Hepatitis C treatment in prisons can result in a high
cure rate but people released from prison during treatment are less likely to
be cured due to challenges in medication supply, continuity of care, follow-up
and viral load testing, researchers report from New York in the journal Open
Forum Infectious Diseases.
Direct-acting antiviral treatment for hepatitis C is now
offered to prisoners in many European countries and a growing number of states
in the United States. Prison health care can offer the opportunity to test for
hepatitis C on entry and to complete a course of direct-acting antiviral treatment.
Prisons have been identified as one of the key settings for
microelimination of hepatitis C – intensified screening and treatment to
eliminate hepatitis C in a population with a high prevalence of hepatitis C. In
the United States, it has been estimated that around one-third of people with
hepatitis C have spent at least part of a year in a correctional facility.
Prisoners have a higher prevalence of hepatitis C than the
general population due to criminalisation of drug use; sharing of injecting equipment
is also common among the incarcerated. Screening in New York prisons in
2013-2014 showed that around one in five inmates had hepatitis C antibodies.
Prison represents a challenge for continuity of treatment
and care for people with hepatitis C. Going to jail or being placed on remand
in prison during a course of hepatitis C treatment can disrupt care, as can
release from prison before the end of a treatment course. Prisons have high turnover
of inmates; the median stay in New York City jails was 18 days in 2018.
Direct-acting antiviral treatment in New York City prisons
is offered to anyone who will be in prison long enough to complete a course of
treatment and to people with advanced liver disease. People already on
treatment can continue treatment with medication supplied by the Correctional
Health Services division of New York City Health. Anyone released during their course of treatment is given a
7-day supply of medication and linked to care.
Justin Chan and colleagues in New York City Health Services’
Correctional Health Department looked at the outcomes of people who started
hepatitis C treatment in prison or who entered prison during a course of
treatment. They also compared outcomes between people who completed treatment
in prison and people who were released from prison before completing their
course of treatment.
They identified 269 people who started or continued
hepatitis C treatment in prisoners between January 2014 and October 2017.
People in the cohort spent a median of eight months in prison, 94% were male, two-thirds
were over 45 years old, half were Hispanic and 30% non-Hispanic Black. Seventy-five
per cent had a probable opioid use disorder, 28% were on opioid substitution
therapy. Fourteen per cent had a serious mental illness and one-third reported
that they were homeless.
In this cohort, 31% were in urgent need of treatment for
hepatitis C due to advanced fibrosis or cirrhosis. The high prevalence of advanced
liver disease may be connected to HIV co-infection, say the researchers; 25%
were co-infected with HIV.
Of the 269 people treated, 195 had a post-treatment viral
load test and of these 88% were cured. People who completed treatment in prison
were nearly three times more likely to be cured compared to people who were released
on treatment (relative risk 2.93, 95% CI 1.35-634) after adjusting for age and
The reinfection rate was high (10.6 cases per 100
person-years of follow-up, emphasising the importance of treating injection
networks and providing opioid substitution treatment for prisoners and after release.
Needle and syringe provision would also limit reinfection, but this policy is
controversial in most countries.
Post-treatment viral load follow-up was less likely for
people who started treatment in prison, either because they were released from
prison before this point or because the opportunity for viral load testing was
missed while they were in prison. Correctional Health Services has now established
transition clinics for people released into the community to enable healthcare
follow-up and improved its systems for checking viral load follow-up among
people who remain in prison.
The findings also show the importance of diagnosing
hepatitis C early in a prison stay and starting treatment promptly after
diagnosis, as well as the value of treating with a shorter-course regimen wherever
The researchers say their study shows that hepatitis C
treatment can be given successfully in prison populations with high levels of
substance use, serious mental illness and unstable housing after release.