“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”
HIV/AIDS in Prisons: Final
© Canadian HIV/AIDS Legal Network and Canadian AIDS Society, Montreal, 1996
In the 16 months between the release of ECAP's Final Report and that of the
Discussion Paper, several new developments occurred in Canadian and other
prison systems. These developments reinforce the need for measures aimed at
preventing HIV transmission in prisons, and increase their urgency:
- a 40 percent increase in the number of known cases
of HIV/AIDS in federal correctional institutions;
- an increase in the number of prisoners living with
symptomatic HIV infection or AIDS in prisons, requiring more extensive and
costly medical care;
- increasing evidence of high-risk behaviours in
- increasing evidence that, as a result of such
behaviours, HIV is being transmitted in prisons;
- very high hepatitis C seroprevalence rates in
prisons, as evidenced by three Canadian studies that revealed hepatitis C
seroprevalence rates of between 28 and 40 percent;
- legal action undertaken by prisoners in two
Australian states against their prison systems for failing to provide
measures to prevent the spread of HIV;
- reports on HIV/AIDS in prisons issued in other
countries, reinforcing the consensus that more needs to be done to prevent
the spread of HIV in prisons and to care for prisoners living with
- a pilot project of needle distribution in prisons in
Switzerland, demonstrating that sterile needles can be distributed in
prisons safely and with the support of inmates, staff, prison
administrations, politicians, and the public.
Since then, the following developments have occurred:
- a further, although slight, increase in the number
of known cases of HIV/AIDS in federal correctional institutions;
- progress and delays in the implementation of some of
the harm-reduction measures promised by CSC;
- the release of the report of the Commission of
Inquiry into Certain Events at the Prison for Women in Kingston,
highlighting systemic shortcomings within CSC, the absence of a culture
respectful of individual rights, and an unwillingness to be responsive to
outside criticism and to engage in honest self-criticism - issues and
problems that also affect CSC's response (or lack of response) to HIV;
- the release of the results of CSC's Inmate Survey,
confirming that high-risk behaviours are prevalent and that "the problem
of AIDS is especially high behind bars";(93)
- legal action undertaken by a prisoner in British
Columbia against the provincial prison system for failing to provide her
with methadone; and
- an increase in the number of prisons and prison
systems in which sterile needles and syringes are made available to
prisoners, and the release of a study demonstrating the positive effects
of making them available.
The following text provides an update on the
developments in the Discussion Paper and discusses the new developments.
Increase in Known HIV/AIDS Cases
Forty-Six Percent Increase over Two Years
During the month of March 1996, 159 inmates were known
to be living with HIV or AIDS in federal prisons in Canada.(94) This
represents a substantial increase (close to 46 percent) from the 109 inmates
with HIV or AIDS who were known to be living in federal prisons as of April
1994. It means that more than one percent of inmates are known to be living
with HIV/AIDS. In some institutions, particularly in the Québec region of
CSC, more than five percent of inmates are known to be HIV-positive. As
stated by Trudi Nichol, Project Coordinator of the Bleach Pilot Project, "[t]he
rate of HIV infection is growing at an alarming rate."(95)
In provincial prisons, the situation is similar. Studies undertaken in
prisons in British Columbia, Ontario and Québec have all shown that HIV
seroprevalence rates in prisons are much higher than in the general
population, ranging from one to 7.7 percent.(96) As in federal institutions,
the numbers of prisoners with HIV or AIDS in provincial prisons are on the
rise. As pointed out by Nichol, many of these inmates will eventually make
their way to the federal prison system. As a result, "health care costs are
going to rise drastically in the next few years and anything we can do to
prevent this is a bonus."(97)
During the last eight months, the increase in known
cases of HIV and AIDS in federal institutions seems to have slowed down.
Nevertheless, the number of prisoners living with HIV/AIDS in federal and
provincial prisons in Canada will continue to increase. As observed in
ECAP's Final Report, worldwide, the prevalence of HIV infection in prisons
has been found to be closely related to the proportion of inmates who
injected drugs prior to their imprisonment, and to the prevalence of HIV
infection in their community.(98) Over the last years, Canada has been
experiencing an increasing epidemic of HIV among injection drug users, with
many new infections occurring, particularly in the major centres -
Vancouver, Toronto and Montréal. Because the prevalence of HIV infection
among injection drug users outside prisons is growing at an alarming rate,
and because many injection drug users spend years of their lives in
provincial and federal prisons, we already know that the number of prisoners
with HIV or AIDS will continue to grow.
In addition, the above numbers represent only the prisoners with HIV or AIDS
who are known to prison authorities. In fact, many more inmates are living
with HIV, but may not be aware of it themselves because they have not been
tested, or may not want to disclose their HIV status for fear of being
discriminated against by fellow inmates and staff.
Increase in the Number of Sick Inmates
situation with regard to HIV/AIDS in prisons is changing: "Until recently,
most prisoners with HIV were in early stages of the disease. Lately we are
seeing more and more prisoners - both newly admitted and long-term - with
advanced stages of HIV disease."(99)
This reflects the evolution of the HIV/AIDS epidemic in
Canada, mirroring the rise of infection rates among intravenous drug users (IVDUs):
an increasing number of IVDUs, many of whom spend at least part of their
lives in prison, are developing AIDS and becoming sicker.
Prisoners in early stages of the disease normally do not require anything
other than monitoring of the progression of their disease and psychosocial
support. For many, imprisonment has resulted in an improvement of their
general health status, due in large part to reduced drug consumption, better
nutrition resulting in weight gain, and ready access to medical and dental
Today, prison health services are increasingly faced with having to deal
with further-advanced stages of the disease and their manifestations. While
the numbers are rising, they are still relatively small, meaning that the
prison physicians who provide services for them are relatively
inexperienced. The resulting problems can be managed if the physicians
recognize that they cannot provide the necessary specialized services and
treatment, and refer prisoners early enough to outside clinics that provide
HIV-specific care for persons with HIV/AIDS.
However, problems are sometimes not recognized. Most prisoners are regarded
as relatively fit young persons, with drug dependency as their only health
problem. Nurses and doctors who work with prisoners deal well with
well-demarcated chronic illnesses such as diabetes, cancer, arthritis, or
easily recognized emergencies such as acute myocardial infarction or trauma,
but the HIV-positive patient with a low CD4 count, who may look well but not
be well, is a challenge. For example, it is difficult for health-care staff
to appreciate that the headache of a well-looking prisoner, still able to
lift weights, is due to a life-threatening cryptococcal meningitis. This
difficulty is enhanced by the fact that some prisoners have a tendency to
try to manipulate health-care staff, who as a result can be more reluctant
to "believe" the inmate and to intervene immediately by, for example, making
referrals or prescribing medication.
Problems are likely to increase in the years to come: "unfortunately, the
rise in the number of seriously ill patients - with other serious infectious
diseases and/or with HIV - coincides with cuts to health-care budgets."(100)
Increasing Evidence of High-Risk Behaviours in Prisons
Mr. P is
a 43 year old male serving life. He has 20 years in on his sentence. He
started using injectable drugs after he was incarcerated; this was his
method of dealing with his loneliness. Mr. P states his early experiences
were with anyone willing to share a hit. After watching one of his peers die
of AIDS two years ago, Mr. P has his own rig (which is seven years old) and
he shares it with no one.
Mr. S is a 37 year old male serving nine years for drug-related crimes. Mr.
S does not use injectable drugs but has found a market for his 13 rigs
inside the institution. Mr. S rents out his needles for one hour at a time
for three to five packages of cigarettes. Three packages of cigarettes rents
a needle older than two years. Five packages of cigarettes rents a needle
less than two years old. Mr. S has needles that are less than six months old
but they go strictly for cash or stamps valued at $50-100 depending on the
demand. All his needles are cleaned with bleach (when he can steal it) or
toilet bowl cleaner (if he has no bleach).(101)
Such anecdotal evidence of the existence and extent of injection and other
drug use in prisons is confirmed by a number of scientific studies
undertaken in Canada and elsewhere. Results of some of these studies were
reported in ECAP's Final Report.(102) ECAP concluded that injection drug use
is prevalent in prisons, and that the scarcity of needles often leads to
needle sharing. During its prison visits, the Committee was told on some
occasions by inmates that injection drug use and needle sharing are frequent
and that sometimes 15 to 20 people will use one needle without cleaning it
between each use.(103) Many CSC staff, in their responses to a questionnaire
ECAP sent them, also acknowledged that drug use is a reality in federal
correctional institutions, saying that "drugs are part of prison culture and
reality," that "drug use is widespread in institutions," that there does not
seem to be a way to ensure that there will be no use of drugs, and that
there are "many needles in the prisons."(104)
Since then, results of other studies have confirmed the prevalence of
injection drug use and other risk behaviours in prisons.
Scotland: Results of Three Studies
In a first study of drug-using behaviour in Scottish
prisons, 11 percent of a purposive sample of 234 prisoners had injected
during their current sentence, while 32 percent were injecting prior to
imprisonment. However, of those who were injecting in prison, 76 percent
were sharing equipment, while only 24 percent of those who were injecting
prior to imprisonment were sharing.(105)
In a second Scottish study, 76 of 227 prisoners (33 percent) had injected
drugs at some time in their lives, and 33 (15 percent) admitted to injecting
in prison. While injectors tended to use drugs on a daily basis outside
prison, they would normally inject only weekly or monthly while in prison.
However, all those who had injected in prison had shared equipment at least
sometimes. Twenty prisoners had always shared it, compared to only two
prisoners who had always shared outside.(106)
In a third study, aimed at determining prevalence of HIV infection and risk
behaviours among male inmates in a prison in Glasgow, half of IDU inmates
reported having injected while incarcerated and six percent had started to
inject while incarcerated. The study concluded:
consistent harm-reduction policy is needed across prisons in the United
Kingdom to avoid transmission of blood-borne viral infections. Drug
injecting inside prison is common, a proportion of IDU inmates having first
injected while in prison, and much higher rates of hepatitis have been
reported in association with injecting while incarcerated compared with that
for IDUs who only injected outside prison.(107)
NSW - HIV Risk Behaviours in Prison
In a study of 181 prisoners in New South Wales, Australia, 40 percent of
respondents reported having engaged in one of three HIV risk behaviours in
prison: one-quarter reported injecting, one-sixth reported sharing tattooing
equipment, and one-twelfth reported having engaged in oral or anal sex while
in prison. Respondents indicated that they were aware of a mean of 10
injectors but aware of a mean of only four syringes on their wing, a strong
indication that inmates were sharing syringes. Two-thirds of respondents
reported a history of drug injecting, and almost half of all respondents had
injected in prison at some time. One-quarter of respondents reported that
they had injected in the prison where they were surveyed, one-fifth reported
sharing syringes and just under one-fifth reported cleaning syringes with a
disinfectant when sharing.(108)
NSW - HIV Risk Behaviour before, during and after Imprisonment
In a study to assess HIV risk behaviour of injection drug users before,
during and after imprisonment in New South Wales, reports of injecting were
more common before entry and after prison discharge than during
incarceration. However, reported syringe sharing was more common during
imprisonment (over 60 percent) than before entry or after prison discharge
(about 20 percent). The researchers pointed out that
did not prevent IDUs from injecting drugs. The proportion injecting drugs in
prison and the frequency of injection was less than in the community.
However, IDUs in prison had limited opportunities to inject without sharing
syringes. Also, imprisonment may facilitate the mixing of IDUs with others
from diverse social and geographic backgrounds. Engaging in risk behaviours
under these circumstances would have considerably greater public health
impact than risk behaviour of IDUs in the community which now generally
occurs in restricted social networks.(109)
results of this study indicate that prisons may play a more critical role in
the spread of HIV infection among and from IDUs than has generally been
acknowledged. The rapid turnover of prison populations, the mixing of
prisoners from diverse backgrounds and the impediments to introduction of
effective prevention strategies suggests that prisons may be far more
significant in terms of public health measures to control HIV and other
infectious diseases than previously acknowledged.
New York - Self-Reported Risk Behaviours
Mahon conducted a focus-group study among 50 inmates in
state prisons and city jails in New York, in which prisoners and former
prisoners reported frequent and tragic instances of unprotected sex and
often-desperate injection drug use with used injection equipment being used
behind bars.(110 )One woman summarized the prevalence and range of sexual
activity described by participants in the study when she stated:
are having sex with females. Female CO's are having sex with female inmates,
and the male inmates are having sex with male inmates. Male inmates are
having sex with female inmates. There's all kinds, it's a smorgasbord up
With regard to injection drug use, participants stated that it was "very
common" in prisons and jails and that drugs enter the system through a
variety of routes, including correctional and medical staff, visitors, and
personal mail. Drugs and drug paraphernalia were more scarce behind bars
than on the street, and this scarcity increased the level of desperation
among active drug users, heightened the value of drugs and drug
paraphernalia and transformed them into a form of currency. Participants
indicated that they could obtain an array of drugs, including heroine,
cocaine and marijuana. They further indicated that syringes were relatively
difficult to find in prison and therefore were almost always shared. Several
participants indicated that they believed they became HIV-infected from
sharing needles in prison.
Delaware - Sexual Activity
Saum et al report that studies of sexual contact in
prison have shown "inmate involvement to vary greatly."(112) In her own
study of the nature and frequency of sexual contact between male inmates in
a Delaware prison, respondents were questioned extensively about sexual
activities they themselves engaged in, directly observed, and heard about
"through the grapevine." Saum concluded that "although sexual contact is not
widespread, it nevertheless occurs," and that most sexual activity is
Indiana - HIV Risk in Rural Jails
Research undertaken by Kane and Dotson indicates that,
although rural jail administrators and staff may have hoped that their
facilities were free from the HIV/AIDS epidemic taking place in prisons and
large urban jails, they may only be lagging behind and are not at all immune
to increasing rates of HIV infection among their inmate populations.(113)
The data show that rural jails in Indiana do house a population at risk for
HIV infection. In particular, 23 percent of inmates have used needles to
inject drugs at some point in their lives.
The Netherlands - Low Levels of Risk Behaviour?
Van Haastrecht et al undertook research to determine
levels of sexual and injection drug use behaviour of injection drug users
during and immediately following imprisonment in the Netherlands. Within the
(non-prison) setting of a cohort study on HIV/AIDS among injection drug
users in Amsterdam, participants were interviewed about their sexual and
injection drug use behaviours during the last period of imprisonment in the
previous three years and about injection drug use in the week following
release from prison. Between April 1994 and January 1996, 497 injection drug
users were interviewed: 35 percent were HIV-positive, and 191 (41 percent)
reported a period of imprisonment in the previous three years. Mean duration
of last period of imprisonment was 3.6 months. Any use of heroine, cocaine,
and cannabis during imprisonment was reported by 36 percent, 20 percent, and
55 percent respectively; 84 percent received methadone treatment at least
part of the time. Only five injection drug users (three percent) reported
having injected in prison, and no injection equipment was used that had
already been used by someone else. Vaginal/anal sex was reported by two of
the men and none of the women in the study. Relapse to drug injecting during
the week following release from prison was reported by 77 (41 percent) study
participants, in 82 percent of cases on the very day of release. Most (62
percent) took their first shot alone, and all except one reported having
used a sterile needle for their first shot.
The study concluded by saying that, "contrary to findings from other
countries, low levels of HIV risk behaviours occur among imprisoned IDUs in
the Netherlands. Although noninjecting use of cocaine and heroine in prison
is quite common, drug injecting is rare, presumably because of a lack of
available needles and syringes." They further concluded that, therefore,
"there appears to be no ground for increasing the availability of clean
injection material in Dutch prisons."(113a) As reported in the Canadian
media, under the particular circumstances revealed by the prisoners who
participated in the study, a needle program could be
counterproductive.(113b) These circumstances are: in contrast to Canada, all
prisoners in the Netherlands are housed in single cells, which significantly
reduces the possibility of syringes circulating among inmates; in contrast
to Canada, 84 percent of inmates received methadone treatment at least part
of the time they spent in prison, which has been shown to reduce levels of
injection drug use; as a result of these and other factors, lower levels of
HIV risk behaviours occurred among the participants in the study than, eg,
among prisoners in federal institutions in Canada (see infra). Further, even
in the Dutch context, the conclusions of the Amsterdam study need to be read
with caution. Indeed, apart from not being applicable to prisons in Canada
and most other countries, they may not be applicable to many Dutch prisons:
another Dutch study seems to contradict, at least in part, its results. In a
study of 701 drug users in Rotterdam (of whom 494 were injection drug
users), 57 of 492 injection drug users tested HIV-positive, for a prevalence
rate of 12 percent. Importantly, imprisonment constituted an independent
risk factor for a positive test result among injection drug users (never
OR=1; once OR=1,96 [0.61 - 6.28]; more than once OR=3,40 [1.36-8.52]),
providing evidence that risk behaviours do occur in prisons in the
Netherlands and constitute an important factor in the spread of HIV.(113c)
Montréal - Risk Behaviours Among Incarcerated Men and Women
In a study of risk behaviours among incarcerated men
and women in medium-security provincial correctional institutions in
Montréal, 73.3 percent of all men and 15 percent of all women reported drug
use while incarcerated; of these, 6.2 percent of men and 1.5 percent of
women injected drugs, mainly cocaine. Sex in prison was reported by 6.1
percent of the men and 6.8 percent of the women. The researchers who
undertook the study concluded that "[r]isk behaviours are prevalent in
prison, reinforcing the need for aggressive policies to prevent the
intramural spread of HIV.(114)
Québec City - Evidence of Needle Sharing
In another study, of HIV prevalence among inmates of a
provincial prison in Québec City, twelve of 499 male inmates admitted
injecting drugs during imprisonment, of whom 11 shared needles and three
British Columbia - High Rates of High-Risk Behaviours
In a federal institution in British Columbia, as
reported above, Nichol found even higher rates of high-risk behaviours, with
63 percent of inmates reporting that they had received a tattoo or piercing
while in prison, 67 percent reporting IV drug use either in prison or
outside (with 17 percent reporting drug use only in prison), and 18 percent
reporting that they had shared a needle with someone who has tested positive
Dorchester Penitentiary - Lower, But High Rates of Risk-Behaviours
In another federal institution, Dorchester Penitentiary
in New Brunswick, Ploem found lower, but still high rates of high-risk
behaviours, with 62 percent of inmates reporting that they had received a
tattoo while in prison, 7.5 percent reporting IV drug use in prison, and 9
percent reporting having engaged in sexual activity while in prison.(116a)
Results of CSC's Inmate Survey
Inmates participating in CSC's Inmate Survey were
questioned about injection drug use, sexual activity, and tattooing. Results
confirm that risk activities are prevalent.
Injection Drug Use
Eleven percent of those who responded (85 percent of
the entire sample) indicated they had injected an illegal/non-prescription
drug since coming to the particular institution in which they were currently
incarcerated; of these, only 57 percent thought that the equipment they used
was clean, while 17 percent thought that it was not clean and the rest did
not know. Self-reported injection drug use was particularly high in the
Pacific Region of CSC, with 23 percent of inmates reporting injection drug
Further, respondents were asked to estimate the percentage of inmates at
their institution who had injected at least one illegal drug in the week
prior to completing the questionnaire. Twenty-eight percent reported none,
while the majority (54 percent) reported between one and 25 percent. The
remaining 18 percent responded that between 26 and 100 percent of inmates
Respondents were asked to estimate what percentage of
inmates who injected drugs shared their needles. Twenty-five percent
reported none; 43 percent indicated between one and 25 percent; 32 percent
reported that between 26 and 100 percent of inmates who injected shared
their needles. When asked what percentage of inmates cleaned their needles,
20 percent indicated none, while 45 percent responded between one and 25
percent. The other 33 percent reported that between 26 and 100 percent of
inmates cleaned their needles.(118)
Six percent of respondents indicated that they had had
sex with another inmate since coming to the institution in which they were
currently incarcerated; of these, only 33 percent reported using condoms.
Respondents were also asked to estimate the percentage of inmates at their
institution who have sex with other inmates (and the percentage of inmates
who have anal intercourse):
- 19 (20) percent reported that inmates do not have
sex (anal intercourse) with other inmates;
- 69 (70) percent indicated that between one and 25
percent have sex (anal intercourse) with other inmates; and
- 12 (10) percent responded that between 26 and 100
percent have sex (anal intercourse) with other inmates.
Tattooing and Piercing
Forty-five percent of respondents said that they had a
tattoo done in prison, and 17 percent had been pierced.
HIV Risky Practices Scale
In the Survey Report, four questions were combined to
produce an "HIV Risky Practices" scale: "The questions focused on the
proportion of inmates who had injected drugs, not used a condom during sex
and thought tattooing and/or piercing equipment they had used was not
clean."(119) Using this scale, 26 percent of all inmates had engaged in
risky practices; such practices were more prevalent in the Pacific Region
(33 percent) and in maximum-security institutions (30 percent).
Perceived Risk of Infection
Forty-six percent of inmates said that they felt
inmates are in more danger of contracting HIV in prison than they are in the
community, while only 31 percent disagreed, and 23 percent were undecided.
Increasing Evidence of HIV Transmission in Prisons
Until recently, few data were available on how many
prisoners become infected while in prison.(120) According to Hammett et al,
the available data from the US suggested that transmission does occur in
correctional facilities, but at quite low rates.(121) For example:
- Castro et al found that 0.3 percent of a sample of
over 2300 initially seronegative male Illinois inmates had seroconverted
after spending one year in prison.(122)
- Brewer et al found that two of 393 Maryland
prisoners had seroconverted after two years in prison.(123) Applying the
results of the study to the entire prison population, Hammett et al
estimated that 60 HIV infections occur annually in Maryland prisons.(124)
- Several other US studies have found annual
seroconversion rates of less than 0.5 percent.
- In the US Federal Bureau of Prisons, 52 cases of
seroconversion had been identified as of 1992. However, all but four of
these occurred during the first six months following intake testing,
suggesting that at least some of the individuals had been infected, but
were in the "window period" when they entered the prison system.
The results of these studies have sometimes been used
to argue that HIV transmission in prisons is rare, and that consequently
there is no need for increased prevention efforts. However, as pointed out
by Hammett et al, regardless of the rates of HIV seroconversion documented
in studies, it is clear that sex and drug use continue to occur in prisons
and that they represent high-risk activities for transmission of HIV.
Anecdotal evidence that HIV transmission is occurring in prison is abundant.
For example, a Louisiana inmate who tested positive for HIV in 1989 reported
he was infected through sexual intercourse and/or needle sharing with a
cellmate during an eight-month period in which they did "every unsafe thing
you could do."(125) In a survey conducted by the Deutsche AIDS-Hilfe, about
17 percent of HIV-positive participants stated that they believe they
acquired HIV infection while in prison.(126)
Recent events suggest that the extent of HIV infection occurring in prisons
has been underestimated. Since the release of ECAP's Final Report in March
1994, evidence of HIV transmission in prisons in Scotland, the United
States, Australia, and other countries has been published, providing
compelling reasons for the need to take HIV transmission in prisons
seriously. In Canada, there have thus far been no documented cases of HIV
transmission in prisons. However, the only reason for this is the absence of
research in this area: everyone knows that HIV transmission is in fact
The following is a review of the published reports.(127)
Scotland: The Outbreak of HIV Infection in Glenochil Prison
In 1994, a study undertaken in Glenochil prison for
adult male offenders in Scotland provided definitive evidence that outbreaks
of HIV infection can and will occur in prisons unless HIV prevention is
The Outbreak Study
Following the diagnosis of eight cases of acute hepatitis B infection and
two apparently recent seroconversions to HIV infection among prisoners, a
public health initiative was launched in which prisoners were offered
confidential counselling and testing for HIV.
There had been 636 inmates at the prison between 1 January and 30 June 1993;
378 inmates (59 percent) were still incarcerated when the initiative was
launched. Among the 258 inmates who were not included in the study, most (74
percent) had been transferred to another prison and the rest had been
Of the 378 inmates still incarcerated, 227 (60 percent) came forward for
counselling; uptake of counselling ranged from 43 percent to 84 percent in
the 11 subunits in Glenochil. Anecdotal reports suggest that many of those
who declined counselling were injectors from one subunit where injecting was
Of the 227 inmates counselled, 76 (33 percent) had a history of injecting;
33 of these admitted injecting in Glenochil, while 43 admitted having
injected at some point in their lives, but not in Glenochil. Of the latter,
34 were tested, but none tested positive.
In contrast, of the 33 inmates who declared that they had injected in
Glenochil prison, 27 were tested and 12 were found to be HIV-positive; the
remaining 15 tested negative but were still in the window period. A further
two Glenochil injectors had been diagnosed HIV-positive two months
previously, giving a total of 14 HIV-positive drug injectors. Of the 14
HIV-positive inmates, definitive evidence of HIV transmission in prison
existed for eight inmates. Another six infections also possibly occurred in
prison, but acquisition of infection outside prison could not be ruled out.
The true number of infections was probably even higher: based on discussions
with prison medical officers, the Scottish Affairs Committee calculated that
the total number of prisoners infected in prison during that period could
lie between 22 and 43 inmates. They also acknowledged that 258 inmates were
missed by the study because they were either transferred or released within
the six- month study period and that some of these may also have been
Why Did It Happen?(131)
Following the outbreak, 12 HIV-positive inmates and 10 other drug injectors
were interviewed about their risk behaviours in prison.
Quantitative data about drug-use patterns and needle and syringe sharing had
been collected at the time of the outbreak. The aim of the interviews was to
gain more information about the nature and dynamics of risk-taking within
the prison's drug-injecting culture, in order to provide a greater
understanding of how the outbreak occurred and of how a similar incident
could be avoided in future.
Injecting, Sharing and Cleaning
At the counselling session, prisoners were asked about their injecting and
needle-sharing practices both inside and outside prison:
- Seven of the injectors had begun their injecting
careers in Glenochil. For the rest, frequency of injecting was found to be
lower in prison compared with outside. Outside, injecting tended to be on
a daily basis, compared with an average of weekly or monthly while in
- However, although frequency of injecting was greatly
reduced in prison, the opposite applied with regard to sharing injecting
equipment; only two prisoners always injected with used equipment outside
prison, as opposed to at least 20 inside. All Glenochil injectors had
shared there at least sometimes.
- Almost all claimed always to clean their equipment
prior to use. However, the methods they used were mostly ineffective, the
majority usually rinsing with hot or cold water. One of the prisoners who
definitely contracted HIV in Glenochil claimed always to clean needles and
syringes with bleach prior to injecting.
Once this basic information about injecting, sharing and cleaning practices
had been collected and analyzed, and in order to obtain as full as possible
an account of risk-taking within the prison, in-depth interviews were
undertaken with 22 inmates, including all but one of those diagnosed as
HIV-positive. The interviews aimed at elucidating details of sharing
networks, the availability and condition of injecting equipment, and the
procedures used to clean it.
From the interviews emerged a vivid description of random sharing with a
limited number of needles and syringes, which were mostly blunt, broken, or
fashioned out of a variety of materials. What follow are verbatim accounts
from the prisoners themselves.
wouldn't believe it. It was like something out of the Bronx. The cells were
packed with junkies waiting on a hit.
There was only one set of syringes in the hall and there was estimated to be
about fifteen or twenty users.
I've seen, in my cell, seven or eight people waiting to use one set of tools
at one time.
Most inmates claimed always to clean used equipment, but circumstances in
prison mitigate against this being carried out effectively, even if
sterilizing equipment is made available. Because prisoners can be accosted
at any moment by prison officers, injecting and cleaning is a hurried
you're cleaning it [injecting equipment] there are usually a few waiting for
it. I've seen boys just jumping up and giving it a couple of flushes with
cold water and then on to the next boy. A few times I've noticed a few wee
clots of blood still down at the bottom of it.
Even if bleach is available, it may remain either unused or ineffectively
wouldn't use bleach. If you are sitting in a cell and hurrying before lock
up, you just give them a quick flush out, have your hit and on to the next
Effectiveness of Bleach as a Decontaminant
The effectiveness of bleach as a decontaminant for injecting equipment has
been questioned on both biological and behavioral grounds.(132) Drug
injectors have been shown to underestimate the time required for sterilizing
purposes. The chance of effective decontamination is likely to be decreased
even further when the equipment used is as follows:
one time I was using this green spike and it was actually bending because it
was so blunt. I had to get someone to force it in.
My arms are in some mess, big bruises and big massive holes. The spikes were
sharpened on wee bits of sandpaper.
We were all cleaning them out but I reckon we were catching it off the
needle with it being corroded on the inside and maybe blood was clinging to
it. Or the plunger - we had to get a plastic bag and stretch it over and get
a bit of thread and tie it round. But the plastic bag would split when it
was stretched over and I reckon the virus was in that because I've seen - it
wasn't exactly fungus, but it was getting that way.
Shooting galleries and random sharing have been shown to be high-risk
factors in the transmission of HIV.(133) That there was a shooting gallery
in Glenochil is undoubtedly the case.
Reasons Behind the Outbreak
Commenting on the reasons behind the outbreak of HIV infection at Glenochil
institution, Taylor and Goldberg said:
In Scottish prisons, bleach tablets are now available and detoxification
programs have been implemented in some establishments, including Glenochil.
But the two principal and highly successful means of HIV prevention - needle
and syringe exchange schemes and methadone maintenance - are not available.
If HIV transmission is to be most effectively prevented, however,
harm-reduction methods that are implemented in the community should also be
implemented in prisons.(134)
They continued by saying that prison staff are "understandably concerned"
about the possible security risks deriving from the wider availability of
needles and syringes in the prison environment, and that - even with the
success of the pilot needle and syringe exchange schemes in Swiss prisons -
there will still be resistance to such a solution at both political and
cultural levels in many other countries. Nevertheless, they concluded that,
if another outbreak of the type reported from Glenochil is to be avoided,
the "same efforts that have gone into preventing HIV transmission among drug
injectors outside prisons must be given to the prevention of spread inside":
illegality of drug taking and the lifestyle of crime that many injectors
adopt to support their drug use means that drug injectors spend large parts
of their life in prison. For some injectors, prison provides the opportunity
to cease drug use, at least for the duration of their sentence. This in turn
means that some come out of prison healthier than when they went in. On the
other hand, for those who continue, prisons continue to be an extremely
After the outbreak, Gore and Bird pointed out that under current
circumstances "a prison sentence, prohibiting access to clean needles for
injectors, may become a death sentence." They emphasized that "HIV education
alone is not enough to escape the death sentence of HIV transmission," and
politicians had the humanity to grant prisoners the same rights to reduce
their risk of HIV infection as the rest of the population then prison
services could help inmates to stop endangering each other, and they could
deliver those rights without risking disorder in the prisons. Practical
initiatives are impeded for lack of political will and legal reform."(136)
Gore and Bird concluded by emphasizing that - as shown by research -
"inmates are more likely than the outside population to have injected drugs,
to have had many female sexual partners, and to have had sex with other
men."(137) The clear public health implication of this is that prisoners
have a greater need than the general population for practical means of harm
reduction. Apart from urging prison systems to make such means available,
Gore and Bird urge prisons to develop a public health protocol that can be
implemented when HIV transmission occurs in a prison: "This protocol must
guarantee prisoners the right to medical confidentiality while ensuring that
accurate epidemiological information is collected.(138)
Australia: A Network of HIV Infection
Evidence of HIV transmission occurring in the prison
setting was also found in prisons in Australia.
Dolan reported Australia's first confirmed case of custodial seroconversion,
a 32-year-old man imprisoned continuously from before 1980 until after 1990.
Prison medical records confirmed that his serum tested negative for HIV
antibodies in July 1987 but positive in November 1989. His first reported
experience of homosexual contact and drug injection occurred in prison. The
prisoner with whom the man reported sharing needles later died of an
AIDS-related illness, as did a second prisoner with whom he reported having
sexual contact in 1988. Dolan emphasized that high-risk behaviours and
limited opportunities for reducing risk in prisons increase the potential
for HIV transmission, and added that rapid turnover of prison populations
may mean that the chance of detecting such transmission is reduced. She
concluded by saying that greater emphasis on prevention of HIV infection in
prisons is required, "including syringe disinfection and possibly needle and
syringe exchange programs, drug treatment programs (especially methadone
maintenance) and provision of condoms."(139)
Based on the first confirmed case, Dolan later investigated an apparent
network of HIV infection among Australian inmates. Nine injection drug users
and their prison contacts were traced, prison records and medical files were
checked, and likelihood of acquiring HIV infection in prison was rated on:
- testing negative and positive in prison;
- documented probable primary HIV infection more than
28 days after prison entry;
- transfer to a particular prison wing during a
crucial one-month period; and
- reported syringe sharing in prison.
The investigation showed that a possible total of seven injection drug users
were infected in prison, leading Dolan to conclude, once again, that "HIV
transmission in prisoners may be underestimated by current surveillance
methods," and that "HIV prevention in prison needs reconsidering in the
light of new evidence."(140)
Another case of custodial seroconversion was reported in Queensland.(141)
United States: Strong Evidence for HIV Transmission in Prisons in
Mutter and colleagues identified 556 prisoners in the
Florida Department of Corrections who had been continuously incarcerated
since 1977. The medical records of these prisoners were reviewed to
determine whether they had been tested for HIV and, if tested, whether the
results were positive. Eighty-seven of the 556 prisoners had undergone
testing for HIV infection. Of these, 18 (21 percent) were found to be
HIV-positive, providing strong evidence for transmission of HIV in
France - Imprisonment as a Risk Factor
In a study of HIV seroprevalence and risk-factor
information conducted in prisons in southeastern France, 20 percent of
participants were intravenous users, 51 percent of whom reported
needle-sharing prior to incarceration (researchers were not allowed to
collect information about risk behaviours in prison). The most disturbing
result was that, when controlling for age, sex and available risk-factor
information, HIV seroprevalence was significantly higher among prisoners who
had been incarcerated previously (19.9 versus 4.4 percent). According to the
researchers, one hypothesis is that incarceration is a risk factor in itself
- the likelihood of HIV infection increases with the frequency and duration
of incarceration: "Given the low level of preventive strategies in French
prisons, imprisonment is a high-risk situation."(143) The researchers
concluded by saying that the fight against the spread of AIDS must include
an efficient preventive strategy inside prisons themselves: "preventive
measures such as easy access to condoms for inmates, supplying bleach to
IVDUs, implementing syringe-exchange programmes and preventing the illicit
introduction of drugs, should be established or improved as a matter of
Thailand: Dramatic Increase of HIV Infection After Amnesty
In 1987, HIV infection among injection drug users
presenting for drug treatment in Bangkok rose from two percent before 9
February to 27 percent by 7 March.(145) The dramatic increase closely
followed an amnesty on the King's birthday, when numerous prisoners were
released. Substantial HIV transmission in prison was thought to be behind
the high HIV incidence. The study was only suggestive of transmission having
occurred in prison, but indicated that the extent of transmission can
potentially be enormous.
Hepatitis C seroprevalence rates in Canadian prisons
are very high, mirroring the fact that injecting drug users are
over-represented in prisons and that reported levels of seroprevalence among
them are high in the community. While most hepatitis C positive inmates come
to prison already infected, the potential for intramural spread is high:
hepatitis C is much more easily transmitted than HIV, and transmission has
been documented in prisons in Canada,(146) Germany, and the US. As expressed
by the authors of one Canadian study,
C seropositivity in [the prison] population likely represents a marker for
intravenous drug use. Infection may well have occurred prior to
incarceration, but this finding [high hepatitis C seroprevalence rates] does
indicate a significant population with a propensity to high-risk behaviour.
It also indicates a considerable burden of ill health which will fall,
initially, on the prison medical services but, ultimately, on provincial
health care systems.(147)
New Cases of Hepatitis in Federal Prisons in Canada
From January to August 1995, 223 new cases of active
hepatitis C and 22 new cases of hepatitis B were reported in federal prisons
in Canada.(148) In 1996, the number of new cases has increased
substantially: from January to April alone, 167 new cases of active
hepatitis C and 19 new cases of hepatitis B were reported.(149)
Studies in Canadian Prisons
Three studies undertaken in Canadian prisons revealed
hepatitis C seroprevalence rates of between 28 and 40 percent.
Prison for Women
In the first study, undertaken at the Prison for Women
in Kingston, 39.8 percent of the 86.9 percent of inmates who participated
tested positive. This was a voluntary, linked, anonymous, cross-sectional
study that was carried out in conjunction with a study of HIV seroprevalence
in the same population. In the study, no attempt was made to evaluate risk
behaviour because it was made clear by inmate representatives that this
would jeopardize participation.(150)
In the second study, undertaken at Joyceville
Institution, a medium-security federal penitentiary near Kingston, 27.9
percent of the 68.9 percent of inmates who participated tested
positive.(151) An increasing awareness of hepatitis C among inmates of other
penitentiaries in the area led to a rise in the number of prisoners
requesting testing. In the study, hepatitis C testing was offered on a
voluntary nominal basis to the entire population of the penitentiary. The
seropositivity rate is somewhat lower than that found at the women's prison.
According to the authors of the study, this may reflect a different exposure
to risk prior to incarceration in female compared with male prisoners.
Male Inmates in British Columbia
A third study of male inmates in British Columbia
showed a prevalence of 28 percent.(152)
Studies in Prisons Internationally
Similar figures are reported from other prison systems.
In prisons in Victoria (Australia), 39 percent of 3627
prisoners tested had been exposed to hepatitis C; 46 percent had a history
of injecting drugs. Prevalence of hepatitis is as high as 50 percent in
prisons in New South Wales (NSW).(153)
Among male inmates in a study of prevalence and
incidence of hepatitis C in Maryland, 38 percent had antibodies to the
hepatitis C virus (HCV) upon entry into prison. In the study, 87 percent of
HIV-positive persons were also HCV-seropositive. Of 164 initially
seronegative inmates, two seroconverted.(154)
Among female inmates in a study on hepatitis C
prevalence and incidence in Connecticut's sole intake facility for women, 32
percent of a random sample of 174 inmates, 76 percent of 162 injection drug
users, and 46 percent of 154 non-injection drug users who reported sex with
injection drug users tested positive for antibodies to HCV. During a
one-year follow-up, three of 13 HCV-negative injection drug users became
Results of a study undertaken in the prison for women
in Vechta, Lower Saxony, (Germany), showed that at least 20 women had
definitely been infected with hepatitis while in prison.(155)
In the study, 1032 health records were examined to evaluate data on the
prevalence of HIV, hepatitis A, B and C, and syphilis among female prisoners
between 1992 and 1994. About one-third of the study population were
injection drug users (IDUs), and 74 percent had been tested for the
above-mentioned infectious diseases at least once.
- HIV prevalence was 4.9 percent among IDUs and 0.5
percent among non-IDUs;
- prevalence of hepatitis B was 78 percent among IDUs
and 12.7 percent among non-IDUs; and
- prevalence of hepatitis C was 74.8 percent among
IDUs and 2.9 percent among non-IDUs.
Records of prisoners who underwent at least two tests
for the same disease were examined to determine whether seroconversion had
occurred during uninterrupted prison sentences. For 41 IDUs, seroconversion
could be documented; of these, 20 (48.8 percent) had definitely been
infected with hepatitis while in prison.
Alarming Potential for Rise of HIV
The rates of hepatitis C seroprevalence found in these
studies are disturbingly high. Hepatitis C is generally spread by either
blood transfusion or by use of contaminated injection equipment, with sexual
transmission being a more remote possibility. In the prison population,
seropositivity for hepatitis C likely represents a marker for IV drug use at
some time in the majority of those testing positive and "suggests an
alarming potential for the rise of HIV."(156) According to the authors of
two of the Canadian studies, results of the studies "would emphasize, yet
again, the need to implement the harm-reduction strategies outlined in the
report of the Expert Committee on AIDS and Prisons."(157) It will further be
both the specific circumstances of infection, primarily related to drug use
and perhaps sexual activity, and the independent risk of tattooing and other
skin piercing activities. The incidence of infection among inmates while in
prison will also have to be examined.(158)
Legal Action by Prisoners
Three recent cases have raised the issue of
governments' responsibility for the health of prisoners in their care.
The Australian "Condom Case"
As discussed in more detail by Malkin in Appendix 1,
infra, in New South Wales (NSW) in Australia, 50 prisoners launched a legal
action against the state for non-provision of condoms.(159) Their lawyer
noted that "[i]t is no proper part of the punishment of prisoners that their
access to preventative means to protect their health is impeded."(160) Since
then, at least in part because of the legal action, the NSW government has
decided to make condoms available in three prisons on a trial basis. While
the legal action is ongoing and remains to be determined, the prisoners
involved have decided not to push the case while the condom trials are
ongoing. If, as a result of the trials, there is general introduction of
condoms in NSW jails, the case will likely be dropped.
The Australian Seroconversion Case
A prisoner who seroconverted while in a
maximum-security institution in Queensland, Australia, launched an action
for damages for negligence against the Queensland Corrective Services
Commission (QCSC). This was one of a number of cases brought against the
QCSC that alleged misconduct in the treatment of HIV-positive prisoners. The
facts of the case were that:
- prisons in Queensland do not supply condoms or
- prison staff have searched for and confiscated such
- prisoners are tested for HIV on entry, after three
months, after six months, then annually, and on discharge;
- the prisoner in question was a long-term prisoner
who had several negative tests before testing positive;
- all parties accept that the seroconversion happened
- correctional authorities first said that the
prisoner had given first aid to another prisoner who had cuts on his
- it was then alleged that he had been playing
volleyball and had been exposed to the blood of a seropositive prisoner;
- subsequently, seropositive prisoners were banned
from playing contact sports; and
- some suspect that the prisoner contracted HIV
through unprotected sex and/or injection drug use and that the case
therefore raises the question of prisons' duty to provide condoms, bleach,
and sterile needles.(161)
While at least one of the cases brought against the
QCSC is ongoing and set for hearing in September 1996, the action for
damages has been dropped because the case was funded by Legal Aid and would
have been too costly to pursue.
The British Columbia Methadone Case
In April 1996, an HIV-positive woman was sentenced to
21 days imprisonment at the Burnaby Correctional Centre for Women (BCCW) in
British Columbia. At the time of her sentence, she was on a methadone
maintenance program supervised by her primary-care physician. In accordance
with a longstanding BC Corrections Branch policy, the BCCW refused to
provide her with methadone. As a result of this refusal, she petitioned the
British Columbia Supreme Court for relief in the nature of habeas
The petition to the Court argued that, under the circumstances the
petitioner found herself in, her detention was illegal. It raised several
constitutional arguments based on the Canadian Charter of Rights and
Freedoms. In response to the petition, and despite the position it had
originally taken, the BCCW arranged for a staff doctor to examine the
petitioner, and he prescribed methadone for her. After this, she withdrew
her petition seeking habeas corpus.
Importantly, in affidavit material filed in this case, the Director of
Health Services for the BC Corrections Branch indicated that the BC
Corrections policy would be changed to recognize the validity of the
harm-reduction model for prisoners and to allow for methadone treatment of
prisoners in certain circumstances.
The petitioner's primary-care physician has since stated that, although no
precedent was set in law by the case, "it was a precedent that was set by
deed." He continued by saying that he expects that in future Corrections
will act accordingly, and that "[w]e are certainly ready to repeat a court
challenge at a moment's notice if necessary."(163)
These cases show the willingness of prisoners to take
legal action against government inaction. Both in the Australian condom case
and the Canadian methadone case, legal action has provided the catalyst
necessary for the institution of long-recommended changes and reasonable
responses to HIV by prison authorities. Courts have not even had to
pronounce on the substantive issues raised in the cases: governments and
correctional authorities, at least in part because of the cases, have acted
before the courts forced them to do so.
Reports on HIV/AIDS in Prisons
Since ECAP's Report was released in March 1994, reports
on HIV/AIDS in prisons have been published in several other countries.
Generally, these reports contain recommendations very similar to those
issued by ECAP, reinforcing the consensus that more needs to be done to
prevent the spread of HIV in prisons and to care for prisoners living with
The Dutch National Committee on AIDS Control (NCAB)
released a 90-page report called AIDS and Detention: The Combat Against AIDS
in Penitentiary Institutions in the Netherlands.(164) In the report, concern
is expressed about the present state of HIV/AIDS policy in prisons in the
Netherlands. The NCAB points out that many prisoners belong to societal
groups - such as drug users, prostitutes, marginal youth, migrants - that
are especially vulnerable to contracting HIV infection. Prisons are
considered as an opportunity to reach these groups through education and
prevention activities. According to the authors, AIDS policy in prisons
should correspond to AIDS policy in the wider society, and to the WHO
Guidelines on HIV Infection and AIDS in Prisons.
In June 1995, the Prison Service of England and Wales
released its Review of HIV and AIDS in Prison.(165) The report contains 39
recommendations in the areas of research, staff and prisoner education,
prevention, risk reduction and harm minimization, counselling, psychological
and social care, and medical aspects of HIV in prison. Among other things,
it recommends that cleansing agents (washing-up liquid and Milton
sterilizing tablets), and condoms, dental dams, and lubricant be made easily
accessible to prisoners.
All of the Committee's recommendations have been accepted, with one
exception: condoms will not be made easily accessible, but will remain
available only on prescription "if in the clinical judgment of the doctor
there is a risk of HIV infection." At a time when many prison systems
worldwide make condoms easily accessible to inmates - and when experience
has shown that this can be done without creating any problems and with
support from management, staff, and prisoners - this is hardly
The report places emphasis on multidisciplinary teamwork to address the
issues raised by HIV/AIDS in prisons. It is evidence of the existing
international consensus with regard to HIV/AIDS in prisons. Many of its
recommendations are the same as, or at least similar to, those previously
issued by other committees and by the World Health Organization, with one
exception: it does not recommend setting up needle-exchange programs in
prisons in England and Wales. The report fails to deal convincingly with
this issue: the Committee considered recommending the setting up of
needle-exchange schemes, but
such an approach would be fraught with difficulty and would fit uneasily
with the duty of prison authorities and staff to detect the smuggling of
drugs into prison and to prevent drug misuse during custody. The conflict
between encouraging prisoners to use an exchanges scheme and detecting
illicit drug use would have no easy resolution.
However, and in complete contradiction to this argument, the Committee goes
on to say that
probability of HIV infection amongst drugs users in prison is such that the
Prison Service should make available to clandestine injectors the means of
effectively sterilising needles.
Admittedly, making sterile needles available in prisons is more difficult
than making bleach available, but in terms of the conflict invoked by the
Committee there is no difference between making needles and bleach
available: both are an acknowledgment that drug use occurs in prisons, and
both create a conflict between the prison system's mandate to prevent drug
use and its responsibility to prevent the spread of HIV.
Australia: A Community Policy on Bloodborne Diseases
A number of community groups in New South Wales (NSW)
have joined forces and produced a policy on the prevention and treatment of
bloodborne diseases such as HIV and hepatitis C, in the prison system.(166)
The policy was launched on 18 September 1995. It reflects the interests of a
wide range of community-based organizations, including the AIDS Council of
NSW (ACON), a drug-user association, the Hepatitis C Council of NSW, a
prisoners action group, and a group of transgender persons. According to
Geoffrey Bloom, Policy Advisor for ACON, all measures proposed in the policy
"must be implemented before NSW can say that it is doing all that it can to
fight the epidemics."(167)
Among many other things, the policy recommends that:
- all prisoners have "free, confidential access to new
injection equipment on a strict exchange basis"; drug equipment be
"excluded from communal spaces within the prison, except for transport to
and from a point of exchange"; prisoners be provided with information and
education about the correct use of injecting equipment; prisoners "known
to have this equipment should not be subject to discriminatory treatment
or harassing cell searches";
- prisoners have access to bleach, and to
sterilization equipment of a clinical standard for tattoo guns and
- there be no limit to the number of prisoners who
have a history of opiate use having access to the prison methadone
- positive prisoners be given information about and
access to all existing treatments, complementary therapies, and
alternative and natural therapies available outside prison;
- requests from seriously ill positive prisoners for
compassionate early release be considered promptly.
The policy also addresses an issue that underlies many
of the problems raised by HIV/AIDS in prisons - current drug laws that
result in many drug users being sentenced to prison, where they continue
using and run an increased risk of contracting HIV. In order to decrease the
number of drug users sentenced to prison, it recommends a variety of changes
to drug laws.
Scotland: A Report on Drug Use and Prisons
According to the report, the primary objective of
prison is secure custody for those sentenced by the courts:
deprivation of liberty constitutes the punishment which is imprisonment.
Drug rehabilitation should not be seen as a primary objective of prisons,
and for drug users to be sent to prison on that basis would be a retrograde
The report urges governments and prison systems to address the possible
adverse effects of sending drug users to prison, in particular the potential
impact of prisons in increasing risk in terms of HIV and AIDS:
involves both examining what happens to drug users in prison, and after they
are released. A coalition of services is required to liaise with prisons to
minimise the harm which results to prisoners, to lessen the impact on
prisons, and reduce the risk to public health.(169)
The report concludes that it
advantageous if prison authorities were to adopt the aims and objectives of
a harm reduction response to drug use and HIV. This would involve a
pragmatic response, and the realisation that the idea of a drug free prison
does not seem to be any more realistic than the idea of a drug free society,
and that stability may actually be better achieved by moving beyond this
concept. In addition, adopting a harm reduction perspective puts prisons in
the best position to ensure that they are not identified with major areas of
concern for public health, such as the spread of HIV.(170)
Needle Exchange in Prisons
[Swiss Federal Office of Public Health] is of the opinion that inmates
should have the same possibilities as people outside prisons to protect
themselves against HIV infection. Making sterile needles and syringes freely
available is now part of AIDS prevention measures for injection drug users.
The same rights - to have access to clean needles and syringes, and to
counselling and medicosocial help - apply to inmates.(171)
In Canada as elsewhere, providing sterile needles to
inmates has been widely recommended as a health measure necessary to reduce
the spread of HIV in prisons.(172) In its Final Report, ECAP observed that
the scarcity of drug-injection equipment in correctional facilities almost
guarantees that inmates who persist in drug-injecting behaviour will share
injection drug users have stated that the only time they ever shared needles
was during imprisonment and that they would not otherwise have done so.
Access to clean drug-injection equipment would ensure that inmates would not
have to share their equipment.(173)
The Committee concluded that making injection equipment available in prisons
will be inevitable, particularly because of the questionable efficacy of
bleach in destroying HIV.(174) As jointly stated by the Centers for Disease
Control and Prevention, the Center for Substance Abuse Treatment, and the
National Institute on Drug Abuse, "based on recent research, bleach
disinfection should be considered as a method to reduce the risk of HIV
infection from re-using or sharing needles and syringes (and other injection
equipment) when no other safer options are available."(175) The centers
emphasized that sterile, never-used needles and syringes are safer than
bleach-disinfected, previously used needles and syringes.
ECAP therefore recommended that "research be undertaken that will identify
ways and develop measures, including access to sterile injection equipment,
that will further reduce the risk of HIV transmission and other harms from
injection drug use in federal correctional institutions."(176)
ECAP's recommendation - which is consistent with the recommendation of many
national and international committees and organizations - has since been
repeated in a number of other reports and in an Australian study on bleach
availability and risk behaviours in prisons in New South Wales.(177) That
study is important because it was the first in the world to allow the
independent monitoring of a bleach distribution program for prisoners. It
investigated the access of prisoners in New South Wales to disinfectants for
syringe decontamination and the prevalence of injection drug use, syringe
sharing, tattooing and sexual activity in prison. It found that three years
after the distribution of disinfectants began, 62 percent of inmates still
found it difficult to gain access to them. It concluded that "[e]ven if an
acceptable and effective form of disinfectant was identified, operational
problems may still compromise the effectiveness of a syringe cleaning
program for prisoners... ." The study pointed out other shortcomings of a
syringe disinfecting program, such as uncertainty about whether other
bloodborne viruses such as hepatitis B and C can be effectively and rapidly
decontaminated from injecting equipment with the use of bleach. It concluded
that other prevention measures need to be explored and that one such measure
that requires consideration is piloting a syringe-exchange program in
One year later, a follow-up study found that there had been significant
improvement in easy access to bleach from the first study: 56 percent of
respondents found it easy to obtain one of the two forms of bleach (Milton
tablets and liquid bleach) available in prison. Nevertheless, the study
found shortcomings in the bleach program and again recommended that
consideration be given to a pilot study of syringe exchange in prisons.(178)
While CSC rejected ECAP's recommendation to undertake such a pilot study, an
increasing number of prisons worldwide has established - or is planning to
do so in the near future - needle and syringe exchange programs. The
following is a review of these programs.
Switzerland: A Tale of Pragmatism
The Hindelbank Pilot Project
distribution of sterile needles, a preventive measure which has proved
effective outside of the penitentiary environment for many years, has up to
now not crossed the threshold of prison doors. The primary argument against
such a strategy has traditionally been the apparent incompatibility of such
a protective health measure with the illegal status of drugs. The
controversy resulting from this dilemma has, above all, been marked by
speculations and fears concerning the possible repercussions of introducing
this pragmatic measure to a prison environment.
An attempt to dispel such uncertainties was one of the primary objectives of
the pilot project created at the Hindelbank Penitentiary, which among other
measures included the distribution of sterile syringes. The target of the
project was by no means to give 'a green light' for the consumption or
misuse of drugs. Instead, the project's aim was to reduce the associated
health risks faced by the prisoners.(179)
A one-year pilot AIDS prevention program including needle distribution
started at Hindelbank institution for women in June 1994. One year later, a
decision was taken to continue the program because evaluation by external
experts demonstrated clear positive results:
- the health status of prisoners improved;
- no new cases of infection with HIV or hepatitis
- an important decrease in needle sharing was
- there was no increase in drug consumption; and
- needles were not used as weapons.
Hindelbank Institution is the only prison for women in the German-speaking
parts of Switzerland. It can house up to 110 inmates in its six divisions.
During the year in which the pilot project took place, 99 women entered and
112 left the prison, for a mean occupancy rate of 87. The majority of the
prisoners have been sentenced for narcotics offences, and one-third of
prisoners reported having consumed heroin or cocaine before their
History of the Project
At the end of the 1980s, because of the appearance of HIV/AIDS, health-care
workers at the institution became concerned about the increased harms
deriving from injection drug use and began requesting that new and more
effective preventive measures be implemented.(180) In 1988, the
institution's health-care services - without having obtained permission from
the competent authorities - decided to hand out sterile injection equipment
to injection drug users, on their request. When authorities became aware of
this decision, they prohibited the handing out of injection equipment. As a
result, a physician of the institution decided to poll inmates on drug use
and needle exchange. He found that almost all the women who were injection
drug users had exchanged needles with other inmates. Armed with this
information, he proposed, with the agreement of the director of the
institution, launching a pilot project to provide sterile equipment to
inmates. At first the proposal ran up against opposition, but thanks to the
collaboration of the Swiss Federal Office of Public Health, authorization
was finally granted in 1994. After a fairly long process of political
decision-making and a short preparatory phase, the pilot project was
launched at Hindelbank on 13 June 1994.
Aims of the Project
The aims of the pilot project were as follows:(181)
- to study the feasibility of needle distribution in
the prison environment;
- to make sure that the project is accepted by all
persons concerned (inmates and staff);
- in the short term, to reduce the harms from drug
- in the short term, to prevent infection or
reinfection by dangerous pathogenic agents (HIV, hepatitis B virus,
hepatitis C virus, etc); and
- in the medium or long term, to reduce the number of
new drug users and of former users who relapse.
Further, with the help of the independent scientific
evaluation, the project aimed at:
- assessing the impact of the project on drug use,
risk behaviours, and, generally, the health of inmates; and
- drawing conclusions and making recommendations
regarding the application of the adopted measures in other institutions.
The methods used to achieve these goals were directed to all inmates and
included demonstrations, group meetings that used exercises, role playing,
consultations with the project director and his co-workers, a hotline for
discussion of problems, supplementary prevention measures, and written and
The provision of sterile syringes was basic to the project. During their
first interview with the project director or his co-workers, inmates
received a syringe, which could not, however, be used for injection
purposes. The secretariat of the institution provided new inmates with such
a syringe, together with instructions in their mother tongue, upon their
arrival. With the help of this subterfuge (a real syringe without a needle),
or with a syringe that had already been used, inmates could operate an
automatic dispenser to get a sterile, ready-to-use needle. Automatic
dispensers were installed in each of the six sections of the institution, in
different locations - such as showers, toilets, storage areas, etc - that
are easily accessible by prisoners. Prisoners were allowed to keep one (but
not more) piece of injection equipment, but only in a designated toilet
Evaluation was undertaken by a group of external experts. Structured
interviews were carried out with the prisoners and the personnel before
launching the project, and three, six and twelve months thereafter. The
interviews included questions concerning the socio-cultural context of the
individual, consumption of drugs (past and present), risk behaviours, the
level of knowledge concerning AIDS and hepatitis, and the acceptance and use
of preventive measures. Additional data were also gathered, eg, the number
of needles distributed, the number and nature of sanctions, particular
incidents, and the results of the prisoners' medical examinations.
A total of 137 prisoners and 48 staff participated in at least one
interview; 70 staff answered a questionnaire.
One third of prisoners interviewed admitted to using heroin or cocaine while
in prison, with three-fourths doing so by injection.(182) Only women who
already used drugs on a regular basis before entering Hindelbank continued
to do so once in prison. Among women who used heroin or cocaine in the month
preceding their incarceration, three-fourths continued to do so once in
The number of prisoners using heroin or cocaine while in prison has not
fluctuated significantly since the installation of the needle-dispensing
machines. The frequency of consumption and the manner of absorbing drugs
(smoking, injecting, sniffing) also remained more or less the same during
the course of the project. Finally, there was only one case of overdose at
Hindelbank during the course of the project, whereas there had been 16 cases
in one year, two years before the project started.
Distribution of Needles
During one year, 5335 needles were distributed, an average of 14 per day
(with a maximum of 78 and a minimum of 0), or one needle per prisoner every
six days. The use of needles decreased during the second half of the
Utilization of needles seemed to depend primarily upon two factors:
- the availability of drugs; and
- prisoners' capacity to purchase them.
Consumption of drugs, and need for needles, typically increased during a
period of several days after prisoners received their wages and whenever
larger than usual quantities of drugs were available in the institution.
Sharing of Needles
1989-1992, 14 studies were conducted in Switzerland concerning the effects
of the distribution of sterile syringes to drug consumers (outside of the
penitentiary system). All of the above studies revealed a marked decrease in
the sharing of used syringes. The same observations have been made on an
The evaluation of this preventive measure at Hindelbank supports the above
In May 1994, before installation of the distribution machines, eight of 19
intravenous drug users declared having shared needles with other drug users.
One year later, only one individual continued sharing. Generally, after
installation of the machines, needles were shared only when the machines
were out of order or when a situation of trust had been established between
friends who knew themselves to be HIV-negative. Decrease of sharing was
- before the project started, eight prisoners declared
- after three months, four prisoners declared sharing;
- after six months, two declared sharing; and
- after 12 months, one declared sharing.
Upon their arrival at the prison, 94 women underwent a voluntary blood
analysis. A high percentage tested positive:
- 6 percent for HIV;
- 73 percent for hepatitis A;
- 48 percent for hepatitis B; and
- 37 percent for hepatitis C.
Fifty-one of the women were re-tested at the time of
their release from prison; no new infections were diagnosed. This result is
significant, but should nevertheless be taken with caution because only a
fairly short period of time had passed since the first test.
Acceptance of the Prevention Measures
Only about 20 percent of staff did not agree with the installation of the
needle distribution machines; the vast majority either agreed or "totally
agreed." As expressed in the final report about the project,
majority of staff at the institution has in the meantime approved of
prevention measures including distribution of sterile needles, even if this
approval is not dictated by feelings but by reason.(184)
It should be emphasized that during none of the phases was any active
resistance shown. Further, the intervention gave rise to open discussions
about what had gone on that would previously not have been talked about:
It is an
important step when it comes to motivating staff to look more, and more
deeply, into questions relating to infectious diseases and drug use and, in
this respect, to develop greater competence.... [P]reviously, the various
sections would have tended to hide the drug-related problems they had with
their inmates and would have pointed out other sections, whereas now it
almost goes without saying that there is an exchange of experiences.(185)
According to the project director, concrete statements such as the following
helped to overcome the resistance of some staff, and to explain to them why
sterile needles need to be made available:
- Many inmates are in the Hindelbank institutions
because of violations of drug laws. Some have continued to use drugs
although they have been submitted to insecurity-producing tactics. Where
fraud is concerned, wealth of imagination seems to have no bounds; in
spite of the controls, "dope" is always available.
- The statements made by women when they were
consulted in relation to the prevention project highlighted what had been
understood from the outset: women who were never drug-dependent don't need
them and don't have to refuse to use them because they're afraid of
dependency developing rapidly, independent of the availability of
syringes. For women who used drugs or who still do, the fear of damage to
health from the use of unclean syringes is not a reason to abstain. When
they are in withdrawal, they look for, find, and use drugs, whether or not
the available syringes are clean or already used.
- The HIV/drug prevention project did not promote the
use of drugs. Abstinence remains the goal. This involves a long journey
during which the question is one of avoiding further harms - health policy
measures, not drug policies.
- The project is an attempt to live with
contradictions and to find compromises after weighing the judicial
- With regard to infectious diseases, the aim of an
HIV/drug prevention project does not only concern AIDS, but also other
dangerous pathogenic agents such as the hepatitis B and C viruses.
- An HIV/drug prevention project in a penal
institution likely has repercussions with respect to the state of health
of the rest of the population.(186)
The evaluation report concludes:
results of the pilot-project undertaken at Hindelbank Institution do not
provide any argument against the continuation of the distribution of sterile
syringes. The fears expressed at the beginning - that drug use would
increase, that needles would be used as weapons or accidentally cause
injuries, etc - were unjustified.(187)
According to the report,
feasibility of distributing needles and syringes, the positive consequences
it had on the sharing of needles, and the considerable acceptance of the
project by inmates and staff...lead to the conclusion that the distribution
of sterile needles and syringes could also be justified in other prisons.
The Future of the Project
Following the evaluation, the prison authorities have decided to continue
Oberschöngrün: Distribution of Sterile Injection Equipment at a Men's
Hindelbank was not the first institution to distribute sterile injection
equipment to inmates, but was the first to scientifically evaluate such a
program. It was in another Swiss prison, the Oberschöngrün prison for men,
that sterile injection equipment first became available to inmates in 1993.
Oberschöngrün is a minimum-security institution housing approximately 75
prisoners, of whom 10 to 15 "seek to use illicit drugs on a daily basis, so
as not to go into withdrawal."(188)
Probst, a part-time medical officer, working at Oberschöngrün prison in the
Swiss canton of Solothurn was faced with the ethical dilemma of as many as
15 of 70 inmates regularly injecting drugs, with no adequate preventive
measures. Unlike most of his fellow prison doctors, all of whom feel obliged
to compromise their ethical and public health principles daily, Probst began
distributing sterile injection material without informing the prison
director. When this courageous but apparently foolhardy gesture was
discovered, the director, instead of firing Probst on the spot, listened to
his arguments about prevention of HIV and hepatitis, as well as
injection-site abscesses, and sought approval from the Cantonal authorities
to sanction the distribution of needles and syringes. Thus, the world's
first distribution of injection material inside prison began as an act of
Three years later, distribution is ongoing, has never resulted in any
negative consequences, and is supported by prisoners, staff, and the prison
Distribution of syringes is giving altogether satisfactory results. Given
the fact that HIV tests are not mandatory, it is impossible to precisely
evaluate the effect of distribution on the transmission of the virus.
However, a reduction in the number of cases of hepatitis and the complete
absence of new abscesses has been observed. Nothing indicates that drug use
has increased as a result of these measures.(190)
According to the warden, Mr Fäh, initial scepticism by front-line staff has
been replaced by their full support:
have realized that distribution of sterile injection equipment is in their
own interest. They feel safer now than before the distribution started.
Three years ago, they were always afraid of sticking themselves with a
hidden needle during cell searches. Now, inmates are allowed to keep
needles, but only in a glass in their medical cabinet over their sink. No
staff has suffered needle-stick injuries since 1993.(191)
Fäh continued by saying that staff have been told not to use the fact that
they may see injection equipment in a prisoner's medical cabinet as a reason
for asking him to submit to urinalysis: "Because inmates trust this, they
keep the syringes in the cabinet - and this in turn increases staff's
About 700 sterile injection units are handed out yearly by Dr Probst, at a
cost of only 400 Swiss francs (approximately CDN$440), "much less than would
be the costs of caring for the cases of hepatitis and abscesses we avoid by
handing out sterile equipment."(192) A decision was taken not to install
dispensing machines, as at Hindelbank, for two reasons: fear that inmates in
a prison for men would vandalize the machines, leaving injection drug users
without supply when needed. Further, prisoners who obtain injection
equipment from Dr Probst feel that this better ensures anonymity than if
they had to retrieve equipment from a dispensing machine: nobody else knows
why they visit the physician, nobody can see them while they are with him,
and he is bound by a professional obligation of confidentiality not to
reveal who obtains equipment from him. From the physician, who comes to the
institution once every week, inmates can obtain more than one injection unit
at a time, and distribution is not undertaken on a strict one-for-one basis
(one used against one new, sterile, unit). As emphasized by Mr Fäh,
more important to make sure that prisoners who are injection drug users can
always use sterile equipment than to insist on a one-for-one exchange
scheme. We have a fairly good return rate, and are not concerned about not
all equipment being returned to Dr Probst. What we do care about is safety
of staff - and staff has not been exposed to any hidden needles.(193)
Fäh emphasizes that the objective of making sterile injection equipment
available to inmates is not the legalization of drugs, but rather the
prevention of AIDS:
the danger that HIV infection represents, we cannot give up distributing
syringes because we would thereby be forcing drug-using inmates to shoot up
with dirty needles - which is an ethical issue.(194)
Discovered in the course of urine testing or cell searches, the possession
and/or consumption of drugs (but not the possession of injection equipment,
provided it is kept in the designated cabinet in the inmate's cell) is still
a ground for disciplinary measures. In 1993, a total of 623 urine probes
were analyzed to detect prisoners' drug use: 194 tested positive, 412 tested
negative, and 17 had been "faked." Urine is tested only for traces of
opiates, cocaine, barbiturates, amphetamines, methadone, and
benzodiazepines, but not for traces of cannabis products. This decision was
taken because use of cannabis products is not considered a safety and
discipline problem in the institution and because of fear that prisoners
using cannabis products would switch to other, more harmful, drugs if
testing for traces of cannabis was undertaken.
In a pamphlet describing the reasons why injection equipment is distributed
in the institution, the administration concludes that
is and will remain to prevent inmates from using drugs, or to reduce their
drug consumption.... Since we began making injection equipment available, we
have not noticed any significant reduction or increase in drug use. But
surely we have done something useful for the health of our inmates, and for
prevention of the spread of HIV in general.(195)
Geneva: Availability of Injection Equipment in Men's Prisons
As announced by Prof Harding at the interdisciplinary
symposium on harm-reduction strategies in prisons in Berne, Switzerland, on
3 March 1996, distribution of sterile injection equipment to injection drug
users started in at least one prison for men in Geneva on 1 March 1996. The
equipment is made available through health-care services, and is exchanged
on a one-for-one basis.
Lessons from the Swiss Experience
One of the issues debated at the symposium on harm
reduction strategies in prisons in Berne was whether the results of the
Swiss experience could be applied to other prison systems - or whether there
was anything "special" about Switzerland and/or the institutions in which
sterile equipment has thus far been made available, that would make it
impossible elsewhere. After days of debate, experts from around the world
agreed that the lessons learned in Switzerland could indeed be applied
Staff Safety Issues
In Switzerland as elsewhere, one of the major potential obstacles to the
success of needle distribution programs has been the attitudes of prison
staff. At Oberschöngrün, prison officers were fully involved in the decision
to trial the needle exchange, while officers at Hindelbank were less
involved and initially more hostile to the program. In both cases, attitudes
to needle exchange in prison became more positive over time.
The "clash of values" that occurred when prison officers and managers first
considered the possibility of providing needles and syringes in prisons was
minimized by ensuring that needle exchange was established as a health
activity carried out by the prisons' health service rather than an activity
carried out by custodial staff. Further, as emphasized by Dr Margaret
Rihs-Middel, Co-ordinator of Drug Research and Evaluation at the Swiss
Office of Public Health in Berne, the involvement of staff in the decision
to proceed was very important to the success of the program, as were rules
about where needles can be kept to increase safety for custodial staff.(196)
The Swiss experience has shown that sterile injection equipment can be made
available in a manner that is non-threatening to staff and indeed seems to
have increased staff's safety; it has further shown that staff can be
brought to understand that making sterile injection equipment available to
inmates does not mean condoning drug use and "giving up" on drug use in
prisons, but is a pragmatic health measure that is warranted by the fact
that prison authorities have a responsibility to:
the general public: preventing the spread of HIV in prisons and, after
release of the prisoners, to the general public, is a vital part of this;
protect the health of inmates in their custody: prisoners are in prison as
punishment, not to contract a deadly disease.
Because staff don't feel threatened by the distribution of sterile injection
equipment, and because they understand the rationale behind it, they are
supportive of it.
Applicability to Different Institutional Settings
There is not one Swiss model of distribution of sterile injection equipment.
Thus far, every institution has chosen its own model: installation of
dispensing machines, one-for-one exchange, or distribution through the
physician or health-care services. What can and should be done in a
particular institution depends on many factors, including, but not limited
to, the size of the institution, the extent of injecting drug use, the
security level, whether it is a prison for men or for women, the commitment
of health-care staff, and the "stability" of the relations between staff and
inmates. In Switzerland, it has been understood that a measure such as
making sterile injection equipment available could not, and does not
necessarily have to be, introduced in all institutions at the same time and
in the same fashion, but can be undertaken immediately, easily, and at low
cost, with good results, in some institutions. In other institutions, other
measures may be more feasible and are being introduced, such as methadone
maintenance programs or the establishment of drug-free wings.
Making sterile syringes available in prisons in Switzerland was preceded by
a study and consultation phase dealing with the complex range of legal and
policy issues this measure raises. As part of the process, the Swiss Federal
Office of Public Health requested that the Federal Office of Justice examine
the judicial admissibility of the measure. In a report tabled in July 1992,
the Federal Office of Justice concluded that the provision of sterile
syringes and the making available of disinfectants in prisons was judicially
admissible and compatible with responsible health policy.
In its opinion, the Office of Justice held that "drug use in prison
establishments is a reality."(197) According to the Office, it could be
stopped only through very strict measures that would not be compatible with
a liberal enforcement of sentences. The Office acknowledged that
rather easily introduced into prisons, but not syringes, which are a rare
commodity, and this means that they are often exchanged between prisoners
dependent on drugs.
The report analyzes the meaning and scope of the right of prisoners to
adequate medical assistance in prisons, and favours a broad interpretation
that includes prevention:
medical assistance should not be available only when a disease has already
spread...but it is necessary to attempt to prevent the transmission of this
disease through adequate preventive measures.... The provision of sterile
syringes is...one, if not the most important, strategy for preventing the
transmission of HIV/AIDS to IV drug users. As in civilian life, it is clear
that AIDS prevention for those serving sentences is not entirely dealt with
simply through the provision of sterile injection equipment, but that
it...must also include measures involving therapy, withdrawal and
substitutes. Nevertheless, the provision of sterile syringes is the most
Because abstinence in prisons is not achievable, prison establishments must,
according to the report's authors, adapt their internal health policy. They
conclude that, if prison establishments wish to fulfil their duty to provide
medical assistance, the provision of syringes and disinfectants is
recommended and that the establishments will have to comply.
The report also examines the issue of the punishability of those who provide
sterile syringes, including the punishability of prison staff responsible
for providing syringes and the punishability of drug-using prisoners, and
compatibility with criminal law. The authors note that the criminal
liability of staff comes into play only in cases of complications due to
negligent handling in the provision of syringes and that, furthermore, the
availability of syringes in a prison establishment does not in any way
affect the punishability of drug use. The report concludes that, because
drug use remains a punishable act, "if one wishes the provision of syringes
to be a success...it must be done anonymously."
Finally, the authors deal with the question of predicting whether such
measures could put prison staff in danger:
argument has been put forward that the syringes provided...could be used as
weapons by prisoners against staff and that for this reason the provision of
syringes must necessarily be rejected. This argument, although far from
insignificant, is nevertheless an insufficient reason to prohibit the
provision of syringes. Even now, syringes are circulating in prison
establishments; staff have already had to deal with this danger for some
time. Moreover, this is a problem with which staff are already confronted,
in the sense that prisoners have many opportunities to obtain weapons or to
make them themselves.
The Swiss approach to drug use in general and to drug use in prisons in
particular is one characterized by pragmatism and by the desire to reduce
the harms from drug use. Accepting that many years of experience with a
"war-on-drugs" approach to drug use outside and in prisons have demonstrated
that drug use is here to stay - and that governments do not only have a
responsibility to reduce levels of drug use, but first and foremost to
reduce the harms from drug use - common sense, pragmatism and
cost-effectiveness have become the guiding principles of health policy in
the area of drugs and HIV. Politicians, the public, the media, and those
working in prisons are supporting the new, pragmatic approach, because
adherence to the ideal directed at eradicating drug use has proven to
increase the harms to drug users and to society and, generally, is extremely
costly, without resulting in the hoped-for reduction of drug use.
In particular, with respect to prisons, all stakeholders have:
- faced the fact that drugs are consumed in prisons;
- faced the fact that needles and syringes are used
(and shared) in prisons;
- accepted that HIV prevention is more important than
- realized that provision of sterile injection
equipment is not contrary to staff's mandate, and provides more security
for staff and inmates; and
- realized that harm
reduction is more cost-effective than total prohibition.
Programs in Other Countries
As a result of the positive experiences in Swiss
prisons, more and more prison systems around the world are announcing that
they will also make sterile injection equipment available. At the symposium
on harm-reduction strategies in prisons in Berne, representatives of several
German prison systems, as well as the Spanish system, presented their
programs or talked about their intention to start one soon - probably the
best evidence that the lessons learned in Switzerland can be applied
Germany: Lower Saxony(198)
In November 1994, the Minister of Justice of Lower
Saxony established a panel of experts charged with investigating whether
measures such as provision of sterile needles in prisons could result in an
improvement in the health of inmates. The Minister was concerned with the
high prevalence of infectious diseases, in particular hepatitis and HIV,
among drug-using inmates in Lower Saxony. The panel of experts consisted of
prison directors and personnel, some representatives of drug- and
HIV/AIDS-service organizations, and one general practitioner. The
recommendations of the experts(199) served as the basis for a cabinet
decision by the Government of Lower Saxony, giving a green light to the
implementation of a two-year pilot project for the distribution of sterile
injection equipment and provision of communicative methods of prevention, in
a women's prison with 170 inmates in Vechta and a men's prison with 230
inmates in Lingen.
At the time of writing, distribution had started at Vechta, using four of
the same dispensing machines used at Hindelbank since 1994. Distribution at
the men's prison was expected to start during the summer of 1996.(200)
Cooperation between the two prisons in Lower Saxony and the Swiss prisons
started a while ago and includes exchange of staff between Hindelbank and
The projects will be scientifically evaluated, with two main aims:
- to present an objective and realistic account of the
- to assess the usefulness and efficacy of the
measures undertaken, beyond the various interests of the persons and
According to the recommendations given by the panel of
experts, scientific evaluation aims at "closing the gap in the knowledge
about drugs, drug usage, and infections with HIV and hepatitis in prisons on
the one hand and, on the other, at achieving generalizable and practically
relevant recommendations for the effective prevention of AIDS and hepatitis
In Hamburg, distribution of sterile injection equipment
in a prison for men with a capacity of 300 started in May 1996. At the
symposium in Berne, the participant from the Hamburg prison system
emphasized that the decision was warranted by the fact that, outside
prisons, drug policy had changed over the last years, emphasizing harm
reduction rather than abstinence, and including wide availability of
injection equipment and methadone programs:
press, all political parties, and the public are seeing the positive results
of this shift in policy: there are fewer deaths related to drug use, less
criminality, the costs of drug policy have diminished, and persons dependent
on drugs are healthier than they used to be. The gap between what was being
done outside and inside prisons was getting bigger and bigger, and people
started to see that this was counterproductive.
He continued by saying that
members of the public as well. They started seeing that what was done
outside is to the benefit of all, drug users and the public, and started
questioning themselves whether it would not be possible and beneficial to
extend harm-reduction measures to prisons.(201)
In 1995, a commission mandated, by Hamburg's Senator for Justice, with the
development of a drug policy for prisons, emphasized that
has a legal obligation to care for prisoners in its custody. This includes
not only activities directed at caring for the sick, but measures directed
at preventing threats to the health and well-being of prisoners.(202)
It continued by saying that, where the goal of abstinence cannot or cannot
yet be reached, saving the lives of inmates who inject drugs needs to have a
higher priority than achieving a drug-free prison environment. The
commission recommended distribution of injection equipment in prisons as an
"absolutely necessary health-prevention measure," referring to results of
studies showing the correlation between rates of hepatitis and HIV among
injection drug users and their length of stay in prisons.(203) Commenting on
some of the arguments against making sterile injection equipment available
in prisons, the commission said that drug use would likely not increase in
prisons as a result of making equipment available: it depends on the
availability of drugs, not of injection equipment; and that acceptance of
the measure would increase over time, according to the principle "learning
by doing." After extensive meetings with staff, the commission noted that,
while a majority of health-care staff already support needle distribution,
many correctional officers are resistant, "out of a mixture of fears and
information deficits." It acknowledged that the issues raised by
correctional officers need to be taken seriously, but said that - in view of
the very serious and potentially life-threatening consequences that inaction
would have for inmates and the public - these issues should not "be allowed
to be the decisive factor in decision-making":
reasons of health prevention, and because of the legal responsibility and
ethical obligation of prison systems, distribution of sterile injection
equipment in prisons has become an absolute necessity. In the unanimous view
of the Commission, prolonged inaction could not be justified.(204)
The commission recommended that prisoners be allowed to have no more than
one injection unit in their possession; and that there be a requirement to
store it in a place where it cannot pose any danger to others, and to
dispose of it in an "appropriate way." Further, the commission recommended
that clear guidelines be established according to which possession of one
injection unit, when kept in the designated way, cannot be subject to
disciplinary measures, while injection equipment kept in any other way can
be taken away from prisoners.
As reported in the German media, the Senator of Justice
of Berlin has expressed her intention to implement a needle-exchange program
in a prison for women.(205)
At the symposium in Berne, representatives of the
Spanish prison system announced that distribution of sterile injection
equipment would be piloted in a prison in Northern Spain where a methadone
maintenance program is already available to inmates.
A recent study by the Australian National Drug and
Alcohol Research Centre (NDARC) found that needle and syringe exchange is
feasible in Australian prisons.(206) As a result, the Australian Federation
of AIDS Organizations (AFAO) is calling for pilot programs of needle and
syringe exchange in prisons across Australia.(207)
Introduction of syringe-exchange programs in Australian prisons had
previously been recommended by the Community Policy on Prisons and Blood
Borne Communicable Diseases.(208)
Both the then Australian Minister of Health, Dr Carmen Lawrence, and the
then President of the Australian Medical Association (AMA), Dr Brendan
Nelson, had also urged that "serious consideration be given" to introducing
syringe exchanges in prisons.
The study was conducted to consider the issues raised by syringe-exchange
programs in prison and to assess their possible benefits, adverse
consequences and the feasibility of implementing them. This was done by
documenting - in facilitated discussion groups - issues raised by key
stakeholders in the New South Wales (NSW) prison system.
The researchers asked groups comprising correctional officers, prison
health-care staff, ex-inmates, community agencies, and politicians to
provide information on likely safety issues associated with an exchange
program. The groups
- emphasized the necessity for effective, broad-range
treatment and harm-minimization programs in prisons for injection drug
- questioned the implementation and effectiveness of
existing HIV prevention programs; and
- addressed the likely impact on the wider community.
Based on the discussions undertaken, the researchers
concluded that syringe exchanges in prisons are feasible, but only under
certain conditions. In particular, they pointed out that the cooperation of
prison staff would have to be secured before implementation of a
syringe-exchange program could be considered. Among other things, they
recommended that a working committee with representation from health-care
and correctional officers discuss syringe exchanges in prisons to identify
an option that does not represent any risk to staff and is acceptable to
The researchers found that conditions such as the following would be needed
before considering a syringe-exchange pilot:
- establishment of a specialist drug-treatment wing;
- special training for custodial and health staff;
- policy of strict one-for-one distribution of needles
- selection of distribution option by a joint
committee of custodial and health staff and inmates, from the following:
(1) vending machine; (2) nursing staff; (3) outside agency; (4) injection
- assessment of the pilot by measurements such as
increase/decrease in risk of infections to staff or inmates or visitors,
from assault or from occupational or accidental injury.
The researchers further recommended that
- bleach be made available to all prisoners;
- all inmates be assessed and offered methadone
maintenance treatment if suitable;
- peer educators be trained;
- a pilot syringe-exchange program be rigorously
- for evaluation purposes, participants be tested for
hepatitis B and C and HIV every six months.
AFAO welcomed the study's overall findings, and its
Acting National President used the release of the report to call for trials
of syringe-exchange programs in prisons across Australia, expressing support
for the report's recommendations that condoms, methadone, and bleach should
also be made available.
Since then, the AMA has also renewed its call for needle-exchange programs
for prisoners. In its February 1996 Position Statement on Blood Borne and
Sexually Transmitted Viral Infections, the AMA states that "[e]ffective
prevention among prison populations requires the establishment of
preventative education programs, needle exchange programs for intravenous
drug users and safe sex programs for those involved in high risk sexual
Methadone Maintenance Treatment
Treatment with methadone as a substitute for opiate use
has been adopted in a number of prison systems worldwide. It is seen as an
AIDS-prevention strategy that allows people dependent on drugs an additional
option to get away from needle use and sharing. There are ample data
supporting the effectiveness of methadone maintenance treatment (MMT) in
reducing high-risk injecting behaviour and in reducing the risk of
contracting HIV.(210) There is also compelling evidence that MMT is the most
effective treatment available for heroin-dependent IDUs in the community in
terms of reducing mortality,(211) heroin consumption,(212) and
criminality.(213) Further, in most countries where it has been introduced,
MMT attracts and retains more heroin injectors than any other form of
treatment.(214) Finally, there is evidence that people who are on MMT and
who are forced to withdraw from methadone because they are incarcerated
often "return to narcotic use, often within the prison system, and often via
Community methadone programs have rapidly expanded in a number of countries
in recent years, including Canada (in particular, British Columbia),(216)
and many national and international organizations have recommended the
introduction or expansion of MMT in prisons.(217) It has been suggested that
methadone is the best available option to prevent needle sharing in
prisons,(218) and that increasing the number of places available for MMT in
prisons should be considered as a matter of urgency for HIV-positive
In light of this, ECAP recommended that
order to reduce the risk of infection from drug-injecting,...the options for
the care and treatment of drug users include access to methadone. Studies
should be undertaken to establish the most effective ways of implementing
methadone maintenance programs in penitentiaries. Once implemented, these
programs should be evaluated, with participation of inmates and experts
independent of CSC.(220)
This recommendation was rejected by CSC because, as mentioned above,
according to the Service there is no "medical indication" to provide MMT for
opioid-dependent inmates, and "there are relatively few maintenance programs
outside CSC institutions to support methadone-dependent inmates following
While CSC rejected ECAP's recommendation, a small but increasing number of
prison systems worldwide are offering MMT to inmates and a study undertaken
in NSW suggests that the reduction of injecting and syringe sharing
demonstrated in MMT in community settings also occurs in prisons.(222)
Finally, as part of a national experiment with prescribing of heroin and
other drugs to users - to determine whether this will reduce users' criminal
activity and their risk of contracting and spreading HIV and other
infections - eight inmates in one prison in Switzerland are being maintained
on heroin, so far with good results.
The following is a review of methadone provision in prisons internationally.
Methadone Provision in Prisons Internationally(223)
As pointed out by Dolan and Wodak, few papers have
appeared documenting the existing provision of methadone in prison
systems.(224) Their review, based on correspondence with prison authorities
in a number of countries, indicates that MMT has been implemented in prisons
in at least four countries, while methadone detoxification is provided in at
least eight countries.
Australia: New South Wales
In approximately half of the prisons in NSW (a
combination of maximum, medium and minimum security centres), prison
methadone maintenance treatment (PMMT) is provided to prisoners. An
assessment by health-service staff is required prior to any inmate becoming
eligible for entry into the methadone program, which started as a pilot
pre-release methadone program with the major aim of reducing recidivism. As
it expanded, its goals came to include the continuation of community-based
treatment, and the prevention of the spread of HIV and hepatitis in prisons.
More recently, achievement of the latter goal has become its major aim, as
it has for methadone treatment in the community.(225)
According to the HIV/AIDS Policies, Procedures and Management Guidelines for
NSW correctional centres, there are two broad objectives for the corrections
1. Harm reduction to minimize the spread of infectious/communicable diseases
which are secondary to injecting drug use. This is especially important in
the correctional setting where there is no access to needle exchange
2. Maintenance program to be tailored to the individual treatment needs of
A Methadone Policy and Procedures Manual has been developed to effectively
administer the program. At the time of writing, it was intended to expand
the PMMT because demand vastly exceeded supply, opposition from correctional
staff was waning, and concern existed about transmission of HIV and
hepatitis among inmates.
US: Rikers Island, New York City
In the US, the only PMMT program is on Rikers Island, New York City.
In Spain, half of all inmates at the Modelo prison in the region of
Catalonia are treated with methadone maintenance.(227) Initially, prisoners
were only considered for PMMT if they had AIDS, were already on methadone or
had been diagnosed as psychotic, but in an attempt to reduce HIV
transmission in prison, entry criteria have since been expanded to include
According to a survey undertaken by a Swiss working group on methadone,(228)
treatment with methadone is offered in a majority of Swiss prisons. Most
prisons allow prisoners already on MMT at the time of their entry into
prison to continue the treatment, with a majority allowing continuation for
an unlimited period of time, while some prisons only allow for continuation
for a limited time. In addition, slightly less than half of prisons allow
prisoners to start MMT in prison.
The working group recommended that in all prisons opioid-dependent prisoners
be allowed to continue MMT started in the community, and to start MMT under
the same conditions and eligibility criteria as outside prison. It
emphasized that the vast majority of institutions in which MMT is available
had reported that they had never encountered any difficulties with
A project that started in both prisons in the canton of Basel in January
1996 aims at further facilitating access to methadone programs and other
treatment or therapy for drug use. The project contains a flexible methadone
program and includes the possibility of injecting methadone with sterile
needles provided by the institution. Results of this project are expected by
the end of 1996.(230)
In some prisons in Hamburg, prisoners who were on methadone maintenance
before coming to prison are allowed to continue in prison. Further, a
limited number of inmates have been granted permission to start MMT in
The commission mandated by Hamburg's Senator of Justice with the development
of a drug policy for prisons recommended that PMMT programs become available
in all institutions. According to the commission, the positive outcomes
achieved with MMT outside prisons will also likely be achieved in prisons.
In particular, the commission recommended that:
- prisoners on MMT before imprisonment always be
allowed to continue MMT during imprisonment;
- opioid-dependent prisoners be granted permission to
start MMT while in prison;
- psychosocial support for inmates in MMT be adequate;
- measures be taken to ensure that prisoners on MMT be
able to continue MMT after imprisonment.(232)
Methadone maintenance treatment is available or will
also become available in prisons in other German länder. For example, at the
harm-reduction symposium in Berne, a representative of Schleswig-Holstein
announced that MMT would become available in prisons in the region.
Methadone treatment is regularly offered to opioid-dependent inmates who
received such treatment before incarceration. According to a letter received
from the Danish Ministry of Justice,
treatment is mainly offered to inmates, who are expected to stay less than
one year in prison. It is essential that the decision about prescription of
methadone is taken in close cooperation with the treatment centre outside
prison, who [sic] is going to treat the inmate after release.(233)
In Canada, methadone is rarely prescribed to anyone in prison, but this may
change as a result of a recent court case. As mentioned above, in April 1996
an HIV-positive woman was sentenced to 21 days' imprisonment at the Burnaby
Correctional Centre for Women (BCCW) in British Columbia. At the time of her
sentence, she was on a methadone maintenance program supervised by her
primary-care physician. In accordance with a longstanding BC Corrections
Branch policy, the BCCW refused to provide her with methadone, but later
reversed that decision after the woman petitioned the British Columbia
Supreme Court for relief in the nature of habeas corpus.(234) Among other
things, the petitioner argued that not allowing her to continue on the
program contravenes s 15 of the Canadian Charter of Rights and Freedoms:
Generally, BC Corrections Branch provides prisoners with appropriate medical
treatment for illness and injury. Because of her dual status as an
HIV-positive and a methadone-addicted person, methadone maintenance was the
appropriate medical treatment for the Petitioner. Therefore, the policy not
to provide her with methadone is a distinction based on her physical
condition, because if she had any other condition, she would have been
provided with the appropriate medical care.
In response to the petition, the BCCW filed affidavit material challenging
the Petitioner's physician's opinion that methadone withdrawal is
contra-indicated for HIV-positive methadone-addicted patients and that the
Petitioner's physical integrity was endangered by her withdrawal.
Nevertheless, it arranged for a staff doctor to examine the Petitioner, and
he prescribed methadone for her. In affidavit material filed in this case,
the Director of Health Services for the BC Corrections Branch indicated that
BC Corrections policy would be changed to recognize the validity of the
harm-reduction model for prisoners and to allow for methadone treatment of
prisoners in certain circumstances.
In another recent case,234a a man with a long-standing, "serious heroin
problem," who had committed a number of acquisitory crimes and had been in
treatment, without success, several times already, was convicted to two
years minus one day imprisonment - and thus to imprisonment in a provincial
prison in Québec - because that prison had agreed to provide him with
methadone treatment. The defense in the case had submitted that it was
necessary to deal with the root causes of the man's crimes, namely his
heroin addiction, and that treatment with methadone was essential to
overcome that addiction. To the author's knowledge, this was the first case
in which an accused in a criminal case was sentenced to a term of
imprisonment with the specific aim that he be allowed to undergo methadone
Rationale for Prison Methadone Maintenance Treatment (PMMT)
drug use, crime, arrest, imprisonment, release, return to drug use followed
by further criminality are a recurrent pattern in the lives of many IDUs.
This criminal cycle, the potential for blood borne infections within prison
and the now compelling evidence favouring the effectiveness of community MMT
are strong grounds for considering PMMT [reference omitted].(235)
The main aim of methadone maintenance, as stated by Gore,
help people get off injecting, not off drugs. Methadone dose reduction -
with the ultimate goal of helping the client to get off drugs - is a longer
term objective [reference omitted].(236)
With the advent of HIV/AIDS, the arguments for PMMT are compelling.
Prisoners who are injection drug users are likely to continue injecting in
prison, and are more likely to share injection equipment, creating a high
risk of HIV transmission among prisoners and to the public.
Generally, there is abundant evidence that injecting drug users are
over-represented in the prison population. Their concentration among inmates
suggests that targeting treatment at this population is likely to be
cost-effective. Unless treated, prisoners who are injecting drug users are
likely to continue injecting in prisons or to relapse to injecting on their
release, and hence to re-offend and return to prison. Further, imprisonment
is stressful and drug withdrawal can only exacerbate this stress. Methadone
treatment has been demonstrated to effectively reduce withdrawal symptoms.
Methadone also can be prescribed in prison settings for detoxification and
pre-release, which have different aims: the main aim of detoxification is to
get prisoners off drugs, while pre-release methadone programs aim to improve
linkages to community programs that provide continuity of treatment, reduce
deaths from overdose, and reduce criminal recidivism.
authorities generally respond to concerns about drug use in prison by
recommending more stringent detection measures and more severe penalties for
illicit drugs discovered within prisons. These measures are often in
conflict with rehabilitative components of the prison system. However,
injectable drugs still seem to find their way into more tightly controlled
environments in circumstances which are likely to further exacerbate the
hazardousness of risk episodes although such risk episodes may be less
frequent. One of the major obstacles to introduction of PMMT is that
implementation is tantamount to an admission by prison authorities that
injectable drugs cannot be completely kept out of correctional
Another obstacle to PMMT mentioned by Dolan and Wodak
is that prison authorities generally consider that imprisonment should be a
time when injection drug users are forced to abstain from drug use for their
own and the community's benefit:
is considered by many correctional staff as just another mood altering drug,
the provision of which further delays the necessary personal growth required
to move beyond a drug centred existence.(238)
Absence of Education about Rationale
Many prison staff and some prison systems, including
CSC, have not well understood the rationale behind MMT. As pointed out by
Hall et al,(239) in the absence of education about its rationale, some
prison staff regard the program as "pandering" to addicted prisoners by
giving them free access to an opioid drug; they believe that its main
rationale is the reduction of recidivism rather than the prevention of HIV
transmission in prison. Similarly, CSC, in its response to ECAP's
recommendations, said that there was "no medical indication" to provide
methadone maintenance, neglecting to consider the potentially life-saving
effect of such programs, and taking a very conservative approach that seems
to have been shaped before the advent of HIV/AIDS. In contrast, those in
favour of PMMT emphasize that making methadone maintenance available is
necessary to save lives: it would reduce injection drug use and the
resulting risk of HIV infection. In other words, methadone maintenance may
not be completely harmless, but its possible harms are insignificant when
compared with the much bigger harms resulting from injection drug use -
HIV/AIDS and hepatitis C in particular.
Objection on Moral Grounds
Some also object to methadone treatment on moral
grounds, arguing that it merely replaces one drug of dependence with
another. For example, a vocal minority of participants at the Kingston
HIV/AIDS and Prisons Workshop vehemently opposed making methadone available
to prisoners, saying that "methadone does not really help people to get off
drugs" and that "those in methadone maintenance programs only exchange one
sort of dependence, that on narcotic drugs, against another, that on
methadone." If there were reliably effective alternative methods of
achieving enduring abstinence, this would be a meagre achievement. However,
there are no such alternatives:
majority of heroin-dependent patients relapse to heroin use after
detoxification; and few are attracted into, and retained in drug-free
treatment long enough to achieve abstinence. Any treatment [such as MMT]
which retains half of those who enrol in treatment, substantially reduces
their illicit opioid use and involvement in criminal activity, and improves
their health and well-being is accomplishing more than 'merely' substituting
one drug of dependence for another.(240)
benefits demonstrated for methadone detoxification and maintenance in the
community are likely to be generalisable to prisons. However, these benefits
should not be assumed because the institutional environment and stringent
security requirements of correctional facilities makes the generalisability
of community MMT research to prisons uncertain. Therefore research is
required evaluating methadone used for detoxification, maintenance and
Reduction in Injecting and Sharing
Dolan et al evaluated the effectiveness of MMT in
reducing HIV risk behaviour among prisoners. Their study suggests that
of injecting and syringe sharing demonstrated in MMT in community settings
also occurs in prisons. However, inmates need a daily dose of at least 60 mg
of methadone and treatment is required for the duration of incarceration for
these benefits to be realised in prison.(242)
In 1993, Dolan et al interviewed 185 ex-prisoners with a history of
injecting drug use in New South Wales (NSW), of whom 64 reported being in
MMT before, during and after their period in prison, while 80 reported
receiving no treatment during any of the three time periods:
- IDUs who reported receiving MMT in the three months
before prison were significantly less likely to report daily injecting (42
versus 60 percent) and syringe sharing (13 versus 26 percent) than IDUs
not in MMT; and
- IDUs who had been in MMT during imprisonment
reported significantly fewer injections per week than IDUs not in MMT, but
only when the maximum methadone dose exceeded 60 mg and if MMT had been
provided for the entire duration of imprisonment.
Dolan et al concluded that "MMT has an important role
to reduce the spread of HIV and hepatitis in prison."
In Spain, significant reductions in sharing of injection equipment have been
noted in IDU inmates in PMMT compared with a control group.(243) In NSW,
inmates receiving PMMT reported decreases in drug use, drug-related prison
violence, crime following release, and considered that the PMMT was more
effective in preventing HIV in prison than in the community.(244)
Benefits for Staff and the Public
PMMT has been shown to benefit correctional systems. It
has reduced anxiety of correctional staff,(245) who perceived inmates
receiving MMT to be less irritable and easier to manage and who also
reported no conflict between treated and untreated inmates. Methadone
detoxification of heroin-dependent prison entrants in Switzerland was
reported to reduce tension and facilitate custodial management.(246) As
emphasized by Dolan and Wodak,
transmission of blood borne viral infections and easier to manage prisons
are important gains for society as a whole. Lower prevalence of blood borne
viral infections among prison inmates means a safer occupational environment
for correctional staff.(247)
No Black Market for Methadone
In NSW, three studies provided no evidence of
"standover" tactics or a black market for methadone.(248) In Switzerland,
urinalysis showed that only seven percent of inmates on PMMT had used
heroin, and in Scotland prisoners in a drug-reduction program had used fewer
drugs than a control group.(249)
Heroin Maintenance Treatment
As mentioned above, in Oberschöngrün institution in
Switzerland a heroin prescription program was started in 1995.
The Swiss National Experiment
The program is part of a national experiment with
prescribing of heroin and other drugs to users that aims to determine
whether such prescribing will reduce users' criminal activity and their risk
of contracting and spreading HIV and other infections.(250) It started in
January 1994, with sites in eight cities. In each city, the program offers
accommodation, employment assistance, treatment for disease and
psychological problems, sterile syringes, and counselling. Users are in
regular contact with health workers and links to drug-free treatment. Some
programs started off by giving some users heroin and others morphine or
injectable methadone. It was soon found, however, that most users preferred
heroin, which is provided up to three times a day for a small daily fee. The
preliminary reports on the program suggest that heroin maintenance is
efficacious. It has not resulted in a black market of diverted heroin and
the health of the addicts in the program has clearly improved. The
authorities have concluded from these preliminary data that heroin causes
very few, if any, problems when it is used in a controlled manner and is
administered in hygienic conditions. Based on these findings, the Swiss
government expanded the program to more than 1000 users in 1995
(approximately 800 slots for heroin, 100 each for morphine and injectable
Heroin Maintenance at Oberschöngrün
course of the last few years, the penal institution at Oberschöngrün has
been increasing faced with drug-using inmates. It was their dependency that
led them to commit their offences. Repression is not sufficient to prevent
drug consumption in prison. At Oberschöngrün, experience has shown that 90
percent of drug users relapse after release from prison. This is far from
section 37(1) of the SPC, according to which "[i]mprisonment shall be
carried out in such a way as to have an educative effect on the inmate and
to prepare his return to a free life."
The controlled prescribing of heroin, authorized last June by the FOPH for
eight inmates, should provide for the psychological and physical
stabilization of the prisoners involved, and this is an indispensable
condition for as good as possible a future reintegration into society. The
director, Peter Fäh, is of the opinion that "[a]bstinence remains the most
important goal, but reality shows that heroin dependency is a disease and
that it cannot be cured with the same ease as a broken leg."(251)
Heroin maintenance at Oberschöngrün started in September 1995 with a
three-month pilot involving four inmates. Since January 1996 and until 31
December 1996, up to a maximum of eight inmates participate in the project.
To be eligible for participation, inmates have to:
- be 20 years of age or older;
- have been dependent on heroin for a minimum of two
- have been in treatment, without success, in the
- have "deficits in the social sphere"; and
- have sufficient time left in the institution.
Participants live in a separate unit of the
institution, work seven days a week, starting at 5:30 am, participate in
group discussions and individual psychosocial counselling, and inject
themselves with heroin three times a day under medical supervision. The main
aims of the project are to:
- establish the feasibility of heroin maintenance in
- implement harm-reduction measures in prison;
- assist the institution in solving its drug-related
- study its advantages and disadvantages, for clients
and institution, as compared with methadone maintenance.
First results, released at the symposium in Berne on 28
February 1996, show that clients appreciate the medical and psychological
support received, but are afraid that they might become more dependent on
heroin, or that they will not be able to continue on heroin maintenance once
the pilot ends or once they are released from prison. The warden, however,
is confident that the program will continue and hopes that it can even be
extended to allow for participation of more inmates. According to him,
positive results include a marked improvement in the participants' work
performance, a factor that has had an important role in bringing staff on
side. When he visited Oberschöngrün, the author of this report was told on
numerous occasions that staff have been impressed by the work performance of
prisoners in the heroin maintenance program.
Detailed results of the project will be available at the end of 1996.
Heroin Maintenance in Other Countries
Heroin maintenance is offered in an increasing number of countries,(252) but
Oberschöngrün remains the only prison worldwide in which it is available.
In a tradition dating back to the 19th century,
physicians in the United Kingdom prescribe drugs to users. In many regions,
drug- dependency clinics or community drug teams offer flexible prescribing
regimes ranging from short-term detoxification to long-term maintenance. The
majority of clients receive oral methadone, but some receive injectable
methadone, others injectable heroin, and a small number receive
amphetamines, cocaine or other drugs. These drugs are dispensed through
In the Mersey region, where prescribing and other harm-reduction programs
are well-established, anecdotal evidence suggests that drug-related health
problems and acquisitive crime have decreased as a result of these services.
In particular, the level of HIV infection among drug injectors in the region
is very low.
The Netherlands, several German cities, and the
Australian Capital Territory are also preparing to institute heroin
In Canada, as a result of the recommendations contained
in the BC Chief Coroner's report,(253) various agencies are working with
community groups to determine the feasibility of prescribing programs as one
part of their strategy to deal with drug-related harms.
Release of CSC's Inmate Survey
Since the publication of the Discussion Paper, CSC has
released the results of its survey of 4285 inmates. The survey confirmed
fears that "the problem of AIDS is especially high behind bars."(254) As
reported above, it provided evidence that at least 26 percent of inmates had
engaged in "risky practices" at their current institution. In particular:
- 11 percent of inmates considered themselves at high
risk for HIV because they have injected drugs since being incarcerated;
- 13 percent had been tattooed while in prison and
were not sure whether the equipment was safe;
- 6 percent had consensual sex while in prison, often
without using a condom;
- 3 percent of inmates had been sexually assaulted
behind bars, and an additional six percent had been pressured to provide
sexual services; and
- 28 percent of respondents believe that as a result
of CSC's urinalysis program, inmates have switched to drugs that are less
detectable but generally more addictive (and used by injecting).
According to the survey, "[b]oth legislative
requirements and recommendations from the Expert Committee on Aids and
Prisons (ECAP) have provided the impetus for conducting the National Inmate
Survey on behalf of the Correctional Service of Canada (CSC)." The survey,
the first of its kind in Canada, was conducted during the fall of 1995 in
federal prisons across Canada. The results of the survey
expected to enhance CSC's knowledge of federal inmates in a number of new
areas. Especially relevant and innovative within this survey are questions
that gather information on HIV/AIDS, specifically behaviour which places
inmates at risk of infection including sexual practices and illegal
substance use within their own institution. Ultimately, these findings will
provide important information for future direction in a number of key areas,
including institutional operations, offender programming and policy
The CSC Report continues by saying that "ECAP recommended an in-depth study
on drug use and other AIDS risk-taking behaviours in order to determine what
must be done to prevent the transmission of the virus among inmates and
ultimately protect the wider community."(256) This statement very seriously
misrepresents ECAP's recommendation. In reality, ECAP had recommended:
to prevent the transmission of infectious diseases, in particular HIV, due
to the sharing of unclean injection equipment, and because injection
equipment may not be effectively or consistently cleaned by bleach, ECAP has
concluded that access to sterile injection equipment by inmates must be
addressed by CSC. Therefore, ECAP recommends that research be undertaken
that will identify ways and develop measures, including access to sterile
injection equipment, that will further reduce the risk of HIV transmission
and other harms from injection drug use in federal correctional
institutions. This research should be carried out with the active
involvement of Health Canada and by individuals independent of but in
collaboration with CSC. It should be preceded by consultation with inmates,
staff, community groups and independent experts. It should include one or
more scientifically valid pilot projects, and should be accompanied by
planning, communication and education that will expedite making sterile
injection equipment available in the institutions.(257)
The Service had rejected this recommendation and only accepted to
"participate with Health Canada and public health authorities in a program
of research on injection drug use, and other high-risk behavior, and on
prevention strategies." While ECAP would, in principle, not have objected to
a study such as that now undertaken by CSC, it certainly did not think that
the study was necessary "to determine what must be done to prevent the
transmission of the virus among inmates and ultimately protect the wider
community." Rather, ECAP released 88 recommendations aimed at doing exactly
that: prevention of transmission among inmates and protection of staff and
the wider community. Further, it urged CSC to act immediately, without
further delay, and without awaiting the results of further research that
would likely only confirm what was already known: risk behaviours are
prevalent in prisons.
Two years after the release of ECAP's Final Report, the
results of the section on HIV/AIDS in CSC's inmate survey only confirm
ECAP's assessment of the situation with regard to HIV/AIDS and drug use in
federal prisons. They are useful because, once again, they provide clear
evidence of the need to act, but they would not have been necessary for the
purpose of determining what must be done to prevent the transmission of HIV
among inmates and to the public: CSC could and should have acted before.
Release of the Report of the Arbour Commission
imposition of punishment, all authority must still come from the law....A
guilty verdict followed by a custodial sentence is not a grant of authority
for the State to disregard the very values that the law, particularly
criminal law, seeks to uphold and to vindicate, such as honesty, respect for
the physical safety of others, respect for privacy and for human dignity.
The administration of criminal justice does not end with the verdict and the
imposition of a sentence. Corrections officials are held to the same
standards of integrity and decency as their partners in the administration
of criminal law.(258)
The Commission's Report
The Commission of Inquiry into Certain Events at the
Prison for Women in Kingston condemned the actions of CSC in a 1994 incident
in which male correctional officers strip-searched women prisoners. In a
300-page report released in April 1996, the Honourable Louise Arbour,
Commissioner, criticized CSC for a disturbing lack of commitment to the
ideals of justice, and concluded that "there is nothing to suggest that the
Service is either willing or able to reform without judicial guidance and
control." During her investigation, Justice Arbour heard that even though
the prisoners' treatment in this particular case frequently violated
Canadian law and prison regulations, nobody inside CSC did anything about
it: "Instead, it produced an internal investigation report that whitewashed
some actions, ignored others, and blamed the prisoners for everything that
Immediately following the release of the report, the former Commissioner of
CSC, Mr John Edwards, resigned. He has since been replaced by former
Commissioner Ole Ingstrup. Early in June 1996, CSC announced that it would
adopt several recommendations of the report, while saying that some of the
report's most controversial recommendations required further study. In an
interview, Solicitor General Herbert Gray said: "I saw the basic point of
the Arbour report was that the correctional service had to work within the
context of the rule of law in carrying out its responsibilities."(260)
Justice Arbour's objective in bringing forward recommendations on various
aspects of corrections touched upon by the inquiry was to "assist the
correctional system in coming into the fold of two basic Canadian
constitutional ideals, towards which the rest of the administration of
criminal justice strives: the protection of individual rights and the
entitlement to equality."(261)
The Relevance of the Report to HIV/AIDS
While Justice Arbour's report does not deal with issues
raised by HIV/AIDS, it highlights systemic shortcomings within CSC, the
"absence of a culture respectful of individual rights,"(262) and an
unwillingness to be responsive to outside criticism and to engage in honest
self-criticism - issues and problems that also affect CSC's response (or
lack of response) to HIV.
As stated by Justice Arbour,
Mission Statement, the Correctional Service of Canada commits itself to
"openness", "integrity", and "accountability". An organization which was
truly committed to these values would, it seems to me, be concerned about
compliance with the law, and vigilant to correct any departures from the
law; it would be responsive to outside criticism, and prepared to engage in
honest self-criticism; it would be prepared to give a fair and honest
account of its actions; and it would acknowledge error. In this case, the
Correctional Service did little of this. Too often, the approach was to deny
error, defend against criticism, and to react without a proper investigation
of the truth.(263)
With regard to HIV/AIDS, CSC showed remarkable openness by allowing an
external body, the Expert Committee on AIDS and Prisons, full access to its
institutions and, after two years of study, the publication of its Final
Report containing 88 recommendations about what CSC should do to prevent the
further spread of HIV in its institutions and to staff and the public.
Openness was also evidenced by the fact that CSC agreed to fund this study
as a follow-up to ECAP's recommendations.
Nevertheless, the Service has responded very defensively to ECAP's Report,
and the public and the media have been misinformed over the last years about
the true extent of CSC's response to ECAP's Report and the initiatives
undertaken by CSC to implement it. The Service tends to refer to its
official response to ECAP's Report, but has been silent about the fact that,
while many recommendations have been accepted, only few have been
implemented, while little or nothing has been done to implement the others -
nor has a system been put in place to make this possible. Admittedly, as
shown in this Report, positive developments have taken place, but this has
happened thanks to the dedication of some individuals, mainly in health-care
services, and to the involvement of and funding by Health Canada, rather
than a true and widespread change in attitude on the level of CSC's
management and correctional staff. With respect, CSC has been fairly
unresponsive to outside criticism, and little prepared to engage in honest
self-criticism, or to give a fair and honest account of its actions in the
area of HIV/AIDS and drug use.
Another problem referred to in Justice Arbour's report, the "absence of a
culture respectful of individual rights," is also evident in the area of
HIV/AIDS and drug use. First and foremost, the principle of equivalence of
care, requiring that all prisoners receive health care, including preventive
measures, equivalent to that available in the community, is poorly
understood. Secondly, infringements of prisoners' rights may be justified
because of imprisonment. However, in every case, CSC needs to justify the
infringement: it must be necessary, likely to be effective, and the least
invasive and restrictive means available to prevent harms that cannot
otherwise be prevented. Widespread disclosure of HIV-related medical
information, such as envisaged by CSC as a result of a legal opinion by
CSC,(264) does not satisfy these criteria, and is only one example of a
situation in which little understanding of legal rights of prisoners is
demonstrated. As pointed out by Justice Arbour, education is necessary,
education that emphasizes "the supremacy of the Canadian Charter of Rights
and Freedoms and the fact that all authority comes from the law."(265)
93 K Makin. Prisons Haunted by Fear of Violence. The Globe and Mail, 7 June
1996, at A6.
94 Reported Cases of HIV/AIDS in Federal Penitentiaries. Ottawa: CSC, Health
Care Services, March 1996.
95 T Nichol, supra, note 26.
96 For an overview, see Appendix 2: R Elliott. Prisoners' Constitutional
Right to Sterile Needles and Bleach.
97 T Nichol, supra, note 26. See also R Rolland et al. Medical Care Costs
Associated with Jail in Incarceration of People with HIV/AIDS. XIth
International Conference on AIDS, Vancouver, 7-11 July 1996. Abstract
We.D.3667: the cost of medical care for IDU, HIV-positive inmates is more
than 10 times the cost for non-IDU, non-HIV-positive inmates.
98 ECAP: Final Report, supra, note 15 at 6, with reference to TW Harding, G
Schaller. HIV/AIDS Policy for Prisons or for Prisoners? In: Mann JM,
Tarantola DJM, Netter TW (eds). AIDS in the World. Cambridge, MA: Harvard
University Press, 1992, 761-769 at 762-763.
99 S Ford. Health Care for Prisoners Living with HIV/AIDS. Canadian HIV/AIDS
Policy & Law Newsletter 1995; 2(1): 26-27 at 26. The following text is a
revised version of that paper.
101 Accounts of the personal experiences of two prisoners in a federal
institution (personal communication, received on 4 March 1994).
102 Supra, note 15 at 64-65. For a review see also K Dolan. Drug Injectors
in Prison and the Community in England. The International Journal of Drug
Policy 1993; 4(4): 179-183. K Dolan et al. AIDS Behind Bars: Preventing HIV
Spread Among Incarcerated Drug Injectors. AIDS 1995; 9(8): 825-832.
103 Ibid at 73-74.
104 HIV/AIDS in Prisons: Background Materials, supra, note 15 at 85-109.
105 D Shewan, M Gemmell, JB Davies. Drug Use and Scottish Prisons: Full
Report. Scottish Prison Service Occasional Paper, no 6, 1994.
106 A Taylor et al. Outbreak of HIV Infection in a Scottish Prison. Paper
presented at the Xth International Conference on AIDS / International
Conference on STD, Programme No 463C, Yokohama, Japan, August 1994.
107 AG Bird et al. Anonymous HIV Surveillance with Risk Factor Elicitation
at Scotland's Largest Prison, Barlinnie. AIDS 1995; 9: 801-808 at 801. For
another Scottish study, see SM Gore. Drug Injection and HIV Prevalence in
Inmates of Glenochil Prison. British Medical Journal 1995; 310: 293-296. For
an overview of UK studies, see PJ Turnbull, GV Stimson. A Public Health
Approach Is Needed to Prevent the Spread of HIV-infection Among Imprisoned
IDUs. XIth International Conference on AIDS, Vancouver, 7-11 July 1996.
108 K Dolan et al. Bleach Availability and Risk Behaviours in New South
Wales. Technical Report No 22. Sydney: National Drug and Alcohol Research
109 K Dolan et al. HIV Risk Behaviour of IDUs before, during and after
Imprisonment in New South Wales. Addiction Research (forthcoming).
110 N Mahon. High Risk Behavior for HIV Transmission in New York State
Prisons and City Jails American Journal of Public Health September 1996
111 Ibid, with reference to transcript of first focus group of female city
inmates, December 1993, at 46.
112 CA Saum et al. Sex in Prison: Exploring the Myths and Realities. Prison
Journal December 1995.
113 S Kane & J Dotson. HIV Risk in Rural Indiana Jails. As yet unpublished
manuscript of October 1995 (on file with author).
113a HJA van Haastrecht. Low Levels of HIV Risk Behaviour among Injecting
Drug Users during and following Imprisonment in the Netherlands. XIth
International Conference on AIDS, Vancouver, 7-11 July 1996. Abstract No
113b R Matas. Prevention in Jails under Fire. The Globe and Mail, 12 July
1996, at A6.
113c LG Wiessing et al. Prevalence and Risk Factors for HIV Infection among
Drug Users in Rotterdam. XIth International Conference on AIDS, Vancouver,
7-11 July 1996. Abstract Tu.C.2548.
114 C Hankins et al. Prior Risk Factors for HIV Infection and Current Risk
Behaviours Among Incarcerated Men and Women in Medium-Security Correctional
Institutions - Montréal. Canadian Journal of Infectious Diseases 1995;
6(Suppl B): 31B.
115 A Dufour et al. HIV Prevalence Among Inmates of a Provincial Prison in
Québec City. Canadian Journal of Infectious Diseases 1995; 6(Suppl B): 31B.
116 Nichol, supra, note 27.
116a As reported by C Ploem at the XIth International Conference on AIDS,
Vancouver, on 10 July 1996.
117 CSC. 1995 National Inmate Survey: Final Report. Ottawa: The Service
(Correctional Research and Development), 1996 No SR-02 at 138; Inmate
Survey, Main Appendix, supra, note 53 at 348-349.
119 1995 National Inmate Survey: Final Report, supra, note 117 at 139.
120 For a review of five studies, see M Parts. The Eighth Amendment and the
Requirement of Active Measures to Prevent the Spread of AIDS in Prisons.
Columbia Human Rights Law Review 1991; 22: 217-249 at 221-225. For a
comprehensive overview, see K Dolan. Evidence of HIV Transmission in Prison.
As yet unpublished paper.
121 TM Hammett et al. 1992 Update: HIV/AIDS in Correctional Facilities.
Washington, DC: US Dept of Justice, National Institute of Justice, 1994.
122 Castro et al. HIV Transmission in Correctional Facilities. Paper
presented at the VIIth International Conference on AIDS, Florence, 16-21
123 TF Brewer et al. Transmission of HIV-1 Within a Statewide Prison System.
AIDS 1988; 2(5): 363-367.
124 Hammett et al, supra, note 121. The following data are taken from their
126 ECAP: Background Materials, supra, note 15 at 60, with reference.
127 For a review, see also Dolan et al. AIDS Behind Bars. Supra, note 102.
See also V Soriano et al. Spreading of HTLV-II Among IDUs in Spain: Evidence
for Prisons Acting as Shooting Galleries. XIth International Conference on
AIDS, Vancouver 7-11 July 1996. Abstract Mo.C.1677. R Hernandez et al.
Drug-Addiction and AIDS in Prison Populations. Abstract Pub.D.1411; S
Oliveira. Sex of the Angels: Sexual Transmission of HIV in Brazilian Jails.
128 Taylor, supra, note 107; B Christie. Scotland: Learning from Experience.
British Medical Journal 1995; 310(6975): 279; A Taylor et al. Outbreak of
HIV Infection in a Scottish Prison. British Medical Journal 1995; 310(6975):
289-292. DI Yirrell et al. Molecular Investigation Confirming an Outbreak of
HIV in a Scottish Prison. XIth International Conference on AIDS, Vancouver,
7-11 July 1996, Abstract Mo.C.1532. See also R Jürgens. Alarming Evidence of
HIV Transmission in Prisons. Canadian HIV/AIDS Policy & Law Newsletter 1995;
129 See Dolan, Evidence of HIV Transmission, supra, note 120.
130 Ibid, with reference to Scottish Affairs Committee. Drug Abuse in
Scotland: Report. London: HMSO, 1994.
131 A Taylor, D Goldberg. Outbreak of HIV in a Scottish Prison: Why Did It
Happen? Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(3): 13-14. The
following text is a revised version of their article.
132 K Dolan et al. Bleach Availability and Risk Behaviours in Prison in New
South Wales. Sydney: National Drug and Alcohol Centre, Technical Report No
133 D Des Jarlais et al. International Epidemiology of HIV and AIDS among
Injecting Drug Users. AIDS 1992; 6: 1053-1068.
134 Taylor & Goldberg, supra, note 131.
135 Ibid. References omitted.
136 SM Gore, AG Bird. No Escape: HIV Transmission in Jail. British Medical
Journal 1993; 307: 147-148. See also SM Gore, AG Bird. Transmission of HIV
in Prisons. British Medical Journal 1993; 307: 681.
137 Ibid, with further references.
138 Ibid at 147.
139 K Dolan, W Hall et al. Letter to the Editor: Evidence of HIV
Transmission in an Australian Prison. Medical Law Journal of Australia 1994;
140 K Dolan et al. A Network of HIV Infection among Australian Inmates. XIth
International Conference on AIDS, Vancouver, 7-11 July 1996. Abstract
141 M Kennedy. Prison Discrimination Case Continues. [Australian] HIV/AIDS
Legal Link 1995; 6(2): 12.
142 N Mahon. HIV Transmission and Advocacy for Harm Reduction in US Prisons
and Jails. Canadian HIV/AIDS Policy & Law Newsletter 1995; 2(1): 24-25 at
24, with reference to RC Mutter, RM Grimes, D Labarthe. Evidence of
Intraprison Spread of HIV Infection. Archives of Internal Medicine 1994;
143 M Rotily et al. HIV Testing, HIV Infection and Associated Risk Factors
among Inmates in South-Eastern French Prisons. AIDS 1994; 8: 1341-1344 at
1344. See also M Rotily et al. HIV Testing, Prevalence, and Risk Behaviours
Among Prisoners Incarcerated in South-Eastern France. XIth International
Conference on AIDS, Vancouver, 7-11 July 1996. Abstract Tu.C.2632.
145 NH Wright et al. Was the 1988 HIV Epidemic among Bangkok's Injecting
Drug Users a Common Source Outbreak? AIDS 1994; 8: 529-532. As reported in
Dolan, AIDS Behind Bars, supra, note 102.
146 Response to the Discussion Paper by O LeBlanc Pellerin, dated 8 January
147 M Pearson, PS Mistry et al. Voluntary Screening for Hepatitis C in a
Canadian Federal Penitentiary for Men. Canada Communicable Disease Report
1995; 21(14): 134-136 at 135.
148 Health Services Statistics. The Correctional Service of Canada, August
149 Health Services Statistics. The Correctional Service of Canada, April
150 PM Ford, C White et al. Seroprevalence of Hepatitis C in a Canadian
Federal Penitentiary for Women. Canada Communicable Disease Report 1995;
151 Supra, note 147.
152 RG Prefontaine, RK Chaudhary. Seroepidemiologic Study of Hepatitis B and
C Viruses in Federal Correctional Institutions in British Columbia. Canadian
Disease Weekly Report 1990; 16: 265-266; RG Prefontaine et al. Analysis of
Risk Factors Associated with Hepatitis B and C Infections in Correctional
Institutions in British Columbia. Canadian Journal of Infectious Diseases
1994; 5: 153-156.
153 See N Crofts, T Stewart et al. Spread of Bloodborne Viruses among
Australian Prison Entrants. British Medical Journal 1995; 310(6975): 285;
and P Brown, cited in C Zinn. Australia: Climbing the Political Agenda.
British Medical Journal 1995; 310(6975): 279.
154 D Vlahov et al. Prevalence and Incidence of Hepatitis C Virus Infection
among Male Prison Inmates in Maryland. European Journal of Epidemiology
1993; 9(5): 566-569.
154a KP Fennie et al. Hepatitis C Prevalence and Incidence in a Cohort of
HIV+ and HIV- Female Prisoners. XIth International Conference on AIDS,
Vancouver, 7-11 July 1996. Abstract Tu.C.2655.
155 K Keppler, F Nolte, H Stover. Transmission of Infectious Diseases in
Prison - Results of a Study in the Prison for Women in Vechta, Lower Saxony,
Germany (forthcoming). Reported in Canadian HIV/AIDS Policy & Law Newsletter
1996; 2(2): 18-19.
156 Ford, supra, note 150 at 133-134.
157 Ibid at 135.
158 Editorial Comment. Ibid at 136.
159 Prisoners A to XX inclusive v State of NSW (Supreme Court of NSW,
Dunford J, 5 October 1994). See also R Jürgens. Australia: Prisoners Sue for
the Right to Condoms. Canadian HIV/AIDS Policy & Law Newsletter 1994; 1(1):
5; Australia: Update on Prison Condom Case. Canadian HIV/AIDS Policy & Law
Newsletter 1995; 1(3): 3.
160 Editorial. Prisoners Sue for the Right to Condoms. [Australian] HIV/AIDS
Legal Link 1994; 5(1): 1.
161 M Kennedy. Prison Discrimination Case Continues. [Australian] HIV/AIDS
Legal Link 1995; 6(2): 12; and personal communication from Mr Kennedy dated
26 October 1995 (on file with the author).
162 See C McLeod. Is There a Right to Methadone Maintenance Treatment in
Prison? Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(4): 22-23.
163 Letter from Dr S de Vlaming to Mr Soper, no date (on file with the
164 See Canadian HIV/AIDS Policy & Law Newsletter 1995; 1(3): 12.
165 AIDS Advisory Committee. The Review of HIV and AIDS in Prison. London,
England: HM Prison Service of England and Wales, 1995.
166 The AIDS Council of NSW et al. Prisons and Blood Borne Communicable
Diseases. The Community Policy. Darlinghurst: The Council, September 1995.
167 G Bloom. The Community Policy: Prisons and Blood Borne Communicable
Diseases. [Australian] HIV/AIDS Legal Link 1995; 6(2): 14-15.
168 D Shewan, M Gemmell, JB Davies. Drug Use and Scottish Prisons: Summary
Report. Scottish Prison Service Occasional Paper, no 5, 1994, at 24.
169 Ibid at 3.
171 Press conference, 16 May 1994, Information and Public Relations Bureau
of the Canton of Berne, as cited in Canadian HIV/AIDS Policy & Law
Newsletter 1994; 1(1): 1 at 3.
172 See ECAP: Final Report, supra, note 15 at 70-72.
173 Ibid at 77.
175 US Department of Health & Human Services, Public Health Service, Centers
for Disease Control and Prevention. HIV/AIDS Prevention Bulletin, 19 April
1993 [emphasis in the original].
176 ECAP: Final Report, supra, note 15 at 79 (Recommendation 6.3(6)).
177 Bleach Availability and Risk Behaviours, supra, note 108.
178 K Dolan et al. Bleach Easier to Obtain But Inmates Still at Risk of
Infection in New South Wales Prisons. Technical Report. Sydney, National
Drug and Alcohol Research Centre, 1996, at 23.
179 J Nelles, A Fuhrer. Drug and HIV Prevention at the Hindelbank
Penitentiary. Abridged Report of the Evaluation Results. Berne: Swiss
Federal Office of Public Health, 1995, at 2.
180 See ibid, and A Baechtold. Projet-pilote de prévention du sida dans les
établissements pénitentiaires de Hindelbank. Rapport final à l'attention de
l'Office fédéral de la santé publique. Berne: September 1995.
181 Nelles & Fuhrer, supra, note 179 at 10-11. See also the account of the
pilot project. Press conference, 16 May 1994, Information and Public
Relations Bureau of the Canton of Berne. Reported in R Jürgens. HIV
Prevention Taken Seriously: Provision of Syringes in a Swiss Prison.
Canadian HIV/AIDS Policy & Law Newsletter 1994; 1(1):1-3.
182 The following data are taken from Nelles & Fuhrer, supra, note 179 at
183 Ibid at 11.
184 Baechtold, supra, note 180 at 27.
185 Ibid at 27.
186 Ibid at 12.
187 Nelles & Fuhrer, supra, note 179 at 18.
188 Projet-pilote de prévention du VIH et d'aide à la survie en prison.
Spectra - prévention et promotion de la santé 1995; 1(1): 3.
189 J Nelles, T Harding. Preventing HIV Transmission in Prison: A Tale of
Medical Disobedience and Swiss Pragmatism. The Lancet 1995; 346: 1507.
190 Projet-pilote de prévention, supra, note 188.
191 Personal communication with P Fäh, Warden of Oberschöngrün, on 1 March
194 Projet-pilote de prévention. Supra, note 188.
195 Spritzenabgabe im Oberschöngrün. Kanton Solothurn: Strafanstalt
Solothurn. No date.
196 Cited in: D Burrows. Needle and Syringe Exchange in Swiss Prisons.
[Australian] National HIV/AIDS Legal Link 1995; 6(1): 14. See also HIV
Prevention Taken Seriously. Supra, note 181.
197 Federal Office of Justice. Provision of sterile syringes and of
disinfectant: Pilot project in correctional institutions; judicial
admissibility. Berne, 9 July 1992. All quotations are taken from this
198 See R Meyenberg, H Stöver. Presentation of a Scientific Evaluation of
the Pilot-Project "Prevention of Infectious Diseases in the Penal
Institutions of Lower-Saxony (Germany)." Unpublished account of the pilot
project, 1996 (on file with the author). The following text is a slightly
edited version of that account. See also The Editor. Needle Exchange
Programs Now Also in German Prisons. Canadian HIV/AIDS Policy & Law
Newsletter 1996; 2(2): 18.
199 Mitglieder der Expertenkommission (eds). AIDS und Hepatitisprävention im
Strafvollzug Niedersachsens. Empfehlungen der Expertenkommission. Hanover,
19 May 1995.
200 J Voges. Schuß Sauber im Knast. die tageszeitung [Berlin] 16 April 1996.
201 A Thiel, Referent Strafvollzugsamt, Justizbehörde Hamburg,
Strafvollzugsamt, in a discussion group at the symposium in Berne on 29
202 Abschlußbericht, supra, note 70 at 61.
203 Ibid at 62-63.
204 Ibid at 67.
205 S Koch. Politik der Nadelstiche. die tageszeitung, 20 February 1996 at
206 S Rutter et al. Is Syringe Exchange Feasible in a Prison Setting? An
Exploration of the Issues. Technical Report No 25. Sydney: National Drug and
Alcohol Research Centre, 1995. See also The Editor. Australia: Needle
Exchange in Prisons. Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(3):
207 Adapted from D Burrows. Needle Exchange in Prison: The Next Step.
[Australian] HIV/AIDS Legal Link 1996; 7(1): 14-15.
208 See supra, note 166.
209 Reported in [Australian] HIV/AIDS Legal Link 1996; 7(1): 7.
210 D Riley. Methadone and HIV/AIDS. Canadian HIV/AIDS Policy & Law
Newsletter 1995; 2(1): 1, 13-14. See also O Blix, L Gronbladh. AIDS and the
IV Heroin Addicts: The Preventive Effects of Methadone Maintenance in
Sweden. Drug and Alcohol Dependence 7: 249-256; DM Novick et al. Absence of
Antibody to Human Immunodeficiency Virus in Long-Term, Socially
Rehabilitated Methadone Maintenance Patients. Archives of Internal Medicine
1990; 150 (January).
211 K Dolan, A Wodak. An International Review of Methadone Provision in
Prisons. Addiction Research; 4(1):85-97 at 85, with reference to JRM
Caplehorn. Retention in Methadone Maintenance and Heroin Addicts' Risk of
Death. Addiction 1994; 89: 203-207.
212 Ibid, with reference to E Gottheil et al. Diminished Illicit Drug Use as
a Consequence of Long-Term Methadone Maintenance. Journal of Addictive
Diseases 1993; 12(4): 45.
213 Ibid, with reference to RG Newman et al. Arrest Histories before and
after Admission to a Methadone Maintenance Program. Contemporary Drug
Problems 1973(Fall): 417-430.
214 Ibid, with reference to J Ward et al. Key Issues in Methadone
Maintenance Treatment. Sydney: University of New South Wales Press, 1992.
215 ECAP: Final Report, supra, note 15 at 73, with reference. See also D
Shewan et al. Evaluation of the Saughton Drug Reduction Programme. Main
Report. Edinburgh: Central Research Unit, 1994.
216 See J Anderson. AIDS and Overdose Deaths in British Columbia. Canadian
HIV/AIDS Policy & Law Newsletter 1996; 2(3): 1, 25-26; D Riley. Harm
Reduction Around the World. Canadian HIV/AIDS Policy & Law Newsletter 1996;
2(4): 15-18 at 17.
217 See, eg, the 1993 WHO Guidelines, supra, note 13; Advisory Committee on
the Misuse of Drugs. AIDS and Drug Misuse Update. London: HMSO, 1993;
Scottish Affairs Committee, supra, note 130.
218 F McLeod. Methadone, Prisons and AIDS. In J Norberry et al (eds).
HIV/AIDS and Prisons. Canberra: Australian Institute of Criminology, 1991,
at 245, 248.
219 H Heilpern, S Egger. AIDS in Australian Prisons - Issues and Policy
Options. Canberra: Department of Community Services and Health, 1989, at 94.
220 ECAP: Final Report, supra, note 15 at 79 (Recommendation 6.3(7)).
221 CSC's Response to ECAP's Report, supra, note 21.
222 See K Dolan et al. Methadone Maintenance Reduces Injecting in Prison.
British Medical Journal 1996; 312:1162.
223 Most of the following text is taken from Dolan & Wodak, supra, note 211.
224 Ibid at 89, with reference to W Hall et al. Methadone Maintenance
Treatment in Prisons: The New South Wales Experience. Drug and Alcohol
Review 1993; 12: 193-203; S Magura et al. The Effectiveness of In-Jail
Methadone Maintenance. Journal of Drug Issues 1993; 23(1): 75-99; R
Jeanmonod et al. Treatment of Opiate Withdrawal on Entry to Prison. British
Journal of Addiction 1991; 86(4): 457-463; VP Dole. Methadone Treatment of
Randomly Selected Criminal Addicts. The New England Journal of Medicine
1969; 280(25): 1372-1375.
225 Methadone Maintenance Treatment in Prisons, supra, note 224 at 197.
226 New South Wales Department of Corrective Services Prison AIDS Project.
HIV/AIDS Policies, Procedures and Management Guidelines. Sydney: The
227 Dolan & Wodak, supra, note 211 at 89-90, with reference to Ministerio de
Justicia e Interior. Memoria. Delegación del Gobierno para el Plan nacional
sobre Drogas. Madrid: The Ministry, 1993.
228 Commission fédérale des stupéfiants - Groupe de travail Méthadone de la
sous-commission "Drogue". Rapport sur la méthadone: Utilisation d'un
succédané opiacé dans le traitement des héroinomanes en Suisse (troisième
édition). Berne: Federal Office of Public Health, 1995.
229 Ibid at 64-68.
230 Response to the Discussion Paper by D Zeegers Paget, dated 24 January
231 Abschlußbericht, supra, note 70 at 72.
232 Ibid at 75.
233 Response to the Discussion Paper by A Reventlow, dated 7 March 1996.
234 See McLeod, supra, note 162. The following text is an edited version of
234a R v M Povilaitis, unreported judgment of 27 June 1996 (Superior Court,
Criminal Division, Province of Québec, no 450-01-004040-965, Gérald
235 Dolan & Wodak, supra, note 211 at 86.
236 Response to the Discussion Paper by S Gore, received April 1996.
237 Dolan & Wodak, supra, note 211 at 88-89.
239 Methadone Maintenance Treatment, supra, note 224 at 197.
241 Dolan & Wodak, supra, note 211 at 93.
242 Methadone Maintenance Reduces Injecting, supra, note 222.
243 Dolan & Wodak, supra, note 211 at 91, with reference.
244 Ibid, with reference to S Bertram, A Gorta. Inmates' Perceptions of the
Role of the NSW Prison Methadone Program in Preventing the Spread of Human
Immunodeficiency Virus. Sydney: Evaluation of the NSW Department of
Corrective Services Prison Methadone Program. Study no 9. Research and
Statistics Division, 1990.
245 Ibid, with reference to Magura et al, supra, note 224; A Gorta.
Monitoring the NSW Prison Methadone Program: A Review of the Research
1986-1991. Sydney: Research Publication Department of Corrective Services
Publication no 25, 1992; C Herzog et al. Methadone Substitution as an
AIDS-Preventive Measure in the Prison Environment. Paper presented at the
European Symposium on Drug Addiction & AIDS, Siena, Italy, 4-6 October 1993.
246 Ibid, with reference to Shewan et al, supra, note 215, and Herzog,
supra, note 245.
247 Ibid at 93.
248 Ibid at 91, with reference to S Wale, A Gorta. Views of Inmates
Participating in the Pilot Pre-Release Methadone Program. Sydney: Process
Evaluation of NSW Department of Corrective Services Pre-Release Methadone
Program Study no 2. Research and Statistics Division, 1987; A Gorta. Results
of Gaol Urinalyses January - June 1987. Sydney: Process Evaluation of NSW
Department of Corrective Services Pre-Release Methadone Program Study no 2.
Research and Statistics Division, 1987; S Bertram. Results of Gaol
Urinalyses Update: July - December 1989. Sydney: Process Evaluation of NSW
Department of Corrective Services Pre-Release Methadone Program Study no 10.
Research and Statistics Division, 1991.
249 Ibid, with further references.
250 Harm Reduction Around the World, supra, note 216. The following text is
excerpted from Riley's article.
251 Projet-pilote de prévention, supra, note 188.
252 The following survey is taken from Harm Reduction Around the World,
supra, note 216.
263 See AIDS and Overdose Deaths in British Columbia, supra, note 216.
254 K Makin. Prisons Haunted by Fear of Violence. The Globe and Mail, 7 June
1996, at A6.
255 CSC National Inmate Survey: Final Report, supra, note 117 at 1.
256 Ibid at 2.
257 ECAP. Summary Report, supra, note 15 at 21 (Recommendation 6.3(6)).
258 The Honourable Louise Arbour, Commissioner. Commission of Inquiry into
Certain Events at the Prison for Women in Kingston. Ottawa: Public Works and
Government Services Canada, 1996, at XI.
259 H Hess, Reforms to Prison System Announced. The Globe and Mail, 5 June
1996, at A8.
261 Commission of Inquiry, supra, note 258 at XI-XII.
262 Ibid at 93.
263 Ibid at 173.
264 See supra at 15.
265 Commission of Inquiry, supra, note 258, at 182.