HCV prevalent among US inmates; most are not getting the cure
Experts have argued that the United States prison population provides an opportunity to address the hepatitis C virus epidemic because inmates have a high prevalence of infection and are readily reachable for testing and treatment, but recent data show most are not receiving the care they need.
In 2014, Josiah D. Rich, MD, MPH, Scott A. Allen, MD, and Brie A. Williams, MD, wrote in The New England Journal of Medicine that a national strategy to curtail HCV-related disease in the U.S. requires “a clear approach to screening, diagnosing and, when appropriate, treating and curing people both in the community and in correctional facilities.”
“Early detection and treatment in correctional settings has the potential to prevent future need for treatment, which, along with its attendant costs, would occur predominantly in the community,” they wrote, adding that “it could also prevent ongoing viral spread.”
Infectious Disease News revisited the issue and spoke with experts about caring for people living with HCV in correctional facilities.
“We have an opportunity — and a clear obligation — to identify and treat HCV in prisons,” Williams, a professor of medicine in the division of geriatrics and director of the Criminal Justice & Health program at the University of California, San Francisco, told Infectious Disease News. “There is no other rational way to combat this epidemic. At a fundamental level, prison health is public health. What happens — or does not happen — inside prisons and jails to improve the health of millions of Americans has a direct impact on the overall health of our communities.”
Large number of prisoners
The discussion begins with a pair of contributing factors: the prevalence of HCV among injection drug users and the decades-long war on drugs in the United States. Viewed through that lens, the issue of focusing on the prison population is fairly straightforward, according to Rich, a professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital in Providence, Rhode Island.
“In a nutshell, the United States has become the world’s largest incarcerator,” Rich said in an interview. “The forces that created that have resulted in minorities and impoverished populations finding themselves in jail. In our society today, the natural history of addictive disease and mental illness leads directly to incarceration.”
The numbers are undeniable. About 11 million people rotate through U.S. correctional facilities each year. On any given day, around 2.2 million people are incarcerated in U.S. jails and prisons, and around 33% are infected with HCV, according to the CDC. In 2014, a Public Health Reports study indicated that correctional populations may account for almost one-third of the HCV burden in the U.S.
Siraphob Thanthong-Knight, a reporter and former student at Columbia University’s Toni Stabile Center for Investigative Journalism, noticed a lack of comprehensive data on the treatment of state prison inmates with HCV. For his master’s project, Thanthong-Knight surveyed state prisons about their policy for HCV testing and treatment, the HCV drugs in their formulary, the prevalence of infection among inmates and how many had been recently treated.
“According to the survey data, at least 144,000 [state prison] inmates were reported to have hepatitis C nationwide, and roughly 97% of inmates with hepatitis C were not getting the cure,” Thanthong-Knight told Infectious Disease News.
He said the survey did not include information on whether the inmates wanted care, though he did say some prisoners were denied treatment for not meeting state-specific criteria.
The story these numbers tell should be apparent, said Allen, a clinical professor of internal medicine at the University of California, Riverside, School of Medicine, and co-founder of the Center for Prisoner Health and Human Rights.
“The high prevalence within U.S. correctional facilities, combined with the high percentage of people with HCV in the community who rotate through these facilities make it an obvious target of opportunity to intervene in the national hepatitis C epidemic,” Allen said.
He offered a slightly less clinical take on the issue: “According to urban legend, when asked why he robbed banks, Willie Sutton replied: ‘Because that’s where the money is.’ When asked ‘Why prisons?’ in the context of the U.S. hepatitis C epidemic, I reply: ‘Because that’s where the disease is.’”
“In short,” Rich said, “that group has a tremendous amount of HCV. If you want to capitalize on this system to address the problem of HCV, there is an ideal place to start.”
Recent research has demonstrated the promise of treating HCV in prisoners. Earlier this year, a review of studies showed evidence that — as with HIV — testing and treating HCV patients in the prison system reduces the short-term overall burden of infection in this “microenvironment” and could benefit eradication efforts in society as a whole. Redman and colleagues reported that postponing care until after patients are released has been shown to be ineffective in treating these patients.
“Indeed, the prison system may represent the only formal access many of these patients have to specialized health care,” Redman and colleagues wrote in The American Journal of Gastroenterology. “Linkage to care post-incarcerations is also very low, indicating that treatment is best addressed during the period of imprisonment.”
However, there are challenges in targeting the U.S. prison population. Political and clinical obstacles exist and, as with any current discussion of HCV, the cost of direct-acting antivirals (DAAs) is an issue.
Rich described the situation among prisoners as reaching “epidemic proportions,” which should be reason enough to intervene, he said. But observers outside the health care community have suggested that resources be devoted elsewhere first.
“It is understandable that the public can be skeptical about devoting resources to costly care for prisoners,” Allen said. “However, it would be a mistake to consider the issue of hepatitis C in prisons simply as an issue of concern to prisoners.”
“The majority of people who are incarcerated, ultimately, are released back into the community,” he said. “For the same reason that treatment of a serious chronic disease such as hepatitis C early rather than later is cost-effective in the community, even at high prices, it makes sense to treat the disease early in prisons to avoid later costs that would likely be borne by the community after the prisoner’s release. It is a matter of overall public health.”
Then there are the sheer numbers — millions of patients or potential patients in and out of prisons and jails. The authors of the NEJM paper suggested that the task of managing these numbers is not insurmountable.
“From a public health standpoint, the high concentrations of patients with a curable contagious disease living in correctional institutions presents a critical opportunity to have a substantial effect on this epidemic,” they wrote.
“Ignoring prisoners misses an opportunity to interrupt disease and transmissibility in a high-prevalence population with predictable adverse health and financial consequences in the future,” Allen said.
Most U.S. correctional facilities have the infrastructure necessary to test and treat HCV, according to Rich. “However, there is variation in the type and quantity and quality of care. They are all different in terms of structure and workforce,” he said.
Beyond the clinical and epidemiological reasons to treat HCV is the law.
“Both ethically and legally, prisoners have a right to health care for serious and treatable medical conditions,” Allen said. “That point was now twice affirmed by the U.S. Supreme Court, first in Estelle v. Gamble in 1976 and then in Plata v. Brown in 2011. Correctional facilities are therefore mandated constitutionally to provide community standard of care, so all U.S. prisons are health care facilities.”
Rich said this legal mandate for community-level care is a step in the right direction, but it highlights broader concerns with the U.S. health care system.
“Community-standard health care is a relatively low bar to clear,” the authors wrote. “And when it comes to managing HCV infection in correctional settings, as a matter of public health and public policy, care aimed only at meeting a minimal constitutional standard represents a missed opportunity.”
Need for a national strategy
A national strategy is necessary to meet the clinical challenges of testing and treating the U.S. prison population for HCV, according to Rich. He suggested a strategy that draws on lessons learned from the HIV epidemic.
“Correctional facilities faced similar cost and treatment challenges in responding to the HIV epidemic, which was even more complicated because it required long-term treatment with ongoing monitoring,” the authors wrote.
There is a precedent for government intervention into a health care crisis of this nature and magnitude, according to Allen.
“We have called for a federally funded program modeled after the Ryan White CARE Act for HIV in order to support correctional facilities in their effort to follow well-established screening and treatment guidelines for hepatitis C,” he said. “Without such targeted funding support, prisons will struggle to provide care.”
There is evidence elsewhere that a federally subsidized program could work. In Australia, which has a full-time adult incarcerated population of approximately 30,000 people with more than 50,000 moving through the system each year, a program granting prison inmates with HCV infection unrestricted access to DAAs nearly eliminated the virus at one correctional facility, according to findings published in Clinical Infectious Diseases.
The program was funded through the Australian Pharmaceutical Benefits Scheme — part of a national plan that subsidizes the cost of certain medicines — and rolled out at the Lotus Glen Correctional Centre (LGCC) in Queensland in March 2016. After 22 months, the prevalence of documented HCV infection among people in LGCC decreased from 12% to 1%.
The project “demonstrated that high-quality care can be provided in a correctional center without creating a large additional burden on the clinic or its staff,” Sofia R. Bartlett, PhD, adjunct associate lecturer in the Kirby Institute at the University of New South Wales in Sydney, Australia, and postdoctoral fellow at the British Columbia Centre for Disease Control and University of British Columbia, told Infectious Disease News.
“Providing HCV treatment can also have further reaching benefits for patients, other than just HCV cure, as it provides an opportunity for improved health care engagement and linkage to other services, such as drug and alcohol treatment,” she said.
Efforts to maintain the success continued, with three Australian jurisdictions launching statewide prison-based DAA treatment scale-up programs and several others having facility-specific DAA treatment scale-up programs.
“Prison-based DAA treatment for HCV infection can rapidly reduce HCV prevalence if treatment is scaled-up rapidly, providing strong rationale for further prison hepatitis C micro-elimination programs,” Bartlett said.
New therapies have changed the standard of care for HCV and also have raised a number of questions that need to be addressed to develop a public health strategy.
One question surrounds the issue of the cost to treat prisoners with HCV therapies, with estimates reaching into the tens of billions of dollars. Another question the authors of the NEJM paper raised is whether all prisoners should be screened and treated for HCV, particularly in light of the fact that more than 95% are eventually released and most HCV-related illness will occur in the community.
“Should everyone be screened and treated? That approach makes sense in incarcerated populations, given the low cost of screening and the high prevalence. Even screening without treatment, particularly for populations in jail for short periods, could have a substantial effect on the trajectory of disease, especially if it were accompanied by enrollment in insurance coverage made available under the Affordable Care Act,” the authors wrote.
Rich said appropriate incentives and resources will need to be provided to convince prisoners to get treated and to prevent reinfection.
“Current reinfection rates are relatively low, which is good. If we are going to roll out a big program, this needs to be a focus of attention,” Rich said. This, too, is a problem that can be solved, he said.
“Our past experience has shown that prison provides relative stability and relative sobriety for an at-risk population who often do not interact with the health care system and who often live chaotic lives when they are in the community,” Rich said. “For many, prison provides a window of opportunity to treat an otherwise hard-to-reach, high-prevalence population.”
A call for action
Rich, Allen and Williams were unequivocal in their call for action to battle the HCV epidemic in prisoners.
“Although the history of medical care in U.S. correctional facilities has been a story of struggling to meet minimum standards of care, moving beyond those standards in the case of HCV would benefit everyone,” they concluded. “A new standard of correctional health care should be expected on response to epidemics, a standard that necessitates deploying external emergency funding to optimize both correction- and community-based treatment.”
In a recently published paper, Anne C. Spaulding, MD, MPH, associate professor of epidemiology in the Rollins School of Public Health at Emory University, and colleagues looked into the benefits of changing the current standard of care and screening guidelines, noting that “ignoring the portion of the United States’ hepatitis C epidemic made up of persons with a history of incarceration leads to serious underestimations of hepatitis C virus prevalence.”
Due to the market impact of certain federal laws, Spaulding and colleagues explained, pharmaceutical companies are unable to lower prices to a level that would allow prisons to purchase enough supplies to meet population demands.
“One proposal is to amend federal regulations that stipulate which entities are excluded from Medicaid’s best-price rule. There are currently 19 exceptions to the best-price rule, and through legislation a 20th exception could be created,” they wrote.
Spaulding and colleagues explained that by becoming an excluded or exempt entity, state prisons could negotiate lower prices and receive discounts like those available to the VA and Indian Health Services.
They noted research showing that universal HCV screening in prisons would prevent infections not only among people who are incarcerated, but also outside the prison walls, with most of the benefit occurring in the community. They said HCV screening in prisons would prevent 12,500 new HCV infections in the next 30 years — 90% of them in the general population — and 12,500 liver-related deaths, 1,200 liver transplants, 9,000 cases of hepatocellular carcinoma and 7,500 cases of decompensated cirrhosis, also mostly outside of prisons.
Allen also suggested that timely action in prison populations should become a permanent component of the U.S. health care system. Taking such action could have consequences not just in terms of improved infection rates, but also in the general attitude toward prisoners in the U.S., according to the authors.
“In taking this step, we can help to change the perception of the HCV epidemic in the criminal justice system, transforming it from a legal liability to a critical opportunity to change the course of HCV in the United States,” they wrote.
For Rich, the urgency of the situation cannot be understated.
“We know this is going to come crashing down on us,” he said. “Anything we can do to stem the tide now, at the outset, to keep the situation in check, will benefit us in the long run.” – by Rob Volansky and Caitlyn Stulpin
- Bartlett SR, et al. Clin Infect Dis. 2018;doi:10.1093/cid/ciy210.
- CDC. Hepatitis C & incarceration. https://www.cdc.gov/hepatitis/hcv/pdfs/hepcincarcerationfactsheet.pdf. Accessed October 30, 2018.
- Redman JS, Sterling RK. Am J Gastroenterol. 2018;doi:10.1038/s41395-018-0201-x.
- Rich JD, et al. N Engl J Med. 2014;doi:10.1056/NEJMp1311941.
- Spaulding AC, et al. Infect Dis Clin N Am. 2018; doi.org/10.1016/j.idc.2018.02.014
- Varan AK, et al. Public Health Rep. 2014;doi:10.1177/003335491412900213.
- For more information:
- Scott A. Allen, MD, can be reached at email@example.com.
- Sofia Bartlett, PhD, can be reached at firstname.lastname@example.org.
- Josiah D. Rich, MD, MPH, can be reached at Josiah_Rich@brown.edu.
- Siraphob Thanthong-Knight, can be reached at email@example.com.
- Brie A. Williams, MD, can be reached at firstname.lastname@example.org.
Disclosures: Allen, Bartlett, Rich and Williams report no relevant financial disclosures. Spaulding reports associations with Gilead Sciences. Thanthong-Knight reports funding by the Toni Stabile Center for Investigative Journalism at Columbia University.