Securitizing carceral health: a realist review of Canada's prison needle exchange program.

Background: In 2018, in response to a lawsuit and years of civil society advocacy for prison-based syringe distribution due to elevated rates of injection drug use, HIV, and hepatitis C virus among incarcerated people, the Correctional Service of Canada (CSC) developed a Prison Needle Exchange Program (PNEP). Implementation of the PNEP has been slow and has faced significant critiques and challenges. As of early 2025, the PNEP is only available at eleven of forty-three federal prisons in Canada. Employing realist review methodology, an iterative process for synthesizing evidence concerning complex policy interventions, this article investigates CSC's approach to, and implementation of, the PNEP. By recognizing broader social and institutional contexts, and through the integration of environmental considerations, realist reviews consider policy outcomes and implications in addition to efficacy. In our study, we draw upon 114 distinct documentary sources, comprised of scholarly articles, news media, program evaluations, and correctional policies, as well as 257 pages of federal government disclosures acquired through Access-to-Information requests. Together, these allow us to identify factors that have either facilitated or impeded the PNEP's ongoing rollout and uptake among people in prison.

Results: Our results find that perceived risks regarding the circulation of needles and the use of a "Threat Risk Assessment" to determine eligibility function as major impediments to program efficacy. Findings also reveal incarcerated people seeking to enroll in the PNEP are frequently denied access and that the active involvement of correctional officers in enforcing compliance to program requirements acts to the detriment of participation. Results indicate the absence of meaningful confidentiality protections along with elevated rates of program discontinuation. Over roughly seven years of its existence, the PNEP has had extremely low uptake, particularly among women.

Conclusions: We propose a significant revisioning of CSC's PNEP to bring it into alignment with the best practices of similar prison-based harm reduction initiatives internationally, and according to professionally accepted standards of syringe distribution. The Canadian experience provides a cautionary tale to other jurisdictions considering implementing a carceral syringe program.