Prisoners have a higher prevalence of hepatitis C than the general population, both because of risk factors prior to imprisonment and risk factors in the prison environment, including sharing of injecting equipment and tattooing using unsterilised equipment.
The incidence of hepatitis C in prisoners who inject drugs while in prison is very high; a systematic review of studies of hepatitis C virus (HCV) infection in prison found that among people with a history of injecting drug use, 16 out of 100 prisoners would become infected for each year they spent in prison.
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.
However, two reports published in May show the serious shortcomings of hepatitis C prevention, testing and treatment in prisons in the European region.
A survey of prison prevention and harm reduction policy and practice in European countries was carried out by the European Liver Patients Association as part of the Hep-CORE study. Hep-CORE is a cross-sectional study of viral hepatitis policy implementation in Europe, using responses from hepatitis patient groups in 25 countries gathered in 2016 and 2017.
The Hep-CORE study found that 16 countries reported no HCV screening policy for prisoners. Only nine European countries had identified prisoners as a population at high risk of HCV infection and a priority group for screening. Just one country, the United Kingdom, operates a universal opt-out screening programme for all prison entrants.
Access to HCV treatment in prisons is limited. Although 21 countries provide treatment to some prisoners, only five countries (Slovakia, Slovenia, Spain, Sweden and the United Kingdom) provide HCV treatment in all prisons. In other countries, treatment is not available in all prisons or information is unavailable about which prisons provide treatment, the survey found.
Needle and syringe programmes in prisons are permitted only in Romania and Spain but eleven countries offer opioid substitution therapy (OST) to prisoners, the survey found. However, in four out of eleven countries OST is provided only to those people already enrolled in OST programmes at the time of imprisonment, while regional variations to access exist in other countries.
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.
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 available for all prisoners according to European Association for the Study of the Liver and European AIDS Clinical Society 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.
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