Key issues for implementation of needle exchange programmes in prisons. SPAIN

Ministry of the interior: Directorate General for Prisons

Ministry of health and consumer affairs: Secretariat of the National AIDS Plan

Document revised and approved by the WORKING GROUP ON NEEDLE EXCHANGE PROGRAMMES IN PRISON

Members:

Lázaro Elizalde Soto. AIDS Plan for Navarre

Victor Fernández de Larrainoa Palacios. Basauri (Bilbao) Prison

Luis García Marcos. Orense Prison

Miguel García Villanueva. Pamplona Prison

Mercedes Marina Ortega. Martutene (San Sebastián) Prison

Cristina Menoyo Monasterio. Plan for AIDS Prevention and Control in the Basque Country

Alfredo Rubio Sanz. Plan for AIDS Prevention and Control in Andalusia

José Antonio Taboada Rodríguez. AIDS Plan for Galicia

José Veiras Vicente. Tenerife II Prison

Ángela Bolea Laguarta. Secretariat of the National AIDS Plan

Mónica Suárez Cardona. Secretariat of the National AIDS Plan

Coordination:

Juan Antonio López Blanco. Subdirectorate General for Prison Health

Francisco Parras Vázquez. Secretary of the National AIDS Plan

Daniel Zulaika Aristi. Plan for AIDS Prevention and Control in the Basque Country

DRAFTING GROUP:

Cristina Menoyo Monasterio. Plan for AIDS Prevention and Control in the Basque Country

Lázaro Elizalde Soto. AIDS Plan for Navarre

Miguel García Villanueva. Pamplona Prison

Juan Antonio López Blanco. Subdirectorate General for Prison Health

Ángela Bolea Laguarta. Secretariat of the National AIDS Plan

Mónica Suárez Cardona. Secretariat of the National AIDS Plan

INTRODUCTION

The risk of suffering infections (hepatitis B and C, HIV, abscesses, candidiasis, etc.) as a result of the shared use of injection material and drug use in unhealthy conditions is very high amongst injecting drug users (IDUs). In Spain a number of studies conducted on IDU populations find a 30-54% prevalence of HIV infection and much higher of hepatitis C. The percentage of cases of AIDS in IDUs declared to the National Register of Cases exceeds 60%.

Over 50% of the people who go into prison report a history of drug use and almost half of them do so by means of IV injection. Despite the measures adopted by the institutions to try and stop drugs getting in, along with the extension of drug addiction care services to all prisons, ranging from drug-free to methadone maintenance programmes, many IDUs manage to go on consuming on the inside. In a closed medium like prisons, the lack of access to sterile needles and syringes increases the probability of their being re-used and shared. In these circumstances the hepatitis viruses and HIV find the way paved for easy propagation.

In accordance with their function of safeguarding the life, integrity and health of the persons in their charge, the Prison System has to assure inmates of access to the same therapies and means of prevention available to the rest of the community. In 1993 the World Health Organization and the Council of Europe issued recommendations in relation to HIV/AIDS in prisons which stated expressly that "in countries where sterile needles and syringes are available for injecting drug users in the community, the possibility of providing prisoners who so request with sterile injection kits should be considered.....". The degree of application of this guideline had been limited everywhere on the grounds of the alleged illegality and hazard of this measure.

In Spain the first needle exchange programme (NEP) was introduced at Basauri Prison (Bilbao) in July 1997 and stemmed from a Basque Parliament green paper. This programme was planned on a pilot basis in order to verify its feasibility and its impact on security and/or other activities at the institution. Its design, monitoring and evaluation have therefore been very stringent. A year later a second pilot project was started up in Pamplona as a result of the proposal of a Joint Working Committee between the Health and Prisons Departments, with a methodology similar to the earlier one. After two and one year, respectively, since their outset, the results of the evaluation in both cases leave no doubt as to their feasibility and effectiveness, without any impairment of prison security. By February 2000 there were already five NEPs in prisons and they are planned to be extended to other penitentiary institutions in the near future.

At the end of 1999 a joint Working Group Party was set up at the Secretariat of the National AIDS Plan together with the Directorate General for Prisons and a number of Autonomous Communities , in order to promote the development of these programmes. An outcome of the efforts of this Working Group Party is this document, which has the basic aim of harmonising the implementation conditions and the criteria of action and evaluation indicators of the NEPs started up at Spanish prisons. The document sets out to be a useful framework for professionals responsible for implementing these programmes, which will in any case have to be tailored to the specific features and needs of individual prisons.

Publisher's note: Spain is made up of 17 regions called autonomous communities and of two autonomous cities. Regional or autonomous community governments have wide powers in the field of public health. In prison matters, however, only one autonomous community has had powers devolved to date.

BACKGROUND

Special conditions arise in the prison environment that propitiate the spread of infections among injecting drug users: high prevalence of HIV, HBV and HCV, limited access to sterile injection material, and high probability of repeated and shared use of the scarce material available. Harm reduction programmes for drug users aim to minimise the adverse effects for individual and collective health.

Persons deprived of their freedom are entitled to the same therapies and preventive programmes available on the outside. The "Global Substance Dependence Intervention Policy", which lays down the strategies for prevention and treatment of substance dependences in prison, envisages risk reduction programmes amongst its measures.

Needle Exchange Programmes (hereinafter referred to as NEPs) form part of this harm reduction strategy and numerous studies have shown that they successfully modify the risk practices directly connected with drug injection - particularly the shared use of syringes - and are therefore effective in lowering the risk of transmitting infections.

Appraisal of the results of a pilot needle exchange project at a Swiss prison (Hindelbank) and another two at Spanish prisons (Basauri and Pamplona) have revealed the feasibility and effectiveness of these programmes.

OBJECTIVES

The aim of Needle Exchange Programmes is primarily to preserve and improve the health level of the population. They are therefore just another aspect of government policy in the field of health and substance dependence.

Their objectives are:

General objectives: Reduce infection by HIV and other pathogenic viruses associated with drug injection in the IDU prison population by means of preventing the shared use of needles and syringes.
Specific objectives:
- Facilitate access to the largest number of injecting drug users who do not join other drug dependence treatment programmes implemented in the prison environment.
- Reduce the number of circulating syringes and needles contaminated by HIV and other pathogenic germs in the prison
- Promote the adoption of healthy behaviour patterns and modification of risky sexual and injection practices by means of information, health education, advice and motivation of IDUs attending the programme.
- Provide IDUs in prison with ready access to the same preventive measures available to injecting drug users in the community.
- Obtain valid information about the needs and demands of the drug users in prison.

REQUIREMENTS FOR THE IMPLEMENTATION OF A NEEDLE EXCHANGE PROGRAMME IN PRISON

The only essential requirement to implement a NEP in a given prison is the presence in the institution of present or past intravenous drug users. Those institutions that do not consider it necessary to offer programmes of this type should make appropriate arrangements to provide those inmates who may eventually so request with access to sterile injection material.

Prison legislation does not refer anywhere specifically to syringes or other instruments used for drug administration. The ban on needles and syringes is controlled by internal rules drawn up by the Board of Directors of each institution and approved by the Directorate General for Prisons.

Before starting the programme it is essential to amend the internal rules and specifically permit possession of syringes under the conditions set forth in the programme. The possession and consumption of toxic substances and/or narcotics will continue to be forbidden, inasmuch as they are governed by the Prison Act (art. 22) and the Prison Regulations (art. 51), while possession remains a serious offence.

Cooperation and coordination, not only between the prison staff but also with other institutions, are absolutely essential for the proper development of the NEP. The support of the prison authorities and cooperation of the officers are key factors for the success of the programme.

PROGRAMME COORDINATION AND MONITORING COMMITTEE

The first step for the start-up of a programme of these characteristics will be to establish contact with the institutions of the Autonomous Community responsible for supporting and collaborating in the implementation and development of the NEP. A committee or working party will be set up with the following tasks:

Promoting the development of the programme.
Deciding on the composition of the drafting team responsible for writing up the project.
Deciding on the composition and profile of the team for implementing the NEP.
Mobilising the necessary resources to implement the programme and identifying the contributions to it of each one of the parties involved.
Designing the methods and/or persons responsible for evaluating the project.
Monitoring the programme.
Defining how to deal with the programme with regard to the mass media and relations with them, as well as establishing methods, times and channels of dissemination of information on the programme.

It is considered that the following should be represented on this committee:

The governor of the prison.
The Office of the assistant medical director of the prison.
The Office of the assistant correctional treatment director.
The Autonomous Community AIDS Plan.
The Autonomous Community Drugs Plan.
The Subdirectorate General for Prison Health.
The prison magistrate.
The Ombudsman or his Autonomous Community counterpart.

Once the team for evaluating and implementing the programme has been decided, a representative of each should be included in this committee.

Publisher's note: Like the treatment team mentioned below, the Office of the assistant correctional treatment director refers to the personnel responsible for the inmate's re-education and re-integration, for prison grade classification, and for granting leaves.

PROJECT PREPARATION TEAM

A drafting group should be set up with the job of establishing the programme procedural methodology and criteria. The composition of this team will be based on the proposal of the Programme Coordination and Monitoring Committee.

This team should be composed of at least one representative of:

The prison governor
The prison health team
The correctional treatment team
The prison warders
The Autonomous Community Directorate General for Public Health
The Autonomous Community AIDS Plan
Other institutions or groups which are considered should be represented

It would also be advisable if this group included a representative of the teams or NGOs working on the prison drug treatment programmes and a representative of the potential clients of the NEP. In any case, it would be advisable to obtain their report or contributions on the subject.

DEFINITION OF THE PROGRAMME

The criteria and rules for operation of the NEP should be tailored in every case to the needs and features of each particular prison.

Before defining the methodology of the programme a prior analysis should be made of the situation and specific needs of the institution, which will make it possible to estimate the frequency, patterns of use and type of substances consumed, as well as to learn the opinions and attitudes of the actual inmates and staff of the prison with regard to the possible introduction of the programme. This information should be collected on an anonymous basis and preferably through a survey by means of a structured questionnaire, the results of which will also act as the starting point (time 0; see programme evaluation section) for evaluating the possible changes once the programme is under way.

Programme operating criteria
The programme should define its rules of operation precisely, which should be agreed and approved by the Programme Coordination and Monitoring Committee, and distributed to all the parties involved: prison officers, inmates, NEP implementation team or others.

The rules should be defined taking into account that the main aim of the programme is that the largest number possible of injecting drug users should have sterile syringes at the time that they may need them and that the confidentiality of users has to be assured.

The project should clearly define the following aspects:

Type of programme: With human resources, with mechanical means (syringe and needle exchange machines) or mixed

The NEPs that employ human resources are preferable to those using only mechanical means through permitting personalized contact, which helps the aims of the programme to be achieved. For the moment there is no NEP experience in prison with machines in Spain, although they may be a valid alternative. Their main advantage is anonymity.

Location and operating hours: Both are key factors for the success of the programme. Selection of the location and hours when exchange is to take place should comply with the following criteria:
- Assure inmates of maximum physical, psychological (a discreet place that does not give the inmate the feeling of being watched, that does not give rise to apprehension, where transit is not solely for the programme.....) and time accessibility.
- Be tailored to the activities and physical structure of the institution.
Exchange criteria: The operating rules should be clear and easy to understand. Althoug hexchange should take precedence over supply under the programme, an open flexible attitude should be maintained in accordance with the specific needs or demands that may arise at a given time for better achievement of aims and to assist adherence to the programme. Motivation and education of the user are preferable to punitive measures.

Exchange material and other accessory items: The material supplied under the NEP should be tailored to the circumstances of every prison and should be in line with the substances most widely consumed, the NEP operating days and other particular features of the institution. On the basis of this, the committee should decide whether to provide syringes of only one or of two types, syringes alone or included in a kit (which in turn may include one or two syringes), with or without other accessories (paper tissues, distilled water, informative leaflet, condoms.....), containers or other items. In any case, the syringes should always be included in a rigid pack.

Other services of the programme: The NEP should not be confined to the mere supply/exchange of syringes. Personalized contact with the user will enable the professionals of the programme execution team to: a) carry on health education actions with the users so as to instruct and motivate them to adopt safer sexual and injection practices and b) encourage them to join other drug dependence care and treatment programmes in operation at the institution

Person responsible for the programme: It is important that there should be a person who coordinates the courses of action to be undertaken inside the institution and who, at least on a functional basis, acts as the sole reference in the prison both for inmates and for other prison staff for the operational aspects of the programme.
Target population and conditions of access to the programme.
In general terms, any inmate of the prison is to be considered a potential beneficiary of NEP, unless logistic reasons make it advisable at any time to restrict the programme to one part of the population or to one of the modules. Inmates may join the exchange programme freely.

The project should lay down the conditions for joining the exchange programme for the first time (e.g., request for the first kit/syringe for exchange from the medical team or directly from the team responsible for NEP, supply of a programme kit/syringe to newly committed IDUs so requesting at the time of being informed of the programme). Their actual identification particulars should not be asked for, but an identification code or key must be used, possibly supplied by the subject himself, for purposes of evaluation and monitoring of the programme (not of the individual).

Users who join the exchange programme must undertake to observe the operating and time rules laid down, take care of facilities and behave properly towards professionals of the team in charge.
1. Rules and conditions of possession of material
2. Permission will only given for syringes obtained under the NEP. The programme should clearly determine under what conditions, in what number and at what places (specify the specific spot in the cell) the inmates will be permitted to have them in their possession. The rules should also be specified in case of leave, interprison transfers, contact visits and exits from the prison. In the event of being searched, the inmate should advise the officer of the fact that he has a syringe.
  
  As a rule, syringes should always remain in their pack, both when the inmate has them on him and when they are left in the cell. To assist identification of syringes as being from the NEP, it is recommended for them to be put into a specific programme container.
  
  A specific reminder should be given that possession, traffic and use of toxic substances, narcotics and non-prescribed psychotropics continue to be forbidden.
  
  Warders should be well informed of these rules and of others connected with the operation of the programme to prevent possible misunderstandings.
Team responsible for the conduct of the programme
Whatever the initial composition of the team, the tendency should be to phase in the NEPs and gradually turn them into a normal activity to be carried on by the prison medical and/or drug treatment teams.
The team carrying out the programme may be a team made up of prison staff, an external team or a combination of both. The most important thing is that they should enjoy a suitable level of trust by the inmates. If based on an external team, this should be made up of personnel accustomed to working with drug addicts in prison, with experience of harm reduction programmes and who are trusted by the inmates. At least one member of the team should also form part of the Programme Coordination and Monitoring Committee.

The functions of the programme operational team and the mechanisms of cooperation between it and the other prison staff should be clearly defined in the project that is drawn up.
Programme evaluation
The evaluation team should include professionals external to the NEP and the prison with experience in evaluating. This team shall be responsible for laying down the phases, the methodology and the evaluation tools, for analyzing the results obtained, and for writing up the respective reports, which shall be submitted to the Programme Coordination and Monitoring Committee.

The systems for recording activity and identification of the users, methodology and evaluation indicators must be defined right from the outset.

As for the subject matter of evaluation, besides the activity and effectiveness of the programme other aspects should be evaluated relating to the attitudes and opinions of the users and professionals with regard to the programme and to the actual methodology used, which may have or positive or negative effects on the attainment of the aims proposed.

Irrespective of other specific objectives which may be set at each prison, in order to have comparable information for all the programmes implemented, the following indicators are proposed:
1. Programme activity indicators: The team responsible for carrying out the NEP should collect, on a daily basis, at least the following indicators:
  - Number of different persons using the exchange service
  - Number of exchange services carried out
  - Number of kits/syringes supplied by the programme
  - Number of syringes returned to the programme
2. This information will enable statistics and indicators (average number of exchanges/day or month, percentage of used syringes returned, etc.) to be compiled on a monthly, quarterly and yearly basis or any other that may be of interest.
3. Indicators of programme outcome, change in risk behaviour and frequency of drug use associated conditions in the prison population.
4. They will include, at least:
  - Percentage of IDUs who have borrowed syringes previously used by others in the last 30 days.
  - Percentage of IDUs who have lent their used syringes in the last 30 days.
  - Percentage of IDUs who have consumed heroin in the last 30 days.
  - Percentage of IDUs who have consumed cocaine in the last 30 days.
  - Percentage of IDUs who have consumed IV heroin in the last 30 days.
  - Percentage of IDUs who have consumed IV cocaine in the last 30 days.
  - Incidence and/or prevalence of IV drug use associated conditions (hepatitis B/C, HIV, endocarditis, phlebitis).
  Information should also be collected on the number of NEP users who join other prison drug treatment programmes.
5. Attitudes and opinions with regard to the programme: Level of satisfaction with it, with its methodology of action (hours, location, rules....), with the team responsible for carrying it out, favourable and unfavourable effects of the NEP in relation to prison security and relations between inmates, and between inmates and staff, level of information on the programme, etc.
6. This information should be collected both from inmates and from prison officers.
7. It may also be important to collect information on the number of penalties connected with the programme.
8. The information obtained in this way should help to remedy shortcomings observed and enable the programme methodology to be improved and brought into line with the needs detected.
  
  The activity indicators should be collected daily by the team responsible for implementing the NEP.
  
  The outcome and attitude indicators should be obtained by anonymous surveys to be conducted by the programme evaluation team, at the following times: before starting the programme (time 0), after the NEP has been in operation for three (time 1), six (time 2) and twelve months (time 3) during its first year. Afterwards, these indicators should be collected on a yearly basis.
  
  The evaluation at the different times gives rise to differentiated reports by the evaluation team, which should be submitted to the Programme Coordination and Monitoring Committee, which will be responsible for their dissemination via the channels and at the times specified.
Programme budget
The project should include a budget itemizing the personnel, medical devices, evaluation or other costs relating to the start-up of the exchange programme and specifying in each case the organization/institution responsible for financing.

INFORMATION ON THE PROGRAMME

Informing the whole population of the prison, both inmates and staff, of the future implementation of the programme and of its aims and methodology of action is crucial for securing its acceptance and proper operation.

The project drafting team shall be responsible for defining the times, the persons in charge, and the most appropriate methods and subject matter of the information.

It is essential that all inmates, all newly committed inmates and all the prison staff should be aware of the programme, its aims and working methods and the conditions for joining it. To this end, the preparation of back-up material (leaflets, posters, and so on) proves very useful. The communication media available at the prison (newsletters, radio stations, local TV channels or others) may also be used as tools for disseminating information on the programme.

As general criteria:

Before starting the programme, both the inmates and the prison staff should be informed on an individual basis and in small groups.
Subsequent to its start-up, updated information should be given on it at the times considered necessary.

At least during the first months the programme is in operation it is also important to give specific information on the NEP to the prison warders. Once the programme is firmly established, it is wise to keep them informed through meetings, ongoing training courses or other means.

The Programme Coordination and Monitoring Commmittee shall be responsible for institutional and media information.

REFERENCES

Hartgers, C., Buning, EC., Van Santen, GW., Verster, AD., Coutinho, RA. Impact of the needle and syringe-exchange programme in Amsterdam in injecting risk behaviour. AIDS 1989; 3: 571-576.
Stimson, GV. Syringe-exchange programmes for injecting drug users. AIDS 1989; 3:253-260).
World Health Organization. WHO guidelines on HIV infection and AIDS in prisons. Geneva, 1993.
Council of Europe. Recommendation no. R (93) 6 of the Council of Ministries of Member States on the prison and criminological aspects of communicable disease control, especially AIDS, and on related issues of health in prisons. Strasbourg, 1993.
Lurie, P., Reingold, AL., Bowser, B., et al. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Summary, Conclusions and Recommendations. Atlanta: Centers for Disease Control and Prevention. 1993.
Kaplan, EH., Khoshnood, K and Heimer, R. A decline in HIV infected needles returned to New Haven's Needle Exchange Programme: Client shift or needle exchange?. Am J Public Health 1994; 84:1991-1994.
Ameijden, JC., Watters, JK., van den Hoek, JA., Coutinho, RA. Interventions among injecting drug users: do they work?. AIDS 1995; 9 (Suppl A): S75-S84.
Project-pilote de prévention du sida dans les établissements pénitentiaires de Hindelbank. Rapport final á I'attention de l'Office fédéral de la santé publique. Berne, september 1995.
Nelles J., Harding H. Preventing HIV transmission: a tale of medical disobedience and Swiss pragmatism. The Lancet 1995; 346:1507.
Guía para la puesta en marcha de programas de intercambio de jeringuillas. Secretaría del Plan Nacional sobre sida. Ministerio de Sanidad y Consumo, 1996.
Dirección General de Instituciones Penitenciarias del Ministerio del Interior. Memoria de actividades de la Subdirección General de Sanidad Penitenciaria de 1998.
El programa de intercambio de jeringuillas en la prisión de Basauri: 2 años de experiencia. Co-publishers: Dirección General de Instituciones Penitenciarias (Ministerio del Interior), Plan Nacional sobre Sida (Ministerio de Sanidad y Consumo) and Departamento de Justicia, Economía, Trabajo y Seguridad Social (Basque Government). 1999.

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