High hepatitis C cure rate achieved in New York prisons

Keith Alcorn
Published:
09 December 2020
Image: Tanya Nova/Pixabay

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 ethnicity.

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 appropriate.

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.

Reference

Chan J et al. Outcomes of hepatitis C virus treatment in the New York City jail population: successes and challenges facing scale up of care. Open Forum Infectious Diseases, 2020.