In The Name of God, The Compassionate, The Merciful

1. In The Name of God, The Compassionate, The Merciful

2. Methadone Maintenance Program in closed settings (Iran Prison Experience)9 April 2007 Farzad Kasraei,MD Consultant of Deputy for health,correction & Rehabilitation Iran Prisons Organization

3. “Iran has one of the bestAIDS programs, in particular itsneedle-exchange efforts” Dr. Peter Piot* Executive Director of UNAIDS *NEW YORK TIMES    3 JUNE 2005

4. Islamic Republic of Iran • Located in the Middle East • 1.648.195 km2 • 69.200.000 population • Capital: Tehran • 30 Provinces

5. STATISTICS FROM IRAN PRISONS • In Iran there are 176 prisons, 23 juvenile correlation and rehabilitation centers, 20 camps,8 detention centers (totally 227) and 36 centers of after release care. • There are about 10,000 personnel in Iranian prisons organization and the ratio of prisoners to personnel is about 23. • There are 125 quarantine centers, 200 clinics, 15 hospitals, 20 day clinics, 47 isolated rooms, 43 laboratories, 22 radiology centers and 5 physiotherapy centers in health sector of Iranian prisons organization. • Rate of prisoners per population is 214 per 100,000 people

6. Annual turnover is about 600,000 people and the mean residents are approximately 145,000 prisoners • Incarcerated women include 3.5% of prisoners and their place of incarceration is separate from men like most of other countries that will be controlled just by women personnel • The most common crime is crimes related to illicit drugs (48%) • Approximately 3.3% of high risk prisoners are HIV positive.

7. Drug Abuse in Iran • Drug Use Problem in Iran since 400 years ago • Nowadays First Rank in Opiate Drug Use in the world • 3.7 million opiate user (opium, heroin, buprenorphine) • 1.2 million opiate dependent (addiction) • 137,000 Injecting drug users • Trend of Drug Abuse in IRAN during 1978-1998: • 8% annual increase in incidence of drug abuse • Trend of IDU in IRAN during 1988-1998: • 33% annual increase in incidence of drug abuse

8. And the drug abuse statistics in prisons: • 45% of prisoners have drug related crimes • 64% have history of drug use • 30% intention to use drug in prisons • 17-23% IDU • Tattoo in 65% of IDUs *Assesment of drug use in Iranian prisons 2001 (supported with UNODC –Iran)

9. Several assessments were done and according to their results harm reduction measures were planned

10. Assessment of Drug Use in Iranian Prisons*

11. At first a big research was conducted for evaluation of drug abuse and priority of educational needs in prisons. Base on the results, it was clarified that 48 present of prisoners had entered prisons for drug related crimes and 64 present of them have the history of drug abuse. 30 present of them try to abuse drugs inside prisons in any way. 17 to 23% of them abuse drugs by injection mostly with shared and contaminated syringes and handmade tools. On the other hand it was determined that 65% of IDU prisoners tattooed the shin or had the history of tattooing.

12. Assessment of HIV and BBD and psychological disorders in Iranian Prisons

13. Several studies for evaluation of psychologic disorder rate in prisons has been conducted , using SCL90 , showing psychologic disorders are 3 to 3.5 times more than normal population. As a result, psychologic health programs and involving of psychologists, psychiatrist and expert physicians were initiated and it was set that at least 80% of prisoners with psychologic disorders be treated by expert general physicians in 5 years.

14. HIV increase in risky groups 2.1 % in 2002 2.3 % in 2003 3.3 % in 2004 3.5 % in 2005 2.5 % in 2006 (sentinel sites ,common project of MOH&PO) • HBV 5% • HCV 40-60% (Prevalence of HBV and HCV in IDUs in Ghezel-Hesar prison ,Common project of PO&TUMS center for gastrointestinal and liver diseases)

15. Assessment of Training Needs

16. According to educational need assessment, it was determined that knowledge of prisoners is favorite in parts but low in the others and there is a great gap between their knowledge, attitude and practice. Moreover it was seen that peer group education was more effective.

17. There is a large gap between knowledge and practice of prisoners • Peer education is more effective than other methods • 14 title of education has been identified (Health promotion project in Iranian Prisons-2002 supported by prisons organization)

18. PREVENTION

19. In order to prevent this widespread of HIV and hepatitis B and C,planning a comprehensive program, which covers approximately all target groups and all ways of transmission is the only remained solution. And MMT is one of the most important activities in this program.

20. Drug treatment measures in Iran Prisons • Detoxification with clonidin and sedatives • Maintenance Therapy with • Antagonists: Naltroxane • Agonists: Methadone (MMT) • Non medical therapies: • Psychotherapy • Long term residential Psychotherapy Among above mentioned measures MMT is the most popular and most regular measure.

21. There is a standard MMT protocol for prison setting that has approval of MOH, the inclusion criteria are: • -several histories of unsuccessful abstinence • -IDUs who have not the trend of abstinence • -Drug abusers who use drugs heavily or have used drugs for many years • -Youth drug abusers who have started abusing drugs with heroin and at least have used it one year And there are slight changes from MOH protocol due to the nature of prison.for example in MOH centers the client should fulfil four criteria but actually due to limited numbers of MMT centers they only cover HIV+ IDUs.

22. Methadone Maintenance Treatment • First MMT Clinic of Iran in 2002 • Nowadays more than 40 MMT clinics in medical universities, 20 in Drop-in Centers and 60 in Prisons across Iran • 4500 Patients on MMT by MOHME and 8048 others in Prisons (totally 12548) • Nowadays the MMT program in Iran is the biggest MMT program in Prisons of the world • Effectiveness on Iranian patients: • 68% retention in treatment • 20% increase in Employment • 70% decrease in criminal activity • Saving 130 Euro per month per patient

23. Nowadays managers of prisons feel and sense the positive impacts of MMT on prisoners and even on their smoother management for the prison. • There are less • violence • self injury • Theft • Suicide • Drug abuse detection in inspections • Drug trafficking • Abscesses Reported inside prisons that implement MMT.

24. The 15 year Strategic Plan of Iran Prisons Organization • According a 15 year strategic plan, Iran Prisons is suppose to cover all IDU prisoners with MMT and other needed harm reduction measures. Which has started from 2003. • In 2007 Iran prisons will cover 10000 IDU prisoners with MMT

25. Studies showed that at least 10000 prisoners and at most 12000 prisoners in all Iran prisons should be covered with MMT. Till now approximately 8000 prisoners in 60 clinics at 26 provinces have been covered with MMT which is about 66-80% of availability. MMT coverage is rapidly increasing.

26. IMPORTANT NOTE: • In prisons, due to insufficient amount of drugs, extremely high cost of it and lack of security because of smell of abusing drug, the most common method of drug abuse is injection. The method of abuse mostly shifts to injection inside prison instead of other methods. In many cases the first experience of injecting drug have been reported inside prisons. • Moreover unavailability of sterile injection equipments has lead prisoners to use common, old and even handmade tools for injection .

27. Therefore heavy drug abusers who are not still injectors may become eligible for MMT.

28. Ghezel-hesar prisonthe biggest number • Ghezel-hesar is the biggest prison in Iran with more than 12000 inmates located in Karaj city near Tehran (the capital of Iran) and annual turnover of 120000 prisoners. • The prisoners crimes are usually drug related and stealing which can be due to drug abuse. • Last year only 450 IDU prisoners were under MMT and they had lots of problem for scaling up MMT due to budget and human resource limitations.

29. With help of Global Fund project which added 3 physicians and the support of prisons organization and UNODC they are now covering 1048 prisoners under MMT. But there are still 400-500 prisoners in the waiting list. • It’s now the biggest MMT project in closed settings.

30. Besides the previous mentioned positive outputs of MMT the point here is that there is not any MMT severe complication reported! just some constipation and slight side effects. • Especially no death was reported during the last year

31. The clue is peer education among prisoners, they will learn from each other about the complications and overdose of drug injection after MMT. • There is a study being conducted for best practice of MMT in Ghezel-hesar with technical support of Kyoto University and financial support of UNODC. The report of qualitative part will be released soon.

32. Also another positive impact were reminded: • The satisfaction of their families for lowering their expenditures and problems • Therefore strong support of families is backbone of covered prisoners and there is the force of families for being involved in MMT for those who are not covered yet.

33. The complementary step • There are about 36 aftercare centers affliated to PO that provide ex-prisoners with MMT (mostly in centers of provinces) and also there are some agreements with local medical universities and MOH for covering prisoners after release by and introduction letter. Furthermore Drug Control head Quarter and national Harm reduction Committee has approved that prisoners MMT should be continued after release by MOH, but due to limited number of MMT centers affiliated to MOH they don't receive wide range of services nationally.

34. We should have in mind that several other activities besides MMT were done.In this way a comprehensive Harm reduction package is working in Iran Prisons including :

35. Establishment of Voluntary Counseling and Testing Units (Triangular Clinics) • 1-To reduce the harm related to injection drug use, • 2-To deal with sexually transmitted infections • 3-To provide support and care for people living with HIV/AIDS • First Triangular Clinic in Kermanshah in 2000 • Nowadays approximately 70 VCT Units across Iran by MOH and 95 by Prison Organization

36. Triangular clinics for behavioral counseling, as an innovative and comprehensive measure, for prevention, treatment, surveillance and reducing harm of HIV/STI/IDU has been established and the number of them has reached to 60 clinics inside prisons and 34 in after release care centers. It is designed to have 90-100 clinics by the end of the program. These centers provide all services of prevention, treatment, surveillance and harm reduction for all high risk groups.

37. Educational activities: • According to educational need assessment, it was determined that knowledge of prisoners is favorite in parts but low in the others and there is a great gap between their knowledge, attitude and practice. Moreover it was seen that peer group education was more effective. • Consequently educational packages, according to the fourteen needs of prisoners, were prepared in format of film, VCD, DVD, computerized messages, posters, pamphlets, brochures and etc.. About two million pamphlets and posters were produced and distributed. By finishing the educational programs another evaluation was conducted which showed the effectiveness of education and confirmed that education should change from HBM to Benefit Based model.

38. Psychotherapy and treatment of psychologic disorders: • Several studies for evaluation of psychologic disorder rate in prisons has been conducted , using SCL90 , showing psychologic disorders are 3 to 3.5 times more than normal population. As a result, psychologic health programs and involving of psychologists, psychiatrist and expert physicians were initiated and it was set that at least 80% of prisoners with psychologic disorders be treated by expert general physicians in 5 years. (prevalence of mental disorder in Prisoners of Tehran province-Dr. Esmaeeli,Iraj ,2001- Prevalence of psychologic disorder in prisoners of Ardebil province ,Agha-sadeghi,2000- psychopathology of addiction ,Dr. Shahmohamadi et al. , 2001 – Assessment of drug abuse in Iranian prisons ,supported by UNODC,2001) • In addition, yards of long-term psychotherapy cover prisoners in a one year period : 3 month of observation; 3 month of education; 6 month of deep intervention. In recent years at least 10/000 prisoners had deep intervention and re-incarceration for these prisoners has been decreased from 29% to only 3%. (Effectiveness of longterm psychotherapy ,Shams,Ali,2003)

39. Syringe and Needle program: • Which was really the result of success and improvement of harm reduction measures especially MMT on convincing policy makers and governors in such a way that an Executive Order to All Judicial Authorities Nationwide was released by the Head of the Judiciary power for permission of provision of needles and syringes:

40. Executive Order to All Judicial Authorities Nationwide… One of interventions has been done by the Ministry of Health and Medical Education includes provision of needles, syringes and other material used individually by drug addicts and AIDS patients as well as methadone maintenance treatment programs as means of combating HIV and Hepatitis infections among drug addicts…Therefore all judicial authorities must consider the lack of malicious intent in the interventions of the Ministry of Health and Medical Education as well as those of other centers and organizations which are active in this field and not accuse the service providers…Seyed Mahmood Hashemi SharoudiHead of the JudiciaryJan 24th 2005

41. Distribution of bleach and disposable razors: • In order to disinfect tattooing tools, bleach distribution program has been approved, implementing by the AIDS program of Global Fund. • Furthermore, for prevention of sharing shaving blades, after piloting distribution of shavers with plastic guard in two prisons and finally approval of generalization, shavers are being sold with little price in prisons store. This causes shortening of shaver sharing. In near future it will be distributed to prisoners in their health package for free instead of hair remover powders.

42. Conjugal meetings and condom distribution: • To control sexual transmission of HIV, private meeting rooms, with provision of condom and education, were established. Initially it was an award but with suggestion of health office and approval of programming council of prisons organization, it has become a general right for all married prisoners. In addition, condom is easily available in VCTs to cover other prisoners and they can easily have condoms

44. Other Drug treatment facilities : • In order not to shift oral drug abusers to injection use, detoxification facilitations and counseling is available in prisons. For instance, 50000 prisoners used these services in the last year

45. Establishment of hotline counseling: • - Hot line services is being implemented and generalized in some provinces.

46. Decreasing the number of inmates and alternative to incarceration policies: • To decrease total population of prisons as a major harm reduction objective the following measures have taken into action: -The law of replacement punishments - Social punishments - Reducing criminal titles - Elimination of prison punishment for check crimes. - Using the advantage of chronic non-curable diseases and very old age for not being incarcerated . • Court-based treatment • As a result of mentioned measures, total number of prisoners has been decreased from 175000 prisoners in 2002 to 135000 in 2005. Certainly it will be decreased more. Consequently in all low density settings implementation of measures will be easier and more effective.

47. Having sentinel sites: • Sentinel sites are active for epidemiologic study and surveillance of AIDS. These sites are dependent to MOH and each year at a predefined time take 250 to 400 samples for evaluation. Nowadays there are 65 sentinel sites which are observing HIV/ AIDS situation in prisons.

48. Well collaboration with MOH has been initiated for sustainability of services and their continuation after freedom. All prisoners who use services will be referred to public health centers after freedom with a referral form. It is valuable to mention that for re-socializing prisoners in After Release care centers, dependent to prisons organization, there are triangular clinics providing MMT for prisoners in a period of at most three month till they can be covered by public health centers.

49. Thank You For Your Attention. And You are all welcome to visit our activities in Iran