What are the barriers to hepatitis C treatment in prisons?

Keith Alcorn
Published:
15 October 2018

Lack of privacy, lack of peer support and lack of harm reduction are perceived as the biggest barriers to improving the uptake of direct-acting antiviral treatment for hepatitis C among prisoners, a qualitative study among prisoners in Australia has found.

The findings, published in the Journal of Viral Hepatitis, underline the need for messaging from prison authorities which emphasises the opportunity for treatment, say the authors of the study, who are associated with the STOP-C study of hepatitis C elimination in prisons in the state of New South Wales.

Hepatitis C is highly prevalent among prisoners, as many incarcerated people have a history of injecting drug use. The most recent survey of hepatitis C virus (HCV) prevalence among prisoners in Australia found that 22% tested positive for HCV and 58% reported having injected drugs at some point in the past. HCV prevalence among people who inject drugs in prisons in Australia may be as high as 60%.

As well as benefitting the individual prisoner, increasing the uptake of direct-acting antiviral treatment would also have wider preventive benefits, by eliminating hepatitis C in people who are injecting drugs both within closed networks in which sharing of injecting equipment takes place within the prison and also on release. The STOP-C study is examining whether rapid scale-up of direct-acting antiviral treatment in prisons can reduce the incidence of HCV among prisoners.

Although prisoners should have equal access to health care under international human rights agreements, uptake of hepatitis C treatment among prisoners is low even where it is provided.

To explore barriers to starting direct-acting antiviral treatment in prisons, researchers interviewed 32 prisoners at four correctional facilities in New South Wales.

All participants had a history of injecting drug use, half the participants had chronic HCV infection, three had cleared previous infection spontaneously and the remainder had either been cured of hepatitis C or were awaiting the results of post-treatment virological testing. Fourteen were receiving opioid substitution therapy at the time of interview.

Participants found that prison clinics could provide convenient on-site health care that overcame barriers of distance and transport experienced outside prison.

You know the clinic is two hundred yards from where we are living and on the outside if you’ve got to go to the hospital and if you haven’t got transport, people just tend not to, because they’re running around. (Male, HCV undetectable, previously treated with cure).

Some participants also thought that prison provided an opportunity to deal with health issues that might get put to one side in the outside world owing to other pressures. Problems with drug use and housing were cited as examples.

But participants often saw being in prison as a big structural barrier to being cured, due to the lack of access to clean needles and syringes.

Outside is better… Because girls who have undergone treatment in here, they’re going to keep on using aren’t they, so they are going to catch it again…. You won’t get re-infected outside because you’ve got the needles, the cleaner needles. (Female, HCV undetectable, treatment naïve).

Some thought that the best time to complete a course of treatment might be just before release from prison, as that would minimise the risk of being reinfected due to lack of clean needles and syringes.

Confidentiality was also a big concern for participants using prison health clinics. Being identified as having HCV might lead to exclusion from injecting networks in the prison or other undesirable social consequences. Concerns about confidentiality and pressure to disclose reasons for visits to the prison clinic have also been cited in previous research as barriers to HCV testing in prisons.

A lack of support from family and friends was also cited as a barrier – “you know, real friends, genuine friends”, as one male prisoner who had gone through one unsuccessful course of treatment put it.

The investigators suggest that prison health services seeking to encourage the uptake of treatment should emphasise the following messages to prison inmates with HCV:

  • Ease of access to treatment in the prison
  • Accessing HCV treatment in prison is an opportunity for self-improvement prior to release, a 'new start'
  • Treatment is free.

Prisons should also focus on bringing injecting networks into treatment together rather than penalising injecting. Treating entire injecting networks at the same time would also reduce the risk of reinfection in the absence of needle and syringe programmes in prisons.

Reference

Lafferty L et al. Understanding facilitators and barriers of direct-acting antiviral therapy for hepatitis C virus infection in prison. J Viral Hepat, advance online publication August 2018.