Harm reduction
It comes as no surprise to health care workers that sharing syringes and injection paraphernalia increases the risk of HIV/hepatitis C seroconversion. There is a plethora of evidence available that supports the use of needle exchange programs to reduce the incidence of bloodborne disease in a community. Wherever they are implemented, these programs are safe, efficacious, and cost-effective.[1] There is no controversy about this in the 90 countries around the world that have needle exchange programs, including Canada. Evidence shows that these work: A global survey found that “in cities with needle exchange or distribution programs the HIV incidence rate decreased by 5.8% annually. In cities without such programs, HIV incidence increased by 5.9% annually.”[2]

However, one subject that is still controversial is whether to implement needle exchange programs in at-risk prison populations. With the absence of harm reduction options inside Canadian prisons, incarcerated individuals under government care are at greater risk of seroconverting than the nonincarcerated population. Further, someone who seroconverts inside prison, if left undiagnosed and untreated, could potentially pass the virus onto others in the community when they complete their sentence.

Prison health
In Canada, HIV and hepatitis C rates in prison are, respectively, 10 and 30 to 39 times higher than in the general population. In a study of Canadian male prisoners, four out of five federally sentenced prisoners were identified as having a substance-use disorder, two out of three were under the influence of substances while committing the offences they were imprisoned for, and one out of six reported injecting drugs in prison over the previous 6 months.[3]

There are several factors contributing to the significantly higher risk of prisoners contracting or transmitting HIV, hepatitis C, STIs, TB, and MRSA. One critical factor is the lack of harm reduction supplies such as sterile syringes.[4] Injection materials are often shared multiple times over months and years, being repaired and reinforced with rubber bands and resharpened until they are mechanically unusable. Syringe sharing is a preventable cause of bloodborne pathogen transmission inside prisons and preventing such sharing would result in significant cost savings to the health care system. New occurrences of hepatitis C are expected to cost over $60 000 to treat[5] and new occurrences of HIV are estimated to cost around $250 000 in medical treatment over an average patient’s lifetime.[6]

Another factor is the high mobility between prisons and the communities that prisoners return to, with rapid turnover within provincial prisons as prisoners cycle in and out or are granted temporary absences. The result is that many prison-acquired bloodborne diseases go undiagnosed and untreated. When a prisoner is released from jail, prison health issues necessarily become community health issues.[7]

Prison needle exchange programs 
Under the UN’s International Bill of Human Rights, which has been signed and ratified by the Canadian government, there is a clear case for implementing prison needle exchange programs (PNEPs) in Canada. According to the bill, prisoners maintain all rights except those that are explicitly removed by incarceration, such as freedom of movement. Incarcerated populations maintain the right to the highest standard of care and the prohibition of cruel or torturous punishment. As bloodborne disease prevention and needle exchange programs are part of the highest standard of care, it can be argued that it is the government’s obligation to provide this care to prisoners.

Additionally, in Canada, the Corrections and Conditional Release Act guarantees prisoners a standard of health services equivalent to that provided to the general community, which includes adequate bloodborne disease prevention measures such as sterile needles. There have also been arguments put forth that Sections 7, 12, and 15 of the Canadian Charter of Rights and Freedoms serve as a legal basis on which to seek a pilot project of PNEPs.[2] The Canadian government is legally bound to respect, protect, and fulfill guaranteed rights, including the right to the highest attainable standard of health.

As of June 2016, almost 250 organizations had signed a declaration with the Canadian HIV/AIDS Legal Network to immediately implement prison needle exchanges in Canada,[8,9] but that call went unanswered by the Canadian government. A lawsuit was filed in September 2012 against the government of Canada’s refusal to implement adequate harm reduction services in prisons, as a constitutional challenge. Years later, but just a week before mediation talks were about to commence, the government abruptly withdrew from the talks, in effect further delaying the much-needed implementation of evidence-based harm reduction services in prisons.[10]

As part of my research, I attended the HR17 conference on harm reduction in Montreal and listened to talks about prison-based harm reduction. During the Lancet Panel on HIV and Related Infections in Prisons, there was a discussion about the major barriers to implementing a prison needle exchange program. The major arguments against PNEPs that were addressed can be divided into the following three categories.

1. Concern: If we provide syringes to prisoners, they will be used as weapons.  
Response: Among all the prison needle exchanges that operate globally, there are no reported incidents of syringes being used as weapons.[2,11,12] In fact, needlestick injuries often decrease after implementing a PNEP because there is a lack of hidden contraband syringes. In most prison needle exchange models, if a syringe is hidden, a prisoner will receive a disciplinary charge, but they will not when the syringe is out in the open. Having syringes in plain sight reduces the chance of accidental needlestick injuries during cell inspections or prisoner body searches, which means PNEPs are in the best interest of prison workers as well.

2. Concern: If we provide syringes, it may increase the number of prisoners using drugs, or could cause them to start using drugs while in prison. 
Response: There is no evidence to suggest that the availability of sterile syringes in prisons leads to more injection drug use.[2,11,12] Syringes are already available in prison; however, they are nonsterile and frequently shared.

3. Concern: If we provide sterile needles in prison, we are admitting there is a security and screening failure, and that drugs are prevalent in prison.
Response: There is already bleach being offered to prisoners to attempt to disinfect syringes; although, this method is not fully effective in eliminating the risk of transmission and instruction on the effective use of bleach is not routinely shared. There are also voluntary drug-free prison wings inside some prisons. This is an admission that drugs are in every other wing in the prison, and that the influx of drugs into prisons cannot be adequately controlled. 

It is also notable that the inertia in implementing PNEPs in Canada can sometimes be attributed to the strong prison-workers’ unions that are against these projects. This may be alleviated in part through collaboration with these unions, with concerns and barriers being addressed by looking to the reviews of other PNEPs implemented globally. There are many examples of PNEPs operating successfully. 

There is an old maxim, attributed to American journalist H.L. Mencken: “For every complex problem there is a solution that is simple, neat, and wrong.” It serves as a warning to those who may mistakenly think that making a single change to a multifactorial problem will remedy all that ails the system. Implementing PNEPs will not cure all the related harms of intravenous drug use in the prison setting, but it is a humane, ethical, and critical part of the solution. 

The question we must ask is not if they will work, but how they will work. Different prisons have different cultures, populations, and needs, and each requires a solution that considers multiple factors and caters to them specifically. This solution will require working with prisoners, advocates, correctional staff, and policymakers to address the specific needs in each location. Ina Tcaci, coordinator of UNODC Project Moldova, said during her talk at HR17 that:

You must negotiate with the inmates themselves to understand how these programs can be implemented, how they will be used by them, what they need and want. You cannot simply adapt a community needle exchange to operate inside a prison. Each prison will be different, and each population must be considered.[13]

PNEP models
Four models of PNEPs have proven successful around the world, organized here by syringe-distribution method:

- Distribution by private dispensing machines.
- Distribution by peer workers.
- Distribution by nongovernmental organizations or external personnel.
- Distribution by prison health services.[6]

These examples represent what is possible—a jumping-off point for a pilot project—but we must remain flexible and open to modifying a program if it does not address the needs of, or is not being accessed by, the population that it serves.

Call to action 
Change is not easy, especially in large institutions. Change on this scale requires the metaphorical aligning of planets between the needs of the incarcerated, public opinion, political powers, and an army of change-makers and leaders inside the system and outside the gates. Our collective voices matter, and speaking up matters. The evidence has long been established yet there has not been aggressive change. A conversation needs to take place among health professionals and in the greater public arena to bring PNEPs into reality. In 2006 Ralf Jürgens and Glenn Betteridge[2] wrote:

In many countries, including Canada, there has been lack of political leadership and political will to provide prisoners with the means to protect their health. Increasing the quantity of the same type of existing research is unlikely to lead to an increase in the likelihood of PNEP implementation . . . [as] the evidence strongly suggests that countless people have become infected with HIV as a result of sharing injection equipment in prison, even though the means to prevent many of those infections are available and have been proven to be feasible and effective. This represents not only a human tragedy, but also a gross infringement by governments of prisoners’ rights to the highest attainable standard of physical and mental health.

We need to stand united, as health care workers and Canadians, and demand implementation of evidence-based medicine to combat the increasing prevalence of bloodborne disease in prisons. PNEPs are necessary to alleviate needless suffering of incarcerated populations and stop preventable transmission of bloodborne diseases inside prisons and in the greater community.

Acknowledgments
I would like to acknowledge Dr Ruth Elwood Martin for being a supportive and knowledgeable mentor and supervisor as well as Dr Jane Buxton, Mr Blake Stitilis, and Ms Ciara Morgan-Feir for their thoughtful comments and edits.

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This article has been peer reviewed.

References

1. Wodak A, Cooney A. Effectiveness of sterile needle and syringe programmes. Int J Drug Policy 2005;16:31-44.

2. Lines R, Jürgens R, Betterridge G, et al. Prison needle exchange: Lessons from a comprehensive review of international evidence and experience. 2006. Accessed 23 October 2017. www.aidslaw.ca/site/wp-content/uploads/2013/04/PNEP-ENG.pdf [9].

3. Canadian HIV/AIDS Legal Network. On point: Recommendations for prison-based needle and syringe programs in Canada. 2016. Accessed 1 April 2017. www.aidslaw.ca/site/on-point-recommendations-for-prison-based-needle-and... [10].

4. World Health Organization, Regional Office for Europe. Prisons and health. Accessed 13 March 2017. www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf [11].

5. Webster PC. Prison puzzle: Treating hepatitis C. CMAJ 2012;184:1017-1018.

6. Kingston-Riechers J. The economic cost of HIV/AIDS in Canada. Accessed 24 October 2017. www.cdnaids.ca/wp-content/uploads/Economic-Cost-of-HIV-AIDS-in-Canada.pdf [12].

7. Ontario Medical Association. Improving our health: Why is Canada lagging behind in establishing needle exchange programs in prisons? 2004. Accessed 1 March 2017. www.iprt.ie/files/oma_pnep_doc.pdf.  [13]

8. Canadian HIV/AIDS Legal Network. Nearly 250 organizations across Canada call for prison-based needle and syringe programs. 2016. Accessed 1 April 2017. www.aidslaw.ca/site/nearly-250-organizations/?lang=en.  [14]

9. Canadian HIV/AIDS Legal Network. Canada can’t wait: The time for prison-based needle and syringe programs is now. 2016. Accessed 1 April 2017. www.aidslaw.ca/site/canada-cant-wait/?lang=en [15].

10. Canadian HIV/AIDS Legal Network. Government walks away from talks on critical harm reduction measure in Canadian prisons. 2017. Accessed 1 February 2017. www.aidslaw.ca/site/government-walks-away-from-talks-on-critical-harm-re... [16]

11. Stöver H, Nelles J. Ten years of experience with needle and syringe exchange programmes in European prisons. Int J Drug Policy 2003;14:437-444.

12. Dolan K, Rutter S, Wodak AD. Prison-based syringe exchange programmes: A review of international research and development. Addiction 2003;98:153-158.

13. Tcaci I. The impact of adopting evidence-based HIV harm reduction programs in prisons. Presented at the Harm Reduction International Conference, Montreal, QC, 14-17 May 2017.

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Mr Danroth is part of the UBC MD class of 2020. He holds a BSc in molecular biology and biochemistry from SFU (2016), and has research interests in HIV, prison health, substance use, and harm reduction.