ATODA Submission to the ACT Budget Consultation 2011 2012 Excerpt

ATODA Submission to the ACT Budget Consultation 2011 – 2012 Excerpt

Attachment B:

Needle and Syringe Program Trial in the Alexander Maconochie Centre

B1.Proposal

To prevent and reduce the transmission of blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B), improve the safety of staff, and improve the health of prisoners by conducting a trial, which includes a feasibility study, of a needle and syringe program (NSP) in the Alexander Maconochie Centre (AMC).

B2.Background and Rationale

Over 80% of all newly acquired hepatitis C infections in Australia and the vast majority in most Western countries are associated with injecting (illicit) drug use.[1] Sharing injecting equipment is the primary manner in which blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B) are spread in this population. NSPs are one of the major components of Australia’s approach to reducing the spread to blood-borne viral infections among injecting drug users.

Each case of hepatitis C infection, a blood-borne virus, costs the Australian community and health services between $798 and $18,835 per year.[2] NSPs in the ACT have been cost-effective at preventing the spread of blood-borne viruses, including hepatitis C.[3] However, the substantial savings from NSPs in the community are being eroded by transmission of hepatitis C among a confined and identifiable population (i.e. prisoners).

The 2007 Australian prison entrants blood-borne virus survey found that 35% of 740 consecutive prison entrants were HCV antibody positive, compared with 0.2% in the general Australian population.[4]

Prisoners have high rates of hepatitis C upon entry into prison.[5] For most, this has resulted from unsafe injecting practices. Injecting drug use occurs in Australian prisons[6] and continued injecting behaviours and the sharing of injecting equipment causes the transmission of hepatitis C among prisoners who continue to inject in prison[7]. NSPs reduce the rate of transmission of hepatitis C and other blood-borne viruses in this population.[8]

Prison staff safety is essential. The risk of punishment for possessing injecting equipment means that prisoners attempt to hide used syringes which places staff at risk of needle-stick injuries and contracting blood-borne viruses.[9] The prohibition of injecting equipment also means that prisoners who do inject are at a greatly elevated risk of negative health outcomes. Syringes are often used many times, increasing the likelihood of blood-borne virus transmission among prisoners, and making a substantial contribution to the spread of blood-borne viruses throughout the community. The very fact that substantial numbers of prisoners continue to inject in prison demonstrates that appropriate treatment and support is not reaching many prisoners who need it most.[10]

This population should be targeted for interventions which reduce the risk of blood-borne virus infection. Prisoners who may contract hepatitis C in prison are generally released into the community within a relatively short period of time; such prisoners become a substantial contributor to the spread of hepatitis C in the ACT community.

The overwhelming evidence indicates that incorporating NSPs into prisons is safe and effective in reducing the risk of blood-borne virus transmission among prisoners, staff and the community.[11]

B3.Aim and Objectives

The primary aim is to reduce and prevent the transmission of blood-borne viruses and enhance the safety of staff through trialing an NSP that will make sterile injecting equipment available to prisoners. The objectives include:

1. To reduce blood-borne virus transmissions among prisoners, and as a consequence, the wider ACT community;
2. To improve the safety of staff by reducing the risk of needle-stick injuries and the contraction of blood-borne viral infections;
3. To improve prisoners’ engagement with health services to improve the rates of appropriate alcohol, tobacco and other drug (ATOD) treatment among substance misusing prisoners;
4. To reduce the social and economic costs of blood-borne viruses on prisoners, prison health services, community health services, and the general community;
5. To enhance the AMC’s human rights compliance; and,
6. To reduce the exposure of the ACT Government to litigation for failing to exercise its duty of care towards prisoners.

The trial will determine the feasibility of introducing and operating an NSP in the AMC and will evaluate its outcomes.

B4.Priority populations

B4.1Prisoners who inject drugs

More than half of Australia’s prison entrants have a history of injecting drug use[12] and nearly one-third test positive for the hepatitis C antibody.[13] Many of these prisoners will continue to inject in prison.[14] Data from NSW has found that 43% of females and 24% of males had injected drugs whilst in prison. Of those, 72% of females and 67% of males had reused the needle and syringe after someone else.[15]

Because the AMC is a relatively new facility, there is limited publicly available data on rates of blood-borne viral infections, injecting drug use, or the sharing of injecting equipment among inmates. However, and despite substantial efforts on the part of AMC staff; drugs and injecting equipment have been found in the AMC.The Chief Minister has said:

“I would accept, on the information that is available and on the knowledge that we have, illicit substances are still finding their way into Alexander Maconochie despite our best efforts and there is access through whatever illegal means to contraband within AMC.”[16]

Injecting drug use occurs in the AMC. Consequently, prisoners are almost certainly sharing injecting equipment. There has already been one documented case of a prisoner contracting hepatitis C during their imprisonment at the AMC. The Minister for Health has confirmed that a detainee contracted hepatitis C while in the AMC, less than one year after its opening.[17]

The first ACT Inmate Health Survey has been conducted (report yet to be released); and the Burnet Institute, commissioned by the ACT Government, is currently reporting on an Evaluation of Drug Policies and Services within the AMC. These reports will provide further information as to the current situation.

B4.2Aboriginal and Torres Strait Islander Injecting Drug Users

The over-representation of Aboriginal and Torres Strait Islander people in Australia’s prisons is partly due to the high rates of alcohol and other drug misuse in these communities.Consequently, injecting drug use in prison may be major contributor to growing rates of hepatitis C infection among this population.[18]

Aboriginal and Torres Strait Islander prisoners are more likely to have hepatitis C before entering prison than other prisoners and are also more likely to inject drugs in prison than other prisoners.[19] Consequently, preventing the transmission of blood-borne viral infections in prisons may have a substantial impact upon improving the health of Aboriginal and Torres Strait Islander people.

B5.Evidence of Effectiveness and Safety

The arguments for introducing a NSP into the AMC are many and widely accepted by international and domestic bodies, health professionals, and the ACT Government. The overwhelming evidence indicates that incorporating NSPs into prisons is safe and effective in reducing the risk of blood-borne virus transmission among prisoners, staff and the community.[20]

Prison NSPs are cost-effective, safe, and endorsed by international and domestic bodies. They have been introduced in 12 countries, where they have been the subject of extensive evaluation. The results demonstrate that prison NSPs can:

• Reduce rates of needle stick injuries among corrections staff and reduce the likelihood of contracting a blood-borne virus among those who do sustain a needle-stick injury;
• Reduce the rate of blood-borne viral transmission among prisoners who inject drugs in prisons; and,
• Improve the uptake of appropriate treatment among people who inject drugs in prisons.[21],[22],[23],[24],[25]

The ACT Minister for Health has stated:

“From a health point of view, it is a no-brainer; you have a Needle and Syringe Program in the jail as soon as you can.”[26]

Prison staff’s attitudes to NSPs in prisons have been generally positive once they have been implemented. In a 2004 review of NSPs in European countries, the World Health Organization found that not a single case of syringes being used as weapons by inmates had been reported.[27] In Australia, there has been only one reported case, in 1990, in which a prison officer was assaulted with a syringe. However this occurred when there were no NSP facilities available in the prison.

Evaluations of Needle and Syringe Programs in overseas prisons have shown that they do not increase drug consumption or injecting and they effectively reduce needle sharing.[28] Additionally, there have been no documented cases of adverse events from NSPs in prisons anywhere in the world, making NSPs in prisons a safe health intervention.

B6.Safety guarding the community from blood-borne virus infection

The National Drug and Alcohol Research Centre’s technical report 112 reviewing international research and program development for prison-based syringe exchange programs concludes the following:[29]

“The rationale for establishing syringe exchange programs in prisons is even stronger than in communities. This rationale is accepted by an impressive number of prestigious bodies… Because of the rapid turnover of inmate populations, spread of blood borne viral infections among prisoners cannot be considered to remain for long within the confines of correctional facilities. There is increasing evidence that experience of incarceration is a strong predictor of HIV and hepatitis C infection.”

The authors elaborate:

“The failure to reduce the risk of hepatitis C and other blood borne viral infection transmission in prisons severely undermines the work being conducted in the community with injecting drug users.”

B7.Improve the uptake of ATOD health services by prisoners

Prison drug treatments are effective in reducing substance misuse and their associate risk behaviours.[30] However, for these treatments to be effective, prisoners in need must first access these services. Alcohol, tobacco and other drug (ATOD) assessments of prisoners cannot guarantee that prisoners with ATOD issues are identified and appropriately treated.[31] Additionally, the risk of punishment for engaging in drug use in prison, or possessing injecting equipment, ensures that some prisoners will intentionally avoid contact with needed AOD treatment services. Consequently, there is a need to promote engagement with health services among prisoners with problematic AOD issues. NSPs in the community are a primary point of contact between injecting drug users and AOD treatment services. This can also be the case in custodial settings,[32] so long as this effort does not act as a barrier to prisoners accessing the NSP.

B8.Enhancing the Human Rights Compliance of the AMC

Developing a human rights culture in the ACT is a progressive process which builds upon the Territory’s previous success. The AMC is a unique opportunity to develop a truly human rights compliant prison. Currently, prisoners are not afforded the same standard of healthcare made available to them in the general community. Dr Helen Watchirs, ACT Human Rights Commissioner, suggests: “To deny protection against disease transmission in such a high-prevalence and closed population in prison may be viewed as inhumane.” [33]

The ACT Human Rights Commission conducted two audits of the operation of the ACT’s corrections facilities in 2006 and 2007. One of the Commission’s recommendations was for a trial of an NSP, which was based on a prisoner's right to life, which includes protection from infectious diseases, as well as the right to the highest attainable standard of health.[34][35]

B9.Support for a NSP in the AMC

A range of international bodies with responsibility for developing an international response to drugs and blood-borne virus transmission have indicated strong support for prison NSPs as one of many methods to reduce the spread of hepatitis and HIV/AIDS in prisons. These include the United National Office on Drugs and Crime,[36] the World Health Organization, and the Joint United Nations Programme on HIV/AIDS.[37]

The Australian National Council on Drugs (ANCD), the primary advisory council to the Australian Government, appointed by the Prime Minister, has recommended:

“That each jurisdictional department responsible for the management of prisons and juvenile detention centres, in consultation with staff, health authorities and relevant community-based organisations, develop occupationally safe and culturally appropriate policies, protocols and procedures regarding the introduction of trial needle and syringe programs within at least one of its prisons and juvenile detention centres.”[38]

The National Hepatitis C Strategy 2010-2013 states:

“In view of the well documented return on investment and effectiveness of Australian community-based needle and syringe program, combined with the international evidence demonstrating the effectiveness of prison needle and syringe programs it is appropriate throughout the life of this strategy for State and Territory governments to identify opportunities for trialing the intervention in Australian custodial settings.”[39]

The ACT Human Rights Commission has recommended that:

"[a] pilot program for a needle and syringe exchange with provision for safe disposal of needles should be developed for the Alexander Maconochie Centre…"[40]

The ACT Chief Minister’s and the ACT Minister for Health’s comments, quoted above, further strengthen this support. Adding to that, the Attorney General has stated, "What we want to do is stop the spread of disease that comes from sharing needles.”[41]

The ACT Greens have called for the establishment of an NSP, developed a discussion paper and a consultation summary.[42] Anex, an national leader in public health, has also recently released a paper supporting NSPs in prisons.[43]

B10.Policy Context

Trialing a NSP in the AMC is:

• Consistent with the principles of the ACT Adult Corrections Health Services Plan 2007 – 2010;
• Consistent with initiatives being undertaken through the Alexander Maconochie Centre including the evaluation of drug polices and services;
• A recommendation from the ACT Human Rights Commission’s Human Rights Audit on the Operation of Correctional Facilities under Corrections Legislation; and the ACT Legislative Assembly’s Standing Committee on Health report 2003;
• Consistent with and progresses Actions 19, 20, 29, 30, 57 from the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014;
• Consistent with and progresses Action 26 from the A New Way: The ACT Aboriginal and Torres Strait Islander Health and Family Wellbeing Plan 2006 – 2011; and the recommendations from the Winnunga Nimmityjah Aboriginal Health Service report You do the Crime, You do the Time;[44]
• Part of a broader NSP program which is supported by the National Drugs Strategy, the National HIV/AIDS Strategy and the National Hepatitis C Strategy as part of a harm minimisation framework that is based on the three pillars of supply reduction, demand reduction and harm reduction.

B11.Issues for Consideration

B11.1Addressing the concerns of some staff

Corrections Officers, their representatives, and ACT Corrective Services have concerns over the introduction of a trial NSP into the AMC. Their concerns to date have focused on issues of occupational health and safety (OH&S) for staff - the risk of needle-stick injuries and injecting equipment being used as weapons. The evidence states that:

“International experience has shown that regulated prison NSPs do contribute to institutional safety, and that they do not result in syringes being used as weapons. The introduction of prison-regulated and controlled NSPs would be consistent with efforts to comply with OHS principles, as well as the approved standards for corrections in Australia.”[45]

The ACT Minister for Health has said:

“From a corrections staff point of view—I have said this in these forums a number of times—it is more complex than that. Corrections staff have mixed and strongly held views around the commencement of a Needle and Syringe Program. It would be a brave new step. We would be the first jail in the country to head this way—not the first jail in the world but the first jail in the country.”[46]

Appropriate education and training to staffcomplemented by appropriate amendment to OH&S policies and practices will need to form part of a trial NSP. However, to maximise the potential benefits of a trial NSP, it will be necessary to have the support of staff.

ATODA believes that engagement by staff with the issues, evidence, and experiences of colleagues from prisons in which NSPs have been introduced will help to facilitate a change in mindset from one of opposition to one of engagement. Opportunities for key staff and representatives to investigate, first hand, the experiences of overseas prisons in which NSPs have been introduced should be considered. Additionally, all staff at the AMC would benefit from hearing the experiences of colleagues from overseas about the introduction of a NSP in their prison.