Quebec co-lead Dr. Nadine Kronfli discusses her team’s work in optimizing Canada’s innovative prison harm reduction strategies
One in four people in Canadian federal prisons have been previously exposed to hepatitis C. Hepatitis C can have a major long-term impact on liver health, but it can be challenging to access testing or treatment in prison.
Needle exchange programs offer a solution — not just for viral hepatitis, but other blood-borne viruses, like HIV.
While the approach is rare in prisons across the globe, Canada is leading the way with an innovative study that aims to ensure that needle exchange programs in federal prisons are accessible to everyone who needs them. We spoke with two of the scientists leading the study, infectious disease specialist Dr. Nadine Kronfli and CTN+ postdoctoral fellow Dr. Olivia Price, to discuss their research.
Moving the Needle
“Injection drug use is ubiquitous: it occurs in every single prison around the world,” said Dr. Nadine Kronfli, a scientist at the Research Institute of the McGill University Health Centre and co-lead of the CTN+ Quebec Regional Team.
That’s why harm reduction programs are so important. That’s the term given to a variety of interventions designed to minimize harmful effects related to injection drug use including opioid agonist therapies and clean injecting equipment through needle exchange programs.
Dr. Kronfli’s research began with hepatitis C testing and linkage to care, born out of a CTN pilot trial (CTNPT 034) from 2019 that investigated the impacts of screening incarcerated people in Quebec provincial prisons for hepatitis C with a point-of-care test. Her team found a very high level of uptake, as high as 100% in the case of a finger prick test, showing just how welcome such testing could be.
From there, her team’s research has grown in scope to include harm reduction, as well as the screening and prevention of all sexually transmitted and blood-born infections. Backed by a five-year grant from the CIHR, they’re working with prison teams across Canada to improve existing harm reduction programs in federal prisons.
Needle exchange programs are a big part of that work. By allowing people to easily trade in used needles for unused ones, these programs can significantly decrease transmission rates of blood-borne viruses.
“Among people who inject drugs, sharing injecting equipment is the main transmission pathway for blood-borne viruses like HIV, hepatitis B or C, and so providing access to sterile injecting equipment in prisons is important to reducing transmission,” explained Dr. Olivia Price, who is a public health researcher and a 2025 CTN+ postdoctoral fellow. Dr. Kronfli, who supervises Dr. Price, was once a CTN postdoctoral fellow herself, showing the long-term success of this important program as it continues to foster the careers of Canada’s rising research stars.
Needle exchange programs have a host of downstream benefits, making it easier for patients to access the health care they need including programs to help manage their substance use challenges. Dr. Price said, “We’re working with all prison staff to make it easier for people who inject drugs in prison to access harm reduction programs such as needle exchanges.”
Reducing Harm
Dr. Kronfli said, “Our research is about working with people with substance use without judgment, without coercion, without discrimination, to advocate for their support in accessing evidence-based harm reduction programs.”
“We’ve got very strong evidence that these harm reduction strategies help prevent blood-borne virus transmission in community settings,” said Dr. Price. “What we really need is better evidence on how they work in prison settings, if we’re going to scale them up.”
Initial research since the needle exchange program’s launch in 2018 found it to be highly cost-effective, with a paper from 2024 by Dr. Kronfli reporting that every dollar invested saved $2 in hepatitis C and injection-related infection treatment costs. However, that doesn’t mean the program is perfect. Dr. Kronfli was inspired to conduct this research by an evaluation released several years ago, “which found that less than one in ten people who inject drugs in prison was accessing these services.”
If these harm reduction programs are effective, why is uptake so low? Worried about the future of the programs, Dr. Kronfli’s team set to determine the roadblocks — and dismantle them.
Small Changes, Big Impact
“For the last two years, we’ve traveled to all nine federal prisons to understand the barriers to the uptake of these programs,” Dr. Kronfli said, explaining that this research includes working with incarcerated people who are and aren’t using the program — but also, uniquely, all levels of leadership within the prisons. “This is the very first time this has been done anywhere in the world. We’re interviewing high-level prison leadership to understand: How are the prison’s policies obstructing access to the needle exchange programs?”
From these interviews, the researchers have been making lists of the barriers to accessing these programs. Teams of researchers at each prison then implement small changes on a monthly basis and measure their impact on uptake. These changes could include things like decreasing the wait times or advertising the services on the internal prison TV system.
“One change project a team implemented was to check whether introducing the needle exchange program when people are newly admitted to a prison would result in increased uptake,” said Dr. Kronfli. “And what do you know? It did.”
Prison Health is Public Health
Dr. Kronfli never expected to be a doctor. “I would have loved to have been a journalist,” she said, laughing, “and I have always dreamed of being a humanitarian lawyer.” It was a combination of these interests in combination with medicine that eventually brought her to this field of research. “Advancing the health of people in prison is an area that combines all of the things that I am passionate about and that I could not have otherwise done all at the same time,” she added.
The legal aspect of the work is an important driver in Dr. Kronfli’s motivation. Following the adoption of the Nelson Mandela Rules, people in prison are expected to have the same access to health care benefits and services that they would have in the broader community. “But often that simply does not happen,” explained Dr. Kronfli.
Additionally, Dr. Kronfli argues that harm reduction programs like this benefit far more than the individual. “Focusing on the health of people in prison benefits everybody in society, particularly those in surrounding communities, because there is a constant turnover of people from prison into the community.”
The goal of a prison is not to hold people indefinitely, but to help individuals rehabilitate and re-enter society. Every year, over 6,000 people are released from Canadian federal prisons and into community supervision. Dr. Kronfli said, “Many are under community supervision. They are likely involved in community activities that many people who have never been in contact with the prison system are also involved in.
“If we fail to ignore their health and well-being, there will be consequences to public health,” she added, explaining why it’s so important that infectious diseases are both prevented and treated within prisons. “Porous borders exist between prisons and the broader community, and failing to recognize that this border is permeable will harm everyone.”
Overcoming Challenges
Health research can be difficult at the best of times, but working within prisons introduces its own unique obstacles. This can range from struggling to find office space within older buildings to scheduling around lockdowns.
In Dr. Kronfli’s view, though, the biggest challenge is changing peoples’ attitudes towards prioritizing the health of people in prison. “It does take a certain individual to commit to this type of research,” Dr. Kronfli admitted wryly. “I’ve been called tenacious on many occasions; ‘no’ is simply not an answer I am willing to take.”
Two years into their five-year project, the team is hopeful about the progress they’re already making. Dr. Price said, “What so excites me about this role is being part of this next step which is: now that we’ve found a problem with implementation, how are we going to help solve it?”
“It’s rare for health and corrections to come together in prisons and work towards a single unified goal,” added Dr. Kronfli. The program is giving everyone within the prison a shared sense of responsibility. “People are saying ‘We want to improve uptake of this program for people in prison.’ Something that they might not have prioritized, or even supported in the past, is now front and centre.”
This research has the potential to change the lives of people in prisons, not just within Canada, but across the globe. Dr. Kronfli said, “It’s very magical for me to see this all happen. I very much look forward to sharing the results with the world when our study is complete.”
