What is the evidence (in the research literature where possible) for
institutional based models of harm reduction
(reducing the harm associated with drug use). What is the evidence for
community based models of harm reduction. How do they compare? (Please
focus mainly on injecting drug users (IDU)not drug users in
general.)

---

Request for Question Clarification by welte-ga on 05 Feb 2006 13:12 PST

Hi jordan04-ga, What types of outcomes are you interested in (i.e.,
reduction in HIV infection rates, total infected with HIV, etc.)?  Are
you just looking for a general overview of harm reduction in the
institutional and community settings?
 
  -welte-ga

---

Clarification of Question by jordan04-ga on 12 Feb 2006 01:08 PST

They are good points. Sorry this is a difficult question thats why i
put it out there. i'm looking for examples of models of harm reduction
in institutions (hospitals, jails, rehab centres etc.) if possible
compared with the community setting (outreach, primary healthcare
clinics, community centres etc.).
Outcomes of efficacy might be HIV incidence but i imagine there is
little about this in the literature. therefore proxy outcomes such as
reduction in risk behaviour, sharing equipment, sex risk behaviour,
acceptibility, feasibility, cost effectiveness etc...those kind of
proxy outcomes. CAn be anywhere in the world but i would imagine
mostly USA, Asia, AUstralia and Europe.

Hi again jordan04-ga,

No problem... I just wanted to make sure I was going in the right
direction and focusing on the right areas.

One of the best summaries of the literature comes from, believe it or
not, the US government.   Henry A. Waxman, representative for the 30th
district in California, wrote a letter to John P. Walters, Director of
the Office of National Drug Control Policy (ONDCP) on May 25, 2005. 
This letter was a response to the ONDCP's request for the scientific
basis of harm reduction programs.  As the letter points out, it is
rather remarkable that the director of the ONDCP was apparently
unaware that there was scientific evidence (rather overwhelming
actually) that harm reduction programs are effective in reducing HIV
infection, without increasing illicit drug use.  Unfortunately, the
entire letter is a scanned PDF file, so the (rather long) links to
documents included are not directly accessible.  I have reproduced
them below with some excerpts, so that you can simply click on them,
rather than typing in the entire URL.


Here is Representative Waxman's home page:
http://www.house.gov/waxman/

You can find a copy of his letter here:
http://www.democrats.reform.house.gov/Documents/20050525110831-63007.pdf

This document includes analyses from some of the most respected
scientific and medical bodies in the world and I think you would be
hard pressed to find a more authoritative list of studies addressing
harm reduction, needle exchange programs, and HIV infection.  I will
go through these studies and provide some links to the direct
information for the most informative ones where possible.

________

An early report (July, 1991) from the National Commission on AIDS
gives a good overview of the situation at that time:

"The city of New York has an estimated 200,000 IV drug users (who are
50 percent HIV positive) with only 38,000 publicly funded treatment
slots."

"The National Institute on Drug Abuse (NIDA) recently estimated (based
on provisional data) that approximately 107,000 persons are currently
on waiting lists for drug treatment."

"71 percent of all female AIDS cases are linked directly or indirectly
to IV drug use."

This report also goes on to summarize the highly variable acceptance
of needle exchange programs around the world, even in light of hopeful
success rates:

"Examples from some U.S. cities and the U.K., the Netherlands, and
Australia show that cooperation of law enforcement and public
officials can make a major difference in the success of outreach
programs. In Tacoma, where the city and county jointly run the health
department, all city and county representatives who sit on the health
board have been educated about AIDS. The chief of police is also "AIDS
educated" and was able to cooperate with the outreach programs in the
city. This syringe exchange and basic needs outreach program in Tacoma
has resulted in "approximately an 80 percent reduction in risk
behavior in terms of injecting practices of the people that use the
exchange as opposed to those who don't." In the documentary "Taking
Drugs Seriously," a film about the Merseyside Regional Health
Authorities' harm reduction approach in the U.K., Allan Parry,
Director of the Maryland House in Liverpool, believes that "the main
reason we're keeping down the spread of the virus is because of the
police support of [syringe exchange] activity." Detective
Superintendent and Drug Squad Chief Derek O'Connell explains that
while they do not support decriminalization..., "because of the AIDS
problem which is now recognized by the government as a very, very
serious problem, it would be remiss if we didn't give support wherever
it was needed." In fact, since beginning their new "cautioning"
program which steers individuals toward drug dependency programs
instead of prosecuting, they have seen "an 85% success rate; that is,
people  not re-offending."(30)"

________

In 1995, the National Acadamies of Science published the report
Preventing HIV Transmission: The Role of Sterile Needles and Bleach. 
You can purchase this report here:

http://www.nap.edu/bookstore/isbn/0309052963.html

A news summary is available here:
http://www4.nationalacademies.org/news.nsf/isbn/0309052963?OpenDocument

This report looked in part at compliance among IVDU:

""Observational studies of injection drug users indicate that
compliance with recommended procedures for disinfection may vary
greatly, both in the method and the frequency of bleach use," the
panel said. "Moreover, adherence to recommended disinfection protocols
after training appears to decrease with time."

"Observational studies also have failed to demonstrate a significant
protective effect against HIV infection for drug users who report
consistent use of bleach to decontaminate needles and syringes
previously used by other users. Consequently, uncertainty now exists
among health officials, laboratory scientists, community outreach
workers, and drug users concerning the value of bleach disinfection as
a public health intervention, the panel said."

""When used according to recommended procedures, it is very likely
that bleach is, in fact, an effective method to disinfect needles and
syringes and limits their potential to transmit HIV infection," the
panel concluded. "However, it is clearly a secondary intervention to
be used when injection drug users have no safer alternatives.""

________

The American Medical Association published Report 8 of the Council on
Scientific Affairs (A-97) in June, 1997. You can find the full text
here:

http://www.ama-assn.org/ama/pub/category/13636.html

This document covers both non-IVDU and IVDU both within the US and worldwide.  

"Although a variety of programs have been developed for reducing the
spread of HIV infection among drug injectors, needle exchange has been
one of the most important and effective. In many countries, the
response to reports of escalating HIV prevalence among intravenous
drug users was creation of needle and/or syringe distribution
programs, most of them requiring participants to return dirty needles
in exchange for sterile ones. The Netherlands was a leader in this
regard; in fact, because of its early commitment to harm reduction
philosophies, needle exchange was implemented there in the early
1980s, prior to emergence of the AIDS crisis.[16] By the late 1980s,
governments in England, Switzerland, Australia, and Germany also had
begun needle-exchange programs and, within a few years, most other
European countries had followed their lead.[17] "

The report gives some idea of the variability in needle exchange programs:

"While differing in format and size, needle-exchange programs share a
commitment to maximizing the availability of sterile needles and
syringes--offering them at multiple locations, through storefronts,
outreach workers, or mobile vans. In some cities, needles and syringes
are distributed at drug-treatment centers[18] and, in Amsterdam, even
police departments have joined the effort.[19] More recently, "vending
machines" that yield a clean syringe if a syringe is deposited have
been placed in high drug-use areas to make clean needles available
around the clock.[20] Pharmacists also have been encouraged to sell
needles and syringes to drug users and, in Liverpool, England, some
pharmacies operate needle-exchange programs.[21]"

Clearly in smaller scale efforts, particularly those where a center or
building is not involved, pharmacists will play a role in drug
exchange programs, with some possibly refusing to participate, similar
to the situation with the Morning After Pill and birth control.


The report above also discussed the efficacy of needle exchange
programs and the failure of attempted controls:

"There is substantial evidence of reduced needle-sharing among regular
participants in needle-exchange programs.[22,23] More importantly, HIV
infection rates among drug users have been consistently lower in
cities with needle-exchange programs--as well as lower in cities that
implemented programs early in the AIDS epidemic, compared with those
doing so later.[24,25] For example, while the HIV infection rate among
injection drug users remained 1% to 2% in the Scottish city of
Glasgow, where a needle-exchange program was quickly established, it
reached 70% in nearby Edinburgh, where the response of government
officials was to implement even more stringent controls over injection
equipment.[26,27] While the intended purpose of the increased controls
was to discourage drug injection, the consequences included increased
needle-sharing and escalating HIV rates."

There are 46 references at the end of this report for further details.

________

In August, 1997, the American Public Health Association published a
report that supported lifting the federal ban on funding for needle
exchange programs.  You can find the press release here:

http://www.apha.org/news/press/1997/needle.htm

________

The Institute of Medicine Committee on HIV Prevention Strategies in
the United States published the online textbook No Time to Lose:
Getting More from HIV Prevention in 2001.  You can find the main page
here:

http://fermat.nap.edu/books/0309071372/html

There is a wealth of information in this book.  For example, on pages
33-34, one can find the cost effectiveness of various interventions to
put things in perspective:

Interventions to protect the blood supply:
"An estimated eight additional transfusion-related cases of HIV were
prevented, producing a cost-effectiveness ratio of $7.5 million per
HIV infection prevented, compared to HIV antibody screening alone."

Perinatal transmission interventions:
"Combining the $5,700 cost of treatment for HIV-infected mothers with
the HIV screening costs for all pregnant women in the United States
results in a total estimated cost of $51 million, and a
cost-effectiveness estimate of roughly $32,700 per HIV infection
prevented."

Needle exchange programs:
"Depending on the specific program model employed, the
cost-effectiveness of needle exchange is estimated to range from
$3,000 to $50,000 per HIV infection prevented (Kaplan, 1995; Kahn,
1998), figures that are competitive with the cost-effectiveness of
zidovudine for preventing perinatal transmission."


"Together, these decisions imply a very wide range of implicit
valuations regarding the monetary value of preventing an HIV
infection. These decisions suggest, for example, that society
implicitly values preventing a transfusion-related infection 150 times
more ($7.5 million per infection averted) than preventing a
drug-related infection through needle exchange ($50,000 per infection
averted). While some variation in these values is to be reasonably
expected,[6] it is difficult to reconcile a difference of such
magnitude."

________

The Centers for Disease Control has an excellent syringe exchange
site, with a summary of the past and current situation with exchange
programs

In terms of cost-benefit analysis, the report summarizes that...

"Economic studies have concluded that SEPs are also cost effective. At
an average cost of $0.97 per syringe distributed, SEPs can save money
in all IDU populations where the annual HIV seroincidence exceeds 2.1
per 100 person years.(12) The cost per HIV infection prevented by SEPs
has been calculated at $4,000 to $12,000, considerably less than the
estimated $190,000 medical costs of treating a person infected with
HIV.(13)"


Deeper in this web site is some very useful information on state policies, etc.:

http://www.cdc.gov/idu/facts/aed_idu_pol.htm

The CDC "Comprehensive Approach" is a more detailed document 
http://www.cdc.gov/idu/pubs/ca/toc.htm

This document does discuss the situations where community based harm
reduction programs have proven to be more effective.  See, for
example, this section:
http://www.cdc.gov/idu/pubs/ca/3.6.htm

This section mentions the Science-based Community Outreach Program
called Taking it to the Streets in Detroit.  This is one of the
community based programs supported by the NIDA.  The efficacy of these
community based interventions have been studied.


Pinkerton SD. Holtgrave DR. DiFranceisco W. Semaan S. Coyle SL.
Johnson-Masotti AP. Cost-threshold analyses of the National AIDS
Demonstration Research HIV prevention interventions. [Journal Article.
Multicenter Study] AIDS. 14(9):1257-68, 2000 Jun 16.

This article is not freely available, but you can request a free
reprint from Dr. Pinkerton:
pinkrton@mcw.edu
http://www.mcw.edu/display/router.asp?docid=7950

Table 1 shows the efficacy of bleach distribution, which you can view here:
http://img97.imageshack.us/img97/926/table16kx.png

Table 3 summarizes the overall results:
http://img143.imageshack.us/img143/2364/table38lq.png

This article also mentions the cost effectiveness of one community
based program in Durham:

"A recent, thorough cost analysis of the Durham North Carolina Co-Op
intervention estimated that the program cost $94 791 per year to
operate and reached 347 IDU in its first year, for an average
per-participant cost of $273 [21]. Importantly, this estimate includes
only program costs and excludes costs associated with evaluating the
program. About 60% of the total cost of the Durham Co-Op program was
related to outreach activities, while the intervention activities
themselves accounted for the remaining 40%. Overall, about 85% of the
total cost of the program was spent on labor. Although the exact
breakdown and overall costs are likely to differ for the NADR
interventions, we believe that the $273 figure provides a reasonable,
though not exact, estimate of the per-client cost of the NADR
program."

Section 3.8 of this document discusses interventions in institutional
settings.  See, for example, this portion:
http://www.cdc.gov/idu/pubs/ca/3.8.htm


Another important distinction that effects the efficacy of community
versus institutional harm reduction programs is the relative rarity
with which institutional programs have been implemented and the
different methods employed.  Just thinking of needle exchange
programs, there have been none in place in jails.  Here is a summary
from the above document:

"Prevention services currently offered to incarcerated populations
vary widely across state, county, and city jails and prisons. They
include instructorl-ed and/or peer-led HIV education, pre-and
post-test counseling, multi-session prevention counseling, the use of
audiovisual materials, and the distribution of printed materials
(Hammett et al., 1999)."

"Risk reduction strategies have not been widely adopted in U.S.
correctional systems. For example, only two state prison systems and
four city/county jail systems make condoms available to inmates.
However, most correctional systems provide HIV antibody testing,
although testing policies differ widely. Few systems routinely screen
inmates for STDs and only limited viral hepatitis prevention and
treatment services are available."

http://www.cdc.gov/idu/pubs/ca/appendixA.htm#intervention


Another important difference is that it has been found to be more
effective in prisons to have peer-led interventions rather than
professional-led.

"One of the most important types of interventions in prisons and jails
is education and prevention efforts led by inmates themselves. These
programs can be cost-effective and flexible, and they have an added
credibility that programs led by outsiders cannot match. Peer-led
programs also provide significant benefits to peer educators
themselves. Through participating in the programs, these inmates can
develop a positive focus in their lives, regain a sense of purpose and
empowerment, and realize that they are able to influence others in
ways they never believed possible (Hammett et al., 1999). The careful
selection of peer trainers and open support of corrections staff are
among the factors contributing to the success of such innovative
programs as the peer program at Louisiana State Penitentiary in
Angola, the AIDS Counseling and Trust program at Louisiana?s Avoyelles
Correctional Center, the peer programs in California?s state prisons
at San Quentin, Frontera, and Vacaville, and the AIDS Video Project
and Peer HIV Education Project in the Los Angeles County Juvenile
System. Several innovative models of instructor-led HIV/ AIDS
education and prevention programs also have evolved in correctional
systems. These include the Forensic AIDS Project conducted in the San
Francisco jails and the Corrections AIDS Prevention Program conducted
at Rikers Island in New York City (Hammett et al., 1999)."



You may also find Appendix B of the above report helpful, which
details the articles cited in Appendix A and gives a table of what
types of interventions are discussed in each article.  A rather unique
and helpful way of doing a bibliography.

http://www.cdc.gov/idu/pubs/ca/appendixB.htm

________

The National Institute on Drug Abuse (NIDA) has an excellent resource
examining the many interventions employed to reduce HIV transmission. 
Here is the reference:

Principles of HIV Prevention in Drug-Using Populations: A
Research-Based Guide: A Research-Based Guide.
http://www.drugabuse.gov/POHP/

This document gives summaries of the National AIDS Demonstration
Research (NADR) Program and Cooperative Agreement (CA) Program

________

You may also be interested in Ethnography and the Evaluation of Needle
Exchange in the Prevention of HIV Transmission on page 231 of
Qualitative Methods in Drug Abuse and HIV Research from the NIDA
(1995):
http://www.drugabuse.gov/pdf/monographs/157.pdf

________

One of the best resources I have found on harm reduction with respect
to IV drug abuse comes from the International Federation of Red Cross
and Red Crescent Societies called Spreading the
Light of Science: Guidelines on Harm Reduction Related to Injecting
Drug Use.  This document has a global scope and discusses harm
reduction in the community and institutional settings.

http://www.ifrc.org/cgi/pdf_pubs.pl?health/hivaids/harm_reduction.pdf

________

There are a few references in this position statement that you may want:
http://www.astho.org/policy_statements/HIV%20Position%20Statement.pdf

________

Here is the World Health Organization (WHO) Policy Brief: Provision of
Sterile Injecting Equipment to Reduce HIV Transmission:
http://www.wpro.who.int/NR/rdonlyres/BA463DB4-2390-4964-9D86-11CBABCC9DA9/0/provisionofsterileen.pdf

This document summarizes the WHO review of over 200 studies.  Here are
some excerpts relating to the scale of implementation recommended:

"Programmes should be implemented on a large enough scale to stop and
reverse HIV/AIDS epi­demics among injecting drug users. Pilot
pro­grammes may have a place in allowing the intro­duction of such
programmes and testing different delivery mechanisms in different
contexts. How­ever, the international experience across coun­tries and
regions is so convincing that there is no longer any real
justification for such small-scale programmes. Pilot programmes may
further delay the much-needed expansion phase and result in inadequate
coverage. However, the exact modali­ties of needle and syringe
programmes as well as service delivery options have to be adapted to
spe­cific local circumstances."


"There is only limited evidence supporting the effectiveness of
disinfection and decontamination schemes. They should only be
advocated as tempo­rary measures where it is not feasible to implement
programmes for the provision of sterile injecting equipment."

The 2004 UN Report on the global AIDS epidemic: Bringing Comprehensive
Prevention to Scale discusses harm reduction with respect to IV drug
users and their sexual partners on page 84:

http://www.unaids.org/bangkok2004/GAR2004_pdf/Chapter4_prevention_en.pdf

On a global scale, 

"A review comparing HIV prevalence in cities across the globe with and
without needle and syringe  programmes found that cities which
introduced such programmes showed a mean annual 19% decrease in HIV
prevalence. This compares with an 8% increase in cities that failed to
implement prevention measures. In Australia alone, these programmes
prevented an estimated 25 000 HIV infections, and saved hundreds of
millions of dollars in HIV treatment costs (Drummond, 2002)."
________

You may also be interested in this editorial on harm reduction and human rights:
HIV, harm reduction and human rights. CMAJ. 2005 Mar 1;172(5):605, 607. 
http://www.cmaj.ca/cgi/content/full/172/5/605

________

The Centre for Harm Reduction was commissioned to review New Zealand's
Needle and Syringe Exchange Programme (NSEP) in March 2002.  Here is
their report:

http://www.chr.asn.au/freestyler/gui/files//NZ_NSEP.pdf

The article points out an interesting dynamic:

"Sharing needles and syringes is much more common in prison than in
the community, and needles may be used multiple times by multiple
individuals, making transmission within prison more likely per sharing
event (Crofts et al, 1995)."

From the previous references, however, there are fewer harm reduction
programs in institutions, particularly prisons.  In fact, at the time
of the above report, New Zealand had not yet implemented their very
successful NSEP in prisons:

"As this review demonstrates, the NSEP has been effective in preventing HIV and HCV
transmission among IDUs in the New Zealand community, and prisoners
are highly likely
to have histories of IDU; thus the most pragmatic course of action
would be to extend the
NSEP into New Zealand?s prisons. Provision of sterile injecting
equipment to prisoners
has been trialled in Switzerland, with apparently excellent outcomes
(Nelles and Harding,
1995). Unfortunately, despite the benefits to public health that would result such
initiatives are frequently unpalatable to governments due to their
potential for political
misrepresentation (?encouraging drug use by convicted criminals?,
etc). Nevertheless, the
topic continues to be raised, most recently in Australia by the
Australian National Council
on Drugs in their position paper on Needle and Syringe Programs
(Australian National
Council on Drugs, 2002)."

==============================

Given the relative lack of information on institutional examples of
harm reduction, I have also drudged up some information focusing on
this area.


Mahon N. New York inmates' HIV risk behaviors: the implications for
prevention policy and programs.[see comment]. [Journal Article]
American Journal of Public Health. 86(9):1211-5, 1996 Sep.

This article is not freely available, however, you can request a free
reprint from Nancy Mahon:
Nancy Mahon, Esq, Open Society Institute, 888 7th Ave, New York, NY 10106

This article describes the situation in prisons rather well...

"Drug use and HIV risk reduction. According to participants, drug use
was very common in prisons and jails. As one participant explained,
"just because I was locked up, didn't mean I was going to stop getting
high" (Men's State 2, p. 28). Participants indicated that an array of
drugs--including glue for sniffing, heroin, cocaine, and
marijuana--entered the facilities through a variety of routes,
including staff, visitors, and personal mail. Participants also stated
that drugs and drug paraphernalia were more scarce behind bars than on
the street and that this scarcity increased the level of desperation
among active drug users and heightened the value of drugs and drug
paraphernalia. One male participant explained how he obtained syringes
in prison and rented them out: "The first move I made was to get to
know that guy in the clinic, the orderly or whatever, got a couple of
sets of works this way.... Anybody that come in with drugs, that was
my in, because I always had money, cigarettes, whatever."

Participants stated that syringes were relatively difficult to find in
jail or prison and were therefore almost always shared. Some female
participants spoke of picking dirty syringes out of the garbage can in
the jail's medical clinic and reusing them, while a few male
participants detailed instances of using a variety of makeshift
syringes to shoot drugs, including basketball pump needles, pieces of
light bulbs, and pens.

In discussing HIV risk reduction, participants indicated that liquid
bleach was difficult to obtain in custody because it was contraband
and that the only inmates who had access to it were those who worked
in the kitchen or laundry facilities. They also stated that prisoners
could obtain clean needles only by stealing them from the health
clinic, getting them through visitors, or exchanging sex or money with
staff. Several participants also indicated they believed that they or
those they knew became HIV infected from dirty needles in jail or
prison.

In discussing drug treatment, many participants indicated that, as on
the street, many inmates would not stop using drugs even if a drug
treatment program were available. Other participants stated that some
prisoners wanted to confront their addiction, but had difficulty doing
so for a variety of reasons, particularly lack of self-esteem and peer
pressure. Some participants indicated that there needed to be more
forensic drug treatment programs."

________

Teplin, Linda A. PhD; Mericle, Amy A. PhD; McClelland, Gary M. PhD;
Abram, Karen M. PhD HIV and AIDS Risk Behaviors in Juvenile Detainees:
Implications for Public Health Policy. American Journal of Public
Health. HIV RETURNS. 93(6):906-912, June 2003.

You can request a free reprint from the Feinberg School of Medicine:
psycho-legal@northwestern.edu

I include this article only because it points out that harm reduction
in juveniles is an entirely different consideration.

"The public health system must

? Provide interventions for detained youths. Because many detainees
are truant,[53] they may miss school-based interventions.
Interventions could improve HIV and AIDS knowledge, attitudes, and
behavioral skills.[27,30,54] Intervening with detained youths could
reduce the likelihood of the onset of the most risky HIV and AIDS risk
behaviors-having unprotected anal sex, using or sharing needles, and
trading drugs for sex-that are still relatively rare."

________

Buavirat, Aumphornpun; Page-Shafer, Kimberly; van Griensven, G J P;
Mandel, J S; Evans, J; Chuaratanaphong, J; Chiamwongpat, S; Sacks, R;
Moss, A.  Risk of prevalent HIV infection associated with
incarceration among injecting drug users in Bangkok, Thailand:
case-control study. BMJ. 326(7384):308, February 8, 2003.

You can request a free reprint from Dr. Page-Shafer:
shafer@psg.ucsf.edu

This paper analyses risky HIV behavior in metropolitan Bangkok, giving
some idea of how big the problem is, even among incarcerated persons. 
Tables 2 and 3 summarize the data:

http://img45.imageshack.us/img45/497/bk25vz.png
http://img151.imageshack.us/img151/7449/bk34yk.png

The problems with implementing harm reduction strategies in the US are
likely as pervasive in Thailand:

"Despite increased risk of HIV and recommendations to make harm
reduction measures accessible inside prison, [8, 21, 22] prevention
activities, including clean needles, condoms, and methadone
maintenance, are rare in prisons. [23] Counselling and drug
detoxification should also be targeted to injecting drug users in
holding cells. Barriers to prison based HIV interventions can be
overcome by developing collaborative prevention partnerships between
public health and law enforcement. [24] As injecting drug users tend
to serve short prison terms owing to the petty nature of their crimes,
[12] most will soon return to society. Both prisoners and people in
close contact with them after their release will benefit from targeted
comprehensive efforts to prevent HIV infection."

________

Bird AG. Gore SM. Hutchinson SJ. Lewis SC. Cameron S. Burns S. Harm
reduction measures and injecting inside prison versus mandatory drugs
testing: results of a cross sectional anonymous questionnaire survey.
The European Commission Network on HIV Infection and Hepatitis in
Prison. [Journal Article] BMJ. 315(7099):21-4, 1997 Jul 5.

You can request a free reprint from Dr. Gore:
sheila.gore@mrc-bsu. cam.ac.uk

This study looked at IV drug use in 3 prisons in the UK and how often
prisoners used clean needles or sterilizing tablets.  The data is
summarized in Tables 2 and 3:

http://img137.imageshack.us/img137/6593/t29km.png
http://img19.imageshack.us/img19/7016/t32wo.png

________

Kent H. Should prisons ease drug prohibition to help reduce disease
spread?. [Journal Article] CMAJ Canadian Medical Association Journal.
155(10):1489-91, 1996 Nov 15.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8943942&query_hl=24&itool=pubmed_docsum

This article looked at harm reduction in prisons.  The author is a
freelance writer and the article is an overview of the situation in
Canada and other western countries in the mid-90's.  She raises an
interesting point regarding needle exchange programs in prisons:

"In Canada, prison staff worried about the potential for needle-stick
injuries continue to argue against such programs. In Switzerland, said
Jurgens, prison staff "participated in the design of the programs,
their security concerns were taken into account and they realized that
such programs are in their own interest." Guards at one prison told
him that they feel safer now because there used to be a constant fear
of needle-stick injuries during cell searches; because inmates no
longer have to hide syringes, this danger no longer exists."

Most people don't consider accidental needle sticks as an issue when
considering exchange programs for inmates, but this is clearly a
factor.  Here is another article that highlights this danger:

Seamark R. Gaughwin M. Jabs in the dark: injecting equipment found in
prisons, and the risks of viral transmission. [Journal Article]
Australian Journal of Public Health. 18(1):113-6, 1994 Mar.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8068783&query_hl=30&itool=pubmed_docsum

She also includes the perspective of an HIV positive prisoner:

"A prisoner offered his perspective on drug use and HIV in prison
during a satellite session at Vancouver's recent international AIDS
conference. Michael Linhart, an HIV-positive federal inmate who
addressed the session via videotape, has spent 5 years lobbying for
harm-reduction strategies in Canadian prisons."

In the last 5 years, Linhart has known six inmates who died of
HIV-related disease and another 20 who are infected with HIV. He
described himself as a "recovering addict," with recovery requiring
"time, effort, support and daily work." Since being infected, "I have
managed to stay alive to the point where I have chosen recovery. As
long as methods for protecting against HIV/AIDS are available to drug
users, there remains the chance that they will stay alive and the hope
that recovery is possible."

Linhart called the plan to introduce needle-bleaching kits in all
federal prisons this fall "the most significant step forward to date."
Project coordinator Trudy Nichol said a recently concluded pilot
project at British Columbia's Matsqui prison was very successful."

________

You can find a nice review of harm reduction techniques, with 110
references for further reading, here:

Hilton BA. Thompson R. Moore-Dempsey L. Janzen RG. Harm reduction
theories and strategies for control of human immunodeficiency virus: a
review of the literature. [Review] [110 refs] [Journal Article.
Review] Journal of Advanced Nursing. 33(3):357-70, 2001 Feb.

You can request a free reprint from Ann Hilton, RN, PhD:
hilton@nursing.ubc.ca

This is an excellent article, with a thorough history and review of
the literature.  It covers the dispensing of drugs (e.g., methadone),
needle exchange programs, harm reduction in prisons, etc.

________

The following article is an in depth analysis of harm reduction in
prisons in Canada.

Gerald Thomas. Canadian Centre on Substance Abuse. National Policy
Working Group. Policy Discussion Document. Assessing the Need for
Prison-based Needle Exchange Programs in Canada: A Situational
Analysis. December, 2005.

http://www.ccsa.ca/NR/rdonlyres/62CB53B4-F416-455E-8069-9561275C1931/0/ccsa0113242005.pdf


"All prison systems in Canada have programs to reduce the demand for
illicit substances and reduce harms among prisoners who use drugs;
however, the sophistication of their approaches varies significantly
(Lines, 2002).[22] For example, CSC has a comprehensive substance
abuse treatment regime that provides accredited, evidence based
programming to thousands of prisoners annually based on individualized
risk and need assessments (Thomas, 2003). In contrast,  substance
abuse treatment programs in most provincial prison systems in Canada
are not as well-designed and do not meet the full demand for treatment
among prisoners. In terms of reducing potential harms among prison
injectors, three programs at the federal level deserve special
consideration: providing bleach for sterilizing drug injection
equipment, methadone maintenance
treatment (MMT) for prisoners dependent on opiates, and the Safer
Tattooing Practices Initiative (STPI) pilot program.[23]"

Table 3 from this report summarizes the outcomes of the various
programs in Germany and Spain, where data is available.
________

Since you are looking at both institutional and community harm
reduction models, you may be interested in this article, which looked
at linking harm reduction in prisons to community programs for
released prisoners (Project Bridge).

Rich JD. Holmes L. Salas C. Macalino G. Davis D. Ryczek J. Flanigan T.
Successful linkage of medical care and community services for
HIV-positive offenders being released from prison. [Journal Article]
Journal of Urban Health. 78(2):279-89, 2001 Jun.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11419581&query_hl=28&itool=pubmed_docsum

You can request a reprint from Dr. Rich:
jrich@lifespan.org

An overview can also be found here:
http://www.hawaii.edu/hivandaids/Linking%20HIV%20Positive%20Inmates%20to%20Services%20after%20Release.pdf

=================================

So, to summarize, it's difficult to compare community and
institutional harm reduction programs directly, in part because the
populations they target and the methods they employ are fundamentally
different.  That being said, community programs are more prevalent,
easier to access by participants, and have higher compliance rates.
The lower number of institutional programs is due at least in part to
steep political pressures in western countries.  This prevents their
widespread adoption, in spite of their proven efficacy and cost
effectiveness and the higher rates of drug use and HIV transmission in
prisons compared to community settings.  The only arguments put forth
against harm reduction programs have not been based on scientific
findings, but rather on cultural and political beliefs.  This is a
general trend throughout the world.

There have been some programs (see examples above) linking
institutional harm reduction with post-release programs.  One such
example is Project Bridge.  These programs have been successful in
terms of reducing HIV trasmission and risky behaviors after
participants leave the institutional setting.


I hope this information is useful.  Please feel free to request any
clarification prior to rating.

       -welte-ga

Very good answer. In retrospect I should have defined the topic more
precisely. The answer was comprehensive given the general lack of
information on the area.