Navigating harm reduction and security mandates: Prison leadership perspectives on implementing prison needle exchange programs in Canada

BACKGROUND: Prison needle exchange programs (PNEPs) reduce bloodborne virus transmission among people who inject drugs, yet global implementation remains limited. Canada introduced PNEPs in 2018, but uptake is low, and barriers to implementation persist. While perspectives of correctional officers, healthcare workers, and incarcerated individuals have been examined, little is known about how prison leadership shapes program delivery. Drawing on interviews informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, we sought to identify the organisational, system, and structural/policy-level barriers to PNEP implementation from the perspectives of prison administrators. METHODS: Between January and March 2025, 27 prison leaders from custodial and medical services from nine Canadian federal prisons with operational PNEPs participated in semi-structured interviews. Data were thematically analysed using the EPIS framework. RESULTS: Implementation was shaped by structural tensions between harm reduction goals and "zero tolerance" custodial mandates. Outer context factors, especially union resistance, lack of policy clarity, and federal directives, created misalignment and ambiguity in program ownership. Prison climate, staff turnover, and leadership engagement influenced shifts in attitudes toward PNEPs over time. Healthcare personnel, though central to delivery, were often tasked with communicating custodial decisions, undermining trust. Intervention fit was shaped by security classification and perceived drug use patterns, with PNEPs viewed as ill-suited for minimum-security settings. Sites that streamlined approval processes and designated leadership roles were better positioned to support program uptake. Time, experiential exposure, and tailored education were key facilitators of cultural change and implementation readiness. CONCLUSION: Addressing outer context barriers and clarifying responsibilities between health and corrections are critical to PNEP sustainability. Leadership engagement is essential to enabling system-wide adoption.