Prison's second death row

Abstract

Needle sharing has spread HIV through prisons worldwide. But prevention programmes that supply clean needles to drugs users are shunned by most institutions. Rachael Davies asks why.“A sentence of imprisonment should not carry with it a sentence of AIDS”. This phrase, often quoted by advocates for controlling HIV/AIDS in prisons, describes a right to health that most people take for granted. But in many countries—including those classed as most developed—it is, sadly, far from the truth.Prisoners contract HIV at a significantly higher rate than the general population. In parts of Europe and the USA, up to 20% of inmates are HIV-positive. The virus is most commonly transmitted through the needles addicts use to inject drugs, but most strategies for dealing with HIV in prisons focus on a zero-tolerance approach to drug users. Rocketing infection rates confirm that this approach doesn't work, but governments are surprisingly reluctant to endorse alternative strategies.Drugs and prisonPeople who inject drugs are at far greater risk of contracting HIV than are other drug users and the general population. And, as a result of their habit, these people make up a large proportion of the prison population.Although prison tends to curb the frequency of injecting, the difficulty of smuggling needles and syringes into penal institutions means that “the few syringes available are shared among several people and are frequently traded”, says Gerry Stimson, executive director of the International Harm Reduction Association.Diseases such as HIV are known to spread rapidly though communities of injecting drug users. Ralf Jürgens, executive director of the Canadian HIV/AIDS Legal Network, a research and policy group examining the legal and ethical issues realted to HIV/AIDS, emphasises that prisoners often have no option but to subject themselves to the risk of HIV infection. But he says they do want safe options. “Drug users in fact do care about their health”, he explains.The response of authorities to the HIV-infection crisis has often been to ignore the situation, rather than be seen to condone criminal activities such as use of illegal drugs. However, there is a wealth of evidence that shows prison epidemics can be prevented, stabilised, and even reversed, by use of simple and cost-effective harm-reduction strategies, such as needle-exchange programmes (NEPs).Clean needles neededMaking sterile injecting equipment available through NEPs is viewed by some as the most effective HIV-prevention intervention for injecting drug users. These programmes, which suffered intense criticism early on, have been shown to be effective and viable for controlling HIV spread, and do not impede the safety or effectiveness of drug-prevention policies. Furthermore, NEPs are inexpensive to operate; such programmes have been successfully implemented in prisons in low-income countries such as Moldova and Kyrgystan.Critics claim that NEPs could promote the use of needles as weapons. However, in surveys on the topic, prisoners consistently emphasise that there are many other things available to them to use as weapons and, more importantly, they see the value of having clean needles available to protect their own health. “They don't want to risk the programmes being closed”, comments Jürgens.In light of all this evidence, why haven't NEPs been implemented in more prisons? According to Jürgens, “there is not a lot of sympathy for prisoners”. He believes there is no political will to improve prisoners' lives and, because most people are unaware of the extent of the HIV/AIDS problem in prisons, there is little recognition of the potentially disastrous consequences for public health.In the mid 1980s, NEPs were approved for drug users in the general population (excluding prisons) by Europe, Australia, and Canada. However such programmes were fiercely opposed in the USA, which continues to view this method of harm reduction as condoning drug use.According to Stimson, drugs policy has been over politicised in the USA, both among minority groups who view NEPs as a white conspiracy and by groups on the political right as “pandering to drug use”.All 50 US states have laws regulating the possession and distribution of sterile syringes as “drug paraphernalia”. The National Institute of Drug Abuse is still forbidden to do any research on needle exchange. But in 2002, injecting drug users accounted for 28% of new AIDS cases.Since the 1970s, the USA has spent billions on law enforcement and imprisonment, in a largely futile effort to stem the influx and use of drugs. This zero-tolerance response to drug use is typified by the allocation of expenditures in the National Drug Control Budget—of US$12 billion, more than 60% ($7·2 billion) has been assigned to law enforcement, prohibition, and supply reduction.Even now, NEPs are not politically popular because they symbolise a failure to keep prisons drug-free. As a result, most people in US prisons have no access to HIV-prevention services.Looking to EuropeBy contrast, many parts of Europe focus on harm-reduction strategies with an emphasis on the health and human rights. Needle-exchange and community distribution programmes have become a vital part of the public-health response to HIV transmission among drug users. Several community-based studies have shown these programmes to be cost-effective and a viable preventive strategy.However, the lack of interest in prisoners and drug use has meant that the response within prisons has been inadequate—consisting mainly of educational programmes, segregation of prisoners with HIV/AIDS, and methadone maintenance treatment.Prison staff in particular are often opposed to NEPs because they have not witnessed the benefits of distributing clean needles. However, Jürgens believes these barriers can be overcome. “When such programmes were intro duced in Europe, the staff were initially opposed, but they understood quite quickly the importance of these measures”, he says.Importantly, some penal institutions around the world have proven that NEPs can work. Switzerland has been distributing sterile injection equipment since 1992. And, as of 2004, NEPs had been introduced in 50 prisons in Switzerland, Germany, Spain, Moldova, Kyrgystan, and Belarus. These measures have decreased rates of drug use, syringe sharing, and HIV transmission. Needles have not been used as weapons, and there has been no recorded increase in drug use.Unfortunately, however, these countries constitute only a tiny proportion of the worldwide prison population; most prisons do not have harm-reduction strategies and HIV-infection rates remain consistently high. Particularly high rates have been reported in Spain (16·6%) and in Portugal (20%). In Eastern Europe, 7% of Ukrainian prisoners, and 15% of those in Lithuania, are reported to be HIV- positive; in South Africa the rate is 41%. In some areas of the USA, HIV infection rates are over 20%.International supportUNAIDS and WHO have pledged support for NEPs in prisons in countries where similar programmes operate in the community. But these endorsements have done little to affect adoption of NEPs in countries that disagree with them. WHO and UNAIDS produced guidelines in 1987 (and revised them in 1993) to provide technical recommendations for the management and prevention of HIV infection in prisons, including the availability of prevention measures and access to treatment equivalent to that in the community.Jürgens says it is now time to revise these recommendations to promote successful studies done with NEPs. “The 1993 guidelines are generally very good, but they are now over 10 years old”, he says. “Countries that have been successful should get presented as best practice”, he adds.More importantly, NEPs need to be promoted by all the UN agencies—especially WHO, United Nations Office in Drugs and Crime, and UNAIDS, says Jürgens. He believes initiatives such as WHO's “3 by 5” should contain an HIV in prisons component and that the Global Fund for AIDS, Tuberculosis, and Malaria should take the needs of the prison system into account.According to Jürgens, tackling HIV in prisons needs a comprehensive strategy. “It is important to understand the promises and limits of treatment for drug use” as well as understanding that “NEPs are crucial but alone will not solve the problem”, he says. Prisons systems that have achieved the most success in preventing the transmission of HIV have developed and promoted harm-reduction and treatment strategies together—making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available.A right to healthExperts agree that future efforts to control HIV in prisons must involve directing scarce resources to known effective treatment interventions for users of injection drugs, and making sure that prison workers facilitate these efforts. “Getting prison staff on-side and prison resources is a crucial public-health issue”, says Stimson. But political support is crucial.On Feb 23, 2004, the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia was launched. It states: “Under national and international law, governments have a moral and ethical obligation to prevent the spread of HIV/AIDS in prison.”People in prison have an equivalent right to health to their free counterparts. This includes preventive measures to protect themselves from HIV. Most people who are sent to prison return to the community and are therefore a potential source of infection for the general population. “Unless we prevent HIV infection in prisons this will have big consequences for the health of everyone”, Jürgens warns. Needle sharing has spread HIV through prisons worldwide. But prevention programmes that supply clean needles to drugs users are shunned by most institutions. Rachael Davies asks why. “A sentence of imprisonment should not carry with it a sentence of AIDS”. This phrase, often quoted by advocates for controlling HIV/AIDS in prisons, describes a right to health that most people take for granted. But in many countries—including those classed as most developed—it is, sadly, far from the truth. Prisoners contract HIV at a significantly higher rate than the general population. In parts of Europe and the USA, up to 20% of inmates are HIV-positive. The virus is most commonly transmitted through the needles addicts use to inject drugs, but most strategies for dealing with HIV in prisons focus on a zero-tolerance approach to drug users. Rocketing infection rates confirm that this approach doesn't work, but governments are surprisingly reluctant to endorse alternative strategies. Drugs and prisonPeople who inject drugs are at far greater risk of contracting HIV than are other drug users and the general population. And, as a result of their habit, these people make up a large proportion of the prison population.Although prison tends to curb the frequency of injecting, the difficulty of smuggling needles and syringes into penal institutions means that “the few syringes available are shared among several people and are frequently traded”, says Gerry Stimson, executive director of the International Harm Reduction Association.Diseases such as HIV are known to spread rapidly though communities of injecting drug users. Ralf Jürgens, executive director of the Canadian HIV/AIDS Legal Network, a research and policy group examining the legal and ethical issues realted to HIV/AIDS, emphasises that prisoners often have no option but to subject themselves to the risk of HIV infection. But he says they do want safe options. “Drug users in fact do care about their health”, he explains.The response of authorities to the HIV-infection crisis has often been to ignore the situation, rather than be seen to condone criminal activities such as use of illegal drugs. However, there is a wealth of evidence that shows prison epidemics can be prevented, stabilised, and even reversed, by use of simple and cost-effective harm-reduction strategies, such as needle-exchange programmes (NEPs). People who inject drugs are at far greater risk of contracting HIV than are other drug users and the general population. And, as a result of their habit, these people make up a large proportion of the prison population. Although prison tends to curb the frequency of injecting, the difficulty of smuggling needles and syringes into penal institutions means that “the few syringes available are shared among several people and are frequently traded”, says Gerry Stimson, executive director of the International Harm Reduction Association. Diseases such as HIV are known to spread rapidly though communities of injecting drug users. Ralf Jürgens, executive director of the Canadian HIV/AIDS Legal Network, a research and policy group examining the legal and ethical issues realted to HIV/AIDS, emphasises that prisoners often have no option but to subject themselves to the risk of HIV infection. But he says they do want safe options. “Drug users in fact do care about their health”, he explains. The response of authorities to the HIV-infection crisis has often been to ignore the situation, rather than be seen to condone criminal activities such as use of illegal drugs. However, there is a wealth of evidence that shows prison epidemics can be prevented, stabilised, and even reversed, by use of simple and cost-effective harm-reduction strategies, such as needle-exchange programmes (NEPs). Clean needles neededMaking sterile injecting equipment available through NEPs is viewed by some as the most effective HIV-prevention intervention for injecting drug users. These programmes, which suffered intense criticism early on, have been shown to be effective and viable for controlling HIV spread, and do not impede the safety or effectiveness of drug-prevention policies. Furthermore, NEPs are inexpensive to operate; such programmes have been successfully implemented in prisons in low-income countries such as Moldova and Kyrgystan.Critics claim that NEPs could promote the use of needles as weapons. However, in surveys on the topic, prisoners consistently emphasise that there are many other things available to them to use as weapons and, more importantly, they see the value of having clean needles available to protect their own health. “They don't want to risk the programmes being closed”, comments Jürgens.In light of all this evidence, why haven't NEPs been implemented in more prisons? According to Jürgens, “there is not a lot of sympathy for prisoners”. He believes there is no political will to improve prisoners' lives and, because most people are unaware of the extent of the HIV/AIDS problem in prisons, there is little recognition of the potentially disastrous consequences for public health.In the mid 1980s, NEPs were approved for drug users in the general population (excluding prisons) by Europe, Australia, and Canada. However such programmes were fiercely opposed in the USA, which continues to view this method of harm reduction as condoning drug use.According to Stimson, drugs policy has been over politicised in the USA, both among minority groups who view NEPs as a white conspiracy and by groups on the political right as “pandering to drug use”.All 50 US states have laws regulating the possession and distribution of sterile syringes as “drug paraphernalia”. The National Institute of Drug Abuse is still forbidden to do any research on needle exchange. But in 2002, injecting drug users accounted for 28% of new AIDS cases.Since the 1970s, the USA has spent billions on law enforcement and imprisonment, in a largely futile effort to stem the influx and use of drugs. This zero-tolerance response to drug use is typified by the allocation of expenditures in the National Drug Control Budget—of US$12 billion, more than 60% ($7·2 billion) has been assigned to law enforcement, prohibition, and supply reduction.Even now, NEPs are not politically popular because they symbolise a failure to keep prisons drug-free. As a result, most people in US prisons have no access to HIV-prevention services. Making sterile injecting equipment available through NEPs is viewed by some as the most effective HIV-prevention intervention for injecting drug users. These programmes, which suffered intense criticism early on, have been shown to be effective and viable for controlling HIV spread, and do not impede the safety or effectiveness of drug-prevention policies. Furthermore, NEPs are inexpensive to operate; such programmes have been successfully implemented in prisons in low-income countries such as Moldova and Kyrgystan. Critics claim that NEPs could promote the use of needles as weapons. However, in surveys on the topic, prisoners consistently emphasise that there are many other things available to them to use as weapons and, more importantly, they see the value of having clean needles available to protect their own health. “They don't want to risk the programmes being closed”, comments Jürgens. In light of all this evidence, why haven't NEPs been implemented in more prisons? According to Jürgens, “there is not a lot of sympathy for prisoners”. He believes there is no political will to improve prisoners' lives and, because most people are unaware of the extent of the HIV/AIDS problem in prisons, there is little recognition of the potentially disastrous consequences for public health. In the mid 1980s, NEPs were approved for drug users in the general population (excluding prisons) by Europe, Australia, and Canada. However such programmes were fiercely opposed in the USA, which continues to view this method of harm reduction as condoning drug use. According to Stimson, drugs policy has been over politicised in the USA, both among minority groups who view NEPs as a white conspiracy and by groups on the political right as “pandering to drug use”. All 50 US states have laws regulating the possession and distribution of sterile syringes as “drug paraphernalia”. The National Institute of Drug Abuse is still forbidden to do any research on needle exchange. But in 2002, injecting drug users accounted for 28% of new AIDS cases. Since the 1970s, the USA has spent billions on law enforcement and imprisonment, in a largely futile effort to stem the influx and use of drugs. This zero-tolerance response to drug use is typified by the allocation of expenditures in the National Drug Control Budget—of US$12 billion, more than 60% ($7·2 billion) has been assigned to law enforcement, prohibition, and supply reduction. Even now, NEPs are not politically popular because they symbolise a failure to keep prisons drug-free. As a result, most people in US prisons have no access to HIV-prevention services. Looking to EuropeBy contrast, many parts of Europe focus on harm-reduction strategies with an emphasis on the health and human rights. Needle-exchange and community distribution programmes have become a vital part of the public-health response to HIV transmission among drug users. Several community-based studies have shown these programmes to be cost-effective and a viable preventive strategy.However, the lack of interest in prisoners and drug use has meant that the response within prisons has been inadequate—consisting mainly of educational programmes, segregation of prisoners with HIV/AIDS, and methadone maintenance treatment.Prison staff in particular are often opposed to NEPs because they have not witnessed the benefits of distributing clean needles. However, Jürgens believes these barriers can be overcome. “When such programmes were intro duced in Europe, the staff were initially opposed, but they understood quite quickly the importance of these measures”, he says.Importantly, some penal institutions around the world have proven that NEPs can work. Switzerland has been distributing sterile injection equipment since 1992. And, as of 2004, NEPs had been introduced in 50 prisons in Switzerland, Germany, Spain, Moldova, Kyrgystan, and Belarus. These measures have decreased rates of drug use, syringe sharing, and HIV transmission. Needles have not been used as weapons, and there has been no recorded increase in drug use.Unfortunately, however, these countries constitute only a tiny proportion of the worldwide prison population; most prisons do not have harm-reduction strategies and HIV-infection rates remain consistently high. Particularly high rates have been reported in Spain (16·6%) and in Portugal (20%). In Eastern Europe, 7% of Ukrainian prisoners, and 15% of those in Lithuania, are reported to be HIV- positive; in South Africa the rate is 41%. In some areas of the USA, HIV infection rates are over 20%. By contrast, many parts of Europe focus on harm-reduction strategies with an emphasis on the health and human rights. Needle-exchange and community distribution programmes have become a vital part of the public-health response to HIV transmission among drug users. Several community-based studies have shown these programmes to be cost-effective and a viable preventive strategy. However, the lack of interest in prisoners and drug use has meant that the response within prisons has been inadequate—consisting mainly of educational programmes, segregation of prisoners with HIV/AIDS, and methadone maintenance treatment. Prison staff in particular are often opposed to NEPs because they have not witnessed the benefits of distributing clean needles. However, Jürgens believes these barriers can be overcome. “When such programmes were intro duced in Europe, the staff were initially opposed, but they understood quite quickly the importance of these measures”, he says. Importantly, some penal institutions around the world have proven that NEPs can work. Switzerland has been distributing sterile injection equipment since 1992. And, as of 2004, NEPs had been introduced in 50 prisons in Switzerland, Germany, Spain, Moldova, Kyrgystan, and Belarus. These measures have decreased rates of drug use, syringe sharing, and HIV transmission. Needles have not been used as weapons, and there has been no recorded increase in drug use. Unfortunately, however, these countries constitute only a tiny proportion of the worldwide prison population; most prisons do not have harm-reduction strategies and HIV-infection rates remain consistently high. Particularly high rates have been reported in Spain (16·6%) and in Portugal (20%). In Eastern Europe, 7% of Ukrainian prisoners, and 15% of those in Lithuania, are reported to be HIV- positive; in South Africa the rate is 41%. In some areas of the USA, HIV infection rates are over 20%. International supportUNAIDS and WHO have pledged support for NEPs in prisons in countries where similar programmes operate in the community. But these endorsements have done little to affect adoption of NEPs in countries that disagree with them. WHO and UNAIDS produced guidelines in 1987 (and revised them in 1993) to provide technical recommendations for the management and prevention of HIV infection in prisons, including the availability of prevention measures and access to treatment equivalent to that in the community.Jürgens says it is now time to revise these recommendations to promote successful studies done with NEPs. “The 1993 guidelines are generally very good, but they are now over 10 years old”, he says. “Countries that have been successful should get presented as best practice”, he adds.More importantly, NEPs need to be promoted by all the UN agencies—especially WHO, United Nations Office in Drugs and Crime, and UNAIDS, says Jürgens. He believes initiatives such as WHO's “3 by 5” should contain an HIV in prisons component and that the Global Fund for AIDS, Tuberculosis, and Malaria should take the needs of the prison system into account.According to Jürgens, tackling HIV in prisons needs a comprehensive strategy. “It is important to understand the promises and limits of treatment for drug use” as well as understanding that “NEPs are crucial but alone will not solve the problem”, he says. Prisons systems that have achieved the most success in preventing the transmission of HIV have developed and promoted harm-reduction and treatment strategies together—making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available. UNAIDS and WHO have pledged support for NEPs in prisons in countries where similar programmes operate in the community. But these endorsements have done little to affect adoption of NEPs in countries that disagree with them. WHO and UNAIDS produced guidelines in 1987 (and revised them in 1993) to provide technical recommendations for the management and prevention of HIV infection in prisons, including the availability of prevention measures and access to treatment equivalent to that in the community. Jürgens says it is now time to revise these recommendations to promote successful studies done with NEPs. “The 1993 guidelines are generally very good, but they are now over 10 years old”, he says. “Countries that have been successful should get presented as best practice”, he adds. More importantly, NEPs need to be promoted by all the UN agencies—especially WHO, United Nations Office in Drugs and Crime, and UNAIDS, says Jürgens. He believes initiatives such as WHO's “3 by 5” should contain an HIV in prisons component and that the Global Fund for AIDS, Tuberculosis, and Malaria should take the needs of the prison system into account. According to Jürgens, tackling HIV in prisons needs a comprehensive strategy. “It is important to understand the promises and limits of treatment for drug use” as well as understanding that “NEPs are crucial but alone will not solve the problem”, he says. Prisons systems that have achieved the most success in preventing the transmission of HIV have developed and promoted harm-reduction and treatment strategies together—making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available. A right to healthExperts agree that future efforts to control HIV in prisons must involve directing scarce resources to known effective treatment interventions for users of injection drugs, and making sure that prison workers facilitate these efforts. “Getting prison staff on-side and prison resources is a crucial public-health issue”, says Stimson. But political support is crucial.On Feb 23, 2004, the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia was launched. It states: “Under national and international law, governments have a moral and ethical obligation to prevent the spread of HIV/AIDS in prison.”People in prison have an equivalent right to health to their free counterparts. This includes preventive measures to protect themselves from HIV. Most people who are sent to prison return to the community and are therefore a potential source of infection for the general population. “Unless we prevent HIV infection in prisons this will have big consequences for the health of everyone”, Jürgens warns. Experts agree that future efforts to control HIV in prisons must involve directing scarce resources to known effective treatment interventions for users of injection drugs, and making sure that prison workers facilitate these efforts. “Getting prison staff on-side and prison resources is a crucial public-health issue”, says Stimson. But political support is crucial. On Feb 23, 2004, the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia was launched. It states: “Under national and international law, governments have a moral and ethical obligation to prevent the spread of HIV/AIDS in prison.” People in prison have an equivalent right to health to their free counterparts. This includes preventive measures to protect themselves from HIV. Most people who are sent to prison return to the community and are therefore a potential source of infection for the general population. “Unless we prevent HIV infection in prisons this will have big consequences for the health of everyone”, Jürgens warns.