Why are we waiting? The urgent need for NSPS in Australian prisons

HIV Australia | Vol. 14 No. 1 | March 2016

By Angella Duvnjak, Nicole Wiggins and Sione Crawford

There are currently no needle and syringe programs (NSPs) operating in any Australian prisons. This is despite a growing body of international research clearly demonstrating that NSPs have been shown to be safe, beneficial and cost-effective within a variety of prison settings.

The continuing high rates of blood borne viruses (BBVs) among prisoners support an urgent need to introduce NSPs into the Australian prison system.

Australia cannot afford to continue to avoid the serious implications of not implementing prison-based NSPs, both to protect prisoners’ health and human rights, and to limit the spread of BBVs as individuals are released back into the community.

Prisons and BBVs: a growing problem

Current data indicate that Australia’s prison population is on the rise, with an increase of 7% in just one year, (from 33,789 to 36,134 people between 30 June 2014 and 30 June 2015).³

Prisons have been shown to be high-risk environments for the transmission of BBVs, including HIV and hepatitis C (HCV), and prisoners are named as a priority population in Australia’s Fourth National Hepatitis C Strategy 2014–2017⁴ and the Seventh National HIV Strategy 2014–2017⁵.

The Hepatitis C Strategy outlines the high prevalence of hepatitis C in prisons, with two-thirds of female and one-third of male prisoners testing positive for hepatitis C. The Strategy also highlights that Aboriginal and Torres Strait Islander people are disproportionally affected, with 43% of those in custody being hepatitis C positive.

These alarming figures are reflected in successive National Prison Entrants Blood Borne Virus and Risk behaviour surveys⁶, which report that the prevalence of hepatitis C is over thirty times higher among prisoners than the general community; it is not surprising therefore, that prisons are widely referred to as ‘incubators for disease’.

Because most prisoners serve short-term sentences (averaging six months to two years), the potential for BBVs to spread from prison settings into the wider community is clear.

Contextualising BBV risks – inside and out

It is well known that incarceration is an issue that disproportionately impacts Aboriginal and Torres Strait Islander people, who account for more than a quarter of adult prisoners despite representing around 2% of the Australian population.⁷

Criminalisation of drug use also results in the mass incarceration of people who use drugs. Illicit drug offences represent the second most common offence for custodial sentences in Australia.⁸ Over the past year there has been a 17% increase in prisoners sentenced for illicit drug offences.⁹

Outside of the prison environment, community-based NSPs demonstrate overwhelmingly high success rates in reducing the spread of BBVs¹⁰, with nine out of ten people who inject drugs (PWID) reporting use of clean needles for all or most of their injections in the month prior to coming into prison¹¹.

Upon entering the Australian prison system, however, access to this basic, evidence-based, harm reduction strategy is non-existent, severely limiting an individual’s ability to access sterile injecting equipment.

The vast majority of injecting episodes inside prisons therefore occur with shared injecting equipment – a practice identified to be one of the most effective ways to transmit HIV and HCV.¹²

Injecting and sharing syringes in the prison context may appear foolish to people without any experience of drug dependence and/or prison, but the harsh realities of prison life make stopping drug use inside prison difficult for many people.

Prison drug rehabilitation programs – where they exist – can have long waiting lists, and methadone as a drug substitution therapy is not available in all settings and is only suitable to those who are opioid dependant.¹³

The most common drug injected in prison is in fact amphetamine, with the prison entrants’ survey showing 59% of prisoners reporting it as the last drug injected.¹⁴ Injecting drug use within prisons is a practice dominated by specific cultural norms unique to the prison context.

Those most vulnerable, such as young people and new prison entrants, are at particularly high risk of becoming HIV- or hepatitis C-positive, as Marcus, a 34 year old ex-detainee, explains:

‘Whoever is the most senior, whoever’s done the most time, they’ll go [inject] first. [It] runs more on politics you know, it’s just the way it is. If it’s a young up and coming bloke, even if he owns the fit, he’ll go last – like the end of the food chain.

‘All the ones [syringes] I’ve used inside [were] “cut down”¹⁵(they’re easier to transport and bring in) …

‘The guy with the fit, who’s in charge he mulled up [mixed the drugs with water], divided it up in his head, and shot everyone up.

‘He goes first – let’s say five lines, and then on to the next guy who gets five lines and the next gets his five lines.

‘Sometimes there might’ve been a bit of a running the tip under the tap [to remove blood residue between users], but not always.

‘So you’ve got to trust him, not only to not miss [the vein], and not just to get everyone’s shot [amount of drug] right, but that he hasn’t got something [hepatitis C or HIV], and that the guy before you and the guy before him doesn’t have something.’

Source: Poeder, F. (ed). (2013).¹⁶

Boredom and frustration can also lead people to (re)commence injecting drug use while incarcerated.

Whatever the reason for choosing to inject, a BBV infection that will impact on the rest of the person’s life is a high price to pay for drug use while incarcerated. Time spent in prison should not result in a lifelong sentence of impaired health.

The evidence is clear – so why are we waiting?

There is a wealth of evidence supporting the provision of needles and syringes as the gold standard for harm reduction when it comes to injecting drug use and the prevention of BBV transmission.

Prison-based NSPs have been successfully operating internationally for more than 20 years, and international evidence has shown that prison NSPs:

are feasible and affordable across a wide range of prison settings are effective in decreasing syringe sharing among PWID, thereby decreasing the risk of BBV transmission (HIV, HCV) between prisons and from prisoners to prison staff n are not associated with increased attacks on prison staff or other prisoners
do not lead to increased initiation of drug consumption or injection
contribute to workplace safety
can successfully coexist with other drug prevention and drug dependence treatment programs.

Source: Stöver and Nelles. (2003).¹⁷

Following an exhaustive review of the evidence, the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended in 2007 that ‘prison authorities in countries experiencing or threatened by an epidemic of HIV infections among PWID should introduce and scale up NSPs urgently’.¹⁸

These key international bodies have added their voices in support of NSP programs in prisons citing the basic requirement to respect the human right to health.

The former UN Special Rapporteur on the right to health, Anand Grover stated: ‘If harm reduction programmes and evidence-based treatment are made available to the general public, but not to persons in detention, that contravenes international law’.¹⁹

Others go further to argue that the right to health and freedom from torture and ill treatment are indivisible particularly in prison settings, thereby requiring governments to take proactive steps to safeguard the health of prisoners.²⁰

Despite all of the above, Australia remains stuck in a frustrating status quo. The recent ‘close encounter’ with a trial program in the ACT was effectively derailed at the final hurdle.²¹^, ²²

Those of us concerned about BBVs in Australia need to urgently take stock of this situation and look towards next steps in this seemingly never ending battle to ensure that prisoners are not denied the most basic of human rights; having the means, and being given the opportunity, to protect their own health.

References

1 AIVL. (2015). Needle and Syringe Programs in Prisons: An International Review. AIVL, Canberra. Retrieved from: www.aivl.org.au

2 Stöver, H., Nelles, J. (2003) Ten years of experience with needle and syringe exchange programs in European prisons. International Journal of Drug Policy. 14(5–6), 437–444. doi: 10.1016/j.drugpo.2003.08.001

3 Australian Bureau of Statistics (ABS). (2015, 11 December). 4517.0 – Prisoners in Australia. www.abs.gov.au. Retrieved from: www.abs.gov.au

4 Department of Health (DoH). (2014). Fourth National Hepatitis C Strategy 2014–2017. Commonwealth of Australia, Canberra.

5 DoH. (2014). Seventh National HIV Strategy 2014–2017. Commonwealth of Australia, Canberra.

6 Butler, T., Callander, D., Simpson, M. (2015). National prison entrants bloodborne virus survey report 2004, 2007, 2010 and 2013, Kirby Institute, UNSW Australia, Sydney.

7 Australian Bureau of Statistics (ABS). (2015, 11 December). op. cit.

8 ibid.

9 ibid.

10 Hagen, H., Pouget, E., Des Jarlais, D. (2011). A systematic review and meta-anaylsis of interventions to prevent hepatitis C virus infection in people who inject drugs. Journal of Infectious Diseases, 204(1),74–83.

11 Butler, T. et al. (2015). op. cit.

12 Sander, G. (2016, February). HIV, HCV, TB and Harm Reduction in Prisons: Human rights, minimum standards and monitoring at the European and International levels. Harm Reduction International, London. Retrieved from: www.ihra.net

13 Currently in Australia, Queensland is the only state that does not provide methadone treatment for prisoners. See: Worthington, E. (2015). Queensland government fails to provide drug treatment. ABC news online. Retrieved from: www.abc.net.au

14 Butler, T. et al. (2015). op. cit.

15 A ‘cut down’ syringe is a syringe that is not full size (usually 1 ml syringe), and has been cut down in a make shift manner usually by inmates to facilitate the ability to be more easily hidden from possible detection by prison authorities.

16 Poeder, F (ed). (2013). Stories from the other side – an exploration of injecting drug use in NSW prisons. NSW Users and AIDS Association Inc., Sydney, 83.

17 Stöver, H., Nelles, J. (2003).

18 World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC), Joint United Nations Programme on HIV/AIDS (UNAIDS). (2007). Interventions to address HIV in prisons: Needle and Syringe Programmes and decontamination strategies. WHO, Geneva.

19 Cited in Sander, G. (2016). op. cit., 12.

20 ibid.

21 For background see: Costello, S. (2011). Support for a prison NSP trial. HIV Australia, 8(4), AFAO, Sydney.

22 See also: Morrison, E. (2015) More harm than good. HIV Australia, 13(1), AFAO, Sydney.

Angella Duvnjak is Program Manager, Hepatitis C and other BBVs Program at the Australian Injecting and Illicit Drug Users League (AIVL).

Nicole Wiggins is Project Officer for the Hepatitis Awareness Project at AIVL.

Sione Crawford is Manager, Canberra Alliance for Harm Minimisation and Advocacy (CAHMA).