BACKGROUND: Drug use is prevalent in carceral settings globally. Although a comprehensive harm reduction package for people in prison (PIP) is recommended by international agencies, its implementation is limited. The aim of this systematic narrative synthesis was to explore barriers and facilitators to accessing harm reduction services (HRS) in prisons.

METHODS: We searched MEDLINE, PsycINFO, SCOPUS, and CINAHL for English and French language articles published before June 26, 2024. Studies evaluating any HRS defined as condoms, pre-exposure prophylaxis, post-exposure prophylaxis, opioid agonist therapy, needle syringe programs, and hepatitis B vaccination in prison were included. Two independent reviewers evaluated articles selected for full text review. Disagreements were resolved by consensus. We performed a qualitative content analysis based on the Socio-Ecological Model, utilizing constant comparative methods to generate themes and subthemes.

RESULTS: A total of 8,324 unique articles were identified, 400 were eligible for full text review, and 94 were included in the final analysis; 80 studies (85%) were conducted in high-income countries. Individual-level barriers included fear of repercussions due to HRS participation, interpersonal-level barriers such as negative perceptions of HRS in PIP and staff, institutional-level barriers such as limited resource allocation and public policy/societal-level barriers including rigid administrative policies. Facilitators of HRS use included education about risk prevention, positive previous experiences with HRS, and support from prison leadership.

CONCLUSION: Several multi-level barriers and facilitators to accessing prison-based HRS exist. To improve HRS uptake, implementing holistic education for PIP and carceral employees, enhancing awareness of HRS through peer-led initiatives, and ensuring buy-in and support from prison leadership will be important. Furthermore, allocation of specific resources and enhanced policies that promote HRS will be beneficial.