Prof. Dr. Heino Stöver Frankfurt University of Applied Sciences Harm Reduction in Penal Practice and Prisons “Drugs and Crime Conference: Drugs, Crime and Punishment – where to draw the line?” 7-8 March 2016, Tallinn University Prof. Dr. Heino Stöver Frankfurt University of Applied Sciences

1. Background 2

Prison health is public health1 Prisoners are a vulnerable group from vulnerable sectors of society and so often is staff! Prisoners are mainly sexually active males aged between 19-35, multi-morbid, risk experienced If left unattended, prisons could easily become incubators for communicable diseases (HIV, TB, STIs, hepatitis). The prison environment of overcrowding and poor ventilation is an excellent breeding ground for communicable diseases. Overcrowding in prisons is a very serious threat to any efforts to control diseases in prison settings. Was nun macht diesen Zauber aus? Für die Humanwissenschaften liegt die besondere Bedeutung des Resilienzkonzepts in der Umkehr der wissenschaftlichen „Denkrichtung“ und des damit verbundenen Forschungsinteresses. Die theoretische und empirische Aufmerksamkeit z.B. in der Entwicklungspsychologie richtet sich nicht mehr überwiegend auf Entwicklungsdefizite oder -störungen bzw. Fehlanpassungen und deren Behebung. Sie nimmt vielmehr die Stärken der Individuen, die positiven und gesunden Widerstandskräfte und deren Förderung in den Blick. Diese neue Blickrichtung ist hoffnungsvoll auf die positiven Potenziale der Individuen gerichtet. So untersucht z.B. die Längsschnittstudie „Pairfam – das Beziehungs- und Familienpanel“ unter anderem, was Liebe glücken lässt. Der wissenschaftliche Blick „richtet sich nicht mehr nur auf die Schattenseiten scheiternder Beziehungen“, sondern darauf, „was zufriedene Paare richtig machen“ (von Bredow 2011:128). Doch was genau ist unter Resilienz zu verstehen und wie kam es zu dieser veränderten Denkrichtung, der neuen Perspektive, dem Paradigmenwechsel? Herkunft des Resilienzkonzepts Resilienz leitet sich vom englischen „resilience“ ab und bedeutet Spannkraft, Widerstandsfähigkeit und Elastizität. Ursprünglich stammt der Begriff aus der Werkstoffkunde, gewinnt aber in den Humanwissenschaften eine übertragene Bedeutung: Resilienz ist die psychische Widerstandsfähigkeit von einigen Menschen gegenüber biologischen, psychologischen und psychosozialen Entwicklungsrisiken, an denen viele andere Schaden nehmen. Das Phänomen der Resilienz bezieht sich auf die Abwehr von fehlangepassten Reaktionen angesichts belastender Lebensumstände (vgl. u.a. Wustmann 2004; Zander 2008). Vulnerabilität (Verletzlichkeit) ist der Gegenbegriff. Er verweist auf die Möglichkeit, dass ein Individuum, besonders ein Kind, unter dem Einfluss von Risikobelastungen verschiedene Formen von Erlebens- und Verhaltensstörungen entwickelt. Resilienz bezieht sich also auf psychische Gesundheit trotz erhöhter Entwicklungsrisiken und verweist auf die Fähigkeit von Individuen, solche Risikobelastungen zu bewältigen. Der Begriff Resilienz wurde zuerst über eine Studie der amerikanischen Entwicklungspsychologin Emmy E. Werner und ihrem Team bekannt. Sie verfolgten 40 Jahre lang die Entwicklungsverläufe von fast 700 Kindern, die 1955 auf der Hawaii-Insel Kauai geboren wurden. Etwa ein Drittel von ihnen wuchs unter für ihre Entwicklung höchst riskanten sozialen Bedingungen auf. Werner und ihr Team fanden, dass etwa zwei Drittel dieser „Risiko-Kinder“ höchst problematische Entwicklungsverläufe nahmen. Unerwartet jedoch wuchs ein Drittel der Risiko-Kinder zu kompetenten, psychisch gesunden, leistungsfähigen und zuversichtlichen Erwachsenen heran. Sie erwiesen sich als resilient gegenüber den Entwicklungsrisiken, die ihr Umfeld barg. Diese und andere Studien aus der Pionierphase begründeten eine neue Forschungsrichtung, die Resilienzforschung. In der Literatur werden drei unterschiedliche Erscheinungsformen von Resilienz genannt: eine positive Entwicklung eines Individuums trotz andauerndem hohen Risikostatus, z.B. bei Aufwachsen in chronischer Armut und niedrigem ökonomischen Status, eine beständige Bewältigungskompetenz unter akuten Stressbedingungen, z.B. infolge (elterlicher) Trennung, Scheidung oder chronischer Krankheit, und eine positive bzw. schnelle Erholung von traumatischen Erlebnissen, wie z.B. dem Tod eines nahe stehenden Menschen, Erleben von Naturkatastrophen und Krieg (vgl. Wustmann 2004; Zander 2008). Diese dezidierte Abkehr vom „Defizitblick“, das neu entstandene wissenschaftliche Interesse am Phänomen der psychischen Widerstandsfähigkeit, führte zu einem neuen Erkenntnisinteresse in Forschung und Praxis. Man beschäftigt sich nun mit den Faktoren, die Resilienz in Kindern und Erwachsenen bedingen, fördern und stärken. 1 WHO (2014): Health in prisons. Copenhagen/Denmark 3

Custodial institutions as high risk environment1 Loss of health-protective means: e.g. condoms, sterile injectiond equipment, opioid substitution treatment, naloxone Denial of risk conditions and risk behaviour from all involved – also from prisoners! Self-harm and suicide over-represented (Sexual) violence (rape)1 Homophobia barrier for effective prevention strategies Poor funding of prison sector remains a major concern health care professionals working in prisons should be charged with leading violence prevention efforts in custodial settings.In addition to screening for violence and detecting violent events upon prison admission, health care professionals in prison must work towards uniform in-house procedures for longitudinal and systemized medical recording/documentation of violence. 1 Pont et al. (2015): Prevention of violence in prison – The role of health care professionals. In: Journal of Legal and Forensic Medicine August 2015 Volume 34, Pages 127–132. http://www.jflmjournal.org/article/S1752-928X%2815%2900105-5/references 4

Key barriers for healthcare and harm reduction in custodial institutions Absence of holistic views towards health and crime risks Health in prisons not the primary task of prisons Ignorance of evidence-based knowledge Political interests, dominance of moral attitudes Integration of civil society remains low Prisons as fragmented systems1 Was nun macht diesen Zauber aus? Für die Humanwissenschaften liegt die besondere Bedeutung des Resilienzkonzepts in der Umkehr der wissenschaftlichen „Denkrichtung“ und des damit verbundenen Forschungsinteresses. Die theoretische und empirische Aufmerksamkeit z.B. in der Entwicklungspsychologie richtet sich nicht mehr überwiegend auf Entwicklungsdefizite oder -störungen bzw. Fehlanpassungen und deren Behebung. Sie nimmt vielmehr die Stärken der Individuen, die positiven und gesunden Widerstandskräfte und deren Förderung in den Blick. Diese neue Blickrichtung ist hoffnungsvoll auf die positiven Potenziale der Individuen gerichtet. So untersucht z.B. die Längsschnittstudie „Pairfam – das Beziehungs- und Familienpanel“ unter anderem, was Liebe glücken lässt. Der wissenschaftliche Blick „richtet sich nicht mehr nur auf die Schattenseiten scheiternder Beziehungen“, sondern darauf, „was zufriedene Paare richtig machen“ (von Bredow 2011:128). Doch was genau ist unter Resilienz zu verstehen und wie kam es zu dieser veränderten Denkrichtung, der neuen Perspektive, dem Paradigmenwechsel? Herkunft des Resilienzkonzepts Resilienz leitet sich vom englischen „resilience“ ab und bedeutet Spannkraft, Widerstandsfähigkeit und Elastizität. Ursprünglich stammt der Begriff aus der Werkstoffkunde, gewinnt aber in den Humanwissenschaften eine übertragene Bedeutung: Resilienz ist die psychische Widerstandsfähigkeit von einigen Menschen gegenüber biologischen, psychologischen und psychosozialen Entwicklungsrisiken, an denen viele andere Schaden nehmen. Das Phänomen der Resilienz bezieht sich auf die Abwehr von fehlangepassten Reaktionen angesichts belastender Lebensumstände (vgl. u.a. Wustmann 2004; Zander 2008). Vulnerabilität (Verletzlichkeit) ist der Gegenbegriff. Er verweist auf die Möglichkeit, dass ein Individuum, besonders ein Kind, unter dem Einfluss von Risikobelastungen verschiedene Formen von Erlebens- und Verhaltensstörungen entwickelt. Resilienz bezieht sich also auf psychische Gesundheit trotz erhöhter Entwicklungsrisiken und verweist auf die Fähigkeit von Individuen, solche Risikobelastungen zu bewältigen. Der Begriff Resilienz wurde zuerst über eine Studie der amerikanischen Entwicklungspsychologin Emmy E. Werner und ihrem Team bekannt. Sie verfolgten 40 Jahre lang die Entwicklungsverläufe von fast 700 Kindern, die 1955 auf der Hawaii-Insel Kauai geboren wurden. Etwa ein Drittel von ihnen wuchs unter für ihre Entwicklung höchst riskanten sozialen Bedingungen auf. Werner und ihr Team fanden, dass etwa zwei Drittel dieser „Risiko-Kinder“ höchst problematische Entwicklungsverläufe nahmen. Unerwartet jedoch wuchs ein Drittel der Risiko-Kinder zu kompetenten, psychisch gesunden, leistungsfähigen und zuversichtlichen Erwachsenen heran. Sie erwiesen sich als resilient gegenüber den Entwicklungsrisiken, die ihr Umfeld barg. Diese und andere Studien aus der Pionierphase begründeten eine neue Forschungsrichtung, die Resilienzforschung. In der Literatur werden drei unterschiedliche Erscheinungsformen von Resilienz genannt: eine positive Entwicklung eines Individuums trotz andauerndem hohen Risikostatus, z.B. bei Aufwachsen in chronischer Armut und niedrigem ökonomischen Status, eine beständige Bewältigungskompetenz unter akuten Stressbedingungen, z.B. infolge (elterlicher) Trennung, Scheidung oder chronischer Krankheit, und eine positive bzw. schnelle Erholung von traumatischen Erlebnissen, wie z.B. dem Tod eines nahe stehenden Menschen, Erleben von Naturkatastrophen und Krieg (vgl. Wustmann 2004; Zander 2008). Diese dezidierte Abkehr vom „Defizitblick“, das neu entstandene wissenschaftliche Interesse am Phänomen der psychischen Widerstandsfähigkeit, führte zu einem neuen Erkenntnisinteresse in Forschung und Praxis. Man beschäftigt sich nun mit den Faktoren, die Resilienz in Kindern und Erwachsenen bedingen, fördern und stärken. 1Price Waterhouse Cooper (PwC) report (2007), Review of Prison-Based Drug Treatment Funding (2007) 5

Previously EU-funded projects… focusing on harm reduction in prisons and throughcare in order to utilize their results and existing networks1: e.g. “Throughcare” “Connections” (Stöver/Thane et al. 2011) “Access” (Zurhold/Stöver 2015) “Care” (Michel et al. 2015) “HA REACT” (> 2015) 1http://ec.europa.eu/chafea/documents/health/hiv-infopack_en.pdf Michel, L.; Lions, C.; Van Malderen, S.; Schiltz, J.; Vanderplasschen, W.; Holm, K.; Kolind, T.; Nava, F.; Weltzien, N.; Moser, A.; Jauffret-Roustide, M.; Maguet, O.; Carrieri, P.M.; Brentari C.; and H.S. (2015): Insufficient access to harm reduction measures in prisons in 5 countries (PRIDE Europe): a shared European public health concern. In: BMC Zurhold, H.; H.S. (2015): Provision of harm reduction and drug treatment services in custodial settings - findings from the European ACCESS study. In: Drugs: Education, Prevention & Policy, online 4 December 2015. DOI: 10.3109/09687637.2015.1112363  H.S.; Thane, K. (2011): Towards a continuum of care in the EU criminal justice system A survey of prisoners’ needs in four countries (Estonia, Hungary, Lithuania, Poland). Schriftenreihe „Gesundheitsförderung im Justizvollzug“, Bd. 20, Oldenburg: BIS-Verlag. http://www.connectionsproject.eu/ 6

Council of Europe Report... “...on the current state of play of the 2003 Council Recommendation on the prevention and reduction of health-related harm, associated with drug dependence, in the EU and candidate countries” (Gesundheit Österreich 2013)1 1http://www.goeg.at/en/BerichtDetail/project_berichte282.html_en.pdf The report presents the updated overview of the implementation of the Council Recommendation in the EU countries and several candidate countries, including country profiles, as well as analyses of epidemiological trends. The study also assesses the availability of - access to- and -coverage of- harm reduction measures based on the answers to a policy survey and a survey among field organisations. The available scientific evidence regarding interventions to prevent and reduce health-harms associated with drug dependence was analysed and in addition four systematic Literature Reviews (peer naloxone programs, prison release management, needle exchange in prison, measures to change the route of administration) were produced. Finally, the report provides country overviews on harm reduction policies, services and facilities. The main output is a set of 13 conclusions regarding the follow-up of the Council Recommendation, based on the application and combination of the scientific effectiveness of interventions and the availability and coverage. Based on these the authors have identified 3 priority areas of action: the reduction of drug-induced deaths, the improvement of harm reduction in prison and the reduction of harm caused by drug-related infections. 7

Conclusions and suggestions1 A. Reduction of drug-induced deaths “…facilitate the use of emergency services, peer naloxone programmes, integration of services (especially prison and treatment release management), B: Improvement of harm reduction in prison“ “Proposed measures: Opioid substitution treatment (OST), syringe provision through specialised programmes (introduction in all prisons), release management, throughcare into and out of prison (regarding OST continuity), housing for released prisoners, health assessments including infection prevention”. Challenges The main challenges cited by Member States in terms of provision of services for HIV, TB, Hepatitis B and C and STIs were: 6.5.1 Overcrowding in prisons was seen as a very serious threat to any efforts to control diseases in prison settings. 6.5.2 Lack of continuation of care - For most Member States there was no clearly defined link or referral system of the prison health system with health services outside the prison system. This makes it difficult to follow-up ex-prisoners who are discharged while on treatment. It was also noted that some individuals coming into prisons sometimes do not have any documentation. 6.5.3 Non supportive legal environment for the provision of some prevention material. Prison population is dominated by males and for most Member States sex in prisons is illegal and male to male sex is not only criminalized but also stigmatised. Although most Member States cited that the revision of such impeding laws could make the availing of all necessary prevention material, the problem of stigmatization would still present its issues. This was evident in some states where laws do not impede, whether implicitly or explicitly. 6.5.4 Poor funding of prison sector remains a major concern for most Member States, thus limiting the number and extent of interventions that could be implemented. 6.5.5 Provision of nutritional support for prisoners especially those needing special care or on treatment. Directly related to this issue was the issue of stigma as difference in diet provided could be used an indicator for ones disease or health status. 1 Gesundheit Österreich 2013 8

HA REACT: Expected Outcomes (1/2) Situation analysis / mapping of needed support in the participating countries implemented Medical, social and other prison professionals trained to work with PWID and to provide harm reduction services (incl. OST, PNSP, condom provision and psychological support) Elaborated E-learning modules1 IEC materials developed for PWID and staff in prisons Challenges The main challenges cited by Member States in terms of provision of services for HIV, TB, Hepatitis B and C and STIs were: 6.5.1 Overcrowding in prisons was seen as a very serious threat to any efforts to control diseases in prison settings. 6.5.2 Lack of continuation of care - For most Member States there was no clearly defined link or referral system of the prison health system with health services outside the prison system. This makes it difficult to follow-up ex-prisoners who are discharged while on treatment. It was also noted that some individuals coming into prisons sometimes do not have any documentation. 6.5.3 Non supportive legal environment for the provision of some prevention material. Prison population is dominated by males and for most Member States sex in prisons is illegal and male to male sex is not only criminalized but also stigmatised. Although most Member States cited that the revision of such impeding laws could make the availing of all necessary prevention material, the problem of stigmatization would still present its issues. This was evident in some states where laws do not impede, whether implicitly or explicitly. 6.5.4 Poor funding of prison sector remains a major concern for most Member States, thus limiting the number and extent of interventions that could be implemented. 6.5.5 Provision of nutritional support for prisoners especially those needing special care or on treatment. Directly related to this issue was the issue of stigma as difference in diet provided could be used an indicator for ones disease or health status. See: www.isff.info 9

HA REACT: Expected Outcomes (2/2) Practical toolkit for prison staff on harm reduction in prisons (as part of the JA training toolkit) Condom provision and other harm reduction measures piloted in one prison Policy brief based on experiences from the component Challenges The main challenges cited by Member States in terms of provision of services for HIV, TB, Hepatitis B and C and STIs were: 6.5.1 Overcrowding in prisons was seen as a very serious threat to any efforts to control diseases in prison settings. 6.5.2 Lack of continuation of care - For most Member States there was no clearly defined link or referral system of the prison health system with health services outside the prison system. This makes it difficult to follow-up ex-prisoners who are discharged while on treatment. It was also noted that some individuals coming into prisons sometimes do not have any documentation. 6.5.3 Non supportive legal environment for the provision of some prevention material. Prison population is dominated by males and for most Member States sex in prisons is illegal and male to male sex is not only criminalized but also stigmatised. Although most Member States cited that the revision of such impeding laws could make the availing of all necessary prevention material, the problem of stigmatization would still present its issues. This was evident in some states where laws do not impede, whether implicitly or explicitly. 6.5.4 Poor funding of prison sector remains a major concern for most Member States, thus limiting the number and extent of interventions that could be implemented. 6.5.5 Provision of nutritional support for prisoners especially those needing special care or on treatment. Directly related to this issue was the issue of stigma as difference in diet provided could be used an indicator for ones disease or health status. 10

UNODC/ILO/UNDP/WHO /UNAIDS1 Comprehensive Package… consists of 15 interventions that are essential for effective HIV prevention and treatment in closed settings. While each of these interventions alone is useful in addressing HIV in prisons, together they form a package and have the greatest impact when delivered as a whole. However, some interventions are insufficient alone (IEC) => Political commitment The Minimum Standards will be highly dependent on the political commitment of each Member State to ensure provision of comprehensive prison health services which are the same as that available outside prison. 4.2 Public health Universal access is a key principle for Public Health, Member States must provide services that reach all including individuals in prisons and other places of detention. 4.3 Confidentiality The principle of confidentiality in the medical status of individuals in prisons or other places of detention should be upheld. 4.4 More emphasis on human rights Member States must uphold human rights of individuals in prisons. Prisoners and detainees retain all human rights except for the right to liberty of movement. They should be treated with respect at all times. 4.5 Equity Provision of health services to the general population, prisons and other places of detention must be according to burden of disease. 1 UNODC/ILO/UNDP/UNAIDS (2012): Policy brief. HIV prevention, treatment and care in prisons and other closed ettings: a comprehensive package of interventions 11

HIV-Prevention – The Comprehensive Package: 15 Key Interventions (UNODC/ILO 2012) 1. Information, education and communication 2. HIV testing and counselling 3. HIV/AIDS treatment, care and support 4. Prevention, diagnosis and treatment of tuberculosis 5. Prevention of mother-to-child transmission of HIV 6. Condom programmes 7. Prevention and treatment of sexually transmitted infections 8. Prevention of sexual violence 9. Drug dependence treatment => Opioid Substitution Treatment, Naloxone 10. Needle and syringe programmes 11. Vaccination, diagnosis and treatment of viral hepatitis 12. Post-exposure prophylaxis 13. Prevention of transmission through medical or dental services 14. Prevention of transmission through tattooing, piercing and other forms of skin penetration 15. Protecting staff from occupational hazards and other closed settings: a comprehensive package of interventions 1UNODC/ILO (2012): HIV prevention, treatment and care in prisons The comprehensive package consists of 15 interventions that are essential for effective HIV prevention and treatment in closed settings. While each of these interventions alone is useful in addressing HIV in prisons, together they form a package and have the greatest impact when delivered as a whole.

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2. Transferring Harm Reduction into Custodial Settings 14

Prison-based Needle Syringe Programs1 Scientific evaluations conducted in 11 prisons with syringe distribution programmes The provision of syringes did not lead to an increase in drug consumption or an increase in injecting Syringes were not used as weapons, and safe disposal of used needles was not a problem Syringe sharing disappeared almost completely In prisons where blood testing was performed, no new cases of HIV or Hepatitis infection were found Most electronic cigarettes comprise a nicotine cartridge, a battery and an atomiser. The nicotine cartridge contains nicotine solution and a diluent such as propylene glycol or vegetable glycol, and flavourings. Smoked tobacco contains approximately 4000 chemical products, many of which are toxic. Most electronic cigarettes are not free from trace substances (nor are medically licensed nicotine replacement therapy products) but chemical analysis of liquids and aerosols finds that trace constituents are manifold times less present than in regular cigarettes and smoked tobacco. There is no evidence that vaping (inhalation) produces exposures to contaminants that would warrant health concerns by the standards that are used to ensure safety of workplaces (Burstyn 2014). In terms of a gradient of risk, electronic cigarettes are at the low end close to NRT products, with smoked tobacco products at the top end (Nutt, Phillips, Balfour, Curran, Dockrell and Foulds 2014). Electronic cigarettes are disruptive for public health and tobacco control organisations. The rapid uptake of electronic cigarettes has been a consumer-led self-help public health movement (Stimson and Costall 2014) with no expenditure of healthcare resources, and has been met with neglect and sometimes antipathy from many public health experts and tobacco control organisations who clearly do not have ‘ownership’ of the innovation. The public health response to regain ownership has coalesced around the precautionary principle. Hence the public health discourse has mainly focused on potential use of e-cigarettes by young people, their potential as a gateway to smoking, and fear that they might undermine the ‘de-normalisation’ of smoking by ‘re-normalising it’. Few public health experts have been engaged in supporting and promoting this grass roots movement, despite the fact that it accords with one of the basic principles of public health as outlined in the WHO Ottawa Charter for Health - that ‘Health promotion is the process of enabling people to increase control over, and to improve, their health . . .’ (WHO 1986). As has been noted ‘This seems to be exactly what electronic cigarette consumers are doing—taking control of things that determine their health’(Stimson 2014).   1 Stöver, H. & Nelles, J.: Ten years of experience with needle and syringe exchange programmes in European Prisons. In: International Journal of Drug Policy Dec./2003, volume 14, Issues 5-6), pp 437-444 15

Needle and Syringe Programmes worldwide1 1 HRI (2015): The Global State of harm reduction

Prison-based needle and syringe programs – UNODC Handbook1 In 60 prisons worldwide – in 10 countries 1 UNODC (2015): A handbook for starting and managing needle and syringe programmes in prisons and other closed settings. UNODC http://www.unodc.org/documents/hiv-aids/publications/Prisons_and_other_closed_settings/ADV_COPY_NSP_PRISON_AUG_2014.pdf

Prison-based Needle and Syringe Programmes in– too little, too late? Most electronic cigarettes comprise a nicotine cartridge, a battery and an atomiser. The nicotine cartridge contains nicotine solution and a diluent such as propylene glycol or vegetable glycol, and flavourings. Smoked tobacco contains approximately 4000 chemical products, many of which are toxic. Most electronic cigarettes are not free from trace substances (nor are medically licensed nicotine replacement therapy products) but chemical analysis of liquids and aerosols finds that trace constituents are manifold times less present than in regular cigarettes and smoked tobacco. There is no evidence that vaping (inhalation) produces exposures to contaminants that would warrant health concerns by the standards that are used to ensure safety of workplaces (Burstyn 2014). In terms of a gradient of risk, electronic cigarettes are at the low end close to NRT products, with smoked tobacco products at the top end (Nutt, Phillips, Balfour, Curran, Dockrell and Foulds 2014). Electronic cigarettes are disruptive for public health and tobacco control organisations. The rapid uptake of electronic cigarettes has been a consumer-led self-help public health movement (Stimson and Costall 2014) with no expenditure of healthcare resources, and has been met with neglect and sometimes antipathy from many public health experts and tobacco control organisations who clearly do not have ‘ownership’ of the innovation. The public health response to regain ownership has coalesced around the precautionary principle. Hence the public health discourse has mainly focused on potential use of e-cigarettes by young people, their potential as a gateway to smoking, and fear that they might undermine the ‘de-normalisation’ of smoking by ‘re-normalising it’. Few public health experts have been engaged in supporting and promoting this grass roots movement, despite the fact that it accords with one of the basic principles of public health as outlined in the WHO Ottawa Charter for Health - that ‘Health promotion is the process of enabling people to increase control over, and to improve, their health . . .’ (WHO 1986). As has been noted ‘This seems to be exactly what electronic cigarette consumers are doing—taking control of things that determine their health’(Stimson 2014).   18

Prison Syringe Exchange (1/3): Models of Distribution: machines Anonymous Syringe Dispensing Machines Lichtenberg Prison Berlin Saxerriet Prison Switzerland Photographs by Rick Lines

Safer use - Material in spanischen Gefängnissen 20

Safer use - Material in Spanish Prisons 21

20y of Prison-Needle Exchange – Where have we got from here? Quantity - Only little increase in the Number of PNSP - Numbers of clients decreasing - Coverage poor and patchy - Independent from responsibility of prison health care Quality - Confidentiality the key problem - Access often arbitrary - Perception of drug use important - Continuous work on the programme needed - HIV/AIDS no longer the key driver Hr ist erfolgreich, z.b. rki, z.B. Drogenkonsumräume, spritzenabgabe 22

3. Drug Treatment: Opioid Substitution Treatment 23

Time gaps in the official introduction of OST in prisons: ~7-8y (Source: EMCDDA; D. Hedrich et al. 2012,) 24 24

OST in Community and Prisons1 1 HRI (2015): The Global State of harm reduction

OST in European prisons1 The PNSP Manual (1/3) Coverage low Detoxification models heterogenous Maintenance varies OST as relapse prevention only in few countries OST provision in prisons varies from country to country, from region to region, from prison to prison… from doctor to doctor within the same prison The principle of equivalence The principle of equivalence means that the health care measures (medical and psychosocial) successfully proven and applied outside prison should also be applied inside prison. With regard to support for drug using inmates in many ways this has turned out as wishful thinking. In most of the countries already basic prerequisites are not given (i.e., no throughcare of treatment, no adequate prevention means).   Nevertheless the principle of equivalence is the guiding criteria, with which prison drug services have to be measured in the context of the national drug service structure and the drug policies pursued in all EU member states. Especially the differentiation of drug services (including drug free treatment, methadone maintenance and harm reduction) outside is not reflected sufficiently inside prison. ‘Prison Health’ has to be integrated in the broader frame of ‘Public Health’. 1 Hedrich et al. 2012; Stöver/Casselman et al. 2006 26

4. Sexual Risks and Condom Programmes

Condom/lubricant provision - How? Condoms need to be easily and discreetly available, ideally in areas such as toilets, shower areas, waiting rooms, workshops or day rooms where prisoners can pick up a condom without being seen by others. Distribution can be carried out by health staff, dispensing machines, trained prisoners (peers) or through a combination of any of these ways. Each prison should determine how best to make condoms available to ensure easy and discreet access C ondoms need to be easily and discreetly available, ideally in areas such as toilets, shower areas, waiting rooms, workshops or day rooms where prisoners can pick up a condom without being seen by others. Distribution can be carried out by health staff, dispensing machines, trained prisoners (peers) or through a combination of any of these ways. Each prison should determine how best to make condoms available to ensure easy and discreet access. Prisoners should not have to ask for condoms, since few prisoners will do so because they do not want to disclose that they engage in same-sex sexual activity. Condoms should be provided free of charge, and can be made available to all prisoners in a health kit given to them upon entry to the facility. The health kit can also contain HIV and other health information, as well as other items such as a shaving kit, toothbrush, soap, etc. A water-based lubricant should also be provided since it reduces the probability of condom breakage and/or rectal tearing, both of which contribute to the risk of HIV transmission. 1 WHO (2014): Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations

Sexual risks in prisons: Contextual MSM1 Sexual activity takes place in prisons and other closed settings, but general access to condoms there is limited. It is important to introduce, and expand to scale, condom and lubricant distribution programmes in prisons and other closed settings, without quantity restriction, with anonymity and in an easily accessible manner (e.g. condom vending machines). Condom use in Australian Prisons >general population: 20-30%2: Aktuelle Presseerklärung weiterer NRW-Justizeinrichtungen 15.09.2014 Oberlandesgericht Hamm: Inhaftierte sind allein aufgrund medizinischer Erwägungen ärztlich zu behandeln Im Justizvollzug ist ein Inhaftierter allein aufgrund medizinischer Erwägungen ärztlich zu behandeln. Um eine derartige ärztliche Behandlung eines in Untersuchungshaft befindlichen Angeklagten zu gewährleisten, kann das Haftgericht ausnahmsweise auch die Verlegung des Angeklagten in eine andere Justizvollzugsanstalt anordnen. Das hat der 3. Strafsenat des Oberlandesgerichts Hamm mit Beschluss vom 03.07.2014 entschieden. Der 40-jährige Angeklagte aus Porta-Westfalica befindet sich seit November 2013 in Untersuchungshaft. Im Januar 2014 verurteilte ihn das Landgericht Bielefeld wegen unerlaubter Einfuhr von und unerlaubtem Handel mit Betäubungsmitteln zu einer Freiheitsstrafe von 6 Jahren und 6 Monaten. Nach der vom Angeklagten eingelegten Revision ist das Urteil nicht rechtskräftig. Der Angeklagte befindet sich weiterhin in Untersuchungshaft. Eine aufgrund seiner Betäubungsmittelabhängigkeit begonnene Substitutionsbehandlung setzte der Angeklagte nach seiner Inhaftierung im November 2013 in der Justizvollzugsanstalt unter Aufsicht des Anstaltsarztes durch die Einnahme von ihm überlassenem Polamydon fort. Nachdem es zu Unstimmigkeiten zwischen dem Angeklagten und dem Anstaltspersonal gekommen war, entschied der Anstaltsarzt, die Substitution zu beenden und reduzierte die dem Angeklagten verabreichten Dosen Polamydon. Auf Antrag des Angeklagten erließ daraufhin die Strafkammer des Landgerichts Bielefeld am 07.03.2014 eine vorläufige Anordnung mit dem Inhalt, dass die Substitution bis zu einer Entscheidung in der Hauptsache fortzusetzen sei. Mit weiterem Beschluss vom 03.04.2014 stellte die Strafkammer fest, dass die ungeachtet der einstweiligen Anordnung vom Anstaltsarzt beendete Substitution rechtswidrig gewesen sei, ohne dass der Angeklagte jedoch einen Anspruch auf Wiederaufnahme der Substitutionsbehandlung habe. Letzteres sei eine medizinische Entscheidung, die dem Ermessen des Anstaltsarztes unterfalle. Der Angeklagte hat daraufhin am 09.04.2014 seine Verlegung in eine andere Justizvollzugsanstalt beantragt und zur Begründung ausgeführt, der Anstaltsarzt habe es abgelehnt, die Substitution wieder aufzunehmen, solange noch ein “Verfahren laufe“. Vertrauen in eine angemessene Krankenbehandlung in der Anstalt habe er, der Angeklagte, nicht mehr. Der Verlegungsantrag hatte Erfolg. Nach der Entscheidung des 3. Strafsenats des Oberlandesgerichts Hamm besteht ein gewichtiger Grund, den Angeklagten in eine andere Justizvollzugsanstalt zu verlegen. Dieser ergebe sich aus dem Umstand, dass der Angeklagte objektiv begründet jedwedes Vertrauen in eine angemessene ärztliche Behandlung in der derzeitigen Justizvollzugsanstalt verloren habe und eine solche Behandlung gegenwärtig nicht gewährleistet sei. Eine angemessene ärztliche Behandlung des Angeklagten im Vollzug sei nur dann gegeben, wenn ärztliche Entscheidungen ausschließlich auf der Basis medizinischer Erwägungen (Indikation/Nichtindikation) getroffen würden. Aufgrund der zurückliegenden Vorfälle bestünden begründete Zweifel daran, dass dies in der derzeitigen Justizvollzugsanstalt gewährleistet sei. Das rechtfertige die Verlegung des Angeklagten in eine andere Justizvollzugsanstalt. Rechtskräftiger Beschluss des 3. Strafsenats des Oberlandesgerichts Hamm vom 03.07.2014 (3 Ws 213/14) Christian Nubbemeyer, Pressedezernent Für Fragen, Kommentare und Anregungen steht Ihnen zur Verfügung: pressestelle@olg-hamm.nrw.de Weitere aktuelle Pressemitteilungen der Justiz des Landes Nordrhein-Westfalen. Abbestellung des Presseservices ist jederzeit durch Klick auf den nebenstehenden Link möglich: Abbestellen Presseservice des Justizministeriums des Landes Nordrhein-Westfalen Herausgeber: Justizministerium des Landes Nordrhein-Westfalen, Pressestelle (Detlef Feige), Martin-Luther-Platz 40, 40212 Düsseldorf, E-Mail: pressestelle@jm.nrw.de Für den Inhalt ist das Pressereferat des Gerichts verantwortlich, das die Presseerklärung veröffentlicht hat.   1 WHO (2014): Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations 2 Dolan, Kate;Lowe, David;Shearer (2004): James Evaluation of the Condom Distribution Program in New South Wales Prisons, Australia The Journal of Law, Medicine & Ethics; Spring 2004; 32, 1; ProQuest Central pg. 124 30

Condom/lubricant provision Consistent and correct use of male condoms reduces sexual transmission of HIV and other STIs by up to 94%. Lubricants (as opposed to petroleum-based) helps to prevent condoms from breaking and slipping While fewer data are available on female condoms, evidence suggests that use of female condoms also prevents HIV and STIs Effective condom programming is particularly important for key populations. 1 WHO (2014): Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations

from Maputo to Munich to Maseru Condoms: from Maputo to Munich to Maseru Maputo/Mozambique: ca. 24% of prisoners HIV+ - no condoms: „…might increase sexual activity …“ Munich/Germany: HIV-prevalence among prisoners 1,5% of men, that is 30-times higher than in the general population condoms available via application medical service 2005-2007 provision of 43 condoms to 13,000 prisoners Official legitimation: „prisoners are informed to behave responsibly right in the beginning“1 Maseru/Lesotho: making condoms „available…“ 1Bayerische Staatszeitung 29.08.2014

Condotainer Maseru/Lesotho Prison

Condotainer San Francisco/US Condoms have been available to prisoners in San Francisco County jails since the 1980s. Under a new law, condom machines like this one may soon be installed in state prisons. (George Lavender/KQED) n the corner of a gym in a San Francisco jail, there’s something you wouldn’t usually find behind bars: a condom machine. Earlier this year, Gov. Jerry Brown signed a new law that makes condoms available for free in all of California’s prisons. While sex between inmates is illegal, supporters of the “Prisoner Protections for Family and Community Health Act” say making condoms available in prison will help prevent the spread of HIV and other sexually transmitted diseases. The law’s author, Assemblyman Rob Bonta, points to the machines in San Francisco’s jails as a model of how condom distribution could work on the state level. San Francisco began providing condoms to inmates in the 1980s in response to the AIDS crisis. There are now more than a dozen condom machines in San Francisco’s jails, according to Kate Monico Klein, director of HIV services for Jail Health, a division of the county’s Public Health Department. The dispenser in Jail Number Four was mounted in a corner of the gym “so that people would have a minor amount of privacy,” Monico Klein explains. The CDC estimates that one in seven people living with HIV passes through correctional facilities each year. Sex in jail is illegal even if it is consensual. Section 286(e) of the California Penal Code outlaws “sodomy with any person of any age while confined in any state prison … or in any local detention facility,” and California’s Code of Regulations prohibits all sexual acts between inmates. “The law’s the law, but should this behavior occur, there’s a safe, safer way,” says San Francisco Sheriff Ross Mirkarimi. “We want people to be protected.” The Centers for Disease Control and Prevention estimate that one in seven people living with HIV passes through correctional facilities each year. “Condoms are good to have around, I think, because it’s a life-saving device,” says Robert Greve, an inmate who’s serving a short sentence in the jail’s special unit for gay and transgender prisoners.  “A lot of people don’t care about their health, I don’t think. Personally, I do. I’d rather not have sex than not use a condom, but some people do.” San Francisco Sheriff Ross Mirkarimi. (Mina Kim/KQED) Having done time in several states, Greve says this is the first time he’s been locked up in a facility where condoms are provided. With a laugh, he says he likes to make use of the machine, taking “10 of them every time.” Another inmate in the jail, Rene Angel Ramirez, says he’s HIV-positive and uses condoms to keep partners safe — and to protect himself from diseases like gonorrhea, chlamydia or hepatitis C. He says he knows people who have contracted HIV while in custody. “We still have the need of sex,” he explains. As Monico Klein recalls, when condoms were first introduced in San Francisco jails, some deputies were unhappy with the plan. Apart from the illegality of sex between inmates, there were concerns that condoms could be used for smuggling drugs, or filled with urine and thrown at staff, known as “gassing.” She says deputies were also concerned that making condoms available would lead to an increase in both consensual sex and sexual assault. The Sheriff’s Department says that hasn’t happened in the years since condoms have been available. But the condoms have been used in some unexpected ways. “We found that among other things, prisoners take the condoms and they use them as hair ties. They use them as pillows,” says Monico Klein. “One of the deputies told me that they blow them up and use them as balloons. While this initially bothered some people, she says, “we realized that this is another way of destigmatizing HIV.” Even after more than two decades, San Francisco Chief Deputy Sheriff Matthew Freeman says not all deputies are comfortable with condoms being available. “I could not report to you that there still is buy-in from the uniformed staff,” Freeman says, and adds there are reasons sex is prohibited in jail. “We know from experiences running and managing jails that even consensual activity amongst inmates can lead to very real problems.”  California has five years to come up with its plan for distributing condoms in state prisons, a move that Mirkarimi says is “years overdue.” Other prisons and jails across the U.S. have been slow to follow San Francisco’s lead, something Mirkarimi attributes to the slow pace of reform in the criminal justice system, as well as homophobia. Inmate Greve says that, based on his own experience in state lockups, the only problem he imagines with providing condoms in California state prisons will be supply, because “people will want as many of them as they can get.”

Further reading on condom/lubricant provision Condom programming for HIV prevention: a manual for service providers. New York, UNFPA, 2005. http://www.unfpa.org/public/global/pid/1291 Comprehensive condom programming: a guide for resource mobilization and country programming. New York, UNFPA, 2010. http://www.unfpa.org/webdav/site/global/shared/documents/publications/2011/CCP.pdf WHO, UNFPA, UNAIDS, NSWP, World Bank. Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions. (Chapter 4). Geneva, WHO, 2013. http://www.who.int/hiv/pub/sti/sex_worker_implementation/en/ Male latex condom specification, prequalification and guidelines for procurement. Geneva, WHO, 2010. http://www.who.int/reproductivehealth/publications/family_planning/9789241599900/en/ WHO, UNFPA, FHI360. Use and procurement of additional lubricants with male and female condoms – advisory note. Geneva, WHO, 2012. http://apps.who.int/iris/bitstream/10665/76580/1/WHO_RHR_12.33_eng.pdf

Conclusions: from harm production to harm reduction Integration of staff Integration of drug using prisoners: „Nothing about us without us“- empowerment! Help people to make informed decisions PNSP: issues around safety in the working place-use UNODC manual as restarting discourse Comprehensive approach is needed => 36

Services involved Improve effectivity and efficiency on prison health Prisons: staff, prisones, Services involved Networks Partnerships Utilization of infrastructure: Doctors, clinics, pharmacies Support by stakeholders

References Websites UNODC/UNAIDS/WHO publications http://www.unodc.org/unodc/en/hiv-aids/publications.html WHO Harm reduction package http://www.who.int/hiv/topics/idu/harm_reduction/en/# Needles, syringes, and paraphernalia for harm reduction http://www.exchangesupplies.org/

„. Prisoners are the community „... Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities “ (Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons) hstoever@fb4.fh-frankfurt.de By entering our penal facilities, prisoners are condemned to imprisonment for their crimes; they should not be condemned to be under pressure to continue their drug abuse or denied the means to protect themselves against communicable diseases. Govern­ments and prison authorities have a moral and legal responsibility to prevent the spread of HIV infection among prisoners and prison staff and to take care for those infected. They also have a responsibility to prevent the spread of HIV among communites. Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities“. (C. Goos, WHO, 1997, S.7) :