Opioid Agonist Treatment (OAT) programmes are regarded as a gold standard treatment for people living with Opioid Use Disorders (OUDs). However, OAT programmes are often unavailable or poorly implemented in prisons, in spite of the large numbers of people living with OUDs and the high risk of HIV transmission in prison settings. Unusually, this systematic review synthesizes qualitative evidence relating to barriers to, and facilitators of, the implementation of OAT programmes in prisons in high- and low/middle-income countries (LMICs) to provide more nuanced, contextualised understandings of how prison stakeholders perceive and/or experience OAT programmes within different prison settings.
We systematically reviewed six electronic databases for studies published between January 2005 and December 2019 involving prison stakeholders: policy-makers, governors, healthcare staff, prison officers, and prisoners. The search identified 8091 studies, of which only 16 incorporated qualitative methods (including qualitative elements of mixed methods) and met our quality criteria. Four of these studies were conducted in LMICs (Kyrgyzstan, Iran (2) and Indonesia).
Findings were organized under three broad themes: (1) perceived benefits of OAT programmes; (2) barriers to the implementation and development of OAT programmes; and (3) treatment processes.
A lack of a clear understanding of the roles of OAT programmes and doubts regarding their effectiveness for people living with OUDs in prisons are critical barriers to prisoner participation in both high-and LMIC countries. Prison systems, particularly in LMICs, often lack the resources to mitigate problems with implementation. This review highlights an urgent need to develop further qualitative studies into prison OAT programmes, employing varied methods to explore such contexts in greater depth and minimize the impact of harms relating to OUDs in prisons.

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