Prison settings

Harm reduction policies and practices help people who are using drugs to stay alive and protect them from HIV and Hepatitis C

Released ahead of International Harm Reduction Day - 7 May 2023

GENEVA, 5 May 2023—Many prison systems are struggling to cope, with overcrowding, inadequate resources, limited access to healthcare and other support services, violence and drug use. In 2021, the estimated numbers of people in prisons increased by 24% since the previous year to an estimated 10.8 million people, increasing the strain on already overstretched prison systems.   

Drug use is prevalent in prisons. UNAIDS Cosponsor, the United Nations Office on Drugs and Crime (UNODC), estimates that in some countries up to 50% of people in prisons use or inject drugs. Unsafe drug injecting practices are a major risk factor for the transmission of HIV and hepatitis C due to limited access to harm reduction services, including condoms, clean needles and syringes, and a lack of comprehensive drug treatment programs, particularly opioid agonist therapy.

People in prison are 7.2 times more likely to be living with HIV than adults in the general population. UNAIDS reports that HIV prevalence among people in prisons increased by 13% since 2017, reaching 4.3% in 2021. Although data are limited, it is thought that around one in four of the total prison population has hepatitis C.

“Access to healthcare, including harm reduction services, is a fundamental human right, and no one should be denied that right because they are incarcerated,” said Eamonn Murphy, UNAIDS Regional Director for Asia Pacific and Eastern Europe and Central Asia. “Prisons are too often ignored in countries' efforts to respond to HIV. A multisectoral, multifaceted approach is urgently needed to save lives, which includes access to clean needles and syringes, effective treatment for dependence on opioid drugs and reducing stigma and discrimination.”

Both drug use and HIV infection are more prevalent among women in prison than among imprisoned men. In particular, women who use drugs and sex workers are overrepresented in prisons. Highlighting the urgent need to scale up the implementation of community-led harm reduction services for women who use drugs and women in prison. 

Ms Ghada Waly, Executive Director of UNODC, said, “It is time to put compassion at the heart of our responses. To take a more serious look at de-penalization and alternatives to incarceration for minor drug offenses, focusing instead on treating and rehabilitating. To use a gender-sensitive lens when looking at women and girls who use drugs, and to ensure that they have equal access to treatment. To reach out to young people, who are using drugs more than ever before, understand their vulnerabilities to substance abuse, and help them be part of the solution. To stand with marginalized and vulnerable people, including people in prisons who are underserved by treatment programmes, and people who inject drugs, who are far more likely to be living with HIV, yet far less likely to access life-saving services”.

Among the countries reporting on prisons to UNAIDS in 2019, just 6 of 104 countries had needle and syringe programmes in at least one prison; only 20 of 102 countries had opioid substitution therapy programmes in at least one prison, 37 of 99 countries had condoms and lubricants in some prisons.

UNAIDS, UNODC, and WHO have long supported expanding harm reduction services to all prisons. However, according to Harm Reduction International, only 59 countries globally provide opioid agonist therapy in prisons.

Some countries have made huge progress in recent years. Despite the challenges faced by the influx of refugees and the repercussions of the war in Ukraine, Moldova, (which has an HIV prevalence of 3.2% in its prisons, compared to 0.4% among the general population) has committed significantly more resources into its prison systems.

In the early 2000’s few of its prisons provided harm reduction services. Today all of the country’s 17 penitentiaries provide harm reduction services including, methadone (an opioid agonist therapy), access to psychiatrists, doctors and treatment programmes, needle and syringe exchange and HIV prevention, testing, treatment and care.

Svetlana Plamadeala, UNAIDS Country Director in Moldova said, “It’s about putting people front and center, treating them as equals and taking on a solid, public health approach, grounded in human rights and evidence.”

UNAIDS, UNODC, UNFPA, WHO, ILO and UNDP recommend 15 comprehensive and essential interventions to save lives and ensure effective HIV programming in prisons. These include HIV prevention, testing and treatment, condoms, lubricant, opioid agonist therapy and post-exposure prophylaxis. However, this is only part of the solution. UNAIDS also recommends that countries amend their laws to decriminalize the possession of drugs for personal use.

UNAIDS has set ambitious targets for 2025 which include: 95% of people in prisons and other closed settings who know their HIV status, 95% who know their status are on treatment; and 95% on treatment are virally suppressed; 90% of prisoners used condoms at last sexual activity with a non-regular partner; 90% of prisoners who inject drugs used sterile needles and syringes at last injection; and that 100% of prisoners have regular access to appropriate health system or community-led services.

UNAIDS advocates that communities take an active role in planning, providing and monitoring HIV services. However, this is not always facilitated in prison settings. Without community engagement it will be impossible to reach the global AIDS targets.

For more information on Moldova’s work on HIV in prisons please read Moldova expands harm reduction services to all prisons and watch https://youtu.be/JQYtnsiJKs0

Fact sheet: UNAIDS Human rights fact sheet on HIV in prisons

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

“AIDS came to my door as a surprise. It all started in 1988, when my partner, Rafael, started to get sick. We were both 28 years old at the time,” said Georgina Gutiérrez, who has been a human rights activist for people living with HIV in Mexico for more than 30 years.

Today, she is a representative of the Mexican Movement for Positive Citizenship, which aims to promote the empowerment of people living with HIV in prison. She is also part of the Latin American and Caribbean Movement of Positive Women.

“In those years, stigma and discrimination were widespread. I knew about HIV only through television and many women who had HIV-positive partners assumed they were living with HIV without ever having been tested,” she said.

Her partner was imprisoned in Santa Martha Acatitla Penitentiary in Mexico City, where he spent eight years. This was when she got to know the reality inside prison, and it was this experience that would set the course of her life towards working with jailed people living with HIV.

“People living with HIV in prison are invisible to society. I remember many years ago, as a protest they would burn their mattresses, just to demand dignity in their access to HIV treatment,” Ms Gutiérrez recalled.

Ms Gutiérrez knew that there was a need for action to protect the physical and mental health of people living with HIV in prison. This is how she and others started a project against HIV and COVID-19 in the Santa Martha Acatitla Penitentiary.

The project is one of 30 initiatives selected from more than 190 applicants for the UNAIDS 2020 call for proposals for community-based organizations working on HIV in Latin America and the Caribbean that received funding. The project received an award of US$ 5000 to help its work.

The Santa Martha Acatitla Penitentiary houses around 2000 inmates, including 180 people living with HIV, some in the advanced stages of AIDS-related illnesses. People living with HIV are concentrated in Dormitory 10 in the prison.

“Dormitory 10 is overcrowded and physical distancing is difficult. Hygiene standards were low. In addition, most of them had not received COVID-19 personal protective equipment—the very few who were able to access such equipment did so through their families,” said Ms Gutiérrez.

In addition to the 180 people living with HIV in the prison, each of whom received personalized face coverings and other personal protective equipment and who attended a series of trainings, approximately another 1000 staff and inmates benefited from the project.

“I have been able to see them change. They have told me many times that they feel safer with the tools and knowledge they have gained,” said Ms Gutiérrez. “They feel good to know there are people concerned about them during this health crisis.”

“With our trainings and donations, the prisoners can now keep their rooms clean and can frequently wash their hands, clothes and personal belongings.” 

Working for HIV prevention is, “A commitment I have in every drop of my blood,” she said. “With these actions, we are giving life to forgotten people. I thank UNAIDS for financing this project—with it we are supporting a population that is being left behind.”

On any given day, approximately 11 million people worldwide are incarcerated. The risk of sexual violence among prisoners—and their inadequate access to condoms, lubricants, pre-exposure prophylaxis and harm reduction services—increases their chances of contracting HIV, hepatitis C and other sexually transmitted infections.

On any given day, approximately 11 million people worldwide are in confinement. Drug injection and sexual intercourse occur worldwide in prisons. The risk of sexual violence among prisoners—and their insufficient access to condoms, lubricants, pre-exposure prophylaxis and harm reduction services—heighten their chances of acquiring HIV, hepatitis C and sexually transmitted infections.

Among people who inject drugs, recent incarceration is associated with an 81% and 62% increased likelihood of HIV infection and hepatitis C infection, respectively.

Closed settings should, in theory, favour the delivery of effective testing and treatment services, although treatment interruptions and concerns about confidentiality and discrimination pose challenges. In 2019, 78 countries reported to UNAIDS that HIV testing was available at any time during detention or imprisonment, and 104 countries reported that antiretroviral therapy was available to all prisoners living with HIV. Coverage of antiretroviral therapy is good, although gaps remain.

The COVID-19 pandemic has affected everyone, including key populations at higher risk of HIV. And the gains made against other infectious diseases, including HIV, are at risk of being reversed as a result of disruptions caused by COVID-19. This is the background to a new report published by FHI 360, in collaboration with UNAIDS and the World Health Organization (WHO), which gives advice on how to minimize the impacts of COVID-19 on key populations.

“With a focus on key populations, this guidance complements ongoing efforts to sustain access to HIV prevention services and commodities, sexual health and family planning services, prevention of gender-based violence and HIV counselling, testing and treatment during the COVID-19 pandemic,” said Paula Munderi, Coordinator of the Global HIV Prevention Coalition at UNAIDS. “Preserving essential HIV services for key populations and promoting the safety and well-being of staff and community members during the COVID-19 pandemic is vital to maintaining the hard-fought gains of the AIDS response.”

With practical guidance on how to support the continuation of HIV services for people living with HIV and key populations, the report is aimed at helping the implementers of programmes to carry on their work.

“Key populations are particularly vulnerable to HIV service interruptions and additional harm during the COVID-19 pandemic. We urgently require rights-based solutions that maintain or increase key populations’ access to HIV services while minimizing potential exposure to COVID-19 and promoting individuals’ safety. These must support physical distancing and decongestion of health facilities, but in ways that respond to the current realities of key populations,” said Rose Wilcher, from FHI 360.

The report gives practical suggestions in three main areas.

The first is on protecting providers and community members from COVID-19. HIV services can only continue to be provided during the COVID-19 pandemic if steps are taken to prevent coronavirus infection among programme staff, providers and beneficiaries. Links to COVID-19-related screening and care, and services to support the mental well-being of providers and beneficiaries, can also be given as part of HIV services.

The second area is supporting safe and sustained access to HIV services and commodities. HIV programmes can integrate physical distancing measures, offer virtual consultations and give multimonth dispensing of HIV medicines. Physical peer outreach should be continued where possible.

Monitoring service continuity and improving outcomes is the third area covered by the report. Since there are likely to be service disruptions, HIV programmes will need to adjust their monitoring and evaluation systems in order to allow for regular assessments of continued HIV service delivery and of the impact of COVID-19 on HIV programmes and their beneficiaries. This may require setting up strategic information systems that use physical distancing measures such as virtual data collection and reporting tools.

“The COVID-19 pandemic shouldn’t be used as an excuse to slow momentum in the global response to HIV among key populations. Instead, the pandemic is a time to draw lessons from our work to end AIDS. It is also an opportunity to provide relief to health systems overstretched by COVID-19 by fully funding community-based organizations led by gay and bisexual men, people who use drugs, sex workers and transgender people to ensure improved access to HIV services for key populations,” said George Ayala, Executive Officer of MPact.

“It remains critical to ensure access to HIV prevention, testing and treatment services during COVID-19 and sustain access to life-saving services. This document provides practical guidance and know-how on maintaining essential health services for key populations in these challenging times,” said Annette Verster, the technical lead on key populations at the WHO Department of HIV, Hepatitis and STIs.

The report was developed by FHI 360 as part of the Meeting Targets and Maintaining Epidemic Control (EpiC) project, which is supported by USAID and the United States President’s Emergency Plan for AIDS Relief. UNAIDS, WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria and partners gave inputs and advice.

Signed by Ghada Fathi Waly, Executive Director, UNODC; Tedros Adhanom Ghebreyesus, Director-General, WHO; Winnie Byanyima, Executive Director, UNAIDS; Michelle Bachelet, United Nations High Commissioner for Human Rights. — * We thank UNDP for their contributions to this statement.

We, the leaders of global health, human rights and development institutions, come together to urgently draw the attention of political leaders to the heightened vulnerability of prisoners and other people deprived of liberty to the COVID-19 pandemic, and urge them to take all appropriate public health measures in respect of this vulnerable population that is part of our communities.

Acknowledging that the risk of introducing COVID-19 into prisons or other places of detention varies from country to country, we emphasize the need to minimize the occurrence of the disease in these settings and to guarantee that adequate preventive measures are in place to ensure a gender-responsive approach and preventing large outbreaks of COVID-19. We equally emphasize the need to establish an up-to-date coordination system that brings together health and justice sectors, keeps prison staff well-informed and guarantees that all human rights in these settings are respected.

Reduce overcrowding

In the light of overcrowding in many places of detention, which undermines hygiene, health, safety and human dignity, a health response to COVID-19 in closed settings alone is insufficient. Overcrowding constitutes an insurmountable obstacle for preventing, preparing for or responding to COVID-19.

We urge political leaders to consider limiting the deprivation of liberty, including pretrial detention, to a measure of last resort, particularly in the case of overcrowding, and to enhance efforts to resort to non-custodial measures. These efforts should encompass release mechanisms for people at particular risk of COVID-19, such as older people and people with pre-existing health conditions, as well as other people who could be released without compromising public safety, such as those sentenced for minor, non-violent offences, with specific consideration given to women and children.

A swift and firm response aimed at ensuring healthy and safe custody, and reducing overcrowding, is essential to mitigate the risk of COVID-19 entering and spreading in prisons and other places of deprivation of liberty. Increasing cleanliness and hygiene in places of deprivation of liberty is paramount in order to prevent the entry of, or to limit the spread of, the virus.

Compulsory detention and rehabilitation centres, where people suspected of using drugs or engaging in sex work are detained, without due process, in the name of treatment or rehabilitation should be closed. There is no evidence that such centres are effective in the treatment of drug dependence or rehabilitation of people and the detention of people in such facilities raises human rights issues and threatens the health of detainees, increasing the risks of COVID-19 outbreaks.

Ensuring health, safety and human dignity

All states are required to ensure not only the security, but also the health, safety and human dignity, of people deprived of their liberty and of people working in places of detention at all times. This obligation applies irrespective of any state of emergency.

Decent living and working conditions as well as access to necessary health services free of charge form intrinsic elements of this obligation. There must be no discrimination on the basis of the legal or any other status of people deprived of their liberty. Health care in prisons, including preventive, supportive and curative care, should be of the highest quality possible, at least equivalent to that provided in the community. Priority responses to COVID-19 currently implemented in the community, such as hand hygiene and physical distancing, are often severely restricted or not possible in closed settings.

Ensuring access to continued health services

Prison populations have an overrepresentation of people with substance use disorders, HIV, tuberculosis (TB) and hepatitis B and C compared to the general population. The rate of infection of diseases in such a confined population is also higher than among the general population. Beyond the normal infectivity of the COVID-19 pandemic, people with substance use disorders, HIV, hepatitis and TB may be at increased risk of complications from COVID-19.

To ensure that the benefits of treatments started before or during imprisonment are not lost, provisions must be made, in close collaboration with public health authorities, to allow people to continue their treatments without interruption at all stages of detention and upon release. Countries should embrace a health systems approach, where prisons are not separated from the continuity-of-care pathway but integrated with community health services.

Enhancing prevention and control measures in closed settings as well as increasing access to quality health services, including uninterrupted access to the prevention and treatment of HIV, TB, hepatitis and opioid dependence, are therefore required. Authorities must ensure uninterrupted access and flow of quality health commodities to prisons and other places of detention. Staff, health-care professionals and service providers working in closed settings should be recognized as a crucial workforce for responding to the COVID-19 pandemic and receive appropriate personal protective equipment and support as necessary.

Respect human rights

In their responses to COVID-19 in closed settings, states must respect the human rights of people deprived of their liberty. Restrictions that may be imposed must be necessary, evidence-informed, proportionate (i.e. the least restrictive option) and non-arbitrary. The disruptive impact of such measures should be actively mitigated, such as through enhanced access to telephones or digital communications if visits are limited. Certain fundamental rights of people deprived of their liberty and corresponding safeguards, including the right to legal representation, as well as the access of external inspection bodies to places of deprivation of liberty, must continue to be fully respected.

Adhere to United Nations rules and guidance

We urge political leaders to ensure that COVID-19 preparedness and responses in closed settings are identified and implemented in line with fundamental human rights, are guided by World Health Organization (WHO) guidance and recommendations and never amount to torture and other cruel, inhuman or degrading treatment or punishment. In prisons, any intervention should comply with the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules).

People deprived of their liberty exhibiting symptoms of COVID-19 or who have tested positive should be monitored and treated in line with the most recent WHO guidelines and recommendations. Prisons and other places of detention must be part of national COVID-19 plans with dedicated participation of affected populations. All cases of COVID-19 in closed settings should be notified to responsible public health authorities, who will then report to national and international authorities.

In line with our mandates, we remain available to provide support in the rapid deployment of the recommendations outlined above.

This document is available in Arabic, Chinese, French, Portuguese, Russian and Spanish. 

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Environmental, social, cultural, human rights and biological factors all lead to a greatly increased risk of contracting tuberculosis and HIV in prisons.

Risk behaviours such as sharing of used needles and syringes, unprotected sex, sexual violence and lack of access to comprehensive HIV prevention and harm reduction services put people in prisons at heightened risk of HIV and other infections. Globally, HIV prevalence among people in prison is much higher than among the general population, with incarcerated people on average five times more likely to be living with HIV compared with adults outside. Key populations―people who inject drugs, sex workers and, in some countries, transgender people and gay men and other men who have sex men―tend to be overrepresented among incarcerated populations.

Despite the relative ease of reaching people within prisons, HIV services are not provided in prisons in many countries. Across the last three years of country reports to UNAIDS, very few countries reported programme data on the provision of condoms (32 countries), opioid substitution therapy (24 countries) and sterile injecting equipment (three countries) in prisons, but 74 countries reported programme data on antiretroviral therapy coverage and 83 countries reported HIV testing in prisons.