Marie Claire Van Hout and Elie Aaraj
It is imperative that governments and prison authorities in the Middle East and North African (MENA) region accept the presence of sexual and drug related virus transmission in prisons and use evidence-based approaches of harm reduction (HR) to tackle the spread of disease among prisoners and on their return to communities. This imperative coincides with the COVID-19 pandemic, and the instigation by many MENA states of early release schemes to tackle prison congestion and rapid spread of COVID-19 (for example Iran has released over 80,000 prisoners and other MENA countries are following suit). It underpins the need for MENA states to consider decriminalization of the use of drugs, alongside HR approaches in prisons and communities. Provision of good-quality and accessible HR within and outside prisons is a legally binding human rights obligation and cannot be dismissed by government as an unwanted policy option.
Our Viewpoint comments specifically on the interplay between the rise in injecting use of drugs, spread of blood borne viruses (HIV, hepatitis), and prison responses in the MENA region. Intravenous drug using and risky sexual behaviors are important transmission routes for HIV and hepatitis C in this region. It has one of the two fastest growing HIV epidemics in the world, and also has the highest hepatitis C prevalence globally (20% of all chronically infected individuals reside here). Egypt and Pakistan are currently facing hepatitis C epidemics of historic proportions. Estimates in the region indicate that half the people who inject drugs (estimated at 630,000) have been infected with hepatitis C, but with great variation in antibody prevalence across specific MENA countries. There is no community level data on people who no longer inject drugs, but who have contracted hepatitis C.
Knowledge around transmission routes and related sexual and drug injecting risk behaviors is worryingly low in key vulnerable and overlapping groups (men who have sex with men, female sex workers, people who inject drugs, people in prison). These highly stigmatized groups are over-represented in prisons. Over 600,000 people are deprived of their liberty in the MENA region, the vast majority of whom are male and detained on drug related charges. The proximity of many MENA countries to opium production regions and trafficking routes contributes to this profile. Intravenous drug use is the primary mode of blood borne virus transmission in prisons located in the region.
In Iran, HIV prevalence in prisons varies but is higher than in most MENA countries.. About half all prisoners are drug dependent with many introduced to intravenous injecting during incarceration. In 1990, a serious HIV outbreak in Iranian prisons resulted from unsafe drug injecting which stimulated a progressive and rapid shift towards HR measures and government endorsement of HR. These measures included promotion of de-stigmatisation and legalisation, research into virus transmission in prisons and communities, establishment of addiction centres, HIV testing and counselling, sexually transmitted infection services, and provision of opioid substitution treatment (OST) and needle and syringe programs in prisons. Iran was seen as the forerunner of a scaled up ‘top down’ HR programming approach in prisons in the MENA region. Unfortunately the approach was restrained by budget cuts during the term of President Ahmadinejad (2005-2013), resulting in a rise in HIV and hepatitis C prevalence in prisons and communities. Morocco follows close behind in HR implementation, with a ‘bottom up’ civil society led response underpinned by the 2011 national drug policy which spans public health and human rights (Rabat Declaration).
Despite the evident success of the Iranian model supported by political commitment and financial investment, the links between prison and public health relating to HIV and hepatitis C rates have not led to policy reform in other MENA governments. Prison data is insufficient in the region to estimate the size of the key risk groups. Given the increasing evidence of significant virus transmission in MENA prisons, hidden HIV and hepatitis C clusters cannot be ruled out.
The spread of diseases between prisons and communities is a significant threat to regional and national public health. Centralized political power, and ‘top down’ health systems in the MENA region do not normally support HR as a public health priority. Few countries in the region make explicit mention of HR in their national strategies (the present exceptions being Afghanistan, Pakistan, Iran, Morocco, Tunisia, Lebanon, Palestine, and Egypt). Restrictive laws, rejection of HR strategies at the policy level, lack of political commitment, and restrictions on access of civil society into prisons all compound the threat of disease in prisons and communities. As a consequence, the current HR response in MENA prisons has been very low (with exception of Iran, Lebanon, and more recently some capacity building initiatives have taken place in Egypt, Tunisia and Morocco). Unfortunately there is also a global reduction in donor funding for HR interventions.
Evidence shows that neglecting HR fuels the emergence and re-emergence of viral epidemics in prisons in this region. The current lack of commitment and consideration of robust measures to reduce harm constitutes an infringement of the human rights of prisoners throughout the MENA region which, compounded by COVID-19, will result in further suffering and mortality.
Marie Claire Van Hout is Professor of Public Health Policy and Practice, Liverpool John Moore’s University, United Kingdom. Email: email@example.com.
Elie Aaraj is Director, Middle East and North African Harm Reduction Association (MENAHRA), Lebanon. Email: firstname.lastname@example.org
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