Genetic markers for treatment responsiveness.

Why can't Arizona coordinate with community service providers so people can start treatment in prison and successfully complete it after release? Is the ADC or the health department just not up to it? Or does it just not matter that much? Not worth the effort? or has no one even considered trying? Just because most other prisons do it one way, that doesn't mean Arizona can't do it better. We sure aren't copying the rest of the country on most other incarceration models and trends...

The rest of the article is fascinating, too - this testing being widely available for Hep C prisoners could make a difference for a lot of people who may otherwise be written off as poor treatment responders before they even get a chance.

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Management of Hepatitis C Among Prisoners Using IL28B Testing
Society of Correctional Physicians
Originally published June 21, 2010

By Madhura A. Hallman, MD, MPH Candidate and Anne C. Spaulding, MD, MPH

Posted on June 21, 2010 -Over the past decade, availability of hepatitis C treatment for appropriate inmate-patients has increased in most state prison systems. Written policy has guided eligibility criteria, such as a length of stay sufficient to complete treatment1. In New York, where follow up care has been coordinated with local health centers, a possible return to the community no longer disqualifies candidates for treatment2. Nonetheless, these advances have not made treatment any easier. Among patients with genotypes 2 and 3, 80% clear the virus. The 50% success rate in treating genotype 1 continues to frustrate both clinicians and patients.

This situation may soon change since genetic analysis of the host will soon be able to predict which patients are more likely to respond to treatment. Just as testing for the HLA-B*5701 allele has helped physicians predict which HIV+ patients will have a hypersensitivity reaction to Abacavir, a similar genetic assay may soon be available to assist prediction of response to treatment for hepatitis C patients.

A paper published in September 2009 by Ge et al. represents an advance in personalized medicine that will address an issue important for many people. Researchers identified a polymorphism (rs12979860) near the IL28 gene on chromosome 19 that was highly correlated with a favorable response to interferon among patients infected with genotype 1 of the hepatitis C virus3. The methods for their genome-wide association study (GWAS) are explained in an editorial that accompanied Ge’s article4. In American patients of European and Hispanic descent, homozygosity for this allele was correlated with a twofold increase in response to treatment compared those in whom the allele was absent. In patients of African descent, a threefold increase in response was noted; however, homozygosity was rare among these patients, which could partially explain their low rates of response to interferon. The authors estimated that this genetic variant accounted for approximately half the difference in treatment response between African-Americans and European-Americans.

Suppiah et al. and Tanaka et al. identified a second polymorphism (rs8099917) in a similar region near the IL28 gene which was strongly associated with response to combination treatment with interferon/ribavirin in Australian and Japanese patients, all infected with viral genotype 15,6. Most recently, Rauch et al. conducted a GWAS including all viral genotypes 1-4, and found that the rs8099917 minor allele was associated with both progression to chronic hepatitis C and failure to respond to treatment, with the strongest effects in patients infected with genotypes 1 or 47.

Several of these findings have important implications for correctional medicine. If 25% of prisoners have hepatitis C disease8 and 70% of these have genotype 1, then this advance will be important for about 1 in 6 patients currently in US prisons. Moreover, given that this genetic variant could explain much of the low response to treatment in African-Americans, having a test for the variant will be a useful tool in guiding treatment decisions. If and when a test for this genetic variant becomes commercially available, there will be some important caveats to consider:

• Having the test result will be important for both pre-treatment and during treatment counseling, especially if interferon tolerability becomes an issue.

• Although the response rate in persons without this gene is low and since one cannot predict who will respond, its absence should not disqualify a motivated patient from attempting treatment after appropriate counseling.

It is clear that we still need more treatment options and more effective treatments for hepatitis C. Currently, HCV specific protease inhibitors are in phase three trials. For patients who are responsive to interferon, triple agent therapy (interferon, ribavirin and the virus-specific agents) may eventually improve treatment outcomes. It is unlikely that the genetic markers that contribute to interferon and ribavirin resistance will have an influence on direct antivirals. At this point in time, no interferon sparing regimen is currently in trials and so those who test negative for IL28B testing will continue to face poor recovery rates.


References

1. Spaulding AC et al. A framework for management of hepatitis C in prisons. Annals of Internal Medicine 2006;144(10):762-9.
2. Klein SJ et al. Promoting HCV treatment completion for prison inmates: New York State's hepatitis C continuity program. Public Health Reports 2007;122 Suppl 2:83-8.
3. Ge D et al. Genetic variation in IL28B predicts hepatitis C treatment-induced viral clearance. Nature 2009;461(7262):399-401.
4. Iadonato SP et al. Genomics: Hepatitis C virus gets personal. Nature 2009;461(7262):357-8.
5. Suppiah V, et al. IL28B is associated with response to chronic hepatitis C interferon-alpha and ribavirin therapy. Nature Genetics 2009;41(10):1100-4.
6. Tanaka Y, et al. Genome-wide association of IL28B with response to pegylated interferon-alpha and ribavirin therapy for chronic hepatitis C. Nature Genetics 2009;41(10):1105-9.
7. Rauch A, et al. Genetic variation in IL28B is associated with chronic hepatitis C and treatment failure: a genome-wide association study. Gastroenterology 1345;138(4):1338-45.
8. Weinbaum C et al. Prevention and control of infections with hepatitis viruses in correctional settings. CDC. MMWR Recomm Rep 2003; 52(RR-1):1-36. .

HOUSING is a Right, Not a Privilege.

This link seemed both timely and appropriate, since so many people with HEP C are also co-infected with HIV, and the issues of stigma and discrimination are similar. The Fair Housing Act and the Americans With Disabilities Act apply to them, however, even if they are in prison or on parole.

It's tough to tell why people may discriminate, though, when they have plenty of other legitimate reasons to do so. In Ann Arbor, a lot of the folks we saw who ended up going back to jail or prison repeatedly (when I worked with people who were homeless) gave up because the odds that they could establish themselves in a sustainable job or live on disability income which might even allow them to support their family were seemingly insurmountable. Being a felon alone is a perfectly legal reason to get the door closed in your face.

Emerging from a total institutionalized experience after 5 or 10 years with an under-treated, chronic mental illness, overlying PTSD from incarceration, and the label you carry with your particular offense (I've broken my hand twice punching walls instead of people, which could have made me a violent criminal in the wrong company when that happened. Never mind that both cases were related to agitation secondary to medications needing adjustment, not an indication that I'm predisposed to violence) - has a multitude of challenges. There's not only the stigma and huge mountain of fear out here people have to climb to "get their lives together" - convincing others to employ, them, rent to their family, extend them credit, and cut them a break on the petty stuff if they're trying to live right by them selves and their community; but there's also the nagging doubts from within that one can "make it". Prison doesn't tend to reinforce one's sense of social competence; there are different norms, nuances, languages even, inside. Once one is institutionalized (I was as a kid), it's hard to know how to get by out here again, except to revert to what you always did before to survive.

Some of the folks I knew who put themselves back into the custody of the state - via criminal or probate/mental health courts - wanted and knew they needed treatment, or some kind of protective setting that could help them get clean and be safe for awhile - but couldn't get it without being criminalized or involuntarily committed because that was the only way a funding source wold be available to cover their stay.

Unfortunately, once criminalized or hospitalized and adjudicated as criminal or incompetent (God forbid, both), it's up to others and community resources what happens to you - many people just get incarcerated and detox cold turkey (some die that way) with no therapeutic intervention or even comprehensive psychiatric assessment. They fall back into similar types of relationships in prison as they had on the street - forced to by the need to survive yet another hostile environment.

How does that change anything they're going to do once free again? If you're too focused on the nuts and bolts of daily survival, you may not organize revolution against your captors, but you also can't meet your other human needs sufficiently enough to thoughtfully build relationships, critically assess your circumstances, grow, transcend the impulse to retaliate if what you're experiencing is injustice.

Women especially need to have an opportunity within the context of their confinement to exercise agency, to organize their collective voice, to assert their rights meaningfully, since as many as 80% were victims of violent crime to begin with, invisible until criminalized ourselves, then brutally silenced, shamed, and secreted away in prison for as long as possible. Our rehabilitation as "law-abiding citizens" necessitates that our trauma be transformed into a source of power, that our compulsions to self-medicate with illegal substances be medically evaluated and appropriately treated (be it with a 12-step program, legal medications, or both), that our relationships with our families remain intact and nurtured by the support systems our children have, that we have the opportunity to still be a source of support and nurturing for our families - not an economic and emotional drain through the course of our incarceration.

Our rehabilitation requires that you keep our kids safe, if you take us from them. We know that once they are in foster care - or God forbid end up in the juvenile justice system here - they're much more likely to be molested, physically abused, neglected, impoverished, drop-out, and grow up emotionally damaged due to our incarceration than if we had remained at home (unless we were their abuser or enabled their access, of course, in which case, keep them safe from us). We cannot simply "trust god, clean house, and help others" if our child is being punished so brutally for what we did too. The guilt is paralyzing, and only breeds rage for the suffering of one's kid - which in turn justifies vengeance - that's what the state breathes into our kids. Then the cycle of violence begins again.

According to the Director of the Arizona Department of Corrections, Chalres Ryan, Prison IS the punishment - it is not the place to get be punished by further abusive and humiliating and traumatizing conditions. This was his partial response to what happened to Marcia Powell, anyway, and the outrageous suggestion that those cages were routinely used to "punish" people - torture them, really - which the investigation revealed they were.

I'm glad to know that's not a practice consistent with his philosophy or departmental policy, at least. While I do recognize the need for internal order and discipline, so to speak, I have problems with the lack of appropriate policies and due process for prisoners to protect themselves once inside. I hope the sentiment referenced above of Director Ryan's is sincere and goes deeper than the politics here.

Prison should not be a place where your mother or sister or daughter - or son or husband or father - should have to worry about being raped or sexually exploited, assaulted by prisoners or guards, trapped in an inferno because of decades of ignoring code violations, infected with a fatal virus, or die from medical neglect after begging guards for three days, three months - or even three hours - for help.

Anyway, I found in my work over the years that advocates and tenants alike need to know their rights - and people hitting the street after prison are at the biggest disadvantage. This guide book applies to protections under federal law; state laws enumerate other rights and responsibilities of tenants, and can usually be found on the Secretary of State's website (that's the AZ tenant/landlord link) .

The tip on this new guide came over the UNSHACKLE list-serve, by the way, a fabulous resource on everything HIV, prison, health care, PIC, etc. It's run by the folks at CHAMP (Community AIDS Mobilization Program) in New York. It's worth getting on their list to stay up on the latest news about incarceration, health care in prison, unshackling pregnant women, and of course HIV/AIDS and HCV (Hep C).

The network itself is also a great resource - there are some very skilled and experienced AIDS and prisoner rights' activists on it, and people seek each other out there for support and ideas all the time...it's a task-oriented, working community, though, not a support group. These folks are kicking ass every day. What they do on behalf of prisoners with AIDS, they do for us all.

I'll have a permanent widget for them soon so it's easy to find, but in the meantime, here's a good new guide to download if you hit this page.

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NEWLY UPDATED
from The Center for HIV Law and Policy
www.hivlawandpolicy.org

Housing Rights of People Living with HIV/AIDS: A Primer, The Center for HIV Law & Policy

Categories

• Housing
• HIV as a Disability Under Antidiscrimination Law
• Human Rights
• International

Resource Type

Legal Guides

Description

One in a series of primers on various legal issues as they pertain to people living with HIV/AIDS, this primer on housing law provides guidance on the laws protecting people with HIV from housing discrimination and ensuring their ability to find safe and stable housing. The primer focuses on the Fair Housing Act as it relates to tenants with HIV/AIDS, and provides information on Housing Opportunities for Persons with AIDS (HOPWA) and other federal housing assistance programs. The primer also provides information on the effect of past criminal activity on the ability to secure federal housing assistance. In March 2010, the Primer was updated to include a section on how U.S. advocates can use international human rights law to support a person with HIV's right to safe, stable, and affordable housing.

File

Click here to download this document [ 1.17 MB ]