Surviving Hepatitis C in AZ Jails, State Prisons, and Federal Detention Centers.

Surviving Hepatitis C in AZ Jails, State Prisons, and Federal Detention Centers.
The "Hard Time" blogspot is a volunteer-run site for the political organization of people with Hepatitis C behind and beyond prison walls, their loved ones, and whomever cares to join us. We are neither legal nor medical professionals. Some of us may organize for support, but this site is primarily dedicated to education and activism; we are fighting for prevention, detection, treatment, and a cure for Hepatitis C, particularly down in the trenches where most people are dying - in prison or on the street... Join us.


Sunday, March 21, 2010

HEP C: Pray For the Dead, and Fight like Hell for the Living.

Julie Acklin (holding photo), our young "prisoners",
and our comrades at the American Liver Foundation.
Annual Liver Life Walk, Indian Steele Park, Phoenix, AZ.
March 20, 2010.

Cross-posted from Prison Abolitionist:

Thanks to Mother Jones and AIDS activists for the inspiration, and thank you to those of you who joined or supported the walkers at the Liver Life Walk, Saturday. The T-shirts and banner invited a number of opportunities to raise awareness about Hepatitis C in jail and prison, and it was good to meet so many other people interested in working towards some common objectives. We also made a huge birthday card for Davon.

Friends and Families of Arizona's Prisoners. "Happy Birthday Davon!" Phoenix, March 20, 2010.

Arizona Department of Corrections:

Our Families are your Prisoners, too.

The new blog is up, now: hit it at Let us know how it w
orks for you, if you have other resource ideas for us to link to or upload, or if you’d like to help organize and keep posts current. I'll be anchoring it for awhile as Julie learns the mechanics, so shoot me an email if you have thoughts on content, links, layout, tone, etc. ( If you need to connect about family organizing stuff, start with Julie. You can track her down fastest at .

The audience here is mainly us: friends and families of prisoners, ex-prisoners, anarchist and Unitarian sympathizers, and hopefully the folks inside as well, since some articles would be good to put together and mail out as a newsletter for those who aren't on-line.

We expect the State to be listening in from time to time as well, and will probably automatically shoot them our posts to keep them informed. ADC employees on the line or in health services who share our concerns and have information to offer, we will respect your anonymity. We’re much more about finding out who’s going to take responsibility for helping us through this with as many survivors as possible, than we are about ferreting out who’s to blame for where we’re at to begin with.

Really, I’ve done some research and we’re in about the same place most of the states and the Feds are - only we’re lifting the veil of silence that fell over this epidemic soon after it was announced, a decade ago. They must have realized how much it would cost to treat all those infected, and decided to just watch it, for the most part, until the more important socioeconomic classes were affected. Criminals and their families – and their communities (mostly of color) – are intended to be exploited; that’s why the 13th Amendment was written as it is. It’s i

nteresting that they designated the “duly convicted”, not the “guilty,” as slaves of the state.

Anyway, as for the HARD TIME blog, the authors and editors are us, too. We're developing some basic guidelines for guest blogs/submissions so we can maintain a constructive dialogue, but anyone interested in posting (beyond a comment after someone else's) should contact myself or Julie ( with their interest and the email address they want to use to log on. We still have to decide editorial responsibility, etc. once we have a more developed collective of family/prisoner activists. Since this is the time frame when we work that stuff out - dividing responsibility and power, basically - it would be a good time to get involved.

Coming together…

The Liver Life walk was an amazing experience, by the way, and brought home to me again the importance of what we’re doing. I’ve lost several family members to liver cancer or disease, and am hoping not to lose my big brother that way; his Hep C has already been wreaking havoc on his liver, and he’s not eligible for treatment. He’s nearly 50 now, though, and at least he’s a free man. Not many people can say that, even in their 70’s with no criminal record. I think Billl could honestly say he’s a free man if he was in prison – on a good day, anyway. God knows he’s transcended hell enough time himself – he might as well have been getting shuffled through USP-Lewisburg and beat up each time, as they appear to be fond of doing there…

I’ll be calling on folks for help with that place soon, by the way. It’s the federal pen in PA that Leonard Peltier and my buddy Byron Chubbuck are at right now, among others. I have documentation of more than one person’s abuse at the hands of guards, now, which is on its way to the PA ACLU and the DOJ. If any of those prisoners out there are further abused or retaliated against, I want their families to notify us and the DOJ and the PA ACLU immediately. I’m asking directly for a CRIPA investigation of the place, not just blogging it (though I know they read that post). After mailing our letter to the DOJ, we (Arizona Prison Watch) will make sure it gets posted in as many places as possible to increase the intensity of the spotlight on both the BOP and the DOJ.

It should be a far more serious offense for an officer of the law to do violence to an institutionalized person – a captive who is completely at the mercy of them and their institution – than for a prisoner to defend himself against a rogue guard (or six of them with tasers). We expect more of people in uniform than that. The officers in question in each of the abuse cases (I’m sure Warden Bledsoe already knows who they are) should be removed from positions in which they can harm prisoners pending the outcomes of multiple investigations – internal and external alike.

More on the Liver Life Walk once I recover. Thank you to the American Liver Foundation for all the good work you do, and the lives you help save. Please, folks, if you even just drop them $10 with a note to “support Hep C treatment for prisoners,” it would be awesome. There were even some folks from the GLBTQ activist community in drag, there. The Liver Foundation was accommodating of everyone who cared about their constituents. I think this means they consider prisoners with Hep C to be “theirs”, too. That’s actually more than I might have expected, after the way I’ve seen the “duly convicted” treated in recent months – particularly Jamie Scott.

I don’t know what’s up with the Mississippi Kidney Foundation. It would help if a wealthy Mississippi citizen contacted them to let them know you think prisoners have the right to life, too. We throw a lot of victims in with a handful of hungry predators when we fill our jails and prisons with the desperately poor or addicted. In America, the innocent can’t be protected if we don’t assure that the “duly convicted” still retain the access to reasonably speedy remedies for their conviction or sentence. It’s an emergency when people are held against their will in hostile and dangerous environments – vulnerable to fire, disease, medical neglect, sexual abuse, and assault. Remember Davon, the Scott Sisters and Courtney: they could be anyone’s kids out there…


t-shirts on demand by Julie.

Saturday, March 20, 2010

Hep C, Hard Time, and the Right to Life.

Sent this Email out early this am, to a whole bunch of media and activists and other people, including ADC and the governor's office. Don't think it got through to everyone - had to keep trimming the list to not be cut as spam...So, now its on the blogs just in case. This was my attempt at PR. I may have trouble with all the photos right now, but the rest is self-explanatory.

- peg


Well, this is pretty loaded and I'm making a unilateral decision to fire off these photos for the Governor. I think this is the only way she'll end up seeing them - if everyone else does. Hope I don't hit any friendlies, though. Duck now, if you're in prison, in case there's return fire (Prisoners are on the front lines, folks, not the garbage heaps. Front lines. This is America. Think poor, young Black/Indigenous/Latino men and canaries. Very valuable, actually, in terms of what we will pay to dispose of them in the interest of the greater good).

Don't let all that alarm you. My dad was a solider. I grew up in Army green, and just talk like that. I'm really much the pacifist. I just think it's important to know how intensely personal and emotional - and absolutely political - this matter is for so many people. We will not just go away if ignored. This Hep C Mom, Julie, has been a vessel for Divine Intervention to happen in the lives of many people. I've seen it.

Don't underestimate her. She's got the raw, engaging humanity of a righteous Susan Sarandon, the faith and fearlessness of Alice Paul, and the fire and flair of Georgia O'Keefe.

I'm the wrong person to deal with media or this would have been done a long time ago, by the way. It was done much earlier today but bounced back. I'm not a technowhiz. Spacebook is beyond me. Blogspot's as sophisticated as I get.

I should never be delegated this task. I have impulses to vandalize media outlets. I don't know why. It hasn't made for good media relations, though. So I'm stuck writing my own stories. This one isn't mine, though - it's about other people's kids and brothers and, it's fine to ignore me because my family is dying or free now - but please don't ignore them. I tried to tell them not to give this to me, but everyone's swamped. I have no good excuse, I guess, except for my anti- authoritarianism. I don't trust "media". I trust people, if they earn it. The only one out there I can say I really trust is Dennis Gilman - and he's not "mainstream" but he can be trusted to find the truth of an experience and let it tell itself. He's awesome.

Alright, so, I know it's just hours now before this event, and most of you are getting this after the fact. I believe it's all perfect timing, in the bigger picture, but I know that's a drag for others when it messes up their schedules. So, I'm sorry. I'm unconventional. It drives my friends and lovers crazy. Don't think we expect anyone but the Governor and a few curious folks from the ADC to be there in the AM, so no pressure - and the Governor hasn't exactly confirmed or anything. Just contact us if you want photos or info afterwards about our organizing activities (now in the works: "Make-a-Wish for Justice..." Who would you liberate with your last wish, and why? Enough of us are dying each day from poverty that we should be able to use our last wishes for mercy and Justice securing eachother's liberation.).

This Liver Walk thing is not an "event" announcement, by the way, so I'm really not late. It's not "our" event at all, anyway. It's the Liver Foundation's!

"please save my brother"

This is really just an FYI so folks know we're out there and make a point of backing up the Liver Foundation if they get any hassles for letting us walk (with what could be seen as pretty provocative signs about hep c - they didn't get this close a preview, so don't hold them responsible - but give them credit). Put a word in with the Governor about compassionate releases, too - Julie's kid needs one so she knows he's got access to the full range of treatment options before too much damage is done...attached is the note we dropped off for her office this week about the walk. They're the ones who encouraged us to get it to them, so, we'll see. (Hopefully no one thinks I'd ambush them...).

Hope all of you are well and up for this.

Don't expect much Anarchy at this, by the way. I'd recommend that ADC follows Julie's lead, frankly - learn to dance more gracefully, or her people will take you out kicking and screaming. They're Unitarians and senior citizens (the banner was sewn by an octogenarian), moms and dads and sisters of prisoners, survivors of the war on the poor - most of them ex-prisoners who evidence some degree of PTSD. They do things like hide their legal documentation outside of their homes in case the state comes and ransacks their place to destroy their defense capabilities. It's apparently quite common...

Thanks for whatever help you can send, by the way. We can use a little amplification out here. It's a desert. No one notices living or dying bodies in the desert in Arizona except litterbugs and good samaritans/potential terrorists. You can be prosecuted for even knowing that your student's father might not be documented and not reporting your suspicion (the police will follow it up - all you need to do is report suspicions).
How are migrant communities supposed to stay safe if they can't report rapes and murders to the police without fear of entire families being imprisoned?

COPWATCH! That's how. It's cross-movement organizing at it's finest. And Anarchy seems to be the organizing principle.

Give me till after the walk to open up that blogspot - it'll just say it's not accessible until I do. I'm spent for the night.

Women's Health Week begins with Mother's day this year - begin planning now. And we'll be having a memorial for those who have died in the custody of the state on May 20; location TBA. I believe the 19th is World Hepatitis Day, too, right?

Thanks for your time. It's never too late to check in.

Don't be surprised to see this note go up as my next blog post on all sites, by the way - especially if I can't get these emails through to everyone. Both voices (here and below) are mine.

- peg



At the Liver Life Walk SAT AM (March 20), Arizona prisoners' friends and families and former prisoners will be walking together and asking the state to respond to the Hep C epidemic in prisons and jails. 40% of women and 30% of men prisoners across the country are confirmed to be infected with hep c - the rates are likely much higher, and it disproportionately affects minorities and people in poverty. Undiagnosed and untreated in prison, HEP C becomes a threat to the community when people are released - which 95% of state prisoners eventually are. Approximately 20% of people with Hepatitis C eventually die of cirrhosis or liver cancer; most of the rest develop some degree of liver disease.

Julie Acklin is your contact. Her son has HEP C, is in an AZ prison, and has just been ruled out as a candidate for treatment.

We think he got Hep C in prison.

Julie's number is 623-594-4433. She is the principal organizer of prisoners' families and ex-prisoners with this new initiative. Children in will be in ADC Orange; Adults in Blood Red. Team is "A Mother's Cry" - Look for "Hard Time: Hepatitis C in Arizona State Prisons." New blog by that name up tomorrow.

Ryan and Brewer have already had a heads-up. No word back from Governor's office - not holding our breaths.

AZ Liver Foundation says advocate for hep c testing, treatment, research, prevention, and save lives.

That takes guts.

Those are Good people.

Support them with a note "for Hep C in Prison", if you can

Catch up with us next week if you miss us tomorrow. Donate to the Liver Foundation. Hit the HARD TIME blog. Tell AZ HEP C prisoners and their families to send us their stories. We'll be organizing support and action groups soon.

- Peggy Plews

The "Hard Time: Hep C in Arizona's State Prisons" blogspot is a free virtual info-type space for Arizona prisoners with Hepatitis C, their families, their friends, and their communities. We aspire to facilitate access to research and gather other resources about Hep C, as well as share stories, in order to collectively build foundations from which to strategize comprehensive, humane responses to the challenges of this epidemic among America's prisoners.

(Coming March 20, 2010...)

Thursday, March 18, 2010

Called to Care

The following post from Julie was originally posted at the "Called to Care" site this past week. Their ministry has been very supportive of helping get the word out about Hep C in the prisons.

Here's the link to their
legislative action page:
Called to Care

I love this image,
also from their site:

A Mother's Cry: Julie Acklin

A Mother's Cry
written by Julie Acklin

Julie Acklin is a concerned mother of her twenty-three year old son, Davon, who has serious mental illness. Read her story here,

First Page : : Second Page : : Third Page : : Fourth Page

Davon has been incarcerated in the state prison system since 2007. Although diagnosed with serious mental illness the prison has refused to provide adequate treatment. Instead prison authorities confine him to solitary confinement to control his behaviors.

Recently, she learned that Davon contacted Hepatitis C. In collaboration with other church and advocacy organizations she arranged to organize a team for the Liver Foundation Walk called the Liver Life Walk: March 20 @ Steele Park

The name of her Walk Team is: "A Mother's Cry." She is looking for the donation of red tee shirts to identify her team members. For those who want to donate red tee shirts size large and extra large leave them in the First Church office or see Robert Koth after the 10:30 AM or 5:30 PM worship service.

Update from the Mother:

Wrongfully accused and behind the cold walls of an Arizona prison...

On Feb 2nd, 2010, I sat waiting for a call from my son that never came. My heart sank because, in the prison world, that means one of many things.

Either the Facility is on Lock Down, during which the phones don't work; or he has been transferred (which they frequently do without even notifying the families.) So I called the prison to see what was happening. The answer I received chilled me... "they said he wasn’t there!"

My heart sank once again. I knew that something God was telling me wasn't good.

When I asked where he was, they told me he was at the CDU. Now, the CDU is an acronym for "Complex Detention Unit" at Santa Rita. Eventually, I heard from another inmate's mother, that she had gotten a letter from her son, who told her that my son had been set up. Apparently someone placed a shank in his kop bag. A shank is a prison term for a weapon that can be made out of just about anything.

I knew that this was not true, as my son hadn't been in trouble since his incarceration, and had only 14 months to go before coming home. He mentioned in every letter that he was within reach of coming home, and that he was exited... counting the days.

I had to do something, so I called the captain at the facility to ask what had happened. He told me that he would get the details and call me back. While I was waiting for his call, I got a letter from my son in the mail. He wrote that they had handcuffed him, and took him to CDU, and that he was afraid because they were falsely accusing him of having a weapon in his possession. He wrote that someone must have set him up.

He said that he was accused of a class A violation, which is very serious, and that he could be charged with a street charge and be placed in solitary confinement till his release date of 2012.

I was desperate for justice. I sent many letters and cards to Prison Talk, which is a support site for inmates and families of inmates. I also made calls to the facility through concerned advocates; and sent letters directly to the Director’s office.

Prayers were said on my son's behalf by families and friends.

Days passed, and still no call came from the captain. I called the facility a few days later and reached the captain.

You can't imagine my relief when I heard the captain tell me that '...the charges were being dropped because there was not enough evidence to file charges, and that the guys on the yard had come forward, and they were sticking up for him, confirming his innocence.

This was unusual, because inside the prison walls nobody talks for fear of being accused of being "a snitch" and being hurt themselves.

So due to the prayers, and the calls, and by the grace of our dear Lord, the charges were dropped. My son is once again back on the yard, where he is safe; at least for now. They did, however, require that he sign a protective custody waiver, in which "if something happens to him, the DOC cannot be held accountable."

This is my story of A Mother's Cry for help and justice that were echoed by my son and so many others. I hope my story brings courage and strength to believe in the power of prayer, and the strength to stand up for our children. They are all children of God.

Thank you all for being my advocate, and the advocate of my only son Davon, who is just one of the mentally ill that have become incarcerated in these troubled times.

Institute of Medicine Report on Viral Hepatitis

Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C (JAN 2010)

Key findings and recommendations from the Institute of Medicine’s Report:

The committee identified the underlying factors that impede current efforts to prevent and control these diseases. Three major factors were found:

  • There is a lack of knowledge and awareness about chronic viral hepatitis on the part of the health-care and social-service providers

  • There is a lack of knowledge and awareness about chronic viral hepatitis among at-risk populations, members of the public and policy-makers

  • There is insufficient understanding about the extent and seriousness of the public health problem, so inadequate public resources are being allocated to prevention, control and surveillance programs

Surveillance Recommendations

2-1: The Centers for Disease Control and Prevention should conduct a comprehensive evaluation of the national hepatitis B and hepatitis C public health surveillance system.

2-2: The Centers for Disease Control and Prevention should develop specific cooperative viral hepatitis agreements with all state and territorial health departments to support core surveillance for acute and chronic hepatitis B and hepatitis C.

2-3: The Centers for Disease Control and Prevention should support and conduct targeted active surveillance, including serologic testing, to monitor incidence and prevalence of hepatitis B virus and hepatitis C virus infections in populations not fully captured by core surveillance.

Knowledge and Awareness Recommendations

3-1: The Centers for Disease Control and Prevention should work with key stakeholders (other federal agencies, state and local governments, professional organizations, health care organizations and educational institutions) to develop hepatitis B and hepatitis C educational programs for healthcare and social service providers.

3-2: The Centers for Disease Control and Prevention should work with key stakeholders to develop, coordinate, and evaluate innovative and effective outreach and education programs to target at-risk populations and to increase awareness in the general population about hepatitis B and hepatitis C.

Immunization Recommendations

4-1: All infants weighing at least 2,000 grams and born to hepatitis B surface antigen-positive women should receive single-antigen hepatitis B vaccine and hepatitis B immune globulin in the delivery room as soon as they are stable and washed. The recommendations of the Advisory Committee on Immunization Practices should remain in effect for all other infants.

4-2: All states should mandate that the hepatitis B vaccine series be completed or in progress as a requirement for school attendance.

4-3: Additional federal and state resources should be devoted to increasing hepatitis B vaccination of at-risk adults.

4-4: States should be encouraged to expand immunization-information systems to include adolescents and adults.

4-5: Private and public insurance coverage for hepatitis B vaccination should be expanded.

4-6: The federal government should work to ensure an adequate, accessible and sustainable hepatitis vaccine supply.

4-7: Studies to develop a vaccine to prevent chronic hepatitis C virus infection should continue.

Viral Hepatitis Services Recommendations

5-1: Federally funded health insurance programs – such as Medicare, Medicaid and the Federal Employees Health Benefits Program – should incorporate guidelines for risk-factor screening for hepatitis B and hepatitis C as a required core component of preventive care so that at-risk people receive serologic testing for hepatitis B and hepatitis C virus and chronically-infected patients receive appropriate medical management.

5-2: The Centers for Disease Control and Prevention, in conjunction with other federal agencies and state agencies, should provide resources for the expansion of community-based programs that provide hepatitis B screening, testing and vaccination services that target foreign-born populations.

5-3: Federal, state and local agencies should expand programs to reduce the risk of hepatitis C virus infection through injection-drug use by providing comprehensive hepatitis C virus prevention programs. At a minimum, the programs should include access to sterile needle syringes and drug preparation equipment because the shared use of these materials has been shown to lead to transmission of hepatitis C virus.

5-4: Federal and state governments should expand services to reduce harm caused by chronic hepatitis B and hepatitis C. The services should include testing to detect infection, counseling to reduce alcohol use and secondary transmission, hepatitis B vaccination and referral for or provision of medical management.

5-5: Innovative, effective, multicomponent hepatitis C virus prevention strategies for injection drug users and non-injection drug users should be developed and evaluated to achieve greater control of hepatitis C virus transmission.

5-6: The Centers for Disease Control and Prevention should provide additional resources and guidance to perinatal hepatitis B prevention program coordinators to expand and enhance the capacity to identify chronically infected pregnant women and provide case management services, including referral for appropriate medical management.

5-7: The National Institutes of Health should support a study of the effectiveness and safety of peripartum antiviral therapy to reduce and possibly eliminate perinatal hepatitis B virus transmission from women at high risk for perinatal transmission.

5-8: The Centers for Disease Control and Prevention and the Department of Justice should create an initiative to foster partnerships between health departments and corrections systems to ensure the availability of comprehensive viral hepatitis services for incarcerated people.

5-9: The Health Resources and Services Administration should provide adequate resources to federally funded community health facilities for provision of comprehensive viral hepatitis services.

5-10: The Health Resources and Services Administration and the Centers for Disease Control and Prevention should provide resources and guidance to integrate comprehensive viral hepatitis services into settings that serve high-risk populations such as STD clinics, sites for HIV services and care, homeless shelters and mobile health units.


CDC’s Media Statement is available at:

CDC Foundation launches Viral Hepatitis Action Coalition that will respond to the Institute of Medicine Report on Viral Hepatitis and support CDC research and programs:

Page last updated: January 24, 2010

CDC, along with other partners, commissioned the IOM to examine the prevention and control of viral hepatitis infections in the United States. The report was released on January 11, 2010.

REPORT: The IOM released a prepublication version of the report which contains the committee's detailed findings and recommendations Adobe  PDF file [PDF - 191 pages].

WEBINAR: To view a webinar on the IOM report recommendations, featuring the Director of CDC’s Division of Viral Hepatitis, Dr. John Ward, please visit, Web Site Icon.

Monday, March 15, 2010

NCCHC: Hep C In Corrections Position Statement

This is what the professional correctional health care people were saying over 10 years ago...


National Commission on Correctional Health Care

Position Statement: The Management of Hepatitis C in Correctional Institutions


The National Commission on Correctional Health Care and the Society of Correctional Physicians are not-for-profit organizations that work toward the improvement of health services in the nation's jails, prisons, and juvenile confinement facilities. The Commission publishes health services standards and operates a voluntary accreditation program for institutions that meet these standards. The Society is an organization of physicians specializing in correctional medicine.

The issue of Hepatitis C is of great concern to the Commission and Society since it is a threat to the quality of health care provided in prisons and jails. The Commission and Society have adopted the following position statement that, along with the published standards, may assist policy makers and health professionals in designing their own policies and procedures on this matter.


Chronic liver disease is the 10th leading cause of death among adults in the United States. The Centers for Disease Control and Prevention (CDC) estimates that approximately 25,000 deaths occur annually from chronic liver disease, and that hepatitis C virus (HCV) is responsible for 40 percent of that death toll (CDC, 1998).

The HCV is a bloodborne pathogen and is transmitted primarily through large or repeated direct percutaneous exposures to blood (Alter, 1997). In the United States, the relative importance of the two most common exposures associated with transmission of HCV, blood transfusion and injection drug use, has changed over time. Blood transfusion, which accounted for a substantial proportion of HCV infections acquired >10 years ago, rarely accounts for recently acquired infections.

In contrast, drug use consistently has accounted for a substantial proportion of HCV infection and currently accounts for the majority of HCV transmission in the United States. Health-care professionals who are exposed to needlestick injuries in an occupational setting and hemodialysis patients are also at risk from exposure to infectious blood, as are infants born to infected women. In addition, HCV may be transmitted by sexual or household exposure to an infected contact; however, the efficiency of transmission in these settings appears to be low. Although any percutaneous exposure has the potential for transmitting bloodborne pathogens, including HCV, no data exist in the United States indicating that persons with exposures to tattooing and body piercing alone are at increased risk for HCV infection. Further studies are needed to determine if these types of exposures and settings in which they occur (e.g. correctional institutions, unregulated commercial establishments) are risk factors for HCV infection in the United States.

An estimated 3.9 million persons in the civilian, non-institutionalized population are infected with HCV. This estimate is based on the Third National Health and Nutrition Examination Survey (NHANES III) data; however, it does not include the incarcerated, institutionalized, or homeless populations. Still, in the general population, HCV is more prevalent than human immunodeficiency virus and tuberculosis infections in the United States.

The prevalence of hepatitis C virus infection among the prison population has not been sufficiently studied. However, because many inmates have a history of drug use, it stands to reason that correctional systems will experience high HCV prevalence rates. The California Department of Corrections and the California Office of AIDS conducted a 1994 blinded study supporting this concern. The study found 41 percent of entering inmates testing positive for antibody to HCV (Nieto, 1998).

In spite of the morbidity of hepatitis C and the likely high prevalence of HCV infection in the prisoner population, there is no national policy on the screening or treatment for HCV infection in federal or state correctional systems. The following position statement provides guidance to correctional administrators in the management and treatment of hepatitis C.


The diagnosis of hepatitis C should be considered in patients with risk factors, such as injection or inhalation drug use, symptoms such as fatigue, or a history of jaundice or hepatitis. Prior to testing, inmates should be given information about the transmission of HCV, the nature of hepatitis C and chronic liver disease, potential health consequences, the test procedure and meaning of the test results, and the benefits and side effects of treatment.

The standard initial laboratory test for anti-HCV is by enzyme immunoassay (EIA). Several factors may determine how extensive further evaluation should go. Correctional health care workers need to contemplate whether an inmate patient is a candidate for treatment before proceeding much beyond antibody testing (Spaulding, 1999). Patients with persistently normal serum transaminases probably do not benefit from treatment (NIH, 1997). Because of interferon's propensity to induce depression, inmates need to be mentally stable before treatment. Other medical problems also should be under control. The expected benefit of prolonging life with HCV treatment may only be realized decades after treatment. Inmates should have a remaining life expectancy of at least one or two decades. Because HCV disease may progress rapidly in the setting of HIV, less stringent criteria for life expectancy should apply for patients co-infected with HIV and HCV. Treatment for youths less than 18 years old is at present still controversial.

Long term adult facilities should give standard therapy to appropriate patients, in an attempt to treat and perhaps eradicate the virus. Even after treatment for HCV, a patient may reacquire HCV; drug and alcohol rehabilitation should precede HCV treatment (NIH, 1997). Expected remaining duration of incarceration can determine whether a correctional facility ethically bears a responsibility to treat disease (Anno, 1996). Because hepatitis C infection can lead to fatal liver failure and hepatocellular carcinoma, all prisons should develop criteria for appropriate treatment candidates. These criteria should not be so stringent that they exclude all prisoners from a treatment that may be lifesaving.

Prisoners who have a positive EIA test should then be given confirmatory test if treatment is contemplated. There is a high pretest probability that a positive EIA in an inmate with HCV risk factors is a true EIA, the appropriate confirmatory test is one looking for the virus itself, such as a polymerase chain reaction (PCR) test, rather than a recombinant immunoblot assay (RIBA). Prisoners who test positive on their confirmatory tests should be ruled out for other chronic liver disease such as hemochromatosis, Wilson's disease, autoimmune hepatitis, and alpha-1 antitrypsin deficiency. A liver biopsy, though it may convey some useful information, is not a cost effective part of a work up (Wong, 1998).

All inmates who test positive for HCV should receive counseling to encourage behavioral changes that may be required to prevent future contagion of others, and when appropriate, should receive intensive chemical dependency and substance abuse treatment.

HCV infected inmates should be counseled to avoid drinking alcohol. HCV infected inmates also should be encouraged to voluntarily inform their sexual and intravenous drug using partners to advise them of their potential contact with the HCV.

Correctional health care systems also should study the prevalence of hepatitis C in their inmate population and factors that contribute to disease and its transmission. They should use the results of the study to prepare guidelines for prevention, screening, and treatment aimed at reducing the prevalence of the disease.

Education on hepatitis C infection should be incorporated into prison and jail health education programs. This education should include information on modes of transmission, prevention, treatment, and disease progression. Educational programs should include culturally sensitive and scientifically accurate health information providing clear and easily understandable explanations of practices which reduce the risk of becoming infected or transmitting HCV. The target population should be involved in the development and provision of educational programs to encourage acceptance of the disease and changes to life-style and behavior.

Correctional and health staff should receive training on confidentiality as it applies to HCV. Correctional officers and health staff should also be informed about their potential occupational or personal risk for acquiring hepatitis C. When appropriate, staff should pursue testing and treatment from their personal physicians.

Most HCV infected inmates will return to their community soon. State correctional systems should work with their state public health departments to develop state specific health policy guidelines to coordinate the screening, education, and treatment of hepatitis C.

When developing HCV policies, administrators should refer to the following documents for guidance: NCCHC standards on receiving screening, infection control, health promotion and disease prevention, and health assessment, as well as NCCHC's position statement on managing hepatitis B in prisons. In addition, correctional health administrators should refer to the Centers for Disease Control and Prevention or the American Academy of Family Physicians for their most recent recommendations on the prevention and control of HCV.

Position Statement

Correctional health administrators should develop a system and/or facility policy on the management and treatment of hepatitis C.

Adopted by the National Commission on Correctional Health Care Board of Directors
November 7, 1999

Alter, M. J. (1997). Epidemiology of hepatitis C. Hepatology ,26(6):2S-5S.

Anno B. J. et al. (1996). A preliminary model for determining limits for correctional health care services. J Correctional Health Care 1996; 3(1):67-84.

Centers for Disease Control and Prevention (1998). Recommendations for Prevention and Control Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Morbidity Mortality Weekly Report .October 16, 1998, 47 (RR-19)

Department of Health and Human Services, National Center for Health Statistics (NCHS).
NHANES III (National Health and Nutrition Examination Survey, 1988-1994).

Marcellin P. et al., (1997) Long-term histological improvement and loss of detectable intrahepatic HCV RNA in patients with chronic hepatitis C and sustained response to interferon-alfa therapy. Annals Int Med 1997; 127:875

McHutchison J. G. et al (1998) Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. N Engl J Med 1998; 339:1493-9.

National Institutes of Health (1997). Consensus Development Conference Panel Statement: Management of Hepatitis C. Hepatology, 1997 26(Suppl 1:2S-10S).

Ruiz J. D., Mikanda J. Seroprevalence of HIV, Hepatitis B, Hepatitis C, and risk behaviors among inmates entering the California correctional system. Sacramento, California Department of Health Services, March 1996.

Spaulding A. et al (1999). Hepatitis C in State Correctional Facilities. Preventive Medicine 1999; 28: 92-100.

Wong J. B., Bennett W. G., Koff R. S., Pauker S. G. Pretreatment evaluation of chronic hepatitis C: Risks, benefits and costs. JAMA 1998; 280 (4):2088-93.

Friday, March 12, 2010

Harm Reduction Coalition: Principles

This site (HRC) is a useful resource for those interested in harm reduction strategies to reducing the spread of Hep C and other bloodborne diseases.

Principles of Harm Reduction

Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing conditions of use along with the use itself.

Because harm reduction demands that interventions and policies designed to serve drug users reflect specific individual and community needs, there is no universal definition of or formula for implementing harm reduction. However, HRC considers the following principles central to harm reduction practice.

* Accepts, for better and for worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.

* Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.

* Establishes quality of individual and community life and well-being--not necessarily cessation of all drug use--as the criteria for successful interventions and policies.

* Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.

* Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.

* Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.

* Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm.

* Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Wednesday, March 10, 2010

US Prisons ignore HEP C early in epidemic.

A little background on the epidemic of Hepatitis C in American prisons, originally printed in Prison Legal News: August 2003, pp. 1-4.

by MarkWilson

The hepatitis C virus (HCV) is an insidious insidious and relentless disease which is highly unpredictable and eventually fatal. It is a chronic disease which is the leading cause of cirrhosis, liver failure and liver cancer which causes an estimated 10,000 deaths annually in the United States; a number the Centers for Disease Control and Prevention (CDC) expects to triple by 2010.

HCV infection in America’s prisons has reached epidemic proportions. Random seroprevalance studies in state prisons in California, Connecticut, Maryland, Oregon, Texas and Virginia have revealed infection rates between 29 and 54 percent, compared to a 2 percent infection rate in the total U.S. population.

Most states are ignoring the crisis, however, even as prisoners are dying, or being released unaware of their disease and creating a public health risk. “Correctional systems have buried their heads in the sand because they don’t want to know how many prisoners have hepatitis C,” said Eric Blaban, a staff attorney with the National Prison Project of the ACLU. Even when prisoners are tested for HCV, prison doctors in many states fail to inform them of the results - or that they were tested - until years later, if at all.

New Jersey’s Neglect Exposed

A recent investigation by The Philadelphia Inquirer exposed the systemic failure of the New Jersey prison system and its contract medical care provider, Correctional Medical Services (CMS), to properly diagnose and treat HCV infected prisoners. The Inquirer reported that its investigation revealed a systemic failure to:

• Screen all prisoners for HCV, opting to remain “ignorant of the magnitude of the epidemic”;
• “continue treatment for incoming [prisoners] already receiving therapy for hepatitis C”;
• “fully evaluate and treat [prisoners] showing signs of severe liver damage from the virus”;
• “maintain complete patient records, making it difficult to know what tests have been done on individual patients or how many have died from complications”;
• “educate [prisoners], even some infected ones, about how the disease is spread and treated”; and
• “refer [prisoners] to liver specialists, despite requests by prison doctors.”

The Inquirer found that New Jersey does not know how many of its 24,000 prisoners are HCV positive, because it does not test for the disease unless the prisoner requests testing. Additionally, only one New Jersey prisoner was receiving HCV treatment at the time of the investigation, and it took filing a lawsuit for him to begin receiving treatment. Prison officials responded to The Inquirer investigation by ordering a review of how HCV infected prisoners are treated. Devon Brown, the new commissioner of the New Jersey Department of Corrections, said that he was “disturbed about the cases . . . brought to [his] attention” and that his staff immediately reviewed the situation with CMS and ordered changes.

Brown ordered CMS to explain why only one prisoner, out of 1,170 known to be HCV positive, was receiving treatment. He also ordered CMS to inform all 1,170 prisoners of their condition. New Jersey medical director, Dr. Dwight Hutchison, “who oversees CMS, conceded that inmate health records were ‘spotty.’When asked whether, based on such incomplete records, he could assert that patients were getting reasonable care, Hutchison said, ‘If you’re speaking medically, the answer is no.’”

Even physicians currently and formerly under contract with CMS to provide medical care to New Jersey prisoners are frustrated with CMS’s handling of the HCV epidemic. They reported that their “attempts to refer prisoners to liver specialists or to order expensive diagnostic tests” were denied and that “it was difficult to persuade CMS supervisors to authorize certain medical tests.” One doctor who quit out of frustration reported that “orders for diagnostic tests such as liver biopsies were routinely” denied by CMS. “They drag their feet in getting them to a specialist,” the doctor said. “There’s always some type of excuse.”

When asked how many New Jersey prisoners had been screened for HCV, how many prisoners had received additional tests such as liver biopsies, and the reasons for denying treatment, CMS vice president of medical affairs, Louis Tripoli was unable to provide an answer, “citing electronic record-keeping problems.”

The one prisoner receiving HCV treatment had his case reviewed by Esteban Mezey, a liver specialist at Johns Hopkins University School of Medicine, who concluded that the care afforded to that prisoner was “below the usual standard of care and negligent.” The prisoner who had his HCV therapy halted when he entered prison has repeatedly pleaded with prison doctors to begin his treatment again, but to no avail. Although an October 2000 lab report indicated that “the virus was still multiplying in his blood stream” a prison doctor noted in a November 17, 2001 medical report: “Inmate feels he should have more treatment. Assure him he is doing well and needs no further treatment at this point.”

The prisoner continued to beg for treatment, writing: “I am very sick here. Would someone please help me?” But nobody seemed to care. The last entry in his medical file was an April 1, 2002 recommendation “that he get treatment ‘when discharged.’ He currently is scheduled for release in 2007.”

A medical audit conducted as a result of The Inquirer investigation revealed that 121 prisoners were not told of the results of their HCV tests for a period of one to two years and 21 of them were released from prison without being told they were infected.

Art Caplan, a medical ethicist at the University of Pennsylvania, said that failing to tell patients about a potentially life-threatening condition was a fundamental breach of standard medical practice. “The key moral issue is that every person, including a prisoner, has a right to know his health status,” Caplan said. “It’s very disappointing to see this going on in the 21st century,” Caplan said. “If it was done out of indifference, it’s immoral. if it was done out of incompetence, its incredible.”

CMS has been New Jersey’s medical care provider since 1996. The contract was set to expire in October 2002 and CMS has prison officials over a barrel. CMS sought “to increase its fee by 30 percent, or about $30 million a year, not including hepatitis C care.” CMS also told prison officials “it would not treat and test for hepatitis C” unless “the state itself picked up the bill.”

New Jersey rejected the CMS contract proposal because it did not include HCV treatment, but with no other bidders the state ultimately capitulated to the CMS demands, offering a 10-month contract extension worth nearly $100 million and the state agreed to pay all costs associated with HCV treatment.

Meanwhile New Jersey prisoners continue to die; prisoners like Cornell Thomas who was diagnosed with HCV in 2000 but never received treatment. Thomas died July 18, 2002, the third prisoner at Riverfront State Prison in Camden, New Jersey, to die of HCV complications in 2002, “according to the county Medical Examiner’s Office.”

Hopefully the needless HCV-related deaths will soon end in New Jersey, thanks to a lawsuit filed in federal court in October 2002 on behalf of former prisoner William Bennett, who tested positive for HCV in 2000 but was not informed of his illness until two weeks prior to his release in 2002, and ten unnamed prisoners. Attorneys Laura Feldman and Rosemary Pinto filed the suit alleging that CMS ignored the HCV problem in an attempt to extract greater profits from the New Jersey DOC. CMS, of course, denies placing profits before patient care, calling the allegations “absolutely untrue.”

Pennsylvania Lawsuits Bring Changes

New Jersey is far from alone when it comes to systematically reusing to treat HCV infected prisoners. Take Pennsylvania for example.

In 1992, Pennsylvania prisoner Rob Lassen had routine lab work done, but he wasn’t told until 1996 that he tested positive for HCV. The doctor who showed Lassen the 1992 test results gave him little hope of treatment and no explanation for why the results were withheld from him for four years.

Angry that he wasn’t told sooner, and fearful that he would die without treatment, Lassen began his own jailhouse investigation into the HCV problem. He soon discovered that he was not alone. He obtained affidavits from 30 prisoners, half of whom, like him had been tested but not told of their infection. Four prisoners were released on parole, ignorant of their disease and now feared they may have unwittingly infected others.

In 1997 Lassen began feeling run down and lost 20 pounds. A liver biopsy taken a few months later, during an unrelated surgery revealed liver damage. Stunned and frightened, Lassen filed grievances seeking medical care, but they were denied and he filed suit in federal court.

Lassen contacted Angus Love, a Philadelphia lawyer and director of the Pennsylvania Institutional Law Project, which provides legal aid to Pennsylvania prisoners. Love had been receiving similar complaints from prisoners across the state. In August 1999, Love met with prison officials, doctors, and lawyers. Former DOC medical director Fred Maue assured Love that DOC was aware of the HCV problem and the statewide wave of prisoner grievances and lawsuits related to the denial of HCV treatment. Maue informed Love that he was working with the DOC’s three private health care vendors to create a statewide plan for addressing the HCV problem. “We didn’t want litigation,” Maue recently explained. “We were concerned that these people with hepatitis C might truly develop medical complications and liver failure.”

In early 2000, the DOC began screening prisoners who were most at risk of infection due to past drug abuse. Soon, all 37,000 Pennsylvania prisoners were screened. Prison officials found that 23 percent, or 8,510; prisoners were HCV positive, and 17 percent of the 124 prisoner deaths in 2001 were due to HCV complications.

Unlike most states, Pennsylvania is now considered to be aggressively tackling the HCV epidemic within its prisoners. It has launched a comprehensive treatment effort, recognizing that sooner or later taxpayers will pay for treating the disease and it is better to pay up to $20,000 for HCV treatment now, rather than $250,000 for liver transplants later.

Lassen “was a big whistle-blower,” according to Dr. Joseph DiMino, health director for Montgomery County, and former Pennsylvania prison doctor. But his advocacy did not come without a price. In May 1999 Lassen was punished for “unauthorized group activity” related to his HCV advocacy and placed in segregation for 30 days. Because the offense was a major infraction, Lassen was also denied early release eligibility.

Once prison officials finally began treating prisoners in 2000, it was too late for Lassen. He was deemed ineligible-for-treatment because he did not have enough time remaining on his entence. He was released on October 30, 2000, and in 2001 began receiving HCV treatment, but it was unsuccessful.

Lassen sued prison officials for punishing him for his HCV activism. A settlement hearing was held on July 3, 2002, but after two hours the parties were still at odds. Lassen then addressed the court : “I’ve accomplished my goal. Pennsylvania now has a treatment, notification and counseling protocol,” Lassen began. “I have liver disease and it will probably kill me,” he said. “But if I get out of here and get hit by a bus, at least my life had some meaning.” Lassen then turned to the DOC lawyer and said, “To end this here, add a dollar to your offer.” Instantly, the DOC lawyer walked across the courtroom and handed Lassen a dollar bill, for a total settlement of $6,501.

Prisoners are not the only ones who are worried about their health. With one in four Pennsylvania prisoners infected with HCV, guards are nervous too. They are afraid they may be exposed to HCV from combative prisoners, bloody noses, scratches, stabbings, and bites.

Retired prison guard Bob Feldman believes he contracted HCV responding to a prisoner fight. It took a three year legal battle but Feldman’s workers’ compensation claim was finally approved. He is the only Pennsylvania guard to win a claim that his HCV infection is job related, but five other guards have claims pending. A December 2002 change in Pennsylvania’s workers’ compensation law should make it easier for them to prevail. Pennsylvania now joins nine other states which allows prison guards to make work-related HCV claims, assuming on the-job infection and placing the burden upon the employer to prove otherwise.

California Ignores HCV;

A 1999 study conducted by the California Department of Health Services revealed that 33 percent of prisoners entering the California Department of Corrections (CDC) during a short time in 1999, were infected with HCV. Although the study found that more than 50,000 California prisoners may have HCV, the CDC has identified only 14,305 HCV infected prisoners. Only 796, or one in 14 prisoners are receiving treatment, statewide.

California officials have no way of knowing exactly how many prisoners are HCV positive because they do not test all prisoners for the virus. “Treatment costs money, and the Corrections Department is in no hurry to find out how many people need treatment,” said Judy Greenspan of California Prison Focus. State prisoners are screened for HCV only if they or a prison doctor requests a test.

Many suggest that the CDC, like most states, does not make HCV screening routine because of the costs associated with treatment and liver transplants. Yet, a committee of state, federal and local health officials developed a strategic plan advocating early treatment. “One way to minimize these costs is by being pro-active rather than reactive in patient management over the long term,” according to the study by the Steering Committee and Working Group for the Prevention and Control of Hepatitis C in California.

Experts warn that prisons are incubators for HCV which is increasing the risk that prisoners will infect members of the general public upon release. “We’re talking about the health of the community,” said Barbara Van Baren, Kings County’s communicable disease coordinator.

“California’s correction system confronts serious challenges to identify and treat hepatitis C infection within the prison system to prevent transmission within the prison and to the public when prisoners and parolees return to their community,” said Jonathan Fielding, Los Angeles County’s health officer.

As California’s prison population skyrocketed during the last 20 years, so did its medical costs, which totaled $663 million in 2001. Yet, prison officials have dramatically slashed money for HCV treatment. In 2000, the CDC spent $5.5 million for HCV treatment, but in 2001, only $325,000 was budgeted for treatment and prison officials stopped treating new patients.

In 2000 Governor Gray Davis signed a measure appropriating $1.5 million to create the state’s first HCV education and screening program. Half of that money was allocated to prisons and required the CDC to publish an annual report on the prevalence of HCV in prisons, but it did not mandate testing. At the same time, the Governor vetoed a $9.5 million public health bill which cut $60,000 earmarked to allow Kings county disease specialist Debbie Grice to continue working as liaison to CDC prisons.

Deficiencies in the CDC medical care system, including its denial of testing and treatment for HCV infected prisoners, prompted the Prison Law Office to file suit in federal court in 2001, alleging that the state systematically ignores the medical needs of its prisoners. On January 25, 2002, CDC officials agreed to settle the suit, entering into a Stipulation for Injunctive Relief.

Marciano Plata v. Gray Davis, et al., USDC (ND Cal.) No. C-01-1351 T.EH (Stipulation for Injunctive Relief, Jan. 25, 2002) [PLN, Feb. ‘02].

Unfortunately, the HCV epidemic in prisons is not limited to New Jersey, Pennsylvania, and California. This is a problem in virtually every prison in the nation and its not going away anytime soon. We will report on developments in these and other cases.

Sources: The Philadelphia Inquirer, Bradenton Herald, Sacramento Bee, The New York Times, Assn. of State & Territorial Health Officials (ASTHO), National Digestive Diseases Information Clearinghouse (NIDDK), Centers for Disease Control and Prevention (CDC)