Addressing the Risk Environment in Prison: Learnings from a Study Evaluating Canada’s Prison Needle Exchange Program

The 12th International Conference on Health and Hepatitis in Substance Users (INHSU) is an international conference bringing together researchers, clinicians, advocates, and communities of people who use drugs to advance health equity and evidence-based practice to support the health and well-being of people who use drugs. The issues discussed ranged from the elimination of viral hepatitis, to innovative care models, to harm reduction and drug policy.

Held this year in Athens, Greece, the conference also featured the day-long INHSU Prisons 4^th Annual Workshop, focused on work in carceral settings to scale up healthcare, implement strategies to reduce hepatitis C transmission, and advocacy strategies to advance health equity among incarcerated people.  

Dahdaleh Global Health Graduate Scholar Liam Michaud attended INHSU to present the findings of an interdisciplinary study evaluating Canada’s Prison Needle Exchange Program (PNEP), implemented in 2018 after years of civil society advocacy culminating in a lawsuit that was brought against the federal government and the Correctional Service of Canada, for failure to provide essential healthcare. The study's authors include Liam Michaud, Heino Stöver, Emily van der Meulen, Ann De Shalit, Sandra Ka Hon Chu, Rhiannon Thomas, and Jörg Pont. As of 2024, the PNEP is only available at eleven of forty-three federal prisons in Canada.

The legal basis for PNEP is rooted in international and domestic law, including the minimum standards on the treatment of prisoners (known as the Mandela rules). This legal framework emphasizes professionally accepted standards and equivalence of care relative to that which is offered in community settings.

Drug use prevalence in Canadian federal prisons is by any estimate very high, with estimates ranging as high as 70%. Prison needle syringe programs have existed since the early 1990s in roughly a dozen countries. Existing research confirms that such programs do not cause needle stick injuries, security incidents, that they result in reduced HIV and HCV incidence, and increase access to other healthcare.

An evaluation was conducted using realist review method, which integrates an assessment of efficacy with environmental or contextual factors that shape a given policy intervention, to examine access, uptake, and retention. The study included a policy scan of best practice documents, prevention guidelines, correctional policy, and documents gathered through Access-to-Information requests.

To briefly explain how the current PNEP operates:

• It is based on hand-to-hand and 1-for-1 exchange, rather than frequency of drug use, contrary to accepted professional standards.
• While the program is administered by healthcare staff, eligibility is determined by wardens using a threat risk assessment, undermining both confidentiality and the autonomy of prison healthcare staff.
• Correctional officers are responsible for compliance with program conditions, and sanctions are issued for non-compliance with program requirements, ranging from de-enrolment to loss of privileges.  

The study found that the Canadian model developed by the federal correctional service explicitly rejects and departs from expert recommendations, and professional standards of care. We found the program is heavily determined by security preoccupations, and as a result has had high rates of refusal, with more than a quarter of applicants deemed “ineligible”. The program is also characterized by extremely low uptake: multiple prisons had zero participants, and enrolment has remained at roughly 50 Canada-wide for the last 4 years, with enrolment particularly low in women’s prisons. The boundary between healthcare and security staff is also highly permeable, with healthcare staff employed by the prison and subject to dual loyalty.

Enrolment in the program exposes people in prison to both discretionary punishment and additional surveillance. Based on the findings from the study, a number of policy recommendations were issued, including the elimination of the Threat Risk Assessment, delegating penal healthcare provision from prison service to health authorities external to carceral authorities, and revising the prison service’s zero-tolerance drug policy to align with pragmatic, rights-based, and evidence-informed approaches to drug use.

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I am grateful to the Dahdaleh Institute for Global Health Research for their financial support that facilitated my attendance of INHSU 2024.

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