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


International Reports Concerning Prisons and those at risk


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The use of contaminated injection equipment among injecting drug users is among the major forces driving the HIV/AIDS epidemic, contributing about 5-10 per cent of all HIV transmissions world wide. An essential package to prevent HIV transmission from injecting drug use includes needle and syringe programmes, drug substitution treatment, condom programmes, sexually transmitted infection control, HIV/AIDS-related treatment and care, information, education and communication and peer outreach.

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A Rapid Situation Assessment of HIV/STI/TB and Drug Abuse among Prisoners in Uganda Prisons Service

The general prevalence of HIV among prisoners was 11%, higher among female prisoners at 13% compared to their male counterparts at 11%. The general prevalence of syphilis was 5%, lower among female prisoners at 4% than male prisoners at 5%.

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A functioning court system is an integral part of a functioning criminal justice system. The management of the courts must be efficient and effective so that the criminal caseload can be adjudicated fairly, appropriately, and promptly. In many systems, judicial officers are involved in the day-to-day administration of courts, yet it is recognized that too heavy an administrative burden on judicial officers may result in a loss of efficiency. In some systems, court managers have been delegated decision-making authority on operational matters in the courts. A delicate balance must be struck between alleviating judicial officers of unnecessary administrative duties on the one hand, and avoiding the risk of interfering with the independence of the judiciary on the other.

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HIV/AIDS among IDUs remains a neglected issue. Although policy-makers, programme planners at the community and national levels and international donors have paid increasing attention to HIV/AIDS in recent years, the specific epidemics of HIV/AIDS among IDUs and the response needed have attracted much less attention and funding. Efforts have been made within the United Nations to harmonize policies on global drug control and HIV/AIDS prevention and to build interagency collaborative mechanisms; however, country-level capacity to address HIV/AIDS among IDUs remains low. Prevention services remain extremely limited in most places. Care and support services frequently remain unavailable for IDUs and are not tailored to their specifi c needs, even where programming and funding for HIV/AIDS prevention has considerably expanded otherwise. A review of country responses in 2002 noted that IDUs tend to be excluded from highly active antiretroviral therapy, and often even from basic primary care, almost everywhere. An extra effort is therefore necessary to promote equal HIV/AIDS prevention and care among IDUs.

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Despite these potential benefits, there is a widely held view that injecting drug users are poor candidates for ARV therapy because drug dependence undermines drug adherence, or because medical complications and co-morbidities such as hepatitis C make co-infected injecting drug users more difficult to treat and less responsive to ARV therapy. Although these limitations are indeed problems for many HIV-positive injecting drug users, extensive experience and numerous studies have documented that tailored HIV care for injecting drug users, as for other people living with HIV, is often highly successful.

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Cost-effectiveness of Australian NSPs

Sharing of syringes by injecting drug users (IDUs) is an important mode of global transmission of blood borne viruses, such as HIV and hepatitis C virus (HCV).   Both HIV and HCV infection are associated with significant morbidity and mortality [5, 6]. Needle and syringe programs (NSPs) are a public health measure designed to reduce the spread of these infections among IDUs. There are large differences in HIV epidemics among IDUs between different international settings. Ecological studies suggest that where NSPs are not easily accessible, HIV prevalence tends to be substantially greater than in locations where NSPs are available. In contrast to HIV infection, prevalence of HCV among IDUs is generally high in all locations regardless of the existence of NSPs

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Criminal Justice Information

Assessing a criminal justice system can be quite challenging, particularly when there is very little quantitative information available on the system itself, on the problems and the types of crime that it is confronted with, or on the resources at its disposal. The capacity and the current performance of the system itself are difficult to assess in the absence of that information. Unfortunately, the information that is available is often of dubious quality. Even when the required information has been collected and is available somewhere, it is often still difficult to gather and analyze the data that could provide an overview of the crime and security situation and the capacity of the system itself. Analyzing that data and understanding its limitations are sometimes beyond the ability of the assessor who is hard-pressed for time and cannot necessarily meet with representatives of the main agencies responsible for collecting that data.

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Drug Dependence Treatment: Interventions for Drug Users in Prison

Interventions and services for drug users in prison are an essential component of public health care systems as prisoners are part of our community. Drug treatment services in prison, also increase staff awareness. The provision of such services may encourage prison staff to examine their own use of drugs, alcohol and tobacco as well as act as peer educators amongst other staff, their families and the wider community.

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Providing access to and encouraging utilization of sterile needles and syringes for IDUs is now generally considered to be a fundamental component of any comprehensive and effective HIV-prevention programme. A wide variety of measures have been developed to improve access to and utilization of sterile injecting equipment, including needle syringe programmes (NSP), strategies for disinfecting needles and syringes where they are reused or shared, pharmacy-based distribution, sale or exchange schemes, vending machines and other distribution programmes, policies and programmes to encourage more appropriate disposal of used needles and syringes and injecting paraphernalia legislation. Much effort has been expended on improving knowledge, changing attitudes and reducing risk behaviour, but unless the means for behaviour change also become more readily available, improved knowledge and attitudes will not result in reduced risk. Likewise, unless efforts to increase access to sterile injecting equipment are buttressed by other efforts to support behaviour change, risk reduction will remain unaffected. Interventions to improve access to sterile injecting equipment have been implemented in many countries throughout the developed world and to a lesser extent in transitional and developing countries.

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After an outbreak of hepatitis B among IDUs in Amsterdam in 1983, an organization of IDUs asked municipal health authorities to provide sterile injection equipment. This request was initially rejected but the decision was soon reversed, allowing for the establishment of the first official needle syringe programme in the world. The HIV/AIDS pandemic soon became the rationale for this programme and similar programmes were rapidly established in many other parts of the world. Needle syringe programmes now operate officially in over 40 countries. Evaluation of the effectiveness and safety of these programmes began soon after they were first established and a vast literature was rapidly generated.

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Female Drug Use in Pakistan

This study is a part of the overall operational research which includes mapping and size estimation of female drug users, which forms the first key step in developing targeted interventions for this highly vulnerable key population. The results of this mapping study will assist in understanding the drug using scenario among female populations, which will ultimately form a baseline for service provision based on which service providing organizations will develop targeted interventions within a specific geographical setting. In addition to identification of geographical areas where these populations congregate, this study also provides valuable information on overall drug use situation in the targeted communities, economics of drug use, treatment history, criminal justice history, availability of treatment services and various religious and cultural barriers to accessing information and services among the target group.

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The transmission of HIV among injecting drug users and related populations of sex workers, youth and other vulnerable people is greatly adding to the burden of disease in countries worldwide. Evidence from 20 years of research shows that needle and syringe programmes (NSPs) prevent, control and ultimately reduce prevalence of HIV and other blood-borne infections among injecting drug users. These programmes are now operating in more than 60 countries in all regions of the world; yet it is estimated that less than 2% of injecting drug users are able to access sterile needles and syringes through NSPs. The need for needle and syringe programmes, their role in a comprehensive response to HIV among injecting drug users and evidence for their effectiveness can be found in recent documents

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HIV and AIDS in places of detention

This is for anyone who has anything to do with prisons and should be read in conjunction with the other modules. It provides essential background information about HIV and explains why and how addressing HIV in prisons is linked to the wider questions of prison reform and to human rights.

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HIV and Prisons in sub-Saharan Africa

Prisons concentrate great numbers of HIV-infected and at-risk populations, while prisoners comprise one of the least represented populations in national HIV strategies. Prison grounds offer ideal conditions for the transmission of many infectious diseases, including tuberculosis (and now extensively drug resistant TB or XDR-TB), hepatitis (A, B and C), sexually transmitted diseases and HIV6. Overcrowded and unsafe premises where injecting drug use and unprotected sex are common make correctional facilities ideal breeding grounds for HIV infection. The majority of prisoners are male; this is especially the case in Africa. Given this, the prison environment is highly conducive to violence and homosexual sex. Heterosexual and homosexual sex in prisons—whether voluntary or forced—is a key factor driving the spread of the infection. Prisoners are not sealed off; they are often in close contact with the general population, thus making the prison population a significant vector of inward and outward transmission of HIV.

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HIV in prisons

In 2000, Heads of State and Government representatives from 189 countries made an unprecedented commitment in the United Nations Millennium Declaration4 to halt and reverse the HIV epidemic by 2015. At the 2005 World Summit and at the 2006 UN High Level Meeting on AIDS, world leaders committed “to pursuing all necessary efforts … towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010”. Achieving this objective requires the inclusion of all sectors in these efforts, including prisons.

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HIV PREVENTION among young injecting drug users

The most common modes of HIV transmission worldwide remain unprotected sex, unscreened blood and blood products, contaminated needles, and mother-to-child transmission. In many countries of Asia, Latin America, Europe and North America, injecting drug use is the main or a major mode of HIV transmission. With an estimated 12.5 million people injecting drugs across the globe, most being between the ages of 15 and 30, there is a huge potential for further spread of HIV among drug injectors and their sexual partners.

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HIV testing and counseling in prisons and other closed settings

There is an urgent need to introduce comprehensive HIV programmes in prisons and to scale them up rapidly. As part of these programmes, prison systems need to expand access to HIV testing and counselling, while ensuring that: (a) prisoners are able to give informed consent to HIV testing; (b) receive adequate pre-test information and post-test counselling; and (c) the confidentiality of test results and of the fact of seeking the test is guaranteed.

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HIV/AIDS prevention and care for female injecting drug users

Female injecting drug users differ from their male counterparts in terms of their background, their reasons for using drugs, and their psychosocial needs. However, most HIV/AIDS prevention and care programmes are not reaching this vulnerable group because services are designed for men. Attempts to reach and work with female injecting drug users are limited and, in fact, gender sensitive services addressing the specific needs of female injecting drug users hardly exist in most countries.

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HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings

Worldwide, the levels of HIV infection among prison populations tend to be much higher than in the population outside prisons. This situation is often accompanied and exacerbated by high rates of other infectious diseases such as hepatitis and tuberculosis. The generally accepted principle that prisons and prisoners remain part of the broader community means that the health threat of HIV within prisons, and the health threat outside of prisons, are inextricably linked and therefore demand coordinated action.

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The global environment for the HIV response has shifted substantially towards a massive scaling up of prevention, treatment, and care interventions. In particular, Governments made an unprecedented commitment during the United Nations Special Session on HIV/AIDS in 2001 to halting and reversing the epidemic by 2015. More recently, at the 2005 World Summit and at the 2006 High Level Meeting on AIDS, Governments committed to pursue all necessary efforts towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010. In support of this, substantial additional resources to fund an expanded response have become available, including through the Global Fund to Fight AIDS, Tuberculosis and Malaria.

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HIV hit prisons early and hit them hard. The rates of HIV infection among prisoners in many countries are significantly higher than those in the general population. HCV seroprevalence rates are even higher. While most of the prisoners living with HIV in prison contract their infection outside the institutions before imprisonment, the risk of being infected in prison, in particular through sharing of contaminated injecting equipment and unprotected sex, is great. Outbreaks of HIV infection have occurred in a number of prison systems, demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission.

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There is evidence that needle and syringe programmes (NSPs) are feasible in a wide range of prison settings, including in men’s and women’s prisons, prisons of all security levels, and small and large prisons. There is evidence that providing clean needles and syringes is readily accepted by IDUs in prisons and that it contributes to a significant reduction of syringe sharing over time. It also appears to be effective in reducing resulting HIV infections. At the same time, there is no evidence to suggest that prison-based NSPs have serious, unintended negative consequences. In particular, they do not appear to lead to increased drug use or injecting, nor are they used as weapons. Evaluations have found that NSPs in prisons actually facilitate referral of drug users to drug dependence treatment programmes. Ultimately, since most prisoners leave prison at some point to return to their community, implementing NSPs in prisons will benefit not only prisoners and prison staff, but also society in general.

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Illegal drugs are available in prisons despite the sustained efforts of prison systems to prevent drug use by prisoners by undertaking efforts to prevent the entry of drugs into prisons, by tightly controlling distribution of prescription medications, and enforcing criminal prohibitions on illegal drug possession and use among prisoners.

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Coincident with the emergence of HIV, many countries have experienced a significant increase in the prison population, resulting in prisons becoming an important source of health care for socially disadvantaged people, many of whom cycle in and out of prison. For example, in 1997, 20% to 26% of all HIV positive people in the United States passed through a correctional facility (Hammett, Harmon, Rhodes, 2002). Out of the estimated 1600 people living with HIV in Ireland, 300 to 500 had been through the prison system (UNAIDS, 1997).

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Injecting drug use in prison is of particular concern with regard to transmission of HIV and other blood borne infections such as hepatitis B and C. This is because those who inject drugs in prisons often share needles and syringes and other injecting equipment, which is a very efficient way of transmitting HIV.



Some same-sex sexual activity occurs as a consequence of sexual orientation (Zachariah et al., 2002). However, most men who have sex in prisons do not identify themselves as homosexuals and may not have experienced same-sex sex prior to their incarceration. Temporarily, under the conditions of imprisonment, they may engage in same-sex behaviour (Awofeso & Naoum, 2002, with reference to Freud, 1905). Many prisoners do not think of their behaviour as homosexual if they are the penetrating partner (Johnson, 1971), or are reluctant to acknowledge any such practice, which often results in underreporting of sexual activity in prisons (Mahon, 1997).

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Needle & syringe programs

Needle and Syringe Programs have been one of the major public health success stories. However, some people are still uncertain about their role. This booklet provides answers to some of the most frequently asked questions about Needle and Syringe Programs.

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The evidence is clear: early responses to HIV epidemics among and from IDUs can prevent their spread. Even where epidemics have taken off, they can be contained and reversed.

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Drug users tend to be a marginalized group with complex needs and have poorer access to life-saving interventions. Services should have a more coordinated response to drug users’ needs to provide universal access to prevention, treatment and care services at all entry points. This requires collaborative planning between HIV and TB services, specialist drug services and the criminal justice system.

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Prisons and AIDS

Many of those who are HIV-positive in prison were already infected on the outside. Many come from segments of the population that carry a heavier than average burden of HIV infections. In addition, many of those in prison are there because of drug use or trafficking, and they will try to continue drug use inside. Whether the authorities admit it or not -- and however much they may try to repress it -- drugs are introduced and consumed by prison inmates in many countries, and men commonly have sex with men in all-male prisons. Denying or ignoring these facts will not help solve the problem of the continuing spread of HIV -- and both forms of behaviour are HIV transmission risks.

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Protocol on Assessing Drug Use and HIV in Prison Settings

The prison setting population has particular characteristics that set it apart from the general population. Compared to the general population, it has a higher prevalence of psychiatric problems, higher level of suicide and self harm and higher level of social pressures of different types (from stress up to, in certain situations, sexual harassment and sexual and physical abuse). Moreover, the criminal justice system is an institution with regular contact with drug dependent users. The inmate population and given the aforementioned is at higher risk of drug use whether in terms of initiation of the behavior or continuation (in the absence of proper intervention). Post release information suggests that the drug using population within the prison setting has the distinctiveness of having of higher risk of drug overdose on discharge from prison (high post release mortality).

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Provision of sterile injecting equipment to reduce HIV transmission

The provision of access to sterile injection equipment for injecting drug users and the encouragement of its use are essential components of HIV/AIDS prevention programmes, and should be seen as a part of overall comprehensive strategies to reduce the demand for illicit drugs. The equipment is provided through a great variety of approaches categorized as needle and syringe programmes, the goals of which are that drug users have their own sterile injecting equipment and do not share it with others, that the circulation time of used needles and syringes is reduced and that used equipment is disposed of safely.

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There is compelling evidence that increasing the availability and utilization of sterile injecting equipment for both out-of-treatment and in-treatment injecting drug users contributes substantially to reductions in the rate of HIV transmission. For example, a study published in 2002 compared HIV prevalence in 103 cities in 24 countries.  The HIV infection rate had declined by an average of 18.6% annually in 36 cities with needle and syringe programmes, whereas it had increased by an average of 8.1% annually in 67 cities lacking such programmes. These findings confirmed those of earlier reviews. For example a 1997 study compared HIV infection rates among injecting drug users in 52 cities without and 29 with needle and syringe programmes in North and South America, Europe, Asia and the South Pacific. On average the HIV infection rate increased by 5.9% per year in the former and decreased by 5.8% in the cities with needle and syringe programmes.

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Communities or countries threatened by or experiencing an epidemic of HIV infection among injecting drug users should urgently adopt measures to increase the availability and utilization of sterile injecting equipment and to dispose of used equipment. They should provide risk-reduction education, referrals to drug-dependence treatment and abscess management, promote condom use, HIV testing and counselling, and provide care, treatment and support for persons with HIV/AIDS and treatment of sexually transmitted infections. If necessary, legislation related to drug dependence and drug paraphernalia should be reviewed and amended in order to allow for and promote the implementation of needle and syringe programmes.

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Reduce prison overcrowding-Reduce HIV transmission

Every year more than 30 million people worldwide enter and leave prison systems No community remains unaffected

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Reduction of HIV transmission in Prisons

The rates of HIV infection among inmates of prisons and other detention centres in many countries are significantly higher than those in the general population. Examples include countries in Western and Eastern Europe, Africa, Latin America and Asia. the available data on HIV infection rates in prisons cover inmates who were infected outside the institutions before imprisonment and persons who were infected inside the institutions through the sharing of contaminated injection equipment or through unprotected sex. certain populations that are highly vulnerable to HIV infection have a heightened probability of incarceration because of their involvement in behaviours such as drug use and sex work.

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Reduction of HIV transmission through drug-dependence treatment

Numerous studies have yielded consistent and strong evidence that substitution treatment is associated with substantial reductions in illicit opioid use, criminal activity, deaths attributable to overdoses, and risk behaviour related to HIV transmission.

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Reduction of HIV transmission in Prisons

The evidence obtained in more than 15 years of research and evaluation involving various types of research design in different country settings strongly indicates that outreach-based interventions are effective in contacting out of-treatment injecting drug users and providing them with the means for effective behaviour change. Furthermore, outreach programmes can reinforce HIV prevention services provided to drug users in treatment. Specifically, research has consistently revealed significant and strong post-intervention effects

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SEX-RAR Guide: The Rapid Assessment and Response Guide on Psychoactive Substance Use and Sexual Risk Behaviour

This document provides guidance on using RAR to assess the current situation regarding substance use and sexual risk behaviour. An assessment of the local situation, placed in the country, city or specific community context, is a necessary requirement for planning and developing appropriate intervention responses.

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Southern and Eastern Africa Declaration of Commitment for HIV and AIDS Prevention Care, Treatment and Support in Prisons in Africa

Prisoners are exposed to several HIV transmission risks whilst in custody: risks associated with unprotected, forced and consensual sexual practices (especially “contextual MSM”), injecting drug use (IDU), tattooing/piercing, sharing of razors, hair clippers, through to pregnancy and breastfeeding and unsafe medical or dental care.

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Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention


Substitution maintenance therapy is one of the most effective treatment options for opioid dependence. It can decrease the high cost of opioid dependence to individuals, their families and society at large by reducing heroin use, associated deaths, HIV risk behaviours and criminal activity. Substitution maintenance therapy is a critical component of community-based approaches in the management of opioid dependence and the prevention of HIV infection among injecting drug users (IDUs).

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The global epidemiology of methamphetamine injection

This paper represents an important first step in examining methamphetamine on a global level. The relationship between HIV and methamphetamine use is explored within the context of global diversity. While summarising the evidence currently available the authors make clear that much of the picture remains incomplete. Further investigation is urgently required before we can fully understand the extent of methamphetamine use in most countries and the nature and magnitude of related harms.

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The Prison System

Imprisonment can be regarded as the final stage of the criminal justice process, which starts with the commission of offences, their investigation, the arrest of suspects, their detention, trial and sentence. How the criminal justice system deals with offenders determines the size of the prison population, which in turn has a significant impact on the way in which prisons are managed. The criminal justice system itself is on the other hand influenced by the government policies and political climate of the time - determined to a large extent by the public, which, in democratic countries, elect their governments. Thus, in assessing the prison system there needs to be awareness that efficient management and humane prison conditions are not dependent on the prison authorities alone. What happens in prisons is intrinsically linked to how the criminal justice system as a whole is managed, and what pressures that system is under from politicians and the public. Thus, attempts to reform the prison system need to be undertaken as part of a comprehensive programme that addresses challenges in the entire criminal justice system

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The Rapid Assessment and Response guide on injecting drug use

This guide inevitably draws on the work of a vast number of people and organizations who have been involved in work on injecting drug use and HIV infection over the last decade. It has been heavily influenced by others who have worked on rapid assessments, not only of drug use but across a wide range of fields including malaria control, water sanitation and hygiene control. It has also been influenced by many methodologists, especially in sociology, anthropology, epidemiology, and evaluation research. As such it is a distillation of ‘current wisdom’ about applied research methods.

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This package is designed to help organize workshops that orient and train public health policy-makers, programme developers, programme managers, implementers and field workers in outreach to injecting drug users. The workshops draw on experience from training materials and tools used in different parts of the developing and developed world. The approach advocated in these module aims to contribute significantly to the prevention of HIV transmission among injecting drug users. As such, the workshops you are going to facilitate are an integral part of a renewed global and national commitment to HIV prevention.

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UNAIDS Guidance Note on HIV and Sex Work

“…In most countries, discrimination remains legal against women, men who have sex with men, sex workers, drug users, and ethnic minorities. This must change. I call on all countries to live up to their commitments to enact or enforce legislation outlawing discrimination against people living with HIV and members of vulnerable groups…In countries without laws to protect sex workers, drug users, and men who have sex with men, only a fraction of the population has access to prevention. Conversely, in countries with legal protection and the protection of human rights for these people, many more have access to services. As a result, there are fewer infections, less demand for antiretroviral treatment, and fewer deaths. Not only is it unethical not to protect these groups: it makes no sense from a public health perspective. It hurts us all.” Ban Ki-moon1 The Secretary-General of the United Nations

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WHO guidelines on HIV infection and AIDS in prisons

All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status or nationality.

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Women and Drug Abuse: The Problem in India

Within the family, it is often the woman, in the role of wife or mother who is most affected by the individual’s drug use, and has to bear a significant part of the family burden. Such impact becomes even more obvious in a developing country like India, where women are already disadvantaged. This aspect of the burden of drug use on women in India has received scant attention.

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Women and HIV in prison settings

Women prisoners present specific challenges for correctional authorities despite, or perhaps because of the fact that they constitute a very small proportion of the prison population. The profile and background of women in prison, and the reasons for which they are imprisoned, are different from those of men in the same situation.4 In particular, injecting drug users and sex workers are overrepresented. Once in prison, women’s psychological, social and health care needs will also be different. It follows that all facets of prison facilities, programmes and services must be tailored to meet the particular needs of women offenders. Existing prison facilities, programmes and services for women inmates have all been developed initially for men, who have historically accounted for the largest proportion of the prison population.

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Women’s health in prison

Prison policies often overlook the special needs of women and their health. Many women in prison have high levels of mental illness and drug or alcohol dependence as well as sexual and physical abuse and violence. Issues arising from gender-specific health care needs and family responsibilities are also frequently neglected. Although women represent a small percentage of the total prison population, their numbers are increasing and the rate of increase is much greater than that of men.

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