Prison health issues. UNAIDS, UNODC and WHO guidelines on Prison health

Prison health issues. UNAIDS, UNODC and WHO guidelines on Prison health

5th European AIDS Conference

on Clinical and Social Research on AIDS and Drugs

Prof. Dr. Heino Stöver

University of Applied Sciences Frankfurt/Germany

hstoever@fb4.fh-frankfurt.de

BE

SI HR DK

AT CZ

PL

LT LV EE

SK HU RO

BG

EL

TR

MT CY

IE

UK

PT

ES

NL

IT DE

BE

LU

FR UK

FI SE

NO Below 100 per 100.000 pop

Between 100-150 per 100.000 population

Between 151-200 per 100.000 population

More than 201 per 100.000 population

Prison Population Rate in the EU27

Source: Council of Europe Annual Penal Statistics (SPACE I) 2006 Population demographic data: EUROSTAT

(Dagmar Hedrich, EMCDDA)

Part I. Background

„... Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities.“

Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons

Key Problems I: Drug Use and drug- related infectious diseases

~ 1 million prisoners per year in Europe

~ One third opioid users

10–42% report regular drug use in prison 1–15% have injected drugs while in prison 3–26% first used drugs while incarcerated

Up to 21% of injectors initiated injecting in prison Consistently 90% relapse to heroin use after

release

Prisons as risk environment

Drug-related infectious diseases in German prisons

IDUsIDUs HCVHCV HIVHIV

Prisons 21.9–29.6 % 14.3–17 % 0.8–1.2 %

General

population 0.3% 0.4–0.7% 0.05%

Factor ^73–98 26–32 16–24

Prison release mortality Total sample: 183,780

Deaths per thousand person years (Farrel et al.2008)

Key problems II: Coping strategies by by management & policy makers

Denial

Basic orientation supply reduction

Absence of holistic view towards health and crime risks

Ignorance of evidence-based knowledge - few academic staff

- hierarchical system

- political interests

- dominance of moral attitudes

Abstinence-oriented measures

Organisational strategies (drug-free units)

Part II.

Prevention and Harm Reduction

Studies/Responses

5 background

studies/programmes

1. European Commission (2008) 2. UNODC Framework (2006)

3. WHO/UNAIDS (2008)

4. WHO, UNAIDS, UNODC (2007)

5. European Prison Research: ENDIPP etc.

1. Prevention, Treatment, and Harm Reduction Services in Prisons

gathering the evidence

status quo of scientific research Basis for a European Council

Recommendation

1. Prevention, Treatment, and Harm Reduction Services in Prisons: Results

Detoxification with adequate medication is rarely available throughout Europe.

Prison-based OST proved to be effective in reducing mortality, crime and re-incarceration rates and HCV.

Implementation is not equally well accepted and realized.

Evidence for effectiveness of PNEP in different prison settings.

Condoms: No serious negative effects of condom provision in prisons have been found, provision of condoms seems feasible in a wide range of prison settings.

Implementation of drug prevention/treatment services sporadic and not sufficient to meet the needs.

Proposal for a Council of Europe

‘Recommendation on drugs and prison’

Main recommendations (public health objective, range of activities, evaluation, reporting)

Specific recommendations among prisoners to:

1. develop activities to prevent drug use

2. facilitate the access to treatment of drug users,

3. increase access to harm reduction/reintegration services for (ex) prisoners and

4. To monitor/analyse drug use in prisons

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

The Framework is a tool to assist

governments meet their international obligations on human rights, prison conditions, and public health.

Sums up professional standards and

ways of how to implement them

Arabic, Chinese, English, French, Portuguese, Russian, Spanish

3. Monitoring harm reduction in European prisons via the Dublin

Declaration

To assess progress on commitments

Chapter 15 dedicated to

situation in European prisons:

- harm reduction

- iv drug users

- HIV in prisons

Monitoring harm reduction in European prisons via the Dublin Declaration

no data Sexual health services

9 Voluntary HIV testing

and counselling

9 Bleach programmes

17 Substitution treatment

6 Syringe exchange

18 Condoms

No. countries/WHO region

Harm Reduction Measure

0 5 10 15 20 25

Number of countries

Methadone Maintenance

Methadone Detox

Bupren Heroin prescribing

Needle Syringe Programme

Condoms

Outside Prisons Inside Prisons

HIV prevention measures in EU

prisons, outside and inside of prisons

European Commission, April 2007

Conclusions of Evaluation of Dublin Dec.

Dublin Declaration: 80% coverage of

comprehensive HIV programmes and services in prisons by 2010?

Scaling – Up of services example OST: England Proposal for a Council of Europe

‘Recommendation on drugs and prison’:

1. develop activities to prevent drug use

2. facilitate the access to treatment of drug users, 3. increase access to harm reduction/reintegration

services for (ex) prisoners and

4. To monitor/analyse drug use in prisons

4. Effectiveness of Interventions to Manage HIV in Prisons

Provision of condoms and other

measures to decrease sexual transmission Opioid substitution therapies and other drug dependence treatment

HIV care, treatment and support

Needle and syringe programmes and bleach and decontamination strategies

5. European Prison Research

Harm Reduction in European prisons - Models of Best Practice (2007)

Juveniles in Secure Settings: Services for problematic drug and alcohol users.

(2006)

…

Health in prisons

A WHO guide to the essentials in prison health

Part III. Emerging Issues

The problem of implementation

Comprehensive Approach Needed

Harm reduction as an integral part of a

comprehensive social and health approach

Prison health is Public health! Building strong links with community health care services

Benefits of HR, prevention and treatment also for the institutions of CJS and staff

Building bridges and links between all actors Targeting both prison reform and health reform Clear targets and quantifiable output indicators, regular assess-ment of achieving goals

Throughcare is the main orientation

Overcoming barriers in implementing Prevention, HR, and Treatment

Go on publishing and making available information on best practices.

Promote exchange of knowledge and

experience among scientists, politicians, and practitioners

Networking on regional, national and international level

Identifying champions Visit champions

Political action

Involve all CJS-members

Methadone Maintenance Treatments in Prisons in England

0 5.000 10.000 15.000 20.000 25.000 30.000 35.000 40.000 45.000

2004 2005 2006 2007 2008 2009 2010 2011

Year

Number of prisoners treated

(Marteau/Stöver 2009)

„... Prisoners are the community. They come from the community, they return to it. Protection

of prisoners is protection of our communities “

(Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons)

hstoever@fb4.fh-frankfurt.de www.archido.de

Part IV. Emerging Issues

Opioid Substitution Treatment

Opioid substitution treatment

… also works in prisons!

OST most effective treatment for opioid dependence

OST reduces:

- level of injecting

- transmission of blood-borne viruses

- drug-related prison violence and crime following release

- recidivism

Emerging issues of OST in prisons – 1

Time lag of 10–15 years for integration of OST into prison medicine

Imprisonment is very likely to result in discontinuation of OST provided in the community

In many countries OST is provided mostly as a means of detoxification

‘Treatment gap‘

Emerging issues of OST in prisons – 2

‘Re-toxification‘ in some countries

Switch of medication (e.g. buprenorphine to methadone)

Often inadequate dosages

Done too fast, poor communication with patients Coverage poor and patchy: on the average 30%

in the community, but what about prisons?

OST in prisons

OST in prisons

- reduces withdrawal symptoms on admission

- restricts drug trade

- increases manageability of inmates

- has positive effects on institutional behaviour

- helps reduce risk of overdose upon release

- facilitates post-release treatment

- decreases re-incarceration

Continued OST in prison has a beneficial impact on transferring prisoners into drug treatment

after release.

OST and drug-related crime in prison – recent survey results

Physical violence - among prisoners

- between prisoners and guards

seen to have declined by majority of staff.

Psychological violence - among prisoners

- between prisoners and guards

seen to have declined by one third of staff.

Suicide and suicide attempts seen to have declined by one third of respondents.

Less illicit drug use in prison indicated by 42% of the staff.

Decline in intravenous drug use indicated by half of the staff.

Substitution coverage rate in prisons

No substitution treatment in prisons in three

countries: Czech Republic, Greece and Sweden

< 10% Poland (0.3%), Finland (1.5%), Germany (3.5%)

< 15% Italy (12%), Portugal (10–17%), France, Scotland (14%)

< 55% Slovenia (32%), Austria (33%), Ireland (46%), Belgium (50%), Denmark (55%)

> 55% Spain 82% (21,600 from 26,400)

~ 120,000 problematic drug users in prisons - ~ 30,000 receive ST (25%)

Emerging issues of OST in prisons – 2

‘Re-toxification‘ in some countries

Switch of medication (e.g. buprenorphine to methadone)

Often inadequate dosages

Done too fast, poor communication with patients Coverage poor and patchy: on the average 30%

in the community, but what about prisons?

Conclusions

Prisons must recognise consensus on the role and efficacy of OST and other evidence-

measured interventions – equivalence principle Close connection between prison and

community health care services

Health care standards and clear guidelines on the basis of evidence-based knowledge

Prison health can substantially contribute to crime reduction.