Overview of availability of harm reduction interventions in European prisons

Abstract Introduction Prisons are high-risk environments for the transmission of drug related infections, due to over-incarceration of people who inject drugs; often inadequate healthcare, substandard prison conditions; and others. An overview of the availability and coverage of prison-based harm reduction interventions in Europe is presented. Methods National Focal Points of the EMCDDA (30) collected 2019 data, which were integrated with findings from the European funded project HA-REACT (Joint Action on HIV and Co-infection Prevention and Harm Reduction). Results Prison based harm reduction interventions are available in European countries, but only few of them are available in most countries and often with a low coverage (e.g. less than 10% of prison population in Opioid Substitution Treatment (OST) in most countries). Interventions available in most countries (20 or more) include: HIV, HBV, HCV testing (29), OST continued from community (29), Referral to HIV treatment upon release (28), HIV treatment (27), Referral to HCV treatment upon release (25), HCV antiviral treatment (25), Testing for TB (23), HBV antiviral therapy (25), OST initiated in prison (22), Treatment for TB (21), Vaccination for HBV (20). Interventions available in 10 to 19 countries are: condom distribution (19), OST (re)initiated before release (17), prison/community guidelines for implementation of OST (13). Interventions provided in < 10 countries include: distribution of disinfectant (9), condom with lubricant (9), take-home naloxone (5), needles and syringes programs (3). Conclusions Compared to the community, the availability and coverage of harm reduction interventions in European prisons are limited and large information gaps exist. Scaling up harm reduction in prison can achieve important individual and public-health benefits.


Introduction:
The WHO Prison Health Framework was developed to assess prison health system performance and support Member States (MS) in improving their prison health systems. Moreover, it shall enhance MS capacity to evaluate: the impact of changes in governance models, progress in service provision and improvements of the health status of people in prison (PiP).

Methods:
The framework informed the 2021 data collection round of the Health In Prisons European Database Survey. Invitations were sent to all 53 MS of the WHO European Region. Those MS nominating a focal point and providing valid answers were included in the analysis. Results: Answers were obtained from 36 MS, representing a total of 613,497 PiP. Access to immunization was very good across all MS, with the highest for COVID-19 (90% of MS provide it in all prisons). Vaccination against HBV was only available in all prisons of 25 MS. Access in all prisons to HIV post and PrEP were reported, respectively, by 78% and 58% of MS. Screening for diseases at entrance was common for HIV, HCV and HBV. In all prisons of 35 MS soap was provided for free, while needles & syringes and lubricants were only provided free of charge, respectively, in 3 and 4 MS. 5 MS did not have therapeutic spaces to tackle drug problems in any prison, in 73% of those having, accessibility was restricted to some prisons. HIV prevalence ranged from 0-16% and treatment was accessible to 55-100% of those diagnosed. Prevalence of HCV ranged from 0-34%, with access to treatment ranging from 0-91%. The most common format of health records in European prisons was paper based (44%).

Conclusions:
Prison-based data collection systems resulted in limited capacity for extraction so that some countries were unable to provide any data on disease prevalence or treatments offered. Given the scarcity of data on this topic obtained from realworld and not from ad-hoc studies, this snapshot provides an important contribution to public health.

Introduction:
Prisons are high-risk environments for the transmission of drug related infections, due to over-incarceration of people who inject drugs; often inadequate healthcare, substandard prison conditions; and others. An overview of the availability and coverage of prison-based harm reduction interventions in Europe is presented. Methods: National Focal Points of the EMCDDA (30) collected 2019 data, which were integrated with findings from the European funded project HA-REACT (Joint Action on HIV and Coinfection Prevention and Harm Reduction).

Results:
Prison based harm reduction interventions are available in European countries, but only few of them are available in most countries and often with a low coverage (e.g. less than 10% of prison population in Opioid Substitution Treatment (OST) in most countries). Interventions available in most countries (20 or more) include: HIV, HBV, HCV testing (29), OST continued from community (29), Referral to HIV treatment upon release (28), HIV treatment (27), Referral to HCV treatment upon release (25), HCV antiviral treatment (25), Testing for TB (23), HBV antiviral therapy (25), OST initiated in prison (22), Treatment for TB (21), Vaccination for HBV (20). Interventions available in 10 to 19 countries are: condom distribution (19), OST (re)initiated before release (17), prison/ community guidelines for implementation of OST (13).

Introduction:
Coverage of essential prevention and control services and adequate monitoring schemes for viral hepatitis are often suboptimal in prison settings. Yet, evidence shows that targeted interventions are feasible and effective in reducing viral hepatitis burden and decreasing virus circulation among people living in prison and the community at large. To promote transferability and improvement of prison health quality in EU/EEA the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) will identify and disseminate models of care for viral hepatitis elimination in prisons.

Methods:
The models of care were gathered using a data collection tool that has been designed for this purpose based on the literature review and agreed with an expert advisory group. Based on the results of the data collection, a survey for healthcare staff working in 5 selected prison institutions in the EU/EEA has been developed.

Results:
The following models of care were collected: HCV microelimination in prison; transitional care for HCV treatment or HBV prevention/treatment; HCV or HBV care services tailored to women living in prison; HBV or HAV/HBV vaccination in prison settings. Harm reduction and drug treatment services in the prison are essential at all steps of the prevention and continuum of care. Among barriers identified were: engagement of people living in prison and prison governance structure, availability of infrastructural and human resources, daily prison organisation, inter-sectorial collaboration within prison and between prison and community services, training for prison staff and lack of systematic monitoring.

Conclusions:
Evidence of effective and acceptable interventions in prison to prevent and control viral hepatitis is essential to foster inclusion of prison setting within national elimination programmes. Intra-EU benchmarking may help promote awareness, to allocate adequate resources, monitor of impact and ultimately the achievement of the elimination goal.

Introduction:
Vaccinations are one of the most powerful preventive tools discovered by modern medicine. Although expanded programmes of immunization are well established in EU/EEA, significant immunity gaps and suboptimal coverage are registered among specific populations, including people living in prisons (PLP). PLP are also at increased risk to vaccine-preventable diseases (VPD) with potential outbreak in prison, e.g. flu, COVID-19, as well as other VPDs such as HBV. The EU-funded project RISE-Vac, aimed at collecting models of care developed during the pandemic to design tailored vaccine delivery strategies that could be extended beyond the sole COVID-19 vaccine.

Methods:
Through a survey to healthcare staff working in prisons in six countries of the EU/EEA (Cyprus, France, Germany, Italy, Moldova, UK) we collected information on the implementation of COVID-19 vaccination program. The following areas were investigated: challenges & barriers encountered, workload distribution, education & training activities for prison staff and PLP, referral strategies after release, immunization information system.

Results:
The respondents reported that in prisons COVID-19 programs have been implemented efficiently. Strategies for optimal management of the vaccination campaign included: week-day dedicated to vaccination services when vaccines were delivered and immediately administered to overcome cold chain challenges; new staff recruitment & task shifting; administration of booster doses within prison premises for released individuals; distribution of informational material both to PLP & prison staff.

Conclusions:
Our results show that universal immunisation campaigns are feasible, acceptable and effective in places of detention when there is commitment to implementing them. Evidence from the pandemic situation may inform future provision of expanded immunization programmes.