Prof. Dr. Heino Stöver, Bremen Institute for Drug Research (BISDRO), University of Bremen)

1. Prof. Dr. Heino Stöver, Bremen Institute for Drug Research (BISDRO), University of Bremen) Integrated responses to drugs and infections across European criminal justice systemsDrug and Alcohol Misuse in the Criminal Justice System Conference 3rd April 2008The Lowry Centre, Manchester

2. Part I.Background Information

3. Key problems • The understanding of the phenomenon ‘drug dependence’ by staff, doctor, prisoners, partners, families • The belief in abstinence • Control myths re drug use and infectious diseases by management • Prison as a ‘drug free setting’ – no need for harm reduction • NGOs as ‘security risks’? • Discontinuity of treatment, care, and support

4. Prison background data • >600,000 prisoners, approx. 1 Mio per year • Average 121 per 100,000 (56 Slo-337Est) • Increasing number of prisoners; esp. female prisoners • Average 5% female • 8-35% migrants • Overcrowding: average prison density 109

5. The context of the problem: drug use in prisons • drug-related deaths, drug-induced cases of emergency, increase in the number of drug users, dealer hierarchies, debts, mixed drugs, drugs of poor quality, incalculable purity of drugs, and risks of infection (HIV and hepatitis), pressure for prisoners and families… • Lifetime prevalence injecting drug use: 7-38% of all inmates (EMCDDA 1999-2004)

6. Injecting & needle sharing in prison (WHO, A. Verster 2007)

7. Prison as high risk environment • Loss of health protectivemeans • High risk of overdose after release • Self harm over-represented • Discontinuation of treatment • Sexual violence (rape),Violence =>

8. Rape and other forms of sexual violence: Reports to authorities (R. Jürgens) • Only small minority of victims report to prison authorities: • 96 of 2,000 rapes reported (Dumond, 2006): « In some ways, the victim is in a no-win situation » • Other studies found that 29-32% of victimized prisoners informed prison officials (Struckman-Johnson, 1996; Nacci & Kane, 1983) • Only 9% of correctional officers charged with direct supervision believed that rape was a rare occurrence (Eigenberg, 1989)

9. Rape & other forms of sexual violence in prisons: increased vulnerability (R. Jürgens) • Certain prisoners are at higher risk: • Young • First time offenders • With mental illness or development disabilities • Physically small or weak • Known to be homosexual • Transgendered • Not « tough » or « streetwise » • Not gang affiliated • Those previously sexually assaulted

10. Coping with drug use by management • Denial • Abstinence, supply reduction basic orientation • Acquisition and use of drugs dominates life in many penal institutions

11. Drug use in prisons • Regular drug use or dependence prior to imprisonment is reported for 8 % to 73 % of inmates, • 7–38 % of the prison population have ever injected drugs • 8–51 % of inmates report having used drugs within prison, high percentage of drug users among women • 10–42 % report regular drug use • 1–15 % have injected drugs while in prison • 3-26% first used drugs while they were incarcerated • up to 21% of injectors initiated injecting whilst in prison

12. Health Consequences for prisoners • drug related deaths • suicide attempts, • self harm • drug use related diseases (mental illnesses, STIs, TB, etc ) are manifold higher than outside prisons walls • unsafe injections, sexual practices, tattooing and piercing

13. Health Consequences for prison staff • infections with blood borne diseases while searching cells or by accidental needle stick injuries • Violence • Lack of understanding of addiction

14. Transmission of Blood-Borne-Viruses in Prisons • HIV outbreaks • Transmission of HCV/HBV • Imprisonment independent predictor for HCV • Tattooing/piercing

15. Spread of HCV among Prisoners • High risk behaviour and high risk environment: HCV-prevalence 50-90% among IDUs, >17% of all inmates • Poor understanding of HCV dynamics • Unsafe injecting common • Tattooing widespread • Sharing of razors etc.

16. HIV in Prisons in Europe Spain: 10,0% Italy: 17,0% France: 13,0% (500 entries) Switzerl.: 11,0% (cross- sectional in 5 pr.) Greece: 11,0% Several other countries report lower levels of HIV prevalence: Belgium, Finland, Germany, United Kingdom

17. Prison Responses to Health Challenges • Equivalence of health care • Throughcare • Lack of seamless provision of health care • Responsibility for health care • Involvement of NGOs • Lack of funding and human resources • Drug-free oriented treatment and prevention • Interruption of treatment: the case of substitution treatment • Absence of harm reduction measures • Lack of implementation of international standards and guidelines • Missing links with community health care services

18. Proposal for a Council of Europe ‘Recommendation on drugs and prison’ • Main recommendations (public health objective, range of activities, evaluation, reporting) • Specific recommendations among prisoners to: • develop activities to prevent drug use • facilitate the access to treatment of drug users, • increase access to harm reduction/reintegration services for (ex) prisoners and • To monitor/analyse drug use in prisons

19. Part II.Responses

20. Framework for an effective response for HIV/AIDS Prevention Care, Treatment and Support in Prison Setting for Drug Users(modified after Wadih)

21. Consensus on what works: target group iv drug users • Information/Education/Communication (IEC): how to reduce risks: for prisoners and staff; • Distribution of prevention material (needle/syringe programs/NSP, condoms) • Voluntary counselling and testing (VCT) • Antiviral-/antiretroviral treatment • Provision of drug treatment, especially opioid substitution treatment (OST),

22. Introduction of methadone treatment and needle and syringe programmes, in the 25 EU Member States

23. 10-year trend in the number of substitution treatment clients in Europe (EU-15)

24. Substitution Treatment for Opioid Dependence in prisons • … works! • Reduces: • level of injecting • blood borne viruses transmission • drug related prison violence and crime following release • recidivism But needs adequate doses (>60mg)

26. Comprehensive approach • Targeting both prison reform and health reform needed • HIV prevention integral part of a comprehensive approach (e.g. incl. TB) • HIV prevention not a technical intervention only • HIV prevention, care, treatment and support planning with clear targets and quantifiable output indicators, regular assess-ment of achieving goals Make use of the framework!

27. Arabic, Chinese, English, French, Portuguese, Russian, Spanish

28. Education: • Target-group specific information material – ‘tailor-made‘ to the specific needs of various groups (e.g. juveniles, migrants) • Guarantee of confidentiality in counselling processes – the role of external agencies • ‘interactive‘ methods • safer use/safer sex seminars • Training inmates as peer HIV educators • Focus groups to assess service needs of inmates and staff • Starting at different points with different targets

29. Peer Support • Utilising the expertise of the target groups • Self-Help in different phases of imprisonment • Variety of health topics (e.g. infectious diseases, drug use, dental health…)

30. The first day out... • High rate of relapse and recidivism • High rate of mortality within the first 2 days + 4 weeks after release • Drug use after release: finding the right tone, learning from experiences • Anticipating control strategies • Increase risk awareness with provision of information pre release

31. The first day in... • „Guided tour“ – orientation • Risks (suicide, self-harm, overdose) • Screening of infectious diseases…. • Drug use, addiction • Support • Partner/families,

32. Risks entrance phase • Self made drugs • Self made syringes/needles • Debths • Violence/gangs • Sexual contacts/consensual, rape, prostitution, sex for money etc. • dependencies

33. Tattooing • How was the procedure with the last tattooing session? • Availability of bleach? • Boiling possible? • Any information about the last tattoo of staff members?

34. Condoms & other measures to decrease sexual transmission (WHO, Verster 2007, modified) • Providing condoms is feasible in prison settings • No security problems or other negative consequences • Prisoners use condoms when accessible • Need for measures to combat, report rape and sexual abuse • Post Exposure Prophylaxis (PEP) available? Correctional Service Canada, 1999; Dolan, Lowe & Shearer, 2004; May and Williams, 2002; Yap et al., 2007)

35. Provision of Bleach • Obstacles in accessibility? • Next best solutions! Cannot reüplace NSPs • Which bleach can be used for syringes? • What is the exact procedure? • Doubts about the effectiveness • - Conditions in prisons reduce • probability of effective decontamination

36. Evidence of Needle Exchange Programs (NSPs)(WHO, Verster 2007, modified) (Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001)

37. Prepared by Rick Lines Ralf Jürgens Glenn Betteridge Heino Stöver Dumitru Laticevschi Joachim Nelles Published by the Canadian HIV//AIDS Legal Network 2nd edition 2006 English and French www.aidslaw.ca

38. Opioid Substitution Therapy (OST)(WHO, Verster 2007, modified) • OST most effective treatment for opioid dependence • OST in prisons are feasible and effective • reduce IDU, associated needle sharing and other risk behaviour • OST in prisons • facilitates post-release treatment • decreases re-incarceration • has positive effects on institutional behaviour • helps reduce risk of overdose upon release Puerto Rico: Heimer et al., 2005; Spain: Boguna, 1997; Canada: Johnson et al., 2001; Stöver et al. 2004

39. Beneficial Effects of Opioid Substitution Treatment (OST) for Prisoner and Prisons • Mortality: Need to expand prison based programmes and links to community based programmes to reduce opiate related mortality soon after release from prison. Prison Methadone Maintenance to reduce mortality, detoxification alone increases mortality! • Control related issues (e.g. management of opiate addicted inmates)

40. Form and media • Print/electronic • Newspapers • Leaflets • Broadcasting/TV (e.g. I.R. of Iran) • Poster • Quiz/competitions/prize • Films, fotos • ´…

41. HIV/AIDS care, treatment & support (WHO, Verster 2007, modified) • Prisoners respond well to ART • Adherence rates can be as high/higher than in the community • Careful discharge & linkage to community care • As ART becomes available in low- and middle- income countries it is critical to ensure availability in prison systems • Ensuring continuity of care is fundamental for successful treatment scale-up Springer et al., 2004; Srisuphanthavorn et al., 2006; Winarso et al., 2006, Soto Blanco, Perez, March, 2005; Pontali, 2005, Wood et al., 2003; Palepu, 2003; Stephenson et al., 2005; Springer et al., 2004

42. Part III.Methods

43. Form and media • Print/electronic • Newspapers • Leaflets • Broadcasting/TV (e.g. I.R. of Iran) • Poster • Quiz/competitions/prize • Films, fotos • ´…

44. Conclusions (1/3) • Globally and within HIV/AIDS remains a major public health issue as does Hep. C • Prisons remain a major gap, transmission of infectious diseases in prisons & prison release mortality need a coherent and measured response • Principle of equivalence: Consensus on the role and efficacy of substitution treatment and other evidence-measured interventions has to be acknowledged in prison health care

45. Conclusions (2/3) • Close connection between prison and community health care services • Development of transparency of practice and policies – for inmates and the community professionals • Health care standards and clear guidelines on the basis of evidence-based knowledge

46. Conclusions (3/3) • Close connection between prison and community health care services • Development of transparency of practice and policies – for inmates and the community professionals • Health care standards and clear guidelines on the basis of evidence-based knowledge

47. „... Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities“(Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons) heino.stoever@uni-bremen.de www.archido.de www.archido.de Further Information :