This document provides an overview of needle and syringe programs (NSPs) in prisons internationally and in Australia. Key points include: - Over 60% of Australian prisoners have hepatitis C due to high rates of injection drug use and needle sharing in prisons. - International guidelines recommend NSPs in prisons to reduce disease transmission, yet no Australian prisons currently offer NSPs. - Several countries have successfully implemented various NSP models in prisons, including dispensing machines, peer-based distribution, and distribution by health staff or NGOs. These programs reduce syringe sharing without increasing security issues. - Recent developments in the Australian Capital Territory and a federal inquiry indicate potential future policy changes, but the path forward

1. NSP in Prisons:
a brief overview…
Annie Madden
Executive Officer
Australian Injecting & Illicit Drug Users League (AIVL)

2. Overview
 Australia – the Evidence & the Policy:
• BBVs (partic. HCV) in prisons;
• NSP in prisons – as a policy issue
 ‘State of Play’ Internationally:
• Lessons Learnt
• Models Used
• Countries with Programs
Where to from here for Australia?
• Recent developments in the ACT
• Federal Parliamentary Inquiry into HCV

3. Australia – Evidence & Policy
Evidence:
 Most recent data National Prison Entrant Survey 2013;
 At 30 June 2012 – 30,000 people in Australian prisons;
 Looks at entrants and dischargees – 2 weeks before
and expected within 4 weeks of data collection;
 Less than 1% HIV in Australian prisons;
 However, approx. 60% HCV prevalence in Australian
prisons (notifiable disease but no national surveillance
system in prisons);
 1 in 3 male prisoners and 2/3 female prisoners have
HCV;
 NSW Inmate Health Survey & Justice Health Surveys
2009 – have been important data sources;

4. Australia – Evidence & Policy
Evidence:
 Research has found that PWIDs in Australian prisons
were 24 times more likely to have hepatitis C virus than
prisoners who were non-IDUs;
 At least 8 times more likely to contract the virus while in
prison than non-IDUs;
 2 HCV incidence studies (both no longer funded) HITSC
(Community) & HITSP (Prisons);
 While HITSC showed a declining HCV incidence(2009 &
2013) HITSP does not;
 A history of incarceration is an independent risk factor for
HCV infection in Australia;

5. Australia – Evidence & Policy
Evidence:
 In relation to injecting drug use in prisons:
 All Australian governments admit to high levels of illicit
and injecting drug use in prisons;
 Admit that human rights compliant security and
surveillance systems cannot prevent illicit drugs from
entering prisons;
In this context:
 In 2009 Inmate Health Survey showed that 20% female
detainees admitted to using a syringe that at least 6 or
more people had used before them and that they either
did not or could not access bleach for syringe cleaning.

6. Australia – Evidence & Policy
Evidence:
 A new VIC study with 500 PWID who have a history of
incarceration has shown that:
 Detainees are paying between $100-$150 for access to
a needle tip on average;
 $200-$300 to rent a N&S (a good deal more to buy);
 Most tips and N&S have been used 10s if not 100s of
times;
 Drugs and other comodities for sale in exchange for
use/purchase of a N&S;
 No NSP in Australian prisons in 2015

7. Australia – Real World

8. Internationally?
“One major consequence of the ‘war on drugs’ is the wide-
scale incarceration of people who use drugs. At the same
time, injecting drug use in prisons remains widespread. The
absence of sterile injecting (and tattooing) equipment, and
the lack of opioid substitution treatment and hepatitis
services in most prisons and pre-trial detention settings
makes incarceration an independent risk factor for hepatitis
C infection among people who use drugs.”
Global Commission on Drug Policy, 2013
Global Commission on Drug Policy.2013. The Negative Impact of the War on Drugs on Public Health: The Hidden Hepatitis C
Epidemic. Report of the Global Commission on Drug Policy. New York, United States of America. p.5.

9. State of Play Internationally
 Prisoners Right to Health - failure to provide access to
BBV prevention for prisoners is a violation of international
law - Article 25 Universal Declaration of Human Rights and Article 12 of the
International Covenant on Economic, Social and Cultural Rights (ICESCR).
The obligation to respect the right to health requires States to, inter alia,
refrain from denying or limiting equal access for all persons, including
prisoners or detainees.
 WHO, UNODC & UNAIDS have all recommended that:
“prison authorities in countries experiencing or threatened by an epidemic of
HIV infections among people who inject drugs should introduce and scale up
NSPs urgently.”
 The evidence from countries where Prison NSP’s operate
has been summarised in the 2014 UNODC report “A
Handbook for starting and managing needle and syringe
programmes in prison and other closed settings.”

10. State of Play Internationally
 Prison NSP are feasible and affordable across a wide range of prison
settings.
 Prison NSP are effective in decreasing syringe sharing in prison, thereby
decreasing the risk of disease transmission (HIV, HCV) between prisoners
and from prisoners to prison staff.
 Prison NSP are not associated with increased attacks on prison staff or other
prisoners.
 Prison NSP do not lead to increased initiation of drug consumption or
injection.
 Prison NSP contribute to workplace safety.
 Prison NSP can reduce the incidence of abscesses & other IRIs.
 Prison NSP facilitate referral to available drug-dependence treatment
programs.
 Prison NSP can be delivered successfully via a range of methods in
response to staff and inmate needs.
 Prison NSP are effective in a wide range of prison systems and can
successfully coexist with other drug prevention/treatment programs.

11. The Model is EVERYTHING!
 Various delivery models for the distribution of injecting equipment in closed
settings have been implemented and evaluated in different countries. These
include distribution by prison health staff, by peer educators, by NGO
representatives and via dispensing machines. The 4 main models used in
prison-based NSP’s are:
 Hand-to-hand by prison health staff ; social worker, physician or nurse.
This method is used in several Spanish and Swiss prisons. The used
syringes are either exchanged at the cell door or in the medical unit.
 Hand-to-hand by trained peers (i.e., prisoners) to ensure confidential
contact with prisoners who use drugs and access at almost all times e.g.
Moldova.
 Hand-to-hand by external personnel or NGOs who also provide other
harm reduction services.
 Automated dispensing machines e.g., Germany and Hindelbank women’s
prison, Switzerland (one-for-one exchange, starting with a dummy syringe as
the first device).

12. State of Play Internationally
Country Total N.
Prisons
settings
Start Year Implementation modality N. Prison w/NSP
2006 2011 2013 2014
Switzerland 114 1992 Dispensing
machine/NGOs/Health
Service
7 7 7 7
Germany 185 1996 Dispensing machines 1 1 1 1
Spain 82 1997 Prison health service/NGO 38 38 38 38
Molodova 17 1999 Peer based/NGO 7 9 9 9
Kyrgsystan 17 2002 Peer based & health
service/NGO
11 16 16 16
Belarus 32 2003 1 pilot 0
Armenia 12 2004 3 pilot 0
Iran 253 2005 Health service 1 3 pilot 0 0
Luxembourg 2 2005 Health service 1 1 Review ?
Portugal 49 2007 0 Pilot ? 0
Romania 45 2009 Health service 0 3 0 0
Tajikistan 19 2010 0 1 pilot 1 pilot 0
Afghanistan 2013 0 1 pilot 1 pilot 0

13. Australia – Where to From Here?
 ACT:
• Deed of Agreement;
• Problems with Models
• ‘Dead in the Water’?
 Federal Parliamentary Inquiry into Hepatitis C:
• Roundtables (Consultants, Compulsory Treatment,
etc);
• HCV & Prisons Roundtable (CPSU – more
surveillance and more of the same)
THE FUTURE IS UNCERTAIN… (but new AIVL paper)