continue their drug use in prison,52 while another reported that 85% of IDUs used drugs in prison.53 A study found that 28% of community-based IDUs with a history of incarceration have injected drugs in prisons,54 and another reported that 9.7% of drug-using inmates continued to use drugs, mostly heroin, while in prison.55 Also in the Islamic Republic of Iran, opioid use prevalence while in prison was found to be 30.7%, though 54.3% of inmates used drugs before incarceration, indicating a reduction in drug use during incarceration.56 About 25%– 30% of prisoners used drugs in prison in one study,57 with another study indicating that about 30% of prisoners attempt to use drugs in prison and 17%–23% of prisoners use drugs by injection.58 In further studies, 91% of IDUs and noninjecting drug users ever imprisoned reported using drugs while in prison,59 and 18.9% and 6.1% reported using opioid and injecting drugs while in prison, respectively.60 Other studies have also observed IDU in prisons in other MENA countries. In Algeria, 67% of those incarcerated reported using drugs in prison.61 In the Arab Republic of Egypt, about 25% of IDUs who had been incarcerated reported injecting drugs in prison.62 In Lebanon, only 0.16% of prisoners, including IDUs, reported injecting while in prison.63 In Oman, 26%–44% of IDUs reported drug use in prison and 5%–11% reported injecting drugs in prison.64 In Syria, 11% of imprisoned IDUs injected drugs in prison.65 The prison environment is possibly compelling noninjecting drug users to inject while in 52
Ibid. Day et al., “Patterns of Drug Use.” 54 Zamani et al., “High Prevalence of HIV”; Zamani et al., “Shared Drug Injection inside Prison.” 55 Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s Prisons.” 56 Ibid. 57 Mostashari, UNODC, and Darabi, “Summary of the Iranian Situation on HIV Epidemic.” 58 Afshar, “From the Assessment to the Implementation of Services”; Afshar, “Health and Prison.” 59 Day et al., “Patterns of Drug Use”; Zamani et al., “Needle and Syringe Sharing.” 60 Zamani et al., “Needle and Syringe Sharing.” 61 Mimouni and Remaoun, “Etude du Lien Potentiel entre l’Usage Problématique de Drogues et le VIH/SIDA.” 62 Elshimi, Warner-Smith, and Aon, “Blood-Borne Virus Risks.” 63 Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” 64 Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.” 65 Syria Mental Health Directorate, “Assessment of HIV Risk and Sero-Prevalence.” 53
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prison due to the difficulty of clandestine smoking and scarcity of raw opium.66 The higher cost of obtaining drugs in prison has also been cited as a reason for injecting drugs because it is the most cost-effective method of using drugs.67 Inmates find multiple ways of paying for drugs in prison, such as through family financial support, drug dealing, prison work, sex work, forcing their wives to do sex work, selling food and personal effects, gambling, credit, and extortion.68
Use of nonsterile injecting equipment in prisons Although predominantly from the Islamic Republic of Iran, evidence indicates the use of nonsterile injecting equipment in prisons. Studies in the Islamic Republic of Iran found, respectively, that 19%,69 29.9%,70 and 37.1%71 of IDUs reported using nonsterile injection equipment in prison. In further studies in the Islamic Republic of Iran, 82% of those with a history of IDU in prison have injected drugs using nonsterile utensils,72 and 23% of community-based IDUs reported using nonsterile drug injection utensils in prison.73 Twenty-three percent of prisoners in another study used drugs mostly with nonsterile and handmade utensils.74 There is also evidence from other countries of using nonsterile injecting equipment in prisons. In Afghanistan, 30% of IDUs in prison reported using nonsterile needles or injection equipment.75 In Oman, 3%–11% reported using nonsterile needles in prison.76 In Sudan, 3.2% of prisoners reported using nonsterile syringes while in prison.77 In Syria, the majority of IDUs who injected in prison did so by using a nonsterile syringe or a needle.78 66
Day et al., “Patterns of Drug Use”; Kheirandish et al., “Prevalence and Correlates of Hepatitis C.” 67 Zamani et al., “Shared Drug Injection inside Prison”; Zamani, “Methadone Maintenance Treatment (MMT).” 68 S. Zamani, personal communication (2008); Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s Prisons.” 69 Day et al., “Patterns of Drug Use.” 70 Zamani et al., “Needle and Syringe Sharing.” 71 Ibid. 72 Zamani et al., “High Prevalence of HIV.” 73 Zamani et al., “Shared Drug Injection inside Prison.” 74 Afshar, “Health and Prison.” 75 UNAIDS, “Notes on AIDS in the Middle East and North Africa.” 76 Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.” 77 Assal, “HIV Prevalence.” 78 Syria Mental Health Directorate, “Assessment of HIV Risk and Sero-Prevalence.”