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Treating Hepatitis C in PrisonOctober 2009 HCV Advocate
Liz Highleyman
Hepatitis C is much more common among people in jails and prisons compared to the population as a whole, and it is estimated that about one-third of people with HCV in the U.S. – approximately 1.5 million – pass through the correctional system each year.
In recent years an increase in the number of prisoners with advanced HCV-related liver disease and growing public health awareness about the need for treatment has collided with ever-rising healthcare costs and, now, a stubborn recession eating away at correctional system budgets.
How Common Is It?
The high prevalence of hepatitis C in prisons is largely attributable to the fact that sharing drug use equipment is an efficient means of transmission, and a substantial proportion of prisoners are incarcerated for drug-related offenses.
Epidemiological studies have observed prison HCV infection rates in various areas the U.S. ranging from about 10% to more than 50% (averaging around 30%-40%), compared with approximately 2% for the general population. A recent California study found about half of women and 40% of men entering state prisons had hepatitis C, while a survey of shorter-term jail inmates in Chicago, Detroit, and San Francisco found an infection rate of 13%.
Many individuals enter prison already HCV-infected, but a significant number acquire the virus behind bars. In addition to injection drug use – which occurs despite strict rules and the challenges of obtaining drugs and needles – inmates may contract HCV through non-sterile tattooing or exposure to blood during fights.
Furthermore, increasing evidence indicates that sexual transmission of HCV is more common than previously believed, especially when it involves “rough sex,” exposure to blood, or concurrent infection of HIV or other sexually transmitted diseases. Coerced unprotected anal sex would presumably be particularly risky.
Advocates and public health experts have urged prisons to adopt harm reduction strategies such as condoms, clean needles, and methadone maintenance. The World Health Organization recommends that prisoners should have access to condoms and bleach for cleaning injection equipment, and several countries and some U.S. states have implemented various harm reduction measures. But officials in most jurisdictions oppose this approach, arguing that it condones prohibited behavior.
Whom to Treat, and When?
The Centers for Disease Control and Prevention (CDC) recommends that all incoming inmates should be screened for HCV, and those who test positive should be evaluated for treatment. But these guidelines are not mandatory, and states have widely varying polices. Some jurisdictions do not offer routine antibody screening, fearing that testing would obligate them to provide treatment.
The Centers for Disease Control and Prevention (CDC) recommends that all incoming inmates should be screened for HCV, and those who test positive should be evaluated for treatment. But these guidelines are not mandatory, and states have widely varying polices. Some jurisdictions do not offer routine antibody screening, fearing that testing would obligate them to provide treatment.
Incarcerated people may not receive appropriate hepatitis C treatment for a variety of reasons, potentially turning a limited term of incarceration into a death sentence. Cost is the most commonly cited factor. A year of treatment with pegylated interferon plus ribavirin costs around $25,000. Jails holding short-term inmates have an incentive to withhold treatment so the expense becomes someone else’s problem. Longer-term institutions may delay therapy so long that prisoners are eventually released or become too sick to benefit.
Many clinicians have traditionally been unwilling to offer hepatitis C treatment to people with conditions assumed to predict poor adherence or response, including ongoing drug use. Some feel similarly about giving interferon to people with pre-existing depression or other psychiatric conditions.
While incarceration often leads to “enforced abstinence,” and most prisons offer 12-step programs, many inmates manage to continue using drugs behind bars. Older guidelines recommended that patients should be abstinent from drugs or alcohol for at least six months before starting hepatitis C treatment. According to current National Institutes of Health and AASLD guidelines, however, active drug users and those receiving maintenance therapy such as methadone should not automatically be denied treatment.
Treatment for chronic hepatitis C is indicated when people begin to experience liver disease progression. But a majority of people with chronic hepatitis C never go on to develop advanced disease, and therefore may not need therapy. The challenge is determining in advance who falls within which group in a prison setting.
Many prisoners who were infected with HCV years or decades ago are now reaching the later stages of disease, with rising rates of advanced fibrosis, cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver failure. Recent analyses of inmates of the Texas Department of Criminal Justice, for example, found that 54 people per 100,000 had HCC and 131 per 100,000 had end-stage liver disease.
In a presentation to the NCCHC (National Commission on Correctional Health Care), hepatologist Bennet Cecil estimated that about 20% of prisoners with hepatitis C have advanced liver disease, so about 6% of all prisoners – 20% of the one-third believed to be HCV-infected – are potentially eligible for treatment.
Liver disease progression is best determined by liver biopsy; a significant proportion of patients experience disease progression despite persistently normal liver enzyme (ALT and AST) levels. As with HCV antibody screening, prison jurisdictions vary in their policies regarding biopsies – which are themselves expensive – and treatment. Liver transplantation is even more restricted due to its extremely high cost, the shortage of donor livers, and the associated political controversy.
The Federal Bureau of Prisons recommends treatment according to AASLD criteria, but states set their own policies. Some offer treatment as seldom as they can get away with, leading to several legal challenges based on the premise that withholding standard-of-care therapy violates the Eighth Amendment prohibition against cruel and unusual punishment.
Treatment Effectiveness
A growing body of evidence shows that people in correctional settings and former inmates can be successfully treated for hepatitis C, though sustained response rates tend to be lower than those observed in clinical trials.
In the October 1, 2008 issue of Clinical Infectious Diseases, D. Maru and colleagues reported findings from a study of inmates at Connecticut Department of Correction facilities treated with pegylated interferon plus ribavirin during 2000-2006. Sustained virological response (SVR) rates were 43% for patients with HCV genotype 1 and 59% for those with genotypes 2 or 3. This compares with overall average response rates of about 50% for genotype 1 and 70%-80% for genotypes 2 or 3 for the hepatitis C population as a whole.
More recently, K. Chew and colleagues reported in the August 2009 Journal of Clinical Gastroenterology that inmates at Rhode Island Department of Corrections facilities treated with the same regimen had somewhat lower SVR rates, 18% for genotype 1 and 50%-60% for genotypes 2 and 3.
Hepatitis C treatment in correctional settings presents numerous challenges. A disproportionate number of prisoners are black, and a large body of research shows that people of African descent respond less well to interferon-based therapy. But surprisingly, the Connecticut and Rhode Island studies did not see differences in sustained response rates between black and white patients.
Many prison inmates with hepatitis C are coinfected with HIV, which both accelerates liver disease progression and impairs response to treatment. Side effects of interferon-based therapy can be difficult under the best of circumstances, but dealing with depression, fatigue, and malaise can be even harder given the hardships of life on the inside. Furthermore, frequent transfers between facilities and release before treatment is completed can lead to interruption of therapy and treatment failure.
On the other hand, incarceration also offers some unique opportunities. As noted, an estimated one-third of people with hepatitis C pass through correctional facilities annually, many of whom belong to underserved populations and might not otherwise have access to HCV screening and treatment.
Treatment in prison allows for directly observed therapy, frequent monitoring of early response and drug tolerance, and counseling and support around adherence and side effects management. It is critical, however, to provide pre-release planning to ensure continuation of care in the community.
Both treated inmates and those who do not need treatment can receive education about how to prevent HCV transmission (including using condoms and not sharing needles) and encouraging liver-healthy habits such as limiting alcohol consumption and maintaining a healthy weight. In addition, those who are not already immune should be offered hepatitis A and B vaccination.
It should also be emphasized that successful treatment does not protect against future infection, and there is no vaccine for hepatitis C. A study reported at the Interscience Conference on Antimicrobial Agents and Chemotherapy in September found that 22% of current or former prisoners in Vancouver who achieved sustained response to interferon-based therapy became re-infected with HCV. Re-infection was mostly attributable to injection drug use (76%), though 15% had other known risk factors including tattooing, piercing, sexual activity, or direct contact with blood during a fight.
Changing Policies
While there is ample research indicating that many inmates need hepatitis C treatment and interferon-based therapy can be successful in prison settings, evidence is not always enough to encourage greater access to appropriate care.
While there is ample research indicating that many inmates need hepatitis C treatment and interferon-based therapy can be successful in prison settings, evidence is not always enough to encourage greater access to appropriate care.
Many states are unwilling to shoulder the cost of treatment, and some that once provided relatively good care have scaled back in the wake of the ongoing budget crisis. In California, in fact, the budget deficit is so severe that the state is releasing prisoners early.
But deferring treatment can be “penny wise and pound foolish.” Treatment at earlier disease stages can prevent more serious consequences requiring much more expensive management later on.
As reported in the November 2008 issue of Hepatology, a mathematical modeling study by J. Tan and colleagues showed that without using biopsies to determine disease stage, treating all HCV-infected inmates with pegylated interferon plus ribavirin would be cost-saving for all ages and genotypes. This strategy, however, would expose many people who do not need therapy to unnecessary side effects. If pretreatment biopsies were performed, treatment was still cost-saving for prisoners of all ages and genotypes found to have advanced fibrosis or cirrhosis.
Some studies suggest that interferon-based therapy may help slow liver disease progression even if it does not produce a sustained virological response. Furthermore, inmates who are treated and cured will not go on to transmit HCV to others, either in prison or in the community after release.
Given these benefits – and the humanitarian imperative to provide good care for people in government custody – advocates and legislators are working to expand access to hepatitis C education and treatment.
In the future, new treatment options may help turn the tide. Directly-targeted oral agents may be better tolerated, produce higher response rates, and be effective with a shorter course of therapy, tipping the balance toward prompt, presumptive treatment.
Chew, K. et al. Treatment Outcomes with Pegylated Interferon and Ribavirin for Male Prisoners With Chronic Hepatitis C. Journal of Clinical Gastroenterology 43(7): 686-691. August 2009.
Farley, J. et al. Treatment of HCV infection in intravenous drug users in inmates of correctional institutions, Canada: four year follow up − significant likelihood of reinfection. 49th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco. September 12-15, 2009. Abstract H-219.
Hennessey, K. et al. Prevalence of infection with hepatitis B and C viruses and co-infection with HIV in three jails: a case for viral hepatitis prevention in jails in the United States. Journal of Urban Health 86(1): 93-105. January 2009.
Maru, D. et al. Clinical outcomes of hepatitis C treatment in a prison setting: feasibility and effectiveness for challenging treatment populations. Clinical Infectious Diseases 47(7): 952-961. October 1, 2008.
Tan, J. et al. Treating hepatitis C in the prison population is cost-saving. Hepatology 48(5): 1387-1395. November 2008.
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