Hepatitis C virus (HCV) infection can be rapidly eliminated in prison populations with the use of direct-acting antivirals (DAAs), results of an Australian study published in Clinical Infectious Diseases suggests.
The research involved prisoners incarcerated at the Lotus Glen Correctional Centre, Queensland. In the 22 months following the introduction of DAAs, the proportion of people with chronic HCV infection – or HCV viraemia – fell from 12% at baseline to 1% at the end of the study. However, a substantial proportion of DAA-treated people were lost to follow-up and a small number of people were re-infected after cure.
“Micro-elimination of HCV is close to being realised in a large Australian prison, 22 months following unrestricted access to DAA therapy,” comment the investigators. “DAA therapy was highly acceptable among this population.”
- sustained virological response (SVR)
Undetectable hepatitis C RNA after treatment has come to an end. Usually SVR refers to RNA remaining undetectable for 24 weeks (six months) after ending treatment and is considered to be a cure. SVR4 and SVR12 refer to RNA remaining undetectable for 4 and 12 weeks respectively.
The World Health Organization (WHO) has set the target of elimination of HCV as a public health threat by 2030. Key to the achievement of this target is the elimination of the infection in specific populations, otherwise called micro-elimination. HCV is highly prevalent among prisoners, and prevalence is especially high among prisoners with a history of injecting drug use.
Since March 2016, unrestricted access to DAAs has been provided to people with chronic HCV infection in Australia. This treatment programme extends to prison.
Investigators wanted to evaluate the impact of DAA rollout on HCV prevalence and incidence among prisoners. They used as a case study the Lotus Glen Correctional Centre, an all-male high-security prison with 800 inmates.
Individuals with chronic HCV were identified via routine screening and were provided with DAA therapy lasting for up to 24 weeks. Men receiving DAAs were provided with counselling about the avoidance of re-infection with HCV. Those released into the community were linked to healthcare provided at public hospitals and sexual health clinics.
The investigators monitored uptake of DAAs, the proportion of treated individuals attaining a sustained virological response (SVR) 12 weeks after the completion of therapy, and trends in the prevalence of chronic HCV infection in the 22 months after the introduction of DAAs.
A total of 125 men were assessed for DAA therapy. Four individuals refused treatment and two were transferred to another prison. The 119 men who initiated therapy had a median age of 34 years and 12% had liver cirrhosis. Approximately two-thirds carried HCV genotype 3a and the most commonly used DAA regimen was a sofosbuvir and daclatasvir combination lasting 12 weeks.
At the end of the study period, 12 people remained on therapy and nine were in post-treatment follow-up before the SVR cut-off. Of the remaining 98, 32 were lost to follow-up, including 22 individuals released into the community.
“The considerable proportion lost to follow-up highlights the complex nature of treatment delivery and post-treatment evaluation in a setting with high levels of transitioning,” write the authors, who suggest this points to a “need to improve liaison between corrections and community HCV treatment services.”
Treatment outcomes could be evaluated in 66 patients, with 97% of these individuals attaining an SVR. Two men experienced virologic relapse and there were six cases of re-infection.
Immediately before DAA rollout, an estimated 13% of individuals had chronic HCV infection. This had fallen to approximately 4% after 12 months and to just 1% after 22 months.
Of the nine men with HCV viraemia at the end of follow-up (December 2017), five had commenced DAAs and the remaining four were being assessed for treatment.
“The close relationship between injecting drug use, incarceration, and prevalence of blood-borne viruses makes correctional centres a crucial setting for enhanced DAA access and broad prevention strategies,” conclude the investigators. “Population-level HCV elimination success will require effective HCV treatment and prevention programmes among both PWID [people who inject drugs] and people who are incarcerated.”