The provision of harm reduction in prison is central to achieving UNAIDS’ goal of ending HIV by 2030 and meeting Sustainable Development Goals. However, punitive drug policies continue to hinder prevention efforts. The interlinkages between drug policy and the overincarceration of people who use drugs create high-risk environments in prisons for the spread of infectious diseases, including HIV.

Punitive drug policies continue to be a major contributor to prison overcrowding and the disproportionate imprisonment of marginalised communities, including people who use drugs. According to the World Health Organisation (WHO), approximately 30 million people spend time in prison per year worldwide. Out of the 11.5 million people currently in prison, an estimated 2.2 million people globally are held for drug offences, with 22% (470,000 people) for drug possession for personal use. Estimates indicate that up to 90% of people who inject drugs will be imprisoned at some point in their life.

Drug use and risk-associated behaviours increase in prison, leading to a greater prevalence of HIV infections. While imprisonment tends to reduce the likelihood of injecting drug use, other individuals continue, start using additional drugs or initiate injecting drugs unsafely. On average, 32% of people in prison use drugs globally (ranging between 3.4% to 90% depending on the region) compared to 5.6% in the community. Drug use in prison is often done under unsafe conditions, including exchange of needle and syringe, which increases the risks of contracting HIV and other infectious diseases. For example, sharing injecting equipment has been linked to HIV outbreaks in prisons in Iran, Lithuania, Thailand, the UK and Ukraine. Risks associated to drug use in prison can be exacerbated even further by other risk behaviours, including unsafe sex and sexual violence, which also increase the likelihood of contracting HIV. Women in prison are more likely to use drugs, and their populations often have higher prevalence rates for HIV (double or more) when compared to male prisoners.

The over-representation of people who use drugs, with usually intersecting vulnerabilities and layers of discrimination, make them more likely to suffer from poor health and are at high risk of becoming seriously ill if contracting HIV or other disease. This is compounded by suboptimal prison conditions, such us prison overcrowding, limited access to clean water, inadequate sanitary conditions, a lack of healthcare -including HIV testing and treatment-, to name a few, which makes places of detention a high-risk environment for the transmission of diseases.

Additionally, evidence indicates an association between recent imprisonment and increased HIV and HCV acquisition among people who inject drugs, and several studies suggests that the imprisonment of people who inject drugs could be a contributor to the transmission of infectious diseases after release.

Despite harm reduction being recognised as a central element of the right to health and a key strategy to combat HIV,15 HRI’s data shows that people deprived of liberty continue to be severely underserved:

• Only 11 countries have Needle and Syringe Program (NSP) in at least one prison. This is just 12% of the 93 countries that provide NSPs to people outside of prison.
• Naloxone is available in at least one prison in just 11 countries across Europe,17 North America18 and Oceania.
• Opioid Agonist Therapy (OAT) in prisons is available in at least 60 countries20, compared to 93 in the community.
• Data from 2017-2024 shows that only 55 countries were providing condoms and lubricants in prisons and other closed settings. While most countries provide HIV testing and treatment, there is still some barriers to access those services in prison. For example, HIV testing is reported to be widely available in prisons across Europe, with many countries offering testing during medical examinations. However, mandatory HIV testing is still reported in some prisons in European countries, which is not justified based on public health principles. In Latin America and Ester and Southern Africa, all countries provide HIV testing and treatment inside prisons, although there are many documented barriers to access, particularly for women who use drugs, including humiliating and punitive treatment. In the case of Asia, the information is more scattered. Although UNDP reported that none of the province’s 43 prisons, including 5 women’s prisons, provide HIV services, information collected by HRI indicates that at least one NGO, Nai Zindagi, offers harm reduction services in 24 prisons (23 in Sindh and 1 in Khyber Pakhtunkhwa), including three female and three are juvenile prisons. Harm reduction services provided are HIV testing, counselling on safer sex, linkages to antiretroviral treatment (ART) for HIV, adherence support, baseline investigation to initiate ART and linkages to hepatitis C treatment.

According to HRI’s report and monitoring, harm reduction in Low and Middle Income (LMI) countries is facing its most profound crisis. Consistently underfunded, with only 6% of estimated resources needed, US and other countries cuts to foreign aid threatens the sustainability of harm reduction programmes. Harm reduction in prison is particularly vulnerable. Currently these programmes are operating on a limited scale with many relying heavily on external funding and support from international donors. This dependence on international funding makes these programmes particularly vulnerable to changes in the global funding landscape. Any shifts in donor priorities, budget cuts, or policy changes can affect the sustainability of harm reduction efforts in prisons.  

As international fund finishes, some countries are not able to transition to domestic fund. In Romania, NSP, OAT and prevention programmes for groups at increased risk of HIV were dramatically reduced once funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) ended, and the government was not able to take over and sustain the financing of services. In contrast, some prisons in Moldova started offering harm reduction services in 2000 through international funding and technical assistance. Over the years, the country developed a supportive regulatory environment and started funding services from the state budget and has also expanded services. Harm reduction programmes in prisons in Mauritius are funded by the government, mainly through the ministry of health and other ministries’ budgets, with contribution from the Global Fund for specific items. 

According to PRI, in Uganda, as in many other nations in the region, the suspension of USAID funding has severely impacted the provision of HIV/AIDS and sexual and reproductive health services within prisons, creating a dire situation, particularly for women. The reduction of healthcare staff has made it difficult to adequately attend to all prisoners in need, affecting the follow-up care for HIV and TB patients, including those released from prison. This disruption in treatment increases viral loads, exacerbating health conditions and undermining efforts to manage the disease. While HIV itself may not be fatal, the lack of proper nutrition and vulnerability to opportunistic infections pose serious threats to survival. Furthermore, the fear of being unable to continue treatment prevents individuals from effectively suppressing the virus, worsening the overall health crisis in prisons. 

Therefore, incorporation of harm reduction in prison into state budget is key to ensure sustainability of services and protect them from fluctuations in external funding. National scale up and linkage to national HIV and public health programmes are crucial to ensure equity across prisons and between prisons. It is equally important to guarantee the continuity of care upon release.  

Prisons provide an opportunity for universal screening and ‘micro-elimination’ of communicable diseases among a high-risk population, and populations that are usually hard to reach by health and social services outside in the community. However, barriers in accessing the already lacking harm reduction interventions hinders the positive outcomes that may come from those key interventions.   

The GSHR 2024 has identified the following barriers that prevent people in prison from accessing harm reduction:  

Uneven distributions of harm reduction services: states should ensure equal access to health services for all people in prison. However, HRI’s data shows that the limited harm reduction services in prison are unevenly distributed across countries and regions: Apart from Canada and Iran, all identified NSPs in prisons are in Eurasia and Western Europe. The availability of OAT also varied widely between regions, with most of the services concentrated in Western Europe and Eurasia. In Asia, only five countries provide OAT and Puerto Rico is the only country in Latin America and the Caribbean providing OAT in at least one prison. No country in Western and Central Africa provide OAT in prison.  

In some countries, OAT is limited to people who were prescribed this treatment before entering prison. This is the case in some Eurasian countries, including Albania, Bulgaria, Latvia, Montenegro and Serbia. Similar restrictions apply in Lebanon, Macao (China) and Mauritius. Even when OAT is available to everyone, regardless of whether someone has been on OAT before prison, there can be increased barriers for those who start OAT while in prison, such as treatment waitlists, which may lead to leading to treatment withdrawal. 

Perceived risk of sanctions or loss of rights or privileges: One of the most reported barriers experienced by people in prison is the fear of punishment or loss of rights or other privilege resulting from disclosing drug use. They worry that such admission might result in disciplinary actions or jeopardize their chances of accessing home detention, curfew, release on temporary licence or parole. 

In Romania for example, once someone enters a drug treatment programme, they are reportedly declared unfit to work while in prison, which means they will lose their income and cannot participate in meaningful activities. In Indonesia, research found that people participating in OAT programmes in prison were perceived by both prison staff and peers to be engaged in illicit drug use. They were heavily stigmatised; they were seen as lazy, poor, dirty and unproductive and were presumed to have HIV. Similarly, in England and Scotland, service users have reported that while people who disclose use of heroin on admission to prison are offered access to services, those who disclose drug use later are met primarily with a punitive response and are often suspected of selling drugs or other activities which violate prison rules.  

The introduction of laws prohibiting drug consumption and sexual relations in prisons, abstinence and drug-free approaches, and a lack of support from staff and the general population also act as barrier to scaling up harm reduction interventions in prisons. For example, in Australia, unions for prison staff are strongly against prison-based NSP and wield considerable power over aspects of prison policies which they believe -despite a lack of evidence- could compromise their health. 

Lack of confidentiality and anonymity: Sates should ensure complete confidentially of any medical condition, treatment, and healthcare accessed by people in prison, including access to harm reduction interventions, HIV treatment and services for infectious diseases. However, the reality in many prisons often falls short due prison conditions and the lack of independency of medical staff, which leads to privacy and confidentiality breaches.   

In Moldova, uptake of OAT is believed to be limited by confidentiality breaches as well as stigma and a prison subculture that informally regulates access. Those who accept methadone treatment are frequently subject to bullying and isolation, directed by leaders among the prison population. Despite NSP being available in most Moldovan prisons (34 sites, across 15 out of 17 prisons), a survey in 2020 found 22% of people who inject drugs in prison shared injecting equipment, suggesting that the lack of anonymity in accessing the service may be a deterrent. 

Specific barriers for women in prison: Human rights standards prescribe that women require specialised and tailored treatment programmes to address drugs use and drug dependence. The design and delivery of service should consider prior victimisation and trauma, the special needs of pregnant women and women with children, as well as their diverse cultural backgrounds. Women in prison should also receive medical screening on entry and healthcare during imprisonment, including mental healthcare, HIV treatment, care and support, support in relation to suicide and self-harm and preventive healthcare services which are responsive to the specific needs of women. Yet, harm reduction is particularly limited for women in prison, they are not gender-sensitive and are usually concentrated in men’s facilities. For example, the only therapeutic community in Moldovan prisons is in a male facility. The two prisons in Ireland that have consultant-led, ‘in-reach’ drug dependence services only accommodate men. In Georgia, OAT (for detoxification) is not available in the women’s prison. Instead, women in need of OAT are temporarily transferred to a treatment facility in a male prison where they share a psychiatric ward with men. As a result, uptake is low among women who accounted for only 2 of the 754 people that benefited from prison-based OAT in 2021. Discriminatory attitudes from staff and feelings of shame that lead some women to hide their drug use or dependency means it is likely that many women in prison do not access the services available in the system and deal with withdrawal on their own. In Eastern and Southern Africa, civil society has documented widespread barriers to accessing HIV testing and treatment in prison for women who use drugs, including humiliating and punitive treatment by prison staff and services only being available in a limited number of facilities.  

Other marginalised people in prison: States should protect the right to respect and fulfil the right to health with dignity and non-discriminatory manner. However, marginalised groups, including foreign nationals, LGBTQI+ people, children, Black, Brown, ethnic minority and Indigenous people and people engaged in sex work, usually face stigma and discrimination that hinder access to harm reduction in prison. The challenges these marginalised populations face in prisons are often similar to the issues they experience in the community, including services that are not responsive to their needs. In Morocco and Armenia, for example, standard services are generally provided to all individuals without consideration of the specific needs of women, LGBTQI+ people or other groups. Sex workers who use drugs face barriers accessing services due to the layered stigma surrounding drug use, sex work and sexual orientation, which in many countries are all criminalised to varying degrees. In Indonesia, trans and gender diverse sex workers who use drugs who are in prison are failed by existing harm reduction structures. In some countries, such as Ireland, Zambia and the US, trans and gender diverse people in prison are held in long periods of lock-up and solitary confinement, often on grounds of protection, which limits their access to all services in prison, including harm reduction.  

Other barriers for scaling up services: prison healthcare should be organised in close relationship with the national health system in a way that ensures continuity of treatment and care, including for HIV, tuberculosis, other infectious diseases and drug dependence. Although the WHO, UNODC, and human rights standards recommend that the most effective way of doing this is by prison healthcare being managed by the national health authority rather than the prison administration, in many countries, prison health remains under the jurisdiction of ministries of justice, interior or home affair in many countries, which oversees the penitentiary system. As consequence, security approaches are prioritised over prison health and the provision of harm reduction can be fragmented.  

In Germany, for example, prison healthcare is under the ministry of justice in the 16 Länder (states), and care for people with opioid dependency is scattered.  Some Länder have almost no waiting list for prison-based OAT and others provide hardly any treatment at all, meaning people on OAT will not be able to continue treatment in prison. In Armenia, while the Penitentiary Medical Centre collaborates with healthcare institutions that provide harm reduction, significant issues in continuity of care lead to interruptions in the services for people upon detention and after release from prison. The failure to transfer responsibility for prison health to the regional health services in Spain is seen as a barrier to the expansion of harm reduction in prisons.  

Countries that have transferred responsibility for prison health to the health ministry include Norway, Finland, Italy, England and Wales and Kazakhstan. In April 2024, Portugal proposed a gradual transfer, with the aim of ensuring people have uninterrupted access to healthcare in prison and upon release by 2030. 

• Decriminalise drug use and apply health and human rights-centred, and evidence-based responses to drug use to reduce prison populations and promote the right to health;
• Introduce alternative to incarceration, decongestion and early release measures to reduce prison overcrowding, ensuring that drug-related offences are not subject to any blanket restrictions in decongestion and early release mechanisms;
• Recognise harm reduction as an essential element of the right to health and incorporate it into prison health programmes and policies;
• Maintain and scale up harm reduction services for all people in prison and ensure that are provided under the basis of voluntary, informed and free consent and complete confidentiality of any medical condition, treatment, and healthcare accessed by people in prison, including access to harm reduction interventions, HIV treatment and services for infectious diseases;
• Ensure adequate prison conditions and other underlying determinants of health for all people in prison, including access to safe and potable water and adequate sanitation, adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health and women’s specific hygiene needs by, among others, allocating sufficient financial and human resources;
• Eliminate all legal and policy barriers and stigmatising and discriminatory practices that limit the access to essential medicines, healthcare and treatment for people deprived of liberty;
• Improve the coordination between the National Health Service and prisons to ensure continuity of care and treatment for individuals upon release, or consider transferring responsibility for prison healthcare to the national health authority instead of the prison administration;
• Maintain disaggregated data about distribution of harm reduction and essential medicines in prisons; and
• Ensure that people can continue accessing harm reduction services and HIV testing and treatment upon release without discrimination.