Testing rates for hepatitis C virus (HCV) in prisons in the United Kingdom
remain far below the national minimum target of 50% and without radical change,
prison testing rates will pose a major barrier to the elimination of hepatitis
C in the UK, researchers from the University of Nottingham warn in a study
published in the Journal of Viral
The prevalence of hepatitis C is high among prisoners in the
United Kingdom; a 2014 study found that 8% of people in prisons in England and
Wales had hepatitis C antibodies. Incidence of hepatitis C is also high in
prisoners. A Scottish study found that between a quarter and a third of people
who injected drugs during their prison stay acquired HCV, demonstrating the
high risk of HCV transmission in the prison setting and the need for effective
testing, treatment and harm reduction interventions in prisons.
To improve testing rates in prisons in England, opt-out
testing as soon as possible after reception into prison was introduced in April
2014, with the aim of testing at least 50 to 70% of people entering prisons.
Researchers from the University of Nottingham evaluated
rates of testing in 14 prisons in the East Midlands between January 2015 and
July 2017. They also visited prisons to clarify how testing took place and what
difficulties staff had faced in implementing opt-out testing. The prisons varied
from prisons with a low turnover of inmates to prisons admitting large numbers
of people for short periods, either on remand or prior to transfer to other
prisons in the region.
Between July 2016 and June 2017, 20,075 people were admitted
to prisons in the region. In some cases, people were admitted to prison twice
(or more), due to transfer or reoffending. Testing rates varied from 7.6 to
40.7% and prevalence varied from 0.9 to 80%.
The researchers analysed factors potentially associated with
a higher likelihood of testing, based on their investigations in prisons.
Five factors were associated with a higher likelihood of
People were more likely to undergo testing if the majority
of the prison intake came from other prisons rather than the community (OR 2.2,
95% CI 1.9-2.3). Prisons in which the majority of people were admitted from the
community are likely to be short-term remand prisons in which the average stay
is around ten weeks. On admission to prison, people should have an immediate
health check to identify urgent health problems and a comprehensive check-up a
week later. How and when opt-out testing is offered varies from prison to
prison. The lack of resources to deal with opt-out testing of a high volume of
new inmates in prisons may explain the lower testing rate in these prisons.
People were more likely to test if they were in a prison
where they were permitted to walk to the healthcare facility without a prison
officer (OR 1.7, 95% CI 1.5-1.8) or if they were in a prison where at least 50%
of inmates reported that it was easy to see a nurse (OR 2, 95% CI 1.8-2.2).
Testing was more likely in prisons where antiviral treatment
for hepatitis C was not available on the premises than in prisons where it was
provided through an outreach service to the prison from a local hospital (OR
1.3, 95% CI 1.2-1.5). The researchers say that providing an identifiable
hepatitis C service in the prison may lead to stigmatisation of people known to
attend it, and may contribute to reluctance to test.
Testing was also more likely in prisons where health care
was provided by a private sector provider than in prisons where the NHS
provided health care (OR 1.3, 95% CI 1.2-1.5).
The researchers say they found wide variations in how
opt-out testing was presented to people in prison and substantial variation in
understandings among prison staff of what an opt-out testing policy meant.
But the research group concludes that the biggest barrier to
improved uptake of testing is prison infrastructure. “Most prisons are not
equipped in terms of staff or space to deal with the increased workload that a
50% testing target would engender.” They say that remand prisons should be a
focus for quality improvement.