REF2021 21Z_ICS_A Improving health equality for incarcerated people through new harm reduction policy and practices

  • Morag Macdonald (Research Participant)

Impact: Health impacts, Quality of life impacts, Public Policy or Services impacts

Description of impact

Since 2014, research undertaken by Morag MacDonald has led to an increase of policy implementation and uptake of prison-based harm reduction strategies in Europe and Central Asia, where the prevalence of drug-related diseases was up to ten times higher than in the general population. This work particularly benefitted incarcerated individuals with drug-related infectious diseases in those regions. MacDonald's direct involvement in the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia resulted in policy change, increasing harm reduction measures in more than 15 countries. As a result, harm reduction measures in prisons have reached near parity with those of the wider community.

Details of Impact
4.1 Dublin Declaration and changes to drug management and treatment policy in European and Central Asian prisons

MacDonald played a pivotal role in the implementation of harm reduction strategies within prisons, enabled by the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia in 2004. Her research expertise and crucial findings led to her being invited to co-author the Declaration (S01) and incorporating her key findings within its text. According to the World Health Organisation Regional Office for Europe, the Declaration called on officials to take action to address the issue of HIV/AIDS in prisons by implementing comprehensive prevention, care, treatment and support programmes. The Declaration became the goalpost by which to evaluate the progress of European and Central Asian countries in relation to HIV/AIDS in prisons, leading to significant policy changes in 16 countries.

Through the Declaration, MacDonald’s recommendations have been adopted into prison harm reduction policies across Europe and Central Asia, enabling prisons to strategically address and reduce harm. MacDonald’s research (R01-R03) identified three recommendations that were included in the Dublin Declaration. These are (i) opioid substitution therapy, (ii) needle and syringe exchange programs, and (iii) infectious disease testing and treatment in prisons. These recommendations are now being used in guidance provided by the European Centre for Disease Prevention and Control (ECDC) and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and enabled the following advances within European and Central Asian prisons.

(i) Increased opioid substitution therapy (OST): Since 2014, Greece, Cyprus and Lithuania had implemented MacDonald’s recommendation by introducing OST in their prisons, with the latter two countries implementing OST in all prisons by 2018. A total of 14 countries in Europe and Central Asia followed suit and by 2018 it was implemented in all their prisons. Overall, 39 European and Central Asian countries had implemented MacDonald’s OST recommendation by 2018. The significant increase in prisons implementing OST has enabled them to reflect more closely treatment for those outside of the prison system (S02).

(ii) Increased needle and syringe exchange programmes (NSEPs): MacDonald’s recommendation for the use of NSEPs in the Dublin Declaration led to approximately 60 prisons worldwide implementing needle exchange programmes (S03). Between 2014 and 2016, the number of prisons that provided NSEPs in Switzerland, for example, increased by 114% (S04). In 2017 alone, 1,565 prisoners benefited from the introduction of these risk reduction measures in Moldova, with more prisons now providing the service (S05).

(iii) Increased infectious disease testing: England benefitted from the adoption of MacDonald’s recommendation for increased infectious disease testing in prisons. From 2014, Public Health England, NHS England and Her Majesty’s Prison and Probation Service launched a national ‘opt-out testing’ programme across all adult prisons in England (S02), following the recommendations made by MacDonald in the Dublin Declaration. This led to an increase of testing from 4% of the prison population in 2010 to 29% in 2017 (S06). For HCV, only 8.6% of prisoners were tested for the virus in 2013/14 as compared to 24% in 2017 (S07). This had important implications, especially for identifying HCV positive prisoners to enable earlier care and treatment interventions. For instance, in Q1 of 2017/18, 8,797 tests resulted in 18% testing positive for HCV which led to high levels of specialist referrals. In 2016/7, of 34,474 tested for HIV, 942 were HIV positive and could be provided with specific support (S06). The ability to opt-out ensured that the test was voluntary as recommended by MacDonald.

Due to the Dublin Declaration, “in many countries, the HIV rate among drug using prisoners is low compared to 20 years ago” (S03) and, “in both 2016 and 2018, there was significant progress towards meeting the global substantive targets” set out by the Dublin Declaration (S02). A EMCDDA evaluation credits the Dublin Declaration as the reason that harm reduction measures in prisons have reached near parity in the wider community in recent years, closing the gap between services for people inside and outside of prison (S02).

4.2 Providing tools and training to implement harm reduction policies and decrease drug-related disease in Central Europe and Asia

MacDonald’s research identified the difficulties of implementing harm reduction strategies in prison systems due to a lack of practical information and training (R04-R06). To address this concern, MacDonald and the Public Health Commission of the European Union created and distributed a training manual designed for professionals working in the criminal justice system. From 2007, MacDonald was a partner in a project to train criminal justice professionals in harm reduction services for vulnerable groups; the project was funded by the Public Health Programme of the European Commission (€299,956). MacDonald co-authored The Prison Staff and Harm Reduction training manual (S08), which provided the basis for teaching prison staff how to reduce harm from drug-use behaviours through information, education, and medical assistance.

Since 2014, the trainings have led to beneficial outcomes for prisoners. Specifically, in Varna Prison in Bulgaria the prison director informed a project co-researcher that MacDonald’s research findings and training was the reason for the prison taking a harm reduction approach and “a program for counselling and prevention of infectious diseases”. Additionally, “prison staff developed skills and knowledge to implement drug prevention and harm reduction activities” as an outcome of MacDonald’s work, which helped develop “knowledge and skills to integrate harm reduction activities in [the] prison[’s] health strategy” (S09). MacDonald’s research-based interventions also contributed to the prison’s approach to testing and training and increased the “awareness of prison staff about the harm reduction approach” and “increased tolerance and understanding of the staff towards prisoners with problematic use of psychoactive substances”. 46 prisoners underwent opioid substitution treatment following the introduction of harm reduction based on MacDonald’s recommendations. 64 inmates were tested anonymously for hepatitis and HIV/AIDS and “a range of other prison workers, including psychologists, received training in prevention and harm reduction policy and activities” (S09).

The training manual continues to be used as a resource in key areas of professional resources pertinent to criminal justice professionals such as the Southern Caucasus Office on Drugs and Crime and the WHO (Europe), as well as being cited by the Health Research Board of Ireland, the Handbook on Quality Standards for Interventions Aimed at Drug Experienced Young People in Contact with Criminal Justice Systems, and by the EU-funded community project AIDS & Mobility Europe (S010).
Impact date20142020
Category of impactHealth impacts, Quality of life impacts, Public Policy or Services impacts