Drug use stigma and reprisal: Barriers to prison needle exchange in Canada

Abstract
After years of advocacy by a range of civil society groups, supported by scholarly and empirical research, Canada's federal prison service implemented a needle exchange program at select carceral institutions in 2018. Since the program rollout, however, uptake has remained minimal. To understand why, we conducted the first independent and national study of the program, interviewing 30 people who were incarcerated at one of the prisons with a needle exchange. Our findings show that drug use stigma and anticipated or actual reprisal from correctional officers, particularly related to breaches of confidentiality for program participants, markedly impede access and utilization.

Introduction
Community-based needle and syringe programs have long been upheld as an effective harm reduction strategy with the potential to reduce the sharing of injection equipment, transmission of blood-borne infections such as HIV and hepatitis C virus (HCV), injection-related injuries, and other harms to health (see Bruneau et al., 2008; Gibson et al., 2001; Strike et al., 2013, 2021; Tyndall et al., 2002). Decades of international research on prison-based syringe distribution shows similar beneficial health outcomes (Chu & Elliott, 2009; Chu & Peddle, 2010; Dolan et al., 2015; Lines et al., 2005; PHAC, 2006; Stöver & Hariga, 2016; Stöver & Nelles, 2003; Stöver et al., 2021; van der Meulen et al., 2016, 2017). Such programs are especially necessary given the frequency of in-prison injection drug use and the high rates of transmission of blood-borne viruses within carceral settings (Andía et al., 2005; Chu & Elliott, 2009; Chu & Peddle, 2010; Cunningham et al., 2017; van der Meulen, 2017).

In Canada, years of advocacy by people who have experienced incarceration as well as HIV, prisoner rights, harm reduction, Indigenous, and public health organizations in support of prison syringe distribution culminated in a lawsuit in 2012 that sought to compel the Correctional Service of Canada (CSC), the federal agency that oversees prison sentences of 2 years or more, to make sterile injection equipment available. As a result of the court case, in 2018, CSC finally introduced a Prison Needle Exchange Program (PNEP) at two of its 43 institutions, with “best practices” learned at these institutions intended to “inform a full national roll-out” (CSC, 2018, para. 1). Although CSC originally indicated its plan to implement PNEPs in eleven prisons by 2019, at the time of writing a PNEP has only been established in nine (CSC, 2021). CSC also created a complementary Overdose Prevention Service at one institution in 2019 and at two additional sites in 2023 to address concerns around overdose, equipment sharing, and transmission of HIV and HCV (CSC, 2019a; Taekema, 2024).

When CSC developed the PNEP in 2018, it suggested that the program would “strengthen its [CSC's] ongoing efforts to prevent and manage infectious disease in federal penitentiaries and in the community” (CSC, 2018, para. 1), with data from that period indicating that approximately 430 federal prisoners were living with HIV and more than 6,500 with HCV (CSC, 2016a, 2016b). The prevalence of HIV and HCV among people in prison is indeed one of the primary rationales for needle and syringe programs in those settings (Chu & Elliott, 2009; Chu & Peddle, 2010; Dolan et al., 2015; Lines et al., 2005; PHAC, 2006; Stöver & Hariga, 2016; Stöver & Nelles, 2003; Stöver et al., 2021; van der Meulen, 2017). However, in the years since the PNEP began being rolled out, federally incarcerated people in Canada have faced multiple barriers to navigating the program, whether at the initial application stage or in acquiring sterile supplies once registered.

This article examines some of the challenges associated with CSC's PNEP, presenting the results of the first independent and national study of the program. It expands on research published in The Prison Journal in 2017, which explored former prisoners’ experiences and knowledge of accessing and sharing injection equipment in prison. Participants in that study were critical of the limited access to harm reduction supplies in carceral settings and were highly supportive of prison syringe distribution in general, with some program models or approaches seen to be more feasible, effective, and appropriate than others (see van der Meulen et al., 2017). Soon after the publication of The Prison Journal article, CSC introduced its PNEP. And yet despite the high rates of in-prison injection drug use and stated interest in a syringe program, very few have enrolled. To understand how the program is functioning and what barriers and challenges might need to be rectified, we conducted 30 one-on-one interviews with people who were recently released from one of the prisons with a PNEP, as per CSC's website when we began data collection in September 2021. Interviewees shared their perceptions of the program, their concerns and suggestions for improvement, and their insights into the reasons for low participation rates.