1. Introduction
One of the major problems in prisons is the increased drug use. It is estimated that the number of People Who Use Drugs (PWUDs) in prisons is 70%. The risk of HIV transmission in prisons is also high since a significant percentage of PWUDs inject drugs. On the other hand, the frequency of high-risk behaviors in a prison can increase the likelihood of the spread of related diseases in society. Therefore, development of policies and treatment programs for reduction of drug-related harm in prisons are of great importance. In this regard, the health department of Iran’s Prisons, Security and Corrective Measures Organization has implemented programs since the late 1991 to improve the health of prisoners and reduce the risks for public health. One of the concerns of the relevant authorities is the documentation of harm reduction measures and their modification in accordance with the conditions of the prisons. The present study aims to assess the implementation of drug-related harm reduction programs in prisons of Iran and suggest solutions for their improvement.

2. Methods
This is a descriptive cross-sectional study conducted in three steps. First, library method was used to collect information from the documents available in the library of Iran’s Prisons, Security and Corrective Measures Organization. In the second step, performance indicators were extracted and two researcher-made checklists were designed. The face and content validity of the checklists were evaluated based on the opinions of a panel of experts. The third step included a field visit through a semi-structured interview with service providers, service recipients, and prison authorities involved in the implementation of treatment programs and measures for harm reduction.

3. Results
The harm reduction programs were implemented since 2001 with the Methadone Maintenance Treatment (MMT) program conducted as a pilot in Ghezel Hesar Prison. To date, the treatment and harm reduction programs have been implemented in the most Iranian prisons with two major programs including MMT and triangular clinic. Table 1 summarizes the performance indicators of harm reduction programs in provincial prisons of Iran.






As can be seen in Table 1, the coverage rate of programs especially MMT in all prisons was almost 100%. Half of the provinces had no waiting list for treatment, 27% had a considerable number of waiting lists and 23% had low to moderate number of waiting lists. There was shortages of space, staff and budget in all prisons, which was one of the serious barriers to providing services according to the standards of the Ministry of Health. Most of prisons in provinces provided post-release services except in three provinces of Semnan, Kurdistan and Qazvin. Inadequate post-release services were considered as a factor in returning to prison. There was no monitoring and evaluation of the programs in any provinces. One of its reasons was the impossibility of cooperating with other organizations, such as medical sciences universities, research centers, and researchers outside of the prison. Based on field evidence and previous experience, prison officials acknowledged that harm reduction and treatment services had reduced mortality (especially in the quarantine unit), overuse of drugs, self-harm, suicide attempts, and violence.

4. Discussion and Conclusion
The harm reduction programs in prisons of Iran included MMT, diagnosis and treatment of HIV, hepatitis and sexually transmitted diseases as well as psychological interventions and NA meetings. Filed study and interviews revealed the effectiveness of these programs and, despite the budget and staff shortages, they had not been stopped. The implementation of some programs such as vocational training and recreational programs, although were not a part of harm reduction programs, helped reduce harms in prisons. Separate monitoring and evaluation of each program is required. One of the barriers was difficulty in cooperating with organizations such as medical sciences universities. Establishing regular meetings and persuading provincial officials such as judges, and providing advocacy support to the programs are the most important strategies for the continuation of the programs. The main challenges facing these programs were weakness in providing post-release services, insufficient staff and budget, inability to carry out the programs in accordance with the standard protocols, and difficulty in persuading some authorities and judges in implementing these programs. Increasing post-release services, staff and budget, and organizing training courses for the personnel of prisons are recommended.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This study was supported by the Office of Education and Research of Prisons, Security and Corrective Measures Organization. 

Authors contributions
Data collection: Mohammad Bagher Saberi Zafarghandi, Reza Arezoomandan, Arash Javaheri, Neda Vahed, Hosein Mohammadi, & Samaneh Heidari; Conducting interview: Mohammad Bagher Saberi Zafarghandi, Reza Arezoomandan, Hosein Mohammadi, & Samaneh Heidari; Transcription of interviews: Neda Vahed, Samaneh Heidari, and Sahar Eshrati; Study design: Mohammad Bagher Saberi Zafarghandi, Reza Arezoomandan, Marziyeh Farnia, & Sahar Eshrati; Final approval: All authors.

Conflicts of interest
The commissioner of this study was the Prisons, Security and Corrective Measures Organization. The study would not have been possible without the cooperation of the Deputy for Research and the Health Department of the organization. Participation of affiliated members in compiling reports and preparing the article can be an example of conflicts of interest, although they just provided scientific and executive assistance and the final analysis was done without organizational bias.

Acknowledgements
The authors would like to express their gratitude to Dean and Vice-Chancellor for Education of the School of Behavioral Sciences and Mental Health, members of the Department of Addiction Studies, Iran University of Medical Sciences (Dr. Imran Mohammad Razaghi, Dr. Haddadi, Dr. Sabahi Kermani, Dr. Alavi, Dr. Mortazavi, Dr. Nazem for assistance in collecting data, and Dr. Shabazi and Dr. Jafar Bolhari for participation in the interview), and staffs of the Office of Education and Research of Prisons, Security and Corrective Measures Organization.

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