The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases

Abstract

Background:
People who inject drugs are often imprisoned which is associated with increased levels of health risks including overdose and infectious diseases affecting the prison population and the community where they return to. Information about responses to this in prisons is limited and heterogeneous in Europe. The paper aims to give a comprehensive, up-to-date overview of the availability, coverage and policy framework of prison-based harm reduction interventions.
Methods:
Systematic review of international agencies’ data sources and data collection were conducted in 2018 followed by a questionnaire survey in 30 European countries through the Reitox National Focal Points of the European Monitoring Centre for Drugs and Drug Addiction.
Results:
Opioid substitution treatment (OST) is available in 29 countries, but coverage remains below 30% of people in need (low) in half of the countries. Needle and syringe programmes, bleach and lubricant distribution, counselling on safer injecting and tattooing/piercing are scarcely available (in 3/8/9/9/10 countries respectively), and often with low coverage. Testing of drug related infectious diseases (DRID) are provided however typically only upon entry, with a last year population coverage remaining low in about half of the countries. While DRID treatment is available, its coverage is mostly reported high for Human Immunodeficiency Virus (HIV) and Tuberculosis, but lower for Hepatitis B and C (HCV). Health education on DRID, HIV health promotion programmes, and condom distribution are usually provided but at low levels in nearly half of the countries. Post-release linkages to addiction, HIV and HCV care is available in 22/25/17 countries, but implementation is often partial. Other upon-release interventions as OST initiation, take-home naloxone, health education, DRID testing are rarely provided. Harm reduction in prison is addressed in national strategic documents in 21 countries while interventions upon release in only 12.
Conclusions:
Availability and coverage of harm reduction interventions in prisons is limited and delayed compared to community implementation in European countries. There is a critical gap between international recommendations, on-paper availability and the actual implementation of these interventions. Most people will return to the community, therefore interventions in prison and throughcare should be scaled up for individual and public health benefits.