Lack of access to hepatitis C treatment and prevention in European prisons is a public health emergency and risks breaching international agreements on the avoidance of inhumane and degrading conditions, according to an investigation into access to hepatitis C virus (HCV)-related services published this month by the European AIDS Treatment Group.
Governments in the European region have agreed to work towards the elimination of hepatitis C by 2030. To achieve this target, prevention and treatment of hepatitis C in prisoners must be a priority owing to the high prevalence of hepatitis C among prisoners. The prevalence of hepatitis C in prisoners is above the average for the general population in all countries where it has been measured.
HCV prevalence among prisoners is 35% in Armenia, 28% in Bulgaria and around 50% in Georgia. In western Europe, HCV prevalence is 19% in Scotland, around 9-11% in England, 4-6% in France and possibly as high as 42% in Portugal.
To investigate the state of access to HCV-related services in European prisons, the European AIDS Treatment Group collated available evidence on HCV prevalence and services for prison populations in Europe and developed in-depth case studies of six European countries to inform the development of recommendations on best practice from a community perspective.
Bulgaria has a high prevalence of HCV among prisoners but a lack of care for people with HCV. No needle and syringe programmes operate in Bulgarian prisons and opioid substitution therapy is available only at the central prison in Sofia. Only five prisoners with hepatitis C received treatment during 2017 owing to a lack of funding for treatment by the Ministry of Justice.
In Moldova, on the other hand, opioid substitution therapy is available in all prisons, and so are clean needles and syringes. Anyone who tests positive for HCV while in prison receives free treatment if they have symptomatic liver disease, according to national treatment guidelines.
“Moldova […] can be an example of successful provision of harm reduction services in prisons and many other countries can learn a lot of how the process is organised,” the report’s authors comment. They say that neighbouring European Union countries with similar health systems, such as Bulgaria and Romania, could learn a lot from HCV treatment provision in Moldova too.
The Italian prison system also provides free treatment for hepatitis C according to national treatment guidelines, and also provides opioid substitution therapy. However, needle and syringe programmes are not implemented in Italian prisons and there is no systematic policy of confidential testing for HCV.
Italy has made greater progress than neighbouring countries as a result of free treatment funded by the Ministry of Health and longstanding collaboration between NGOs and prisons in northern Italy to raise awareness of HCV and promote screening.
Major recommendations of the report include:
- HCV-related services in prisons should fall under the jurisdiction of the Ministry of Health rather than the justice ministry.
- NGOs should be contracted to deliver services in prisons and funding for services should be sufficient to ensure consistent and sustainable services.
- National surveillance mechanisms for hepatitis C and key populations affected by hepatitis C should be established to monitor the prevalence of HCV and progress towards achieving treatment and prevention goals.
- Comprehensive harm reduction services should be provided in prisons.
- Voluntary and confidential testing for viral hepatitis should be provided.
- Ensure that a positive HCV or HIV diagnosis does not result in discrimination within the prison setting.
- Make direct-acting antivirals (DAAs) available for all prisoners according to European Association for the Study of the Liver (EASL) and European AIDS Clinical Society (EACS) treatment guidelines and train prison doctors in the monitoring and treatment of hepatitis C.
- Ensure that treatment is free and not dependent on health insurance status.
- Introduce incentives for medical professionals to provide services in prisons.
- Improve follow-up after release to ensure continuity of care.
The authors of the report draw attention to several international agreements affecting the health of prisoners including Article 3 of the European Convention on Human Rights, which requires that prisoners should have access to medical care.
In 2007 the European Court of Human Rights ruled that a complainant from Croatia had been wrongly denied treatment for hepatitis C and in 2008 the Court ruled that a complainant from Greece had been wrongly denied treatment for hepatitis B. Both cases create clear precedents, and in 2009, the Court ruled that in view of the number of complaints pending review, the government of Georgia should take immediate steps to introduce screening and treatment for hepatitis C in the country’s prison system.
The report concludes that the “health situation in prisons presents both a public health and human rights emergency that needs to be tackled together by local authorities, civil society and health professionals.”