Canada's Prison Needle Exchange Program, a syringe distribution program in nine federal correctional institutions, faces major limitations and low participation rates, according to a new report.
Based on interviews with people who were formerly incarcerated, the independent report pinpoints barriers to access and outlines recommendations to ensure that the program works as intended.
"Through informal channels, we had heard about problems with and barriers to the program and we felt that developing an independent research study was the best approach to explore these critical issues and provide an opportunity to shed insights on how to improve prisoners' access," Emily van der Meulen, PhD, a professor of criminology at Toronto Metropolitan University, Toronto, Ontario, Canada, told Medscape Medical News.
"If this program is ever going to work, we must engage and listen to people with firsthand experience of being incarcerated in Canada," she said. "People with lived experience know better than anyone what kinds of changes are urgently needed to ensure that Canada has a successful and accessible prison needle exchange program."
The "Points of Perspective" report was published by the HIV Legal Network and Toronto Metropolitan University on November 24.
Problems With Confidentiality
People who are incarcerated are disproportionately affected by HIV and hepatitis C, and the use of injection drugs is a major factor contributing to this risk, the authors wrote. In response to this problem, prison-based needle and syringe programs have provided access to sterile injection equipment in more than 60 prisons in more than 10 countries since 1992.
In 2018, the Correctional Service of Canada (CSC) announced plans to initiate a Prison Needle Exchange Program, which would be introduced to all federal prisons across the country. The original plan was to implement the program in 11 prisons by 2019, but so far, the program has been introduced in nine federal institutions.
A 2020 interim report commissioned by the CSC outlined the structure of the program, rates of participation, barriers to access, recommendations for improvement, and plans to expand harm reduction services. At that time, the process required prisoners to make a request to visit health services, undergo assessment for participation by a nurse, apply to the prison's assistant warden for evaluation, sign a contract that included behavioral expectations, and receive a kit that must remain visible in the participant's cell when not in use. At that time, the HIV Legal Network criticized the process for not meeting public health principles or professional standards accepted worldwide.
The interim evaluation noted that the program had low rates of participation. From 2018 through 2020, 42 participants enrolled at four of the nine institutions. In June 2022, the number had risen slightly to 53 participants nationally. In his 2018-2019 and 2021-2022 annual reports, Canada's correctional investigator commented on persistent barriers to access and low participation rates, calling it "a program largely in name only" and recommending a new process to encourage participation.
Between September 2021 and April 2022, the HIV Legal Network and researchers at Toronto Metropolitan University conducted 30 interviews with formerly incarcerated people across Canada about their knowledge of and experience with the program. Among those interviewed, 21 used prescription or illicit drugs while in prison, including 11 who injected drugs.
Many interviewees reported being unable to access the Prison Needle Exchange Program or being deterred from applying due to fear of punishment, so they used homemade injection equipment, reused needles, or shared equipment with a group of people. They also noted barriers such as confidentiality, privacy, surveillance, stigma, elimination of privileges, and lack of knowledge or misunderstanding about how the program works. Many suggested that correctional officers received information from medical staff, and they experienced a lack of confidentiality and privacy when they had to display the kit "sharps" in the cell during visual inspections.
Greater Awareness Needed
The interviewees provided numerous ideas to remove barriers and increase program access, with anonymity and confidentiality ranked as the highest priorities. They also noted that increasing awareness and training among prison staff was key, since most learned about the program from a poster in the healthcare office. They mentioned informational options for prisoners as well, such as orientation materials for new prisoners, peer education, sessions with the prison nurse, and external partnerships with organizations that specialize in harm reduction.
The report authors made several recommendations, such as removing administrative barriers by eliminating multiple assessments and disseminating sterile injection equipment in secure kits to all people in prison upon request. They pointed to other programs worldwide that distribute sterile equipment in different ways, such as through a peer distribution network or automatic dispensing machines located in areas without cameras or surveillance.
In addition, the report authors suggested mandatory training for prison authorities, correctional officers, and healthcare staff about the benefits of the program and the effects of drug use stigma. They also called for consultation and regular engagement with people in prison about how to improve the program design and adjust it based on the specifics of each prison.
"The Correctional Service of Canada must look closely at successful prison syringe programs globally, some of which have been around for decades, and follow those best-practice examples," Sandra Ka Hon Chu, one of the report authors and co-executive director of the HIV Legal Network, told Medscape.
"As the low participation numbers confirm, the security-oriented model currently implemented in Canada is clearly not working," she said. "Fortunately, we have lots of international evidence that we can draw upon."
"When appropriately used, this type of program can reduce the spread of infectious diseases safely without jeopardizing the security of the institution or the safety of the correctional staff," Ivan Zinger, PhD, Canada's correctional investigator, told Medscape. Zinger was not involved in drafting the report.
"Canada has shown a great deal of openness about the program, and we are one of the more progressive federal-level jurisdictions that has endorsed it and moved forward with it," he said. "Unfortunately, the pressures inside of corrections are such that implementation has been mediocre at best. There has been a certain lack of enthusiasm and pushback, to the detriment of the program."
"What's particularly concerning is the report's findings regarding lack of confidentiality for program participants, which was found to make people less willing to access the program because of the potential repercussions, including intensified surveillance and targeted punishment by correctional officers," Mary Clare Kennedy, PhD, a research scientist at the British Columbia Centre on Substance Use, told Medscape.
Kennedy, who wasn't involved with this report, has studied supervised consumption services and safe supply programs. She and her colleagues have found that these programs reduce harms associated with injection drug use, including the transmission of HIV and hepatitis C.
"The lack of confidentiality for program participants documented in the report suggests that Canada's Prison Needle Exchange Program is not being provided in accordance with accepted professional standards for both prison- and community-based needle exchange programs," she said. "Whether in prison or not, people should be able to access these essential health services easily, confidentially, and without fear of judgment or punishment."
The reported was funded by the Social Sciences and Humanities Research Council of Canada. Van der Meulen, Chu, Zinger, and Kennedy reported no relevant disclosures.
HIV Legal Network. Published November 24, 2022. Full text.
Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.
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Lead image: Dreamstime
Image 1: Toronto Metropolitan University
Image 2: HIV Legal Network
Image 3: Office of the Correctional Investigator
Image 4: British Columbia Centre on Substance Use
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Cite this: Prison Needle Exchange Program in Canada Has Limitations, Low Participation - Medscape - Dec 12, 2022.