Prison Needle Exchange: Lessons from a Comprehensive Review ...

Educational workshops and
consultations with prison
staff have been a key aspect
in the development of prison
needle exchange.
Leadership of prison administration
and support of prison staff
As with other controversial measures, or those measures that apparently
run counter to accepted orthodoxy within a system, it is crucial
to have supportive leaders at the highest level to successfully
create and implement prison needle exchange programs. Practically,
this may mean leadership by key senior officials responsible for
prison health-care services, or prisons generally, and support by the
head of the prison in which the needle exchange is being established. The support of prison
staff has also been shown to be an integral part of successful programs. In all jurisdictions
visited for this report, educational workshops and consultations with prison staff have been
a key aspect in the development of prison needle exchange.
This is not to say, however, that staff in these institutions have been universally supportive
from the start. In several cases, as is evidenced in the evaluations, staff members were
reluctant at the start, yet grew to support the program over time as its benefits were experienced
first-hand. The initial reluctance of staff makes the need for committed, informed,
inclusive leaders supporting the implementation of prison needle exchange programs all the
more important. While bottom-up processes that include the involvement and cooperation of
staff have been shown to be successful, there is mixed evidence on the success of top-down
approaches, where the implementation of prison needle exchanges is directed by government.
Switzerland has experienced problems when a strictly top-down approach has been
followed. On the other had, the experience in Spain has shown that it is possible for government,
including parliament, to take a leading role in setting the agenda for the implementation
of needle exchange programs as long as practicality and flexibility at the prison level
are encouraged.
Need for confidentiality and trust
The issue of confidentiality has been a key factor in the creation of successful needle
exchange programs. From the perspective of many prisoners, confidentiality is the most
important factor in establishing trust in the needle exchange pro-
gram. Inside any prison, absolute confidentiality of prisoners’ personal
information may be impossible. However, in the context of
prison needle exchange programs, it is crucial to preserve the confidentiality
of prisoners who use drugs and access sterile needles to
the greatest extent possible. The successful programs examined in
this report have all striven to identify needle distribution methods
that would gain the trust of the prisoner population and thereby
maximize participation in the program.
In some prisons, syringe-dispensing machines located in areas
where prisoners are housed have proved the best mechanism for confidential needle distribution.
In those institutions where a person-to-person method of exchange is in place, it has
been shown that identifying a discreet area of the prison in which to conduct the service is a
factor in its success. The importance of confidentiality was demonstrated quite vividly in the
Moldovan experience, where the needle exchange pilot in Prison Colony 18 saw a significant
increase in uptake when the physician decided to use peer outreach workers rather than
the medical unit as a point of contact with prisoners who inject drugs. The experience in the
Spanish pilot program in Bilbao, where the evaluations found that prisoners preferred the
program to be administered by an external non-governmental organization rather than prison
It is crucial to preserve the
confidentiality of prisoners
who use drugs and access
sterile needles to the
greatest extent possible.
54 Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience