A range of harm reduction interventions and responses to infectious diseases that have been proven to be effective in the community are also available in prisons in Europe. These are implemented in the three crucial stages of incarceration: upon entry, during imprisonment, and upon release with referral to services in the communities; however actual access and coverage remain critical issues and show great differences across countries and by intervention.
Our findings show that while certain essential harm reduction interventions and responses to infectious diseases are officially available in the majority of countries, including screening for drug-related problems upon entry, OST, vaccination, testing, counselling and treatment of infectious diseases, condom distribution, there is great variation in terms of coverage and mode of offering these services throughout the prison stay. Coverage of HIV/HCV/HBV testing is reported to be low in half of the countries and in most cases, it is only offered upon entry to the prison system instead of through all 3 stages: upon entry; during imprisonment and upon release. While OST is available in all but one country, and studies underpin that a large part of people in prison have had problems related to their opioids use (87, 88), this intervention is only available for a minority of people in need, assessed as low coverage in half of the countries – and often only in continuation from the community. Condom distribution coverage – in terms of prisons covered in a country – is also reported to be low in half of the countries. The proportion of people in prison reached by HIV related health promotion and health education on drug-related infectious diseases are above 30% in the majority of countries, still, some report it to be under this threshold.
Nonetheless, it is shown by our study that various interventions such as PNSPs, bleach distribution, lubricant distribution, counselling on safer injecting and risks of tattooing and piercing are only available in a very limited number of countries, and often with low coverage or only in few prisons within a country.
There are efforts in the majority of countries to provide linkages to addiction and HIV, HCV care for those who are in need of such services, however, the level of availability, the mode and the content of referral services vary between countries. Specific upon-release interventions – such as OST initiation before release, take-home naloxone upon release, health education upon release or HIV,HCV, HBV testing upon release are rarely provided that could prepare people – and particularly those who inject drugs - to return to the community and reduce their own health risks and of the people in their social networks.
In the time of our survey one-third of the countries reported that the ministry responsible for health in a given country is also responsible for prison health, whose structure is probably more effective in integrating prison health services into the community and improve the continuity of care provided for people in prison; ministry of health’s responsibility is also fostered by the World Health Organization’s Health in Prisons Programme initiative (62, 89, 90). In the meantime, in most of the countries, external service providers are involved in providing harm reduction services inside prisons which can facilitate linkages to addiction care in the community upon release. While drug related interventions are mentioned in national strategic documents in most of the countries, harm reduction in prison is specifically addressed in 21 countries, while interventions upon release is highlighted in 12 countries only. While ‘equivalence of care’ and ‘continuity of care’ are included in national level strategic documents in two-third of the countries real life data measured by our survey and also information provided by the countries suggest that they are often implemented only partially.
The availability and provision of harm reduction interventions in prison remains limited and partly significantly below the level of provision of the same interventions in the community. Some interventions – the effectiveness of which are supported by evidence and are largely implemented in the community – are still scarcely introduced. It must be noted that implementation of such services can still be set back by various prison setting specific obstacles, such as: security, overall ban on illicit drug use inside prisons, lack of capacity, adequate resources, technical expertise, infrastructure and trained staff, attitude towards harm reduction in the prisons such as the peculiar prison context as place of punishment and the moral considerations around it (83, 91–95). Moralistic attitude to health in prison should be replaced by pragmatic and scientific evidence-based approach to have a public health impact.
Therefore, besides the individual level of helping those in need and improve their health and social wellbeing and ensuring their right to health (96), harm reduction interventions during imprisonment should be considered as an unmissable public health opportunity (46, 61, 97, 98). During incarceration it becomes easier to contact, test and treat otherwise hard to reach risk groups such as PWID with high levels of health-related problems and risks who later return to the public. Consequently reaching out, diagnosing and treating them in prison also improves the health of their communities after their release which is called the ‘community dividend’ by Moore (61, 99). Besides public health gains addressing drug problems during imprisonment can also help to reduce reoffending among people with drug problems having committed acquisitive crimes which leads to societal benefits as well (100).
In terms of Hepatitis C and B – diagnosis and treatment have become even more feasible and crucial for vulnerable groups such as people who inject drugs and people in prison due to the introduction of highly effective direct-acting antiviral (DAA) therapy, coupled with the 2016 WHO Global health sector strategy on viral hepatitis and the Action plan for the health sector response to viral hepatitis in the WHO European Region (101–103). These politically approved high-level documents set the target to eliminate viral hepatitis by 2030 for which prisons can act as core settings due to high HCV prevalence among its population and frequent imprisonment of PWID which group carries the highest burden of HCV infection among all risk groups in Europe(104, 105).
Our research, however, is subject to several limitations. As for sources of information the Reitox National Focal Points’ workbooks are the best available, as they contain thematic information in English in a format which is harmonised across countries; still the reported data on interventions have a limited comparability across countries, especially regarding coverage and mode of implementation due to lack of information and unified data collection methods across countries.
Countries’ data source selection and publication policies may differ: they are collating information from different sources at national level, such as public administration reports, scientific literature (rarely) and grey literature or expert opinions, the quality of which cannot yet be controlled at European level. In some countries newer scientific sources may be available, however not yet reported by the National Focal Point for authorisation issues. Regional or local differences or variability due to correction facility types or inmate groups can make the picture of harm reduction availability puzzling even within one country. Thus, heterogeneous national data from the different countries were collided to a common set of variables in order to make 30 standardised country profiles. Some collateral data losses and simplification could certainly occur during the process.
Important to mention that this paper is based on the data collected through the HAREACT project and referred to a specific period (2016/2017) since then data may have changed in the meantime because of actual change in the situation.
It is noteworthy, that quality assurance, effectiveness or outcome evaluation of prison-based interventions in prison could not be covered in the mapping process due to the lack of information, which is indeed a normal practice in community prevention, treatment and harm reduction interventions. However, it is questionable whether specific evidence is needed for prisons, if the same community interventions are backboned by robust evidence; also the community dividend public health approach benefits of prison-based interventions are apparent(57, 61, 99).
Our focus was on PWID in prison and on interventions responding to risks and problems related to injecting and infectious diseases. However it must be noted that while people who inject opioids can be addressed by various interventions, stimulant and new psychoactive substance use including injecting are also present phenomena in the prison population (15, 106, 107), but a limited number of harm reduction interventions can respond to their needs (108).
Our findings call for attention of further monitoring efforts and sustainability. The definition of availability of harm reduction interventions has many aspects that may mask significant differences between the countries and extent of service provision (formal availability, actual availability, coverage, and quality of interventions). Public administration may call a service available on the basis of legal context, which not necessary means real availability. Information available on drug related interventions – especially regarding coverage, content and regularity – is still scarce in general in the EU-30 and the available information is limitedly comparable across countries. Information on coverage is limited in the two dimensions: prisons covered and people covered. However, recent efforts are ongoing at European level to improve the data availability and cross-country comparability through the implementation of a European monitoring framework on drugs and prison and piloting of a European model facility survey questionnaire on drug related interventions in prisons that would be available in the coming period (109). Despite several gaps in monitoring and quality, our analysis provides a comprehensive and updated overview on harm reduction interventions in European prisons; the presented data inform international, national and local policy makers and service planners to improve responses for people in prison with drug related problems, providing direct public health benefits.