accepted and met. Seminars should focus on supporting prison staff, helping them to feel more secure in handling drug-related problems. Besides extending their knowledge on drug and drug use related issues, seminars should also answer questions related to the risk to prison staff of getting infected, and inform participants on things like Post-Exposure-Prophylaxis (PEP) after a needle stick injury, first aid in drug-related emergencies, adequate treatment of wounds and the availability of vaccinations. Often guidelines and protocols for avoiding risk exposure and adequate safety behaviour (such as wearing gloves when searching cells etc.) do already exist. These can be used, as basic material and problems in applying these recommendations then can be discussed. Besides taking up the staff’s needs and fears as an initial point of departure for training, one can use major parts of this manual for designing training seminars for prison staff.

Training seminars for mixed groups:

Combining the target groups of prison staff and inmates can be quite powerful with regard to the exchange of information, changes of attitude, etc. Exercises from the European Peer Support Manual have proved to be useful in this respect (Trautmann and Barendregt 1994). Here, again, a needs assessment might be a good thing to start with. From our experiences working with peer support in prisons (Stöver and Trautmann 1998) we know that peer support can be an issue to deal with in seminars for mixed groups. Peer support and peer education can be useful approaches to contribute to risk reduction in prisons. To work out a plan for peer support one could organise a mixed seminar to present and discuss options of peer support as part of a risk reduction strategy. How and what can drug users contribute, how can they be supported by prison staff, etc. could be issues of discussion. Using exercises on safer use (such as how to inject safely, etc.) can show prison staff that drug users do have valuable information and know-how. However, peer support in general should be first introduced to prison staff as part of an introduction of risk reduction strategies in prisons, for example, by seminars on drug use in general. It does not make sense to focus in a seminar or training seminar on peer support without having discussed first the basics of risk reduction. Our experience has also taught us that peer support initiatives are most successful when supported by professional or voluntary organisations (Trautmann and Barendregt 1994). In the closed setting of a prison, a risk reduction strategy would be impossible without the support of prison staff.

7. Formulation of service gaps and recommendations

  1. There is a clear need for prison systems throughout the EU to acknowledge that the use of drugs and sexual activity occurs within their institutions, in order to prevent prison health problems becoming public health problems (Ramsay 2003b).
  2. Alternatives to imprisonment are the logical consequence for drug-using offenders and should always be preferred, as imprisonment is the most severe consequence for the individual’s health and the community. Drug-related treatment that is linked to the penalty has been progressively introduced over recent decades for problem drug users. The alternatives to prison that may be offered to drug-using offenders cover a range of sanctions that may delay, avoid, replace or complement prison sentences for those drug users who have committed an offence normally sanctioned with imprisonment by national law.
  3. Currently, the prison population in Europe is predominantly male (90–95%), with an increasing proportion of foreign prisoners. On the whole, prisoners are a vulnerable group coming from vulnerable areas of society, and their difficulties can be exacerbated by problematic drug use, exposure to infectious diseases, mental health issues and poor conditions within the prison. In addition their behaviour in prison can be high risk, such as injecting and other forms of drug use, unprotected sexual contacts and tattooing/piercing which remain associated with the transmission of infectious diseases. Health problems are over-represented in all prison systems compared to the outside world, and these include drug use, infectious diseases (HCV, HIV/ AIDS, STIs and TB), suicide and self harm. The treatment of chronic conditions such as diabetes or hepatitis in prisons is also problematic due security constraints and lack of resources.
  4. Drug strategies in prisons require actions to be taken both on the level of individual behavioural change and on the structural level. Although targeting programmes at individual prisoners or groups of prisoners is important, there is also a need for more structurally oriented measures to run concurrently, to comprehensively address necessary improvements in the living conditions of the prisoners and the working conditions of prison staff.
  5. Throughout the EU, the introduction of prevention, treatment and harm reduction measures in prisons is still failing compared to developments achieved in the last 20 years in the community and in prison systems in other countries such as Australia and Canada. An EU report emphasises this lack of equivalence, in that interventions in prisons within the EU are still not in accordance with the principle of equivalence adopted by the UN General Assembly13, UNAIDS/ WHO14 and UNODC15, which

13 http://www.pogar.org/publications/garesolutions/a45-111-90e.pdf 14 http://data.unaids.org/Publications/IRC-pub01/JC277-WHO-Guidel-Prisons_en.pdf 15 http://data.unaids.org/pub/Report/2006/20060701_hiv-aids_prisons_en.pdf.

calls for equivalence between health services and care (including harm reduction) inside prison and those available to society outside prison. Therefore, it is important for the European countries to adopt prison-based activities to meet the needs of drug users and to improve access to services which do already exist.

6. The need for continuity of care (throughcare) is particularly important for those receiving substitution treatments, HAART or treatment for HCV prior to their sentence, so they can continue with this treatment during their sentence. Also, this principle must be considered for those receiving any sort of medical treatment or other forms of support such as counselling for those prisoners close to being released, so they continue to get this support in the community.

Health problems are deriving mostly from injecting drug use and afford extra efforts in policy and practice to tackle this severe problem in prison. This needs to be done in order to protect prisoners, staff, but also families and partners of prisoners in the community.

Many public health experts are now aware of the over-representation of health risks of prisoners, however, the strategies to respond to these challenges differed in goals and methods.

  1. However, the degree of success and effectiveness in implementing interventions to treat drug dependence varies widely, as in most countries, problems and difficulties were identified with the distribution of condoms, bleach, clean needles and the provision of differentiated treatment options. Apart from harm reduction strategies that seem politically difficult to implement (e.g. needle exchange projects) many prisons in Europe show awareness and develop actions to reduce health risks for prisoners. Several harm reduction measures can be implemented when these strategies are supported by political leadership (with legislative or regulative changes as supposition for the introduction of harm reduction measures), and professional consensus based on an exchange of prison health care services and those in the community.
  2. Learning from existing experience in developing harm reduction programmes in prisons, and using that knowledge to develop effective measures is an important strategy for prison administrations to adopt. The clear evidence demonstrating the need and effectives of harm reduction measures and how to overcome resistance to them presents useful guidelines and good practice example to ensure, as far as possible, as successful implementation. Infectious disease prevention programmes targeted at injecting drug users in the community, for example, can be a valuable guide in the development of effective initiatives in prisons. Prison-based infectious diseases programmes internationally can provide valuable evaluated models of good and safe practice.
    1. National and international networking and exchange of good practice models seems to be a valuable method for all prison systems to engage in. In addition, international
    2. networks and journals need to disseminate internationally available good practice models and knowledge about evidence-based strategies into the prison settings and/or on the level of prison administration. Guidelines and detailed protocols are needed on how exactly certain treatment options can and have to be implemented to support prison doctors/ nurses and prison administration in delivering adequate health care services (e.g. for substitution treatment to opiate dependent prisoners).
  3. Time limited pilot tests may be utilised as a tool in developing and implementing new or innovative programmes. Pilot test projects may be valuable in developing staff and prisoner education, prevention of infectious diseases, drug treatment services, and medical services. In addition to providing an opportunity to test project implementation processes and evaluate programme outcomes, pilot projects may be used to encourage change in staff culture, and promote wider support for the implementation of HIV programmes and services. It is essential however that pilot tests do not delay action on harm reduction in prisons, nor be used as an end in themselves. Pilot tests should always be designed as a stepping-stone to wider implementation of programmes, rather than a reason to delay or prevent wider implementation, and should be mainstreamed rapidly upon completion. This should include the development of “pilot regions” in which wider integrated responses within prisons, and between the prison and the community, are established and evaluated.
  4. Adequate funding is key to implementing effective action, and national governments and the international donors should address issues of HIV in prisons as a primary concern in developing national harm reduction and public health strategies. At a national level, parameters of any funding allocated to national drug strategies (including harm reduction strategies), national HIV treatment roll-outs, public health programmes, women’s health, youth health, and public medical care should be expanded to incorporate prisons. Similarly, the parameters of national funding to prisons and drug law enforcement should also be expanded to include harm reduction initiatives. In assessing the issue of prisons, national governments should consider the overall cost savings of taking action to prevent the spread of infectious diseases among prisoners and the broader community and the costs of other health damages.
    1. The implementation of any form of intervention should be accompanied by precise evaluation studies. There is clear lack of high-evidence studies for the prison setting. Less than ten randomised controlled trials were found within this literature search. In advance of the implementation of randomised controlled trials ethical issues, such as informed consent, confidentiality, respect for human right and scientific integrity needs to be considered. In particular for the prison setting these ethical issues should be outstanding to ensure the prisoners rights. Despite these ethical issues, there seems to be no hindrance to perform randomised controlled trial. If this is not possible, for instance due to lack of financial resources, at least cohort studies –
    2. retrospective or prospective – with clear defined exposure groups should be accomplished. In this case clear effect measure measures to determine the effect of the exposure on the health outcome can be quantified.
  5. The coercive, punitive ethos and abstinence-based policies (excluding substitution programmes) that currently underpins prison health policy in most countries must be removed. To view the prisoner as a patient seems to be the necessary shift to achieve this, for example for those prisoners with drug dependence, to see it as a disease rather than a criminal activity, subculture and hedonistic pleasure seeking behaviour. Without this major shift, the principle of equivalence will remain only an aspiration. An important step towards this is for public health care institutions to take over the responsibility for providing health care in prisons, as it is done in Norway, France and now in England & Wales.
  6. Finally, governments must acknowledge the fact that respecting the rights of those at risk is good public health policy and good human rights practice.16

16 Declaration of Commitment – United Nations General Assembly Special Session on HIV/ AIDS [ (“UNGASS Declaration”), June 2001 states “Realization of human rights and fundamental freedoms for all is essential to reduce vulnerability to HIV/AIDS. Respect for the rights of people living with HIV/AIDS drives an effective response.” Preventing the Transmission of HIV Among Drug Abusers: A Position Paper of the United Nations System (Approved on behalf of ACC by the High-Level Committee on programme at its first regular session of 2001, Vienna, 26–27 February, 2001), paragraph 25, states “Protection of human rights is critical to the success of prevention on HIV/AIDS. People are more vulnerable to infection when their economic, health, social or cultural rights are not respected. Where civil rights are not respected, it is difficult to respond effectively to the epidemic”.

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Annexes: Country reports

Contents

1. Country reports ...................................................................................................1

1.1 Austria ................................................................................................................ 2

1.2 Belgium............................................................................................................... 6

1.3 Bulgaria ............................................................................................................ 12

1.4 Cyprus .............................................................................................................. 18

1.5 Czech Republic ................................................................................................ 22

1.6 Denmark........................................................................................................... 26

1.7 Estonia .............................................................................................................. 30

1.8 Finland.............................................................................................................. 34

1.9 France ............................................................................................................... 38

1.10 Germany........................................................................................................... 42

1.11 Greece ............................................................................................................... 46

1.12 Hungary............................................................................................................ 50

1.13 Ireland .............................................................................................................. 54

1.14 Italy................................................................................................................... 59

1.15 Latvia................................................................................................................ 62

1.16 Lithuania .......................................................................................................... 66

1.17 Luxembourg..................................................................................................... 71

1.18 Malta................................................................................................................. 75

1.19 Netherlands ...................................................................................................... 79

1.20 Poland ............................................................................................................... 83

1.21 Portugal ............................................................................................................ 87

1.22 Romania ........................................................................................................... 91

1.23 Slovakia ............................................................................................................ 95

1.24 Slovenia............................................................................................................. 99

1.25 Spain ............................................................................................................... 104

1.26 Sweden............................................................................................................ 110

1.27 United Kingdom............................................................................................. 114

1. Country reports

This annex provides an overview on key issues in the context of single countries. It comprises the data which could be compared within the scheme “below EU-mainstream”, “EU-mainstream” and “above EU-mainstream” concerning “Penal Statistics” and “General Population Epidemiology”. Additionally, data and information concerning “Interventions Monitoring” are taken into account as far as they could be compared according to the scheme “100%” of prisons, “>50%”, “<50%” and “0%”. Due to the lack of information, there are no data on “Penal Epidemiology”. The following sources were used:

The data on penal statistics and general epidemiology are from public European databases:

y Council of Europe Annual Penal Statistics (SPACE I, Survey 2002, 2003 and 2004)
y European health for all database (HFA-DB) from the WHO Regional Office for Europe
y “EuroHIV. HIV/AIDS Surveillance in Europe. End-year report 2005. Saint-Maurice: Institut de veille sanitaire, 2006. No. 73.”
y “Euro TB and the national coordinators for tuberculosis surveillance in the WHO European Region. Surveillance of tuberculosis in Europe. Report on tuberculosis cases notified in 2004, Institut de veille sanitaire, Saint-Maurice, France. February 2006”
y WHO Mental Health country reports on suicide

The data and information on interventions monitoring come from the following sources:

y WHO Prison health database 2007 (http://data.euro.who.int/hip/) y EMCDDA National Reports 2006 y Personal communication with key persons (names and organisations mentioned in the respective

tables)

1.1 Austria

Penal Statistics Austria

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Prison population rate x
% of female prisoners x
% of foreign prisoners x
% of prisoners under 18 x
% of prisoners from 18 to <21 x
Prison density x
% of sentenced prisoners x
Sentenced prisoners per inhabitants x
% of drug offences x
% of sentences <1 year x
% of sentences 5 years and lifetime x
Rate of entries per inhabitants x
% of entries before final sentence x
Average length of imprisonment x
% of suicides among total deaths x
Mortality rate x
Suicide rate x
% of treatment staff x
% of custodial staff x
Rate of prisoners by treatment staff x
Rate of prisoners by custodial staff x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 1) and tables (annex 2).

As the first table of 1.1 regarding the Penal Statistics shows, in Austria most of the analysed variables range within the EU-mainstream. No data were given on the percentage of prisoners sentenced due to drug offences.

Variation is found regarding the percentage of prisoners from 18 to less than 21 years that lies above the EU-mainstream as well the category “rates of sentences shorter than one year”. Additionally, in the category ‘mortality rate per 10000 prisoners in penal institutions” Austria shows quite a high rate that ranges far above the EU-mainstream. The high mortality rate can neither be explained by a high suicide rate (refer to the category “suicide rate per 10000 prisoners in penal institutions”) that ranges in the EU-mainstream, nor by the “suicides as a percentage of total deaths” that also ranges in the EU-mainstream.

General Population Epidemiology Austria

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Rate of newly diagnosed HIV infections x
IDU among new HIV infections x
IDU in cumulative new HIV cases x
Rate of AIDS incidences x
IDU among AIDS cases x
IDU in cumulative AIDS cases x
Rate of viral hepatitis incidences x
Rate of incidences of viral hepatitis A x
Rate of incidences of viral hepatitis B x
Rate of incidences of viral hepatitis C x
Rate of tuberculosis incidences x
Rate of syphilis incidences x
Rate of gonococcal incidences x
Rate of homicide and intentional injury x
Rate of suicide mortality x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 2) and tables (annex 2).

Regarding the table on General Population Epidemiology the Austrian data range most of the time within the EU-mainstream. Data on the proportion of intravenous drug users (IDUs) among newly diagnosed HIV infections are missing as well as on IDUs among cumulative totals of newly diagnosed HIV infections.

Deviation from the EU-mainstream is found regarding the rate of incidence of viral Hepatitis B, which lies above the EU-mainstream.

Interventions Monitoring Austria in 2006

Variables 100% >50% <50% 0% no data Comments*
HIV/ Hepatitis Testing
HIV testing on admission x optional, on request of the inmate
Hepatitis B and/or C testing on admission x optional, on request of the inmate
HIV testing on release x optional, on request of the inmate
Hepatitis B and/or C testing on release x optional, on request of the inmate
Substance use
Drug testing in prison x All prisons use drug tests (screening etc.).
- on admission x occasional
- before holidays/ weekend leaves x occasional
- by suspicion of drug consumption* x occasional
- per random routine x occasional
Prevention
Needle/ syringe exchange x not possible
Availability of condoms* x
Availability of disinfectants x
Possibility of non-supervised visits* x In three of 28 prisons (long term visits)
Drug free units* x In three of 28 prisons
Vaccination against Hepatitis B x optional, on request of the inmate
Care
Antiviral treatment for Hepatitis C x on recommendation of the doctor
Antiretroviral treatment for HIV x on recommendation of the doctor
Brief detoxification with medication x on recommendation of the doctor
Drug free treatment w. psychosoc. support x on recommendation of the doctor
Treatment with antagonists x Whereas syringe exchange is not (yet)
Substitution treatment x possible in Austrian prisons, substitution treatment can be continued or started in prison.
External drug services x optional, on request of the care personnel (social worker, psychologist)
External HIV services x optional, on request of the care personnel (social worker, psychologist)
Initiation of substitution treatment x for seamless provision of care; optional on
Referral to outside drug services x request of the care personnel (social worker, psychologist)
Education
Distribution of information material* x
Counselling by professionals x especially before the end of prison to ensure seamless provision of care
Peer education x
Safer injecting/ safer use training x In order to support doctors who attend to
Education for prison staff x persons in prison, the Federal Ministry of Justice issued guidelines for prison physicians.

Sources: WHO Prison Health Database 2007, EMCDDA Annual Report 2006

*In addition, with estimates (no valid data available) and/or comments from Walter Kahl, Federal Ministry of Justice, Vienna/Austria ([email protected])

As the table above on Interventions Monitoring in Austrian prisons shows, HIV, Hepatitis B and Hepatitis C testing is not performed routinely in prisons, but is optional and inmates may be tested on request.

All Austrian prisons use drug tests by suspicion of drug consumption and occasionally in other cases (on admission, before holidays/ weekend leaves, etc.).

Concerning prevention measures, condoms are available in all prisons in Austria, whereas non-supervised visits (long-term visits) and drug free units are only existing in three of twenty-eight prisons. Vaccination against Hep B is optional, i.e. performed on request of inmates. Needle/ syringe exchange is not possible in Austrian prisons.

Antiviral treatment for Hepatitis C, antiretroviral treatment for HIV are offered on recommendation of the doctor. Concerning drug related treatments, brief detoxification with medication and drug free treatment with psychosocial support are offered on recommendation of the doctor as well. Whereas syringe exchange is not (yet) possible in Austrian prisons, substitution treatment can be continued or started in all prisons. External drug services and external HIV services are optional, i.e. intervene on request of the care personnel (social worker, psychologist). Concerning drug-related pre-release interventions, initiation of substitution treatment is possible in all Austrian prisons, whereas referral to outside drug services is optional, i.e. applied on request of the care personnel (social worker, psychologist), for a seamless provision of care.

As regards education measures, distribution of information material, counselling by professionals (especially before the end of prison to ensure seamless provision of care) and education for prison staff

(i.e. the Federal Ministry of Justice issued guidelines for prison physicians) are measures to be found in all Austrian prisons.

1.2 Belgium

Penal Statistics Belgium

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Prison population rate % of female prisoners % of foreign prisoners % of prisoners under 18 % of prisoners from 18 to <21 Prison density % of sentenced prisoners Sentenced prisoners per inhabitants % of drug offences % of sentences <1 year % of sentences 5 years and lifetime Rate of entries per inhabitants % of entries before final sentence Average length of imprisonment % of suicides among total deaths Mortality rate Suicide rate % of treatment staff % of custodial staff Rate of prisoners by treatment staff Rate of prisoners by custodial staff x x x x x x x x x x x x x x x x x x x x x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 1) and tables (annex 2).

In the table above information on the Penal Statistics in Belgium are shown. Data on the percentage of drug offences were missing.

Regarding the Belgium prisons, the percentage of sentenced prisoners as well as the number of sentenced prisoners per 100 000 inhabitants and the percentage of sentences less than one year range below the EU-mainstream. The rate of prisoners by custodial staff also lies below the EU-mainstream.

The percentage of suicides among total deaths as well as the suicide rate range in Belgian prisons above the EU-mainstream. Furthermore, the percentage of foreign prisoners ranges above the mainstream.

General Population Epidemiology Belgium

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Rate of newly diagnosed HIV infections IDU among new HIV infections IDU in cumulative new HIV cases Rate of AIDS incidences IDU among AIDS cases IDU in cumulative AIDS cases Rate of viral hepatitis incidences Rate of incidences of viral hepatitis A Rate of incidences of viral hepatitis B Rate of incidences of viral hepatitis C Rate of tuberculosis incidences Rate of syphilis incidences Rate of gonococcal incidences Rate of homicide and intentional injury Rate of suicide mortality x x x x x x x x x x x x x x x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 2) and tables (annex 2).

Regarding the General Population Epidemiology in Belgium there is some variation referring to the EU-mainstream. No data was found on the rate of viral Hepatitis incidences as well as on the rate of homicide and intentional injury.

On the one hand the proportion of IDUs among new HIV infections ranges below the EU-mainstream. On the other hand the proportion of IDUs among AIDS cases lies above the mainstream. Additionally, the rates of incidences of viral Hepatitis A as well as B and the rate of suicide mortality lie above the mainstream.

Interventions Monitoring Belgium in 2006

Variables 100% >50% <50% 0% no data comments
HIV/ Hepatitis Testing
offered to prisoners if requested, but not
HIV testing on admission x available in all prisons (30% of all prisoners in Belgium requested to be
tested)1
Hepatitis B and/or C testing on admission x offered to prisoners if requested, but not available in all prisons1
HIV testing on release x
Hepatitis B and/or C testing on release x
Substance use
Drug testing in prison only in medical services when needed1
- on admission x
- before holidays/ weekend leaves x
- by suspicion of drug consumption x
- per random routine x
Prevention
Needle/ syringe exchange x
Condoms are available in prison canteens, as well as in the medical services, where they can be obtained for free. Condoms are also available free of charge in the rooms for conjugal visits. In practice, the canteens
do not have their own stocks but have to procure them on demand at the local
Availability of condoms x pharmacy. This expensive and hardly discreet mode of distribution actually limits
accessibility. In the French Community, a specific packaging has therefore been developed. Each packaging is composed of one condom and one attached lubricant.
Different alternative ways of distributing have been studied according to each prison. In 2002, all medical services were advised
Availability of disinfectants x to make disinfectants (liquid bleach solution with guidelines) available whenever prisoners ask for it.
Possibility of non-supervised visits x There are pilot projects for drug-free units
Drug free units x in some prisons (capacity: 60) and one therapeutic community-like
programme in one Flemish prison.
on request; free of charge; offered to risk
Vaccination against Hepatitis B x groups in a minority of prisons, but in a majority of prisons: vaccination against A and/or B in case of HIV+, HCV+, HBV+
Care2
Antiviral treatment for Hepatitis C x
Antiretroviral treatment for HIV x
Brief detoxification with medication x
Drug free treatment w. psychosoc. support x
only when requested by prisoner 1
Naltrexone is an option available to our
Treatment with antagonists x services. However, it is hardly ever used in
Belgium. In prison, we have no patients on
antagonist medication.
Variables 100% >50% <50% 0% no data comments
300 prisoners were undergoing MMT in
2006; ST for acute detox., for prisoners
Substitution treatment x who have been under ST before prison
without time limit; maintenance ST
available to all prisoners.
Assistance to drug users is provided by the
prison health services and the prison
psychosocial services. In addition, a
number of external specialized therapeutic
External drug services x services are invited to assist the prisoners
but difficulties are reported by these
external services. Prisoners can ask to see
their own medical doctor or therapist(NR
2006).
not at the moment, but planning to create it
External HIV services x based on the existing structure of external involvement of HCV services1
Initiation of substitution treatment x
There is also an ongoing project in some
Flemish prisons with a central intake unit
("centraal aanmeldingspunt") that aims at
improving the through-care for prisoners.
In this project, prison staff and specialised
Referral to outside drug services x drug workers cooperate to link prisoners
with treatment upon release. The project
will be expanded to include more prisons.
Specialised drug treatment organisations
also provide treatment to ex-prisoners on
parole or on probation.
Education
The availability of information material
depends on each individual prison and its
medical service and/or on the possible
presence of an NGO specialised in AIDS
prevention.
Distribution of information material x Specific information material on AIDS and hepatitis prevention for drug users in prison
has been developed by NGOs in
coordination with health services of the
penitentiary administration of the Ministry
of Justice and has been widely distributed
in prisons.
Some external therapeutic settings arrange
treatment in prison for prisoners. They also
organise introduction sessions to inform
Counselling by professionals x about treatment possibilities. Aftercare is, when it concerns psychotherapeutic help,
offered by some of them. Social help is
provided by workers of the centres for
Peer education Safer injecting/ safer use training x x juridical welfare. Limited to certain prisons3 1
More than 10 hours drug-specific
training in the basic training courses
Education for prison staff x and regular updates; counselling: psychosocial
department is available; local
steering groups in every prison to look
Variables 100% >50% <50% 0% no data comments
at these problems four times/year (minimum).

Sources: WHO Prison Health Database 2007, EMCDDA Annual Report 2006

1

BE NFP 2

in 2007 3 Personal communication (Alexis Goosdeel)

All other info presented in this table originates from the EMCDDA National Report 2006 (NR 2006).

Information on Interventions Monitoring in Belgian prisons in 2006 are given in the table above.

Regarding HIV and Hepatitis testing in Belgium, HIV and Hepatitis testing on admission as well as HIV testing on release are available for less than 50% of all prisoners. These tests are offered to prisoners if requested, but are not available in all prisons (for example, 30% of all prisoners in Belgium requested to be tested for HIV on admission). Hepatitis testing on release is not available.

Drug testing is only conducted in medical services when needed and is only possible on admission (in less than half of Belgian prisons).

As measures of prevention, condoms, non-supervised visits and vaccination against Hepatitis B (the latter: on request; free of charge; offered to risk groups in a minority of prisons, but in a majority of prisons: vaccination against A and/or B in case of HIV+, HCV+, HBV+) are provided in all Belgian prisons. Condoms are available in prison canteens, as well as in the medical services, where they can be obtained for free. Condoms are also available free of charge in the rooms for conjugal visits. In practice, the canteens do not have their own stocks but have to procure them on demand at the local pharmacy. This expensive and hardly discreet mode of distribution actually limits accessibility. In the French Community, a specific packaging has therefore been developed. Each packaging is composed of one condom and one attached lubricant. Different alternative ways of distributing have been studied according to each prison. In 2002, all medical services were advised to make disinfectants (liquid bleach solution with guidelines) available whenever prisoners ask for it. They are available in more than 50% of the prisons. Furthermore, there are pilot projects for drug-free units in some prisons (capacity: 60; exist in less than half of the prisons) and one therapeutic community-like programme in one Flemish prison. There is no needle/ syringe exchange programme at all in Belgian prisons.

Antiretroviral treatment for HIV and antiviral treatment for Hepatitis C are available in all Belgian prisons. Regarding drug-related treatments, brief detoxification with medication, treatment with antagonists (only when requested by prisoner; Naltrexone is an option available, however, it is hardly ever used in Belgium; in prison, no patients on antagonist medication in 2006) and substitution treatment (300 prisoners were undergoing MMT in 2006; ST for acute detoxification, for prisoners who have been under ST before prison without time limit; maintenance ST available to all prisoners) are available in all Belgian prisons. Drug free treatment with psycho-social support is provided in less than half of Belgian prisons.

As regards external health services, access to external drug services is available in more than half of the prisons. Assistance to drug users is provided by the prison health services and the prison psychosocial services. In addition, a number of external specialized therapeutic services are invited to assist the prisoners but difficulties are reported by these external services. Prisoners can ask to see their own medical doctor or therapist (NR 2006). External HIV health services are not available at the moment, but it is planned to create such an access based on the existing structure of external involvement of HCV services. Concerning drug-related pre-release interventions, all Belgian prisoners beneficiate of initiation of ST and referral to outside drug services. There is also an ongoing project in some Flemish prisons with a central intake unit ("centraal aanmeldingspunt") that aims at improving the through-care for prisoners. In this project, prison staff and specialised drug workers cooperate to link prisoners with treatment upon release. The project will be expanded to include more prisons. Specialised drug treatment organisations also provide treatment to ex-prisoners on parole or on probation.

As measures to prevent drug-related harm and/or infectious diseases, distribution of information material and counselling by professionals are offered in more than half of Belgian prisons, whereas peer education programmes and safer use training are measures limited to certain prisons (less than half). The availability of information material depends on each individual prison and its medical service and/or on the possible presence of an NGO specialised in AIDS prevention. Specific information material on AIDS and Hepatitis prevention for drug users in prison has been developed by NGOs in coordination with health services of the penitentiary administration of the Ministry of Justice and has been widely distributed in prisons. As for counselling by professionals, some external therapeutic settings arrange treatment in prison for prisoners. They also organise introduction sessions to inform about treatment possibilities. Aftercare is, when it concerns psychotherapeutic help, offered by some of them. Social help is provided by workers of the centres for juridical welfare. Education for prison staff is available in all prisons in Belgium (more than 10 hours drug-specific training in the basic training courses and regular updates; counselling: psychosocial department is available; local steering groups in every prison to look at these problems four times/year (minimum)).

1.3 Bulgaria

Penal Statistics Bulgaria

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Prison population rate % of female prisoners % of foreign prisoners % of prisoners under 18 % of prisoners from 18 to <21 Prison density % of sentenced prisoners Sentenced prisoners per inhabitants % of drug offences % of sentences <1 year % of sentences 5 years and lifetime Rate of entries per inhabitants % of entries before final sentence Average length of imprisonment % of suicides among total deaths Mortality rate Suicide rate % of treatment staff % of custodial staff Rate of prisoners by treatment staff Rate of prisoners by custodial staff x x x x x x x x x x x x x x x x x x x x x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 1) and tables (annex 2).

Regarding the Penal Statistics for Bulgaria, the data vary a lot across the analysed variables. Only for the percentage of drug offences no data is available.

The percentage of female prisoners, of foreign prisoners and of prisoners under 18 years lie below the EU-mainstream, as well as the rate of entries per 100 000 inhabitants and the percentage of entries before final sentences.

Additionally, the percentage of suicides among total deaths and the suicide rate lie below the EU-mainstream, while the mortality rate ranges above.

Also above the EU-mainstream is the prison density. Additionally, the percentage of sentence less than 1 year and the average length of imprisonment lies above the EU-mainstream.

While the percentage of treatment staff lies above the percentage of custodial staff is lower than the EU-mainstream. Correspondingly, the rate of prisoners by custodial staff ranges again above the EU-mainstream.

General Population Epidemiology Bulgaria

Variables* below EU-mainstream within EU-mainstream above EU-mainstream no data
Rate of newly diagnosed HIV infections IDU among new HIV infections IDU in cumulative new HIV cases Rate of AIDS incidences IDU among AIDS cases IDU in cumulative AIDS cases Rate of viral hepatitis incidences Rate of incidences of viral hepatitis A Rate of incidences of viral hepatitis B Rate of incidences of viral hepatitis C Rate of tuberculosis incidences Rate of syphilis incidences Rate of gonococcal incidences Rate of homicide and intentional injury Rate of suicide mortality x x x x x x x x x x x x x x x

*Variable labels are abbreviations; for exact and full definitions, please refer to the respective charts (chapter 2) and tables (annex 2).

Regarding the General Population Epidemiology for Bulgaria the data not often ranges within the EU-mainstream. No data is available for the rate of syphilis and of gonococcal incidences.

Above the mainstream are the proportion of IDUs among new HIV infections and the rate of viral hepatitis, hepatitis A and B, likewise the rate of tuberculosis incidences and the rate of homicide and intentional injury.

The rate of newly diagnosed HIV infections, of AIDS incidences and the proportion of IDUs in cumulative AIDS cases ranges below the EU-mainstream.

Interventions Monitoring Bulgaria in 2005

Background

According to the available data, a three-fold rise in the number of drug-using prisoners was observed over the last three years - in 2003 565 drug-using prisoners were registered, in 2005 their number climbed to 1071, and for the last count at the beginning of March 2006, 1728 drug-using prisoners were counted. Most of them are cannabis users - 487 inmates, 313 prisoners use cocaine, 425 – use heroin, and 216 inject drugs. According to the Bulgarian National Report, at the beginning of 2006 15,6 % of all inmates in Bulgaria were drug users. It a relative rise in the number of prisoners detoxified with methadone. Until recently, this treatment was used by between 20 and 30 prisoners, while the last count reports 69 persons undergoing detoxification with methadone. (2)

Variables 100% >50% <50% 0% no data comments
HIV/ Hepatitis Testing
HIV testing on admission Hepatitis B and/or C testing on admission HIV testing on release Hepatitis B and/or C testing on release According to the head of health care at the Bulgarian Department for Punishment Execution, prisoners are tested for syphilis, hepatitis A, B and C and are also offered an HIV test. The HIV test is voluntary but prisoners do request to be tested.1 Testing not provided upon admission and/or release. Testing for HCV, HBV and HIV when suspected due to symptoms.3
Substance use
Drug testing in prison - on admission - before holidays/ weekend leaves - by suspicion of drug consumption - per random routine Medical staff do not use drug tests at admission but ask prisoners if they use drugs (Head of Health Care, Department for Punishment Execution, June 2003).1
Prevention
Needle/ syringe exchange Availability of condoms Availability of disinfectants Possibility of non-supervised visits Drug free units x x 3, 1 Condoms are not available in Bulgarian prisons, nor can they be bought at prison shops. According to the study, the lack of availability seems to be mainly due to budget problems rather than policy-related1 3, 1 There is a the detached therapeutic sector for drug users in the prison of Bourgas which conducts activities on the principle of therapeutic communities2
Vaccination against Hepatitis B yes 3
Care
Antiviral treatment for Hepatitis C Most often only symptoms are treated. In theory, antiviral treatment can be provided
Variables 100% >50% <50% 0% no data comments
as in community in case patient has health
insurance, however limited in practice due
to limited diagnostics in prisons.3
Antiretroviral treatment for HIV x
In Bulgaria, for detoxification, prisoners
would normally go to Sofia prison hospital.
There is some methadone used in the
hospital if the prisoner was using it in the
community for detoxification (NOT ST!).
Although the majority of prisoners go
through withdrawal at the pre-trial prisons
there are still some who come direct to the
prison. There are few medicines available
in the prisons for treating IDUs at the time
Brief detoxification with medication of withdrawal, mainly pain-relief medications.1
HOWEVER, according to the Bulgarian
National Report, all medical units of the
General Directorate “Implementation of
Punishments” are supplied with the
necessary medicaments and consumables
for detoxification. The detoxification of
drug-dependent inmates is more and more
intensively accompanied with
consultations, therapeutic and crisis interventions.2
Bulgaria is one of the countries where drug
treatment can be compulsory in prison if
ordered by the courts and can continue
after the end of the prisoner’s sentence.
Apart from this compulsory treatment set
by the courts, the only other treatment for
drug users is from short-term projects
provided by NGOs. There are two prison
hospitals for compulsory drug treatment
ordered by the courts, one in Sofia and the
Drug free treatment w. psychosoc. support other in Lovech prison. The treatment of
drug users in Bulgaria, both in prison and
the community, is carried out mainly by psychiatrists.1 In the prisons of Bourgas,
Lovetch, Pleven, Stara Zagora and Sofia,
14 psychotherapeutic groups worked with over 200 inmates.2
In Sofia, psychologists accredited by the
GD “Implementation of Punishments”
provide cognitive-behavioural support to drug-dependent inmates.2
Treatment with antagonists x 1
Substitution treatment x
External drug services yes, with NGOs but not every prison1. 2
External HIV services x
Initiation of substitution treatment Referral to outside drug services x some prisons1
Education
Staff at the Bulgarian Department for
Distribution of information material Punishment Execution said that all
prisoners are given information about drug
Variables 100% >50% <50% 0% no data comments
Counselling by professionals Peer education Safer injecting/ safer use training Education for prison staff x taking and communicable diseases and how to get treatment while in prison. According to the study1, this did not seem to be the reality in the prisons. There was no clear prevention and harm-reduction policy in either of the sample prisons. In Bourgas, an NGO called “Dose of Love” provides informative prevention material and condoms to inmates. 2 3

Sources: WHO Prison Health Database 2007, EMCDDA Annual Report 2006

1 A Study of the Health Care Provision, Existing Drug Services and Strategies Operating in Prisons in Ten Countries from Central and Eastern Europe’, MacDonald, 2005

2 Bulgarian National Report 2006, EMCDDA

3 Hepatitis C among Injecting Drug Users in the New EU Member States and Neighbouring Countries: Situation, Guidelines and Recommendations, CEEHRN, 2007

The table above gives information on Interventions Monitoring in Bulgarian prisons in 2005.

According to the head of health care at the Bulgarian Department for Punishment Execution, prisoners are tested for Syphilis, Hepatitis A, B and C and are also offered an HIV test. The HIV test is voluntary but prisoners do request to be tested. Testing is not provided upon admission and/or release, but HCV, HBV and HIV tests are carried out when suspicion due to symptoms.

Medical staff do not use drug tests at admission but ask prisoners if they use drugs (Head of Health Care, Department for Punishment Execution, June 2003).

As regards prevention in Bulgarian prisons, the only measure existing seems to be vaccination against Hepatitis B. Similar to drug free units, there is a the detached therapeutic sector for drug users in the prison of Bourgas which conducts activities on the principle of therapeutic communities. Condoms are not available in Bulgarian prisons, nor can they be bought at prison shops. According to the study (McDonald, 2005), the lack of availability seems to be mainly due to budget problems rather than policy-related. Needle/ syringe exchange and disinfectants are not provided in any of the prisons in Bulgaria.

Concerning measures of care in Bulgarian prisons, most often only symptoms are treated. In theory, antiviral treatment for Hepatitis C can be provided as in community in case patient has health insurance, however limited in practice due to limited diagnostics in prisons. As for drug-related treatment, for detoxification, prisoners would normally go to Sofia prison hospital. There is some methadone used in the hospital if the prisoner was using it in the community for detoxification (not substitution treatment!).

Although the majority of prisoners go through withdrawal at the pre-trial prisons there are still some who come direct to the prison. There are few medicines available in the prisons for treating IDUs at the time of withdrawal, mainly pain-relief medications. However, according to the Bulgarian National Report, all medical units of the General Directorate (GD) “Implementation of Punishments” are supplied with the necessary medicaments and consumables for detoxification. The detoxification of drug-dependent inmates is more and more intensively accompanied with consultations, therapeutic and crisis interventions. Bulgaria is one of the countries where drug treatment can be compulsory in prison if ordered by the courts and can continue after the end of the prisoner’s sentence. Apart from this compulsory treatment set by the courts, the only other treatment for drug users is from short-term projects provided by NGOs. There are two prison hospitals for compulsory drug treatment ordered by the courts, one in Sofia and the other in Lovech prison. The treatment of drug users in Bul