The global state of harm reduction in prisons: Inadequate, unreliable and unlawful

In this expert blog, Gen Sander of Harm Reduction International states that the global state of harm reduction in prisons is inadequate, unreliable, and unlawful. She argues that the provision of good-quality and accessible harm reduction, both inside and outside of prisons, is a legally binding human rights obligation, not just a policy option.

The Sustainable Development Goals commit the international community to end HIV and combat hepatitis C (HCV) by 2030. The target is unambiguous – if any population continues to be affected after 2030, it will not have been hit. And so goes the mantra: “leave no one behind” in the global HIV and HCV response. But the 2016 Global State of Harm Reduction report by Harm Reduction International (HRI) shows that one population particularly vulnerable to HIV and HCV – prisoners – continues to be wilfully left behind.

At the root of the problem is the widespread prohibitionist approach to drug control, which favours criminalisation and punishment over health and welfare. This has resulted in the mass incarceration of people who use and inject drugs with one in every five prisoners worldwide held on drug-related charges, most for personal use and possession. UNAIDS estimates that up to 90% of people who inject drugs will be incarcerated at some stage in their lives. Unsurprisingly, injecting drug use continues to be documented in prisons in every region of the world and prevalence of HIV and HCV remains significantly higher inside than outside of prisons across the globe.

The best way to reduce the risk of HIV and HCV transmission among people who use and inject drugs is through harm reduction interventions, such as needle and syringe programmes (NSPs) and opioid substitution therapy (OST). NSPs supply sterile needles/syringes and related injecting equipment to people who are actively injecting for safer drug use. OST is prescribed medication, supplied to people who use drugs, as a replacement therapy for opioid dependence which greatly decreases or eliminates injecting practice. Both interventions are evidence-based, highly cost-effective and have been implemented safely and effectively in various prison settings around the world.

Yet findings from HRI’s Global State of Harm Reduction reveal that provision of these services in prisons remains extremely limited, particularly when compared to what is available to the broader community.

Of the 158 countries that report injecting drug use, 90 currently provide NSPs outside of prison settings, while only eight (Armenia, Germany, Kyrgyzstan, Luxembourg, Moldova, Spain, Switzerland, and Tajikistan) provide it in at least one prison. Since the last Global State report in 2014, Iran appears to have ceased providing NSPs to prisoners, marking the end of prison-based NSP provision in the Middle East and North Africa region. There is better news from both Nepal and France where recent policy and legal developments could, with political leadership and courage, lead to the introduction of NSPs in at least some of their prisons in the near future. Nonetheless, NSP remains extremely vulnerable to budget cuts, financial crises, and changes in political environments. Civil society organisations in Armenia, Kyrgyzstan, Moldova and Tajikistan report that the loss of international funding could threaten the entire future of prison-based NSPs in these countries.

Opioid substitution therapy (OST) in prisons is more widespread, but still vastly inadequate. Currently 52 of the 80 countries providing OST to the non-prison population also make it available in at least one prison. Encouragingly, this represents a 21% increase since 2014. Five new countries (India, Lebanon, Macau, Morocco, and Vietnam) have introduced OST in at least one prison during this time, while the service has been expanded to two more prisons in both Greece and Moldova. Guidelines on OST in prisons have also been developed in Tajikistan, although actual implementation of the service is still under consideration. Despite this important progress, the Global State report reveals that the quality of prison-based OST varies considerably both between and within countries. Serious barriers, including unnecessary restrictions, long waiting times, as well as stigma and discrimination, also continue to impede access to this essential service where it is available.

Opioid overdose is another drug-related harm that is woefully under-addressed in prisons. Although prisoners face a very serious and heightened risk of overdose in the first months following their release, the Global State report revealed the near universal neglect of this critical issue in practice. Only six countries (Canada, Estonia, Norway, Spain, the UK and the US) provide naloxone – a highly effective opioid antagonist – and some degree of overdose prevention training to prisoners on or prior to their release.

In sum, if the global state of harm reduction in prisons had to be described in three words, they would be not only ‘inadequate’ and ‘unreliable’, but also ‘unlawful’. As the UN Special Rapporteur on the right to health has made clear, the provision of good-quality and accessible harm reduction, both inside and outside of prisons, is a legally binding human rights obligation, not just a policy option.

There has been some recognition of this obligation at an international level. The outcome document from last year’s UN General Assembly Special Session on Drugs urged Member States to provide NSPs and OST alongside antiretroviral treatment and overdose prevention and reversal programmes – the first time that a high-level UN document has done so. Moreover, it included a specific mention of the need to make these interventions available in prisons.

Political leaders and prison authorities must now respond to this high-level challenge by prioritising – and funding – harm reduction in prisons. Meanwhile, efforts to provide alternatives to imprisonment for people who use drugs must be intensified without delay. Ending HIV and HCV is possible and entirely within our reach, but not until these steps are taken and truly no one is left behind.

About the author

Gen Sander joined Harm Reduction International as a human rights analyst in 2014. Prior to that, she was a senior researcher at the University of Essex Human Rights Centre, where she taught a module on human rights and worked with Prof. Paul Hunt, former UN Special Rapporteur on the right to health, on issues relating to health and human rights. She has also been a consultant for the WHO and the Independent Expert Review Group (iERG) on right to health issues, and has worked with various human rights NGOs in Canada, Europe and the Middle East.

Photo credit: Eleonora Sharshenalieva for Penal Reform International, 2016