Rick Lines, Excutive Director Irish Penal Reform Trust Dublin, Ireland Vanguard 2004 Confernence

Advocating for Harm Reduction in Prisons:

The Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia

Rick Lines, Excutive DirectorIrish Penal Reform Trust

Dublin, Ireland

Vanguard 2004 ConfernenceBegrade – 22 May 2004

www.penal-reform.ie 2

“What is Harm Reduction?”

Harm reduction is a pragmatic and non-judgemental approach to drug use and drug users that recognises that quitting drugs is neither realistic nor desirable for everyone.Harm reduction is client centred care. It is about meeting drug users where they are at, and seeing them as the experts on their health issues.Harm reduction prioritises the health of people who use drugs and offers a variety of options for decreasing the harms associated with drug use.Harm reduction recognises that there are different types of problems that result from illegal drugs. There are those that result from the negative effects of a drug on an individual’s health, and there are those that result from society’s efforts to eliminate drugs.


Harm Reduction Challenges Dominant

PolicyHarm reduction accepts the reality of drug use in society.Harm reduction does not necessarily seek to reduce the amount of drug use, but to reduce the negative consequences of drug use.Harm reduction seeks to reduce the harms to the individual and to society.Harm reduction recognises and values the human rights and the health expertise of drug users.


Barriers to Harm Reduction in PrisonsZero-tolerance/abstinence based approaches even more entrenchedSeen as admission of failureDiscrimination against prisonersCriminal laws and punishmentLack of legal frameworkStaff safety concerns/perception of danger


“Why Harm Reduction in Prisons?”

1. High rates of HIV and HCV seroprevalence are evident in in many prison systems internationally.


HIV & HCV in Prisons in CEE/FSU

UKRAINE – 7% of prisoners HIV positive

LATVIA – 20% of HIV infections – half of the new cases diagnosed each year – are found among prisoners.

POLAND – 20% of all people living with HIV/AIDS in the country have spent time in prison or pre-trial detention.

LITHUANIA – 284 prisoners (15% of the total prison population) were diagnosed HIV-positive between May and August 2002.

MOLDOVA – 210 known prisoners living with HIV/AIDS in Moldova prisons, which reflects an infection rate 100 times higher than in the general community (September 2002).

KYRGYZSTAN – 56% of all known HIV cases in the country were among prisoners (November 2002).

HEPATITIS C – Most international studies have found that 30—40% of prisoners are living with hepatitis C.



2. Injection drug use and the sharing of injecting equipment is widespread in many prisons systems across the world.


Injection Drug Use in Prison

RUSSIA – Oblast of Nizhni-Novgorod the authorities found that all of the 220 HIV positive prisoners had contracted HIV through intravenous drug use.

EU – 0.3—34% of the prisoners in the EU and Norway injected while incarcerated. 0.4—21% of IDUs started injecting in prison.

MEXICO – A study in two jails found rates of injection drug use of 37% and 24% respectively.

CANADA – 19% of women prisoners engaging in injection drug use while in prison. A 1998 study found that 24.3% of male prisoners reported using injection drugs in prison.

AUSTRALIA – 31—74% of IDUs reported injecting in prison. 60—91% reported sharing injection equipment in prison.



3. Harm reduction measures have been proven effective in reducing risk behaviour and HIV/HCV transmission, and are operating successfully in many countries.


Harm Reduction in Prisons:Condoms & Safer Sex

MeasuresWHO (1991) – 23 of 52 prison systems surveyed provided condoms to prisoners.CEE/FSU – Ukraine, Moldova, Estonia, Turkmenistan, some parts of Russian Federation provide condomsEU – 18 of 23 EU jurisdictions distributing condoms (August 2001)

CANADA – Condoms available in 11 of 14 jurisdictions


Harm Reduction in Prisons:Bleach & Disinfectants

UNAIDS (1997) – Full strength bleach provided to prisoners as a harm reduction tool in prisons in Europe, Australia, Africa, and Central America.CEE/FSU – Turkmenistan, Kyrgyzstan, Moldova, Uzbekistan (pilot), some parts of Russian Federation EU – Bleach provided in 11 of 23 EU prison systems (August 2001).CANADA – Available in over 20 British Columbia provincial prisons since 1992 and all 52 federal prisons across the country since 1996. Also available in some Quebec prisons.


Harm Reduction in Prisons:Syringe

Exchange/DistributionSwitzerland: First program 1992/93

Today – PSEP in 7 prisons

Germany: Pilots in 1996Today – PSEP in 1 prison (down from a high point of 7 prisons)

Spain: Pilot in 1997Today – PSEP approved for all 69 prisons, and programs operating in over 30 prisons

Moldova: Pilot in 1999Today – PSEP in 3 prisons

Kygyzstan: Pilot in 2002Today – PSEP in all 11 prisons

Belarus: Pilot in 2003Today – PSEP in 1 prison, and being extended into 2 more.


Harm Reduction in Prisons:Methadone/Substitution

TreatmentMethadone available in all EU jurisdictions except Greece, Sweden, and 2 Länder in Germany (Bavaria and Baden-Württemberg). Pilot test in one prison in Estonia.Available in most Canadian prisons and in Australia.Heroin prescription available in two Swiss prisons since 1995.



4. Numerous international instruments support prisoners’ rights to health care equivalent to that available outside prison, including preventive measures.


International Instruments“Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.”

UN Basic Principles for the Treatment of Prisoners

“All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination…with respect to their legal status.”

WHO Guidelines on HIV Infection and AIDS in Prisons

“With regard to effective HIV/AIDS prevention and care programmes, prisoners have a right to be provided the basic standard of medical care available in the community.” UNAIDS


Advocating for Policy Change

Zero-tolerance/criminalisation has failed Evidence-basedCost-effectivePromote legal, ethical, human rightsCollaborationBetween drug users and health professionalsBetween organizationsBetween countries



Prepared for release at the Dublin interministerial conference on HIV/AIDS 23—24 February 2004, attended by government representatives from 55 countries in Europe and Central AsiaDrafted by Rick Lines (Irish Penal Reform Trust, Dublin); Ralf Jürgens (Canadian HIV/AIDS Legal Network, Montreal); Dr. Heino Stöver (University of Bremen, Germany); Dr. Gulnara Kaliakbarova (Penal Reform International, Kazakhstan); Dr. Dumitru Laticevschi (Moldova); Dr. Joachim Nelles (Switzerland); Dr. Morag MacDonald (University of Central England in Birmingham, UK); Matt Curtis (International Harm Reduction Development Program of the Open Society Institute) Translated into English, Russian, German, French and Spanish



Purpose

This Declaration provides a framework for mounting an effective response to HIV/AIDS in the prisons of Europe and Central Asia. The Principles and Articles outlined herein are based upon recognised international best practice, scientific evidence, and the fundamental human rights of people in prison and the obligations of States to fulfil those rights.


Dublin Declaration:Statement of Fundamental PrinciplesPrinciple 1 – People in prison are part of our communities.Principle 2 – People in prison have a right to health.Principle 3 – Good prison health is good public health. Principle 4 – Protecting the health of prisoners, and reducing the transmission

of disease in prisons, also protects the health of prison staff

Principle 5 – Sex and injecting drug use occur in prison, and in many prisons are widespread.

Principle 6 – Harm reduction, rather than zero-tolerance, must be the pragmatic policy basis for fighting HIV/AIDS in prisons and in providing HIV/AIDS care.

Principle 7 – HIV/AIDS in prisons is a major problem in many countries, and States must act collectively and cooperatively in the fight against the epidemic.

Principle 8 – Action to fight Hepatitis C in prisons is as crucial as is action to fight HIV/AIDS, and must be integrated into all initiatives addressing HIV/AIDS prevention and treatment.


Dublin Declaration:Framework for Action

Article 1 – Prisoners have a right to protect themselves against HIV infection. Prisoners living with HIV/AIDS have a right to protect themselves from re-infection and/or co-infection with Hepatitis C and/or TB.

Article 2 – Prisoners living with HIV/AIDS have a right to maintain and promote their health.

Article 3 – Prisoners have a right to keep their HIV status confidential.

Article 4 – Prisoners have a right to informed consent in accessing HIV treatments and therapies, including the right to refuse treatment.

Article 5 – Prisoners have a right to access voluntary, confidential HIV testing, with pre- and post-test counselling. Prisoners have a right to informed consent before being tested for HIV infection, including the right to refuse testing.


Dublin Declaration:Framework for Action

Article 6 – Prisoners living with HIV/AIDS have a right to live free from stigma, discrimination, and violence.

Article 7 – Prisoners have a right to accurate, non-judgemental, and accessible education on HIV/AIDS.

Article 8 – Prison populations have a right to have their diversity acknowledged and respected in the design and provision of HIV/AIDS services.

Article 9 – Prisoners, prison staff, and non-governmental organisations should be consulted in the design and implementation of prison HIV/AIDS programmes.

Article 10 – Prisoners living with HIV/AIDS have a right to a continuity of post-release healthcare services.

Article 11 – Wealthier states have an obligation to assist and support less-wealthy states in providing HIV prevention and treatment options to prisoners.


Dublin Declaration:Current Status

Internationally released during the Dublin conference by CEEHRN, AFEW, AIDS Action Europe, GNP+, Canadian HIV/AIDS Legal Network and Irish Penal Reform TrustEndorsed by over 90 NGOs and HIV/harm reduction experts from over 20 countries – Belarus, Belgium, Bulgaria, Canada, the Czech Republic, France, Germany, Ireland, Italy, Kazakhstan, Lithuania, Luxembourg, Moldova, the Netherlands, Portugal, Romania, Russia, Slovak Republic, Spain, Switzerland, Turkey, Ukraine, the United Kingdom and the United States

We need more individuals and organisations to endorse the Declaration.

We need individuals and groups to take ownnership of the the Declaration and use it as a basis for advocacy in your own countries.


“Our lives begin to end the day we become silent about things that matter.”

Dr. Martin Luther King, Jr.


Contact Information

Rick [email protected]

Irish Penal Reform Trustwww.penal-reform.ie


SourcesSourcesCanadian HIV/AIDS Legal Network (2001/02) “Info Sheets on HIV/AIDS in Prisons”. Canadian HIV/AIDS Legal Network, Montreal.

Canadian HIV/AIDS Legal Network (1999) Injection Drug Use and HIV/AIDS: Legal and Ethical Issues. Canadian HIV/AIDS Legal Network, Montreal.

Central and Eastern Europe Harm Reduction Network (July 2002). Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union. Central and Eastern Europe Harm Reduction Network, Vilnius.

Dolan, K. (1999). The epidemiology of hepatitis C infection in prison populations. National Drug and Alcohol Research Centre, UNSW, at 12, with many references.

European Monitoring Centre on Drugs and Drug Addiction (2002). 2002 Annual Report on the State of the Drug Problem in the European Union and Norway. European Monitoring Centre on Drugs and Drug Addiction, Lisbon.

European Monitoring Centre on Drugs and Drug Addiction (2002) Classifications of Drug Treatment and Social Reintegration and their Availability in EU Member States plus Norway: Final Report. European Monitoring Centre on Drugs and Drug Addiction, Lisbon.

International Harm Reduction Development (2001). Drugs, AIDS, and Harm Reduction: How to Slow the HIV Epidemic in Eastern Europe and the Former Soviet Union. Open Society Institute, New York.

Joint United Nations Programme on HIV/AIDS (April 1997) Prisons and AIDS: UNAIDS technical update. Joint United Nations Programme on HIV/AIDS, Geneva.

Joint United Nations Programme on HIV/AIDS (April 1996). Statement on HIV/AIDS in Prisons. Joint United Nations Programme on HIV/AIDS, Geneva.

Johnson, Sarah L., et al. (September 2001) Institutional Methadone Maintenance Treatment: Impact on Release Outcome and Institutional Behaviour Correctional Service of Canada, Ottawa.

Jürgens, Ralf (September 1996). HIV/AIDS in Prisons: Final Report. Canadian HIV/AIDS Legal Network, Montreal.

Jürgens, R and M B Bijl (2002) Risk Behaviours in Penal Institutions in Bollini P (ed). HIV in Prison: A Manual for the Newly Independent States. MSF, WHO, and Prison Reform International.

Lindesmith Centre-Drug Policy Foundation (2000) About Methadone. Lindesmith Centre-Drug Policy Foundation, New York.

Lines, Rick (November 2002) Action on HIV/AIDS and Prisons: Too Little, Too Late—A Report Card. Canadian HIV/AIDS Legal Network, Montreal.

Magis-Rodriguez, C et al. (2000). Injecting drug use and HIV/AIDS in two jails of the North border of Mexico. Abstract for the XIII International AIDS Conference.

Stöver, Heino and Joachim Nelles. (2002) “10 years of experience with needle exchange programmes in European Prisons: A review of different evaluation studies“ (conference presentation abstract).

Stöver, Heino, and Carl von Ossietzky (August 2001) An overview study: Assistance to drug users in European Union prisons. European Monitoring Centre from Drugs and Drug Addiction, Lisbon.

UNAIDS/WHO (2002). AIDS epidemic update: December 2002. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization: Geneva.

Rick Lines, Excutive Director Irish Penal Reform Trust Dublin, Ireland Vanguard 2004 Confernence

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