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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



HIV/AIDS in Prisons: Final Report

by Ralf Jürgens
© Canadian HIV/AIDS Legal Network and Canadian AIDS Society, Montreal, 1996
ISBN 1-896735-04-5

New Developments

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 prisons;
  • 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 HIV/AIDS;
  • 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)

The Future

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

The 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 facilities.

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:

A 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

[i]mprisonment 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)

They concluded:

The 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.

United States

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:

Male CO's 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 there.(111)

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 consensual.

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 were HIV-positive.(115)

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 for HIV.(116)

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 use.(117)

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 had injected.

Needle Sharing

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)

Sexual Behaviour

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 occurring.

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 taken seriously.(128)

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 released.

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 particularly prevalent.(129)

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 infected.(130)

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 Glenochil.
  • 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.

In-Depth Interviews
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.

You 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 affair:

When 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 used:

They 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 one.

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:

There was 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":

The 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 high-risk environment.(135)

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 added:

If 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 Florida

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 prison.(142)

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 urgency."(144)

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

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,

Hepatitis 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)

Joyceville Institution

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)

US: Maryland

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)

US: Connecticut

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 HCV-positive.(154a)


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 necessary to

explore 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 syringes;
  • prison staff have searched for and confiscated such items;
  • 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 in prison;
  • correctional authorities first said that the prisoner had given first aid to another prisoner who had cuts on his hands;
  • 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 corpus.(162)

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 HIV/AIDS.

The Netherlands

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.

United Kingdom

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 understandable.

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

felt that 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

the 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 body-piercing equipment;
  • there be no limit to the number of prisoners who have a history of opiate use having access to the prison methadone program;
  • 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:

Such 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 step.(168)

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:

This 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

would be 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

The FOPH [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 their equipment:

Some 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 prisons.

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

The 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 occurred;
  • an important decrease in needle sharing was observed;
  • there was no increase in drug consumption; and
  • needles were not used as weapons.

Hindelbank Institution
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 incarceration.

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 use;
  • 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 audiovisual materials.

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 cabinet.

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.

Drug Use
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 prison.

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 project.

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

Between 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 international level.

The evaluation of this preventive measure at Hindelbank supports the above findings.(183)

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 gradual:

  • before the project started, eight prisoners declared sharing;
  • after three months, four prisoners declared sharing;
  • after six months, two declared sharing; and
  • after 12 months, one declared sharing.

Medical Examinations
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,

a clear 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 benefits.
  • 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:

The 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,

the 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 the project.

Oberschöngrün: Distribution of Sterile Injection Equipment at a Men's Prison

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)


Dr Franz 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 medical disobedience.(189)

Three years later, distribution is ongoing, has never resulted in any negative consequences, and is supported by prisoners, staff, and the prison administration:

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:

Staff 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 safety."

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,

it is 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:

Knowing 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

our goal 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 elsewhere.

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:

protect 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; and
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.

Judicial Admissibility
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

drugs are 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:

Such 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, 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 urgent measure.

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 must be done anonymously."

Finally, the authors deal with the question of predicting whether such measures could put prison staff in danger:

The 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.

Swiss Pragmatism
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 upholding "morality";
  • 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 elsewhere.

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 Vechta.

The projects will be scientifically evaluated, with two main aims:

  • to present an objective and realistic account of the projects; and
  • to assess the usefulness and efficacy of the measures undertaken, beyond the various interests of the persons and institutions involved.

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 infections."

Germany: Hamburg

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:

The 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

staff are 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

the state 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":

For 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.


Germany: Berlin

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 users;
  • 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 correctional officers.

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 and syringes;
  • 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 room; and
  • 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 evaluated; and
  • 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 behaviour."(209)

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 injection."(215)

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 drug-dependent prisoners.(219)

In light of this, ECAP recommended that

[i]n 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 release."(221)

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 methadone program:

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 programs.

2. Maintenance program to be tailored to the individual treatment needs of each inmate.(226)

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.

Other Countries

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 HIV-negative inmates.

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 PMMT.(229)

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 prison.(231)

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; and
  • 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,

[s]uch 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 treatment.


Rationale for Prison Methadone Maintenance Treatment (PMMT)

Cycles of 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,

is to 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.


Prison 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 facilities.(237)

Forced Abstention

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:

Methadone 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:

[T]he 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)


Most 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 pre-release purposes.(241)

Reduction in Injecting and Sharing

Dolan et al evaluated the effectiveness of MMT in reducing HIV risk behaviour among prisoners. Their study suggests that

reduction 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,

Reduced 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 methadone).

Heroin Maintenance at Oberschöngrün

Over the 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 years;
  • have been in treatment, without success, in the past;
  • 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 prisons;
  • implement harm-reduction measures in prison;
  • assist the institution in solving its drug-related problems; and
  • 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.

United Kingdom

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 local pharmacists.

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.

Other Countries

The Netherlands, several German cities, and the Australian Capital Territory are also preparing to institute heroin maintenance programs.


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

are 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 development.(255)

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:

In order 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

[I]n the 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 went wrong."(259)

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,

[i]n its 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.

100 Ibid.

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. Abstract We.D.3658.

108 K Dolan et al. Bleach Availability and Risk Behaviours in New South Wales. Technical Report No 22. Sydney: National Drug and Alcohol Research Centre, 1994.

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 (forthcoming).

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 Tu.C.2549.

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.

118 Ibid.

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 June 1991.

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 report.

125 Ibid.

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. Abstract We.D.3814.

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; 1(2): 2-3.

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 22, 1995.

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; 160: 734.

140 K Dolan et al. A Network of HIV Infection among Australian Inmates. XIth International Conference on AIDS, Vancouver, 7-11 July 1996. Abstract We.D.3655

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; 154: 793-795.

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.

144 Ibid.

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 1996.

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 1995.

149 Health Services Statistics. The Correctional Service of Canada, April 1996.

150 PM Ford, C White et al. Seroprevalence of Hepatitis C in a Canadian Federal Penitentiary for Women. Canada Communicable Disease Report 1995; 21(14): 132-134.

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 author).

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.

170 Ibid.

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.

174 Ibid.

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 6-16.

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 1996.

192 Ibid.

193 Ibid.

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 document.

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 February 1996.

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 3.

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): 15.

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 Department, 1994.

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 1996.

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 McLeod's article.

234a R v M Povilaitis, unreported judgment of 27 June 1996 (Superior Court, Criminal Division, Province of Québec, no 450-01-004040-965, Gérald Desmarais J).

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.

238 Ibid.

239 Methadone Maintenance Treatment, supra, note 224 at 197.

240 Ibid.

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.

260 Ibid.

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.