Despite States obligations to protect the right to health of people who use drugs deprived of liberty (clearly recognised by OHCHR, WHO, UNAIDS, and UNODC, among others), and in disregard of the severe health risks that closed settings entail for people who use drugs, the Global State of Harm Reduction 2022 (GSHR)  and its updated report, reveal that people in prisons are still severely underserved by harm reduction services, showing little expansion since 2020. Only 59 countries globally – with no expansion from 2020 – provide Opioid Agonist Therapy (OAT) in at least one prison. While OAT programmes are now operating in prisons in Kosovo, Macau, and Tanzania, this is balanced by new data indicating that prisons in Georgia, Hungary and Jordan only offer opioid agonists for detoxification purposes. The scenario is even worse when it comes to the provision of Needle and Syringe Programmes (NSPs), with only 10 countries in the world operating NSPs in at least one prison. There are no NSPs, OAT or naloxone programmes in prisons in Latin America and West Central Africa. Canada has the only world’s prison-based drug consumption room (DCR).

Incarceration thus represents a significant barrier to accessing essential harm reduction services. This emerged even more clearly during the COVID-19 pandemic, illustrating how pandemics and other health emergencies can disproportionately impact access to health for people deprived of liberty. Despite limited data on COVID-19 prevalence among people who use drugs, evidence indicates that this population, particularly people who inject or smoke, face more significant risks of infection and elevated risk of adverse outcomes if contracting the virus compared to the general population, associated – among others – with pulmonary and respiratory complications, and compromised immune system as a consequence of the prolonged drug consumption. Additionally, people who inject drugs can have underlying medical conditions that increase the risk of COVID-19 and other infectious diseases, such as HIV, viral hepatitis, and tuberculosis.

This health risk are often compounded when the person faces incarceration. Prisons are high-risk environments for the transmission of diseases due to overcrowding, limited access to clean water and inadequate sanitary conditions, lack of healthcare and access to good-quality food, and mistreatment of people in detention, to name a few. Additionally, the over-representation of vulnerable groups, such as people who use drugs, means many people in prison are at higher risk of becoming seriously ill if contracting a disease. Evidence shows that sharing injecting equipment – a common practice in prison – has been linked to outbreaks of HIV in prisons in Iran, Lithuania, Thailand, the United Kingdom, and Ukraine. Globally, the prison population is 7.2 times more likely to be living with HIV than those in the broader community, with 3.2% of prisoners living with HIV and 15.1% living with hepatitis C. People in prison are also disproportionately vulnerable to overdose, both during their sentence and immediately after their release. Male and female prisoners are 19 and 69 times, respectively, more likely to die from an overdose than the non-prison population.

Prison conditions and health risks have been compounded by the COVID-19 pandemic, which has exacerbated the structural problems of the prison system and often worsened inhumane living conditions and access to essential health services, including access to COVID-19 vaccines. Research by HRI and PRI published in December 2021 revealed a widespread lack of transparency and information regarding vaccination rates of people living in prison and prison staff globally, which made it difficult to monitor the access to COVID-19 vaccination and constitutes, in itself, a violation of the right to health. Specifically, failure to provide transparent and desegregated data impeded accurate assessments of governments’ responses to the pandemic by the international community, health services, monitoring bodies, and civil society, thus, also hindering accountability.

Despite evidence of its effectiveness and guidance from international authorities, the inclusion of people detained and working in prison as an at-risk/ priority group in national vaccination plans has been contentious, leading to piecemeal and often insufficient implementation. Countries adopted vastly different approaches to these populations: while some countries explicitly prioritised people in prison and/or prison staff, others included prisoners in their plans but not within a priority group; another group followed the same categories for people in prison as those in the broader community, and a fourth group did not make any reference to prisons at all in national vaccinations programmes. In addition to the lack of uniformity in the vaccination programmes and their rollouts, independent reports raise concerns about prioritisation and/or exclusion of prisoners from vaccination based on political motives in a number of countries. Vaccine hesitancy appeared to be higher in prisons than in the general population in countries such as Finland, Greece, Jamaica, and Trinidad and Tobago, among others; raising concerns regarding the availability, accessibility, and quality of targeted, evidence-based information on COVID-19 vaccines received by people in prison and on the opportunities provided to make an informed and evidence-based decision regarding vaccination.

Additionally, a 2023 HRI report concluded that measures implemented during the pandemic, such as extended lockdowns and suspensions of visits, seriously and unjustifiably impacted the already limited provision of health and harm reduction services, having far-reaching health and human rights implications for people in detention in the countries surveyed. For example, lockdowns were reportedly implemented in prisons at the beginning of the pandemic and at various other times in all countries surveyed, with most people confined in their cells for sometimes 23 or 24 hours a day and with full suspension of regular activities, including work, school, leisure and physical activities. Suspension of visits was also reported in all countries studied, which prevented not only family and friends from coming into prisons, but external services as well, including harm reduction and other health service providers. In some cases, these extreme measures continued to be implemented in prisons far beyond when they were lifted in the community despite the lack of necessity and proportionality, with some health services permanently limited or suspended, raising questions as to their exceptional and temporary nature. That is the case in the UK, where people were found to be locked up in their cells for up to 23 hours a day in February 2022 after restrictions were lifted in the community. Similarly in Mexico, medicine shortage continued to be a problem after the acute phase of the pandemic, and the quality of services reportedly remained subpar. In at least four prisons in Mexico, the number of visits has been permanently reduced, limiting the access to health and sanitary products that people in detention can only have access to through their families.

International human rights obligations bind States to provide harm reduction services and essential medicines to all people, including people deprived of liberty, to prevent and confront the spread of infectious diseases and to ensure the provision of essential services for drug dependence, including methadone and buprenorphine. For the same reason, States should guarantee underlying determinants of health such as fresh air, clean water and adequate sanitation, non-discrimination, and active and informed participation of people deprived of liberty in decisions affecting their health.

In line with such obligations, and following the information provided through this submission, we encourage the OHCHR to recommend Member States to:

1. Eliminate all legal and policy barriers and stigmatising and discriminatory practices that limit the access to essential medicines and treatment for people deprived of liberty.
2. Guarantee equitable access to harm reduction and essential medicines for all people deprived of liberty;
3. Incorporate people deprived of liberty as a priority/high risk group in all pandemic and health emergency responses’ strategies at both national and international level, including in the design, planning and roll-out of vaccination programmes;
4. Maintain disaggregated data about distribution of harm reduction and essential medicines in prisons;
5. In case of future pandemics a, disaggregated data about vaccination rates and other health responses should include people who use drugs, people in detention and prison staff.