Gatekeeping harm reduction in Canadian Federal Prisons: Perspectives on the threat risk assessment for the prison needle exchange program by prison administrative leadership

Abstract

Background and aims: Prison needle exchange programs (PNEPs) are evidence-based, cost-effective interventions that prevent transmission of blood-borne viruses. PNEPs were introduced in a minority of Canadian federal prisons in 2018; however, participation is contingent on a mandatory approval process known as a “Threat Risk Assessment” (TRA). Although the TRA seeks to protect institutional safety and staff well-being, it has delayed access and restricted program participation. We aimed to explore prison administrators' perceptions of the TRA, including its goals and potential alternatives, within the broader PNEP policy objective of facilitating access to clean needles/syringes for people who inject drugs in prison. Design and setting: Qualitative analysis using semi-structured interviews across nine Canadian federal prisons with PNEPs. Participants: Twenty-seven institutional heads, including Wardens, Assistant Wardens of Operations and Chiefs of Health Services. Measurements: Matland's Ambiguity-Conflict model informed this analysis. Findings: Institutional heads largely described the TRA as a security tool, a clear goal consistent with low ambiguity, but whose aims often conflicted with PNEP goals of low-threshold access, placing implementation in a high conflict-low ambiguity political implementation paradigm. In this paradigm, top-down decision making, underpinned by carceral logic and moral hazard framing, prioritizes institutional security over public health. Many also perceived the TRA's function as symbolic, primarily to appease labour partners and demonstrate due diligence to external bodies, an interpretation that increases ambiguity around the TRA's true purpose consistent with high conflict-high ambiguity implementation. Participants proposed two pragmatic alternatives to reduce conflict: re-assigning the TRA to Health through a more bottom-up decision making approach, characteristic of low conflict-high ambiguity experimentation implementation; and streamlining the current TRA process within Operations, consistent with a low conflict-low ambiguity administrative implementation paradigm. A minority advocated to eliminate the TRA and grant automatic PNEP enrolment, aligning with community norms and international practice. Conclusion: Within Canadian federal prisons, the “Threat Risk Assessment” (TRA) appears to be a structural process obstacle within the prison needle exchange program (PNEP) policy that fails to provide low threshold access to PNEPs due to the prioritization of institutional safety at the cost of public health. Alternative options to the current TRA process clarify actionable levels for policy refinement that preserve safety, improve access and better align with evidence and public health goals.