The Royal Australasian College of Physicians Position Statement Needle and Syringe Exchange Programs in Prisons Drugs and

injecting equipment do find their way into prisons worldwide. A prison needle and syringe exchange would protect inmates today and community members tomorrow from preventable transmission of blood-borne viruses. Recommendations 1. That harm reduction should remain the national official illicit drug policy in Australia and New Zealand. This should be considered to be the first line of intervention in the development of a full treatment program. 2. That Governments should provide sufficient funding to allow harm reduction interventions to be expanded to meet public health needs of custodial staff, prisoners and their families. 3. That Australian State and Territory and New Zealand Governments re-define illicit drug use primarily as a health and social issue, with funding for health and social interventions to be increased. 4. That Australian State and Territory and New Zealand Governments should fund the introduction of needle and syringe exchange programs within a nominated prison in each jurisdiction. The trials should be rigorously evaluated by an independent body, with the aim of introducing the program into all prisons, if deemed effective in improving custodial staff safety and prisoner health. 5. The Australian and New Zealand Governments should provide appropriate funding to research bodies and organisations in order to increase the quantity and quality of evaluation of supply, demand and harm reduction strategies and to ensure that data collection and evaluation is consistent across Australia and New Zealand. Most people who are committed to prison will eventually return to the wider community. Any diseases contracted in prison, or any medical conditions made worse by poor conditions of confinement, become issues of public health for the wider community when people are released. This relationship between prison health and overall public health is fundamental.1

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In recent decades there has been an increasing reliance on law enforcement measures to control drugs and drug use. This has resulted in an increase in the number of inmates who use, or have used, injectable drugs. About half of all Australian and New Zealand injecting drug users have histories of imprisonment; about half of all prisoners have histories of injecting drug use; and about half of all imprisoned injecting drug users continue to inject drugs in prison.2 Aboriginal and Torres Strait Islander peoples are incarcerated at a highly disproportionate rate compared with the rest of the Australian population, 3 and evidence suggests that drug-influenced criminal behaviour is a frequent pathway to incarceration. Around 60 per cent of both male and female Indigenous prisoners acknowledged that they had been under the influence of some form of substance at the time of their offence,4 5 although few male Indigenous prisoners attributed committing the crime to their intoxication. Exposure to substances, their use by community members and the opportunity to use these substances influences use, but the effect of supply and demand is an area of research requiring more attention. The Illicit Drug Reporting System uses key experts to estimate the prevalence of drug use in Australian capital cities, and, by extrapolation, the supply of specific drugs. But, in non-urban settings, the collection of such information is more difficult, particularly for illegal or stigmatised drugs.6 Imprisonment exposes injecting drug users to greater risks, than in the community, of infection with blood-borne viruses, (such as hepatitis B, hepatitis C and HIV). Community based Needle and Syringe Programs (NSPs) provide sterile injecting equipment and are: An important part of addressing blood-borne viral infections such as HIV, hepatitis B and hepatitis C in the community A public health measure reducing the spread of blood-borne viral infections such as HIV, hepatitis B and hepatitis C among injecting drug users Provide education and information on harm reduction in drug use, referral to treatment programs, medical care, education on safe-sex practices, legal and social services Supported by Australian and New Zealands harm reduction frameworks.7 NSPs also have a proven return on investment. For example, in Australia, by the year 2000, approximately 21,000 hepatitis C infections and 25,000 HIV infections are estimated to have been prevented among injecting drug users since the introduction of NSPs in 1988. By 2010, 90 hepatitis C and 4,500 HIV deaths would have been prevented.

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The saving in estimated health care costs from HIV infections prevented by NSPs is more than 20 times the estimated cost of running these services.8 More recently the investment of almost $150 million in NSPs has resulted in an estimated return of between $2.4 and $7.7 billion based on the calculated reduction in HIV and hepatitis C infections.9 The provision of sterile injecting equipment through NSPs in the community has proven to be an effective, safe and cost effective harm reduction strategy. Extensive evaluation of NSPs in community settings has suggested similar benefits are likely in correctional environments. NSPs are currently available in prisons in Switzerland, Germany, Spain, Moldova, Kyrgyzstan, Belarus, Luxemburg, Iran and Armenia. The Ukraine and Scotland will commence pilot projects in 2007 and Portugal intends to implement an NSP in prisons in 2008. Evidence overwhelmingly shows that syringe exchange programs have been successfully implemented in a diverse range of prison settings using a variety of effective models.10 Internationally, research into prison syringe exchange programs have found them to be an effective way of reducing risk behaviour and the spread of HIV and hepatitis C in prisons.11 NSPs in prisons have not resulted in an increase in drug use. They have not led to security or safety concerns and have reduced the risk of needle-stick injuries to prison staff. Evaluations have shown that such programmes, in fact, make prisons safer places to live and work.12 Prison syringe exchange programs result in more people accessing drug treatment. They successfully work alongside programs for preventing and treating drug dependence. They do not increase drug consumption or injecting.13 The international community has generally accepted that prisoners retain all rights that are not taken away as a fact of incarceration. This includes the right to the highest attainable standard of health.14 Therefore, prisoners are entitled, without discrimination, to a standard of health care equivalent to that available in the outside community, including preventative measures.15 Failure to provide prisoners with the same health care options available to the general population violates human rights and international standards.

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References
United Nations Office on Drugs and Crime, World Health Organisation and the Joint United Nations Programme on HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response, 2006, http://www.unodc.org/pdf/HIVAIDS_prisons_July06.pdf#search=%22heino%20st%C3%B6ver%20unodc%22, viewed 3 December 2007. 2 Crofts N, A cruel and unusual punishment, Medical Journal of Australia, vol 166, 1997, p.116. 3 ABS Prisoners in Australia, ABS cat. no. 4517.0. Canberra: ABS. 2005. 4 Johnson H Key findings from the drug use careers of female offenders study. Canberra: Australian Institute of Criminology. 2004. 5 Putt J, Payne J, Milner L Indigenous male offending and substance abuse. Canberra: Australian Institute of Criminology. 2005. 6 Clough AR, Cairney S, Maruff P, Parker R Rising cannabis use in Indigenous communities. Medical Journal of Australia 2002; 177(7):3956. 7 Black E, Dolan K and Wodak A, Supply, demand and harm reduction strategies in Australian prisons, Implementation, cost and evaluation, Report prepared for the Australian National Council on Drugs, July 2004. 8 Hurley et al. 1997 9 Health Outcomes International, The National Centre for HIV Epidemiology and Clinical Research and Professor Michael Drummond, Return on investment in Needle and Syringe Exchange Programs in Australia, Summary Report, Australian Government Department of Health and Ageing 2002. 10 Jurgens R, Interventions to address HIV in Prisons: Needle and Syringe Exchange Programmes and Decontamination Strategies, World Health Organisation Evidence for Action Technical Papers, 2007, http://www.who.int/hiv/idu/oms_%20ea_nsp_df.pdf, viewed 3 December 2007. 11 World Health Organisation, Health in Prisons: A WHO guide to the essentials in prison health, Lars Mller, Heino Stver, Ralf Jrgens, Alex Gatherer and Haik Nikogosian (eds.), 2007. http://www.euro.who.int/document/e90174.pdf, viewed 3 December 2007. See also Stver H and Nelles J, Ten years experience with needle and syringe exchange programmes in European prisons, Journal of Drug Policy, vol 14, no 5-6, 2003, pp.437-444. 12 World Health Organisation, Health in Prisons: A WHO guide to the essentials in prison health, Lars Mller, Heino Stver, Ralf Jrgens, Alex Gatherer and Haik Nikogosian (eds.), 2007. http://www.euro.who.int/document/e90174.pdf, viewed 3 December 2007. See also Stver H and Nelles J, Ten years experience with needle and syringe exchange programmes in European prisons, Journal of Drug Policy, vol 14, no 5-6, 2003, pp.437-444. 13 World Health Organisation, Health in Prisons: A WHO guide to the essentials in prison health, Lars Mller, Heino Stver, Ralf Jrgens, Alex Gatherer and Haik Nikogosian (eds.), 2007. http://www.euro.who.int/document/e90174.pdf, viewed 3 December 2007. See also Stver H and Nelles J, Ten years experience with needle and syringe exchange programmes in European prisons, Journal of Drug Policy, vol 14, no 5-6, 2003, pp.437-444. 14 International Covenant on Economic, Social and Cultural Rights, Article 12; United Nations Declaration of Human Rights, Article 25, amongst others. 15 United Nations Office on Drugs and Crime, World Health Organisation and the Joint United Nations Programme on HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response, 2006, p.ix, http://www.unodc.org/pdf/HIVAIDS_prisons_July06.pdf#search=%22heino%20st%C3%B6ver%20unodc%22, viewed 3 December 2007.
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