A Framework for Management of Hepatitis C in Prisons

Inmates with chronic hepatitis C virus (HCV) infection present a major challenge to prison health systems. In the United States, prisons house approximately 1.4 million adults serving sentences that range from 1 year to life (1). State prisoners serve an average of 30 months, and the average annual population turnover is 33% (2, 3). Sixteen percent to 41% of inmates are positive for antibody to HCV (anti-HCV), and 12% to 31% have chronic infection (4). The primary source of HCV infection in the United States is illegal injection drug use; drug offenders make up 20% of state and 55% of federal prison populations (5). Although 95% to 99% of prison inmates are eventually released to the community (6, 7), sentences have increased substantially over the past decade (3). Because of longer periods of incarceration, prison health care systems must provide care for chronic medical conditions, including liver disease. Prison health care officials are faced with the question of whether a chronic disease like hepatitis C, which is usually asymptomatic but is responsible for much of the liver disease previously attributed to alcohol abuse (8), is a health condition that merits identification, medical evaluation, and possible treatment. Prison systems are unlikely to benefit directly from proactive identification of inmates with HCV infection or from treatment of patients whose disease may take years to become symptomatic. In the United States, direct medical expenditures related to chronic hepatitis C are predicted to amount to $10.7 billion from 2010 to 2019 (9). Prison health care budgets could bear a large share of this cost because of the disproportionate number of incarcerated persons with HCV infection. However, current guidelines for identification, counseling, medical evaluation, management, and treatment of persons with chronic hepatitis C specifically recommend offering these services to incarcerated persons (4, 10). To gain insight into the challenges of identifying HCV infection and managing hepatitis C in prisoners, a meeting, funded by the Centers for Disease Control and Prevention and the National Institutes of Health, was held in January 2003. Forty-three state prison systems sent their medical director, a prison administrator, or both to the conference. Experts in prison and public health, hepatology, and infectious diseases (Appendix) gave presentations. The information and viewpoints shared at this meeting were intended to guide development of hepatitis C testing and treatment policies at state departments of corrections. Background The high proportion of incarcerated persons with HCV infection or risk factors for infection makes correctional facilities logical venues to implement hepatitis C prevention and medical management programs. The vast majority of incarcerated persons in the United States are short-term detainees. Although time does not permit these individuals to begin hepatitis C treatment before discharge, all inmates can still greatly benefit from hepatitis C education and appropriate referral for testing and, if infected, for disease evaluation in the community. If incarceration extends to months, diagnostic evaluations can begin. Prisons house inmates for longer sentences. This paper will focus on the long-term occupants of prisons. Many prison systems have established programs to prevent and manage other infectious diseases, such as tuberculosis, HIV/AIDS, and sexually transmitted diseases. Prevention of hepatitis C could feasibly be integrated into such programs (4, 11), which could reduce the incidence of new HCV infections and prevent transmission to others from already infected persons (primary prevention), identify and treat asymptomatic persons with infection to reduce chronic liver disease (secondary prevention), and reduce disability among persons with disease (tertiary prevention) (12). Substance abuse treatment and risk reduction counseling provided within prisons to prevent injection drug use can have effects on primary prevention in and outside the prison system. For inmates found to be infected with HCV, prevention services, such as substance abuse treatment and education about risk and harm reduction, could also reduce transmission of HCV to others. Secondary prevention for inmates with HCV infection begins with a medical evaluation to determine the extent of chronic liver disease, to determine the presence of comorbid conditions (for example, HIV infection and substance abuse), to assess the need for antiviral therapy with or without substance abuse (drug and alcohol) treatment, and to provide immunization against hepatitis A and hepatitis B, as needed. Natural History and Medical Management of Hepatitis C Most persons, including prisoners, with chronic HCV infection are asymptomatic, although 70% to 85% have histologic evidence of active liver disease, including inflammation, fibrosis, or cirrhosis (13, 14). It is not easy to determine which persons with chronic hepatitis C have infection that will progress to symptomatic liver disease and death. However, several factors speed disease progression, including male sex, becoming infected after 40 years of age, alcohol abuse, and co-infection with other viruses, such as hepatitis B virus and HIV (13). The efficacy of hepatitis C antiviral treatment has improved substantially over the past decade. Combination therapy with pegylated interferon and ribavirin achieves an overall sustained virologic response (SVR) of 50% to 60% (15). Although long-term data are not available for the effectiveness of antiviral therapy in decreasing hepatitis Crelated death, intermediate-term data indicate that persons with SVR have improved liver histologic characteristics and diminished liver disease (16, 17). Many correctional systems have developed evidence-based protocols for identification, medical evaluation, and antiviral treatment of inmates with HCV infection. Although these protocols vary in their inclusion criteria, they provide a framework for identifying and managing HCV-infected inmates. The use of protocols minimizes interprovider variability in therapeutic decision making, and their guiding principles permit the flexibility required to tailor treatment and medical management to patient needs (18). Preliminary data indicate that with good adherence to treatment regimens, SVR rates for prison patients treated with combination therapy are comparable to those observed in noninmate patients at similar stages of disease (19-22). However, therapy in prisons can be frequently interrupted (22). Also, in contrast to reports of lower SVR rates among black patients receiving the same therapeutic regimen as white patients in nonprisoner populations, the authors of one small prison study observed that SVR rates were similar among white and black patients with genotype 1 infection treated with interferon and ribavirin under direct observation of correctional nurses (23). The costs of hepatitis C medical management, including liver biopsy, transportation for specialty care, and medication, vary among correctional systems. Although some systems have negotiated lower prices for antiviral drugs and pay as little as 40% of the retail cost for peginterferon and ribavirin combination therapy (Peterson C, PharmD, Georgia Correctional HealthCare. Personal communication, 8 September 2004), the cost of hepatitis C treatment is still substantial in all systems. Treating eligible patients could represent a 15% to 60% increase in the average state correctional system medical budget (4, 24). Challenges to Management of Hepatitis C in Prisons Experts participating in this meeting did not reach consensus about all the issues discussed. However, data and discussion led to the identification of 5 areas in which generalizations could be made about optimal approaches to hepatitis C prevention, identification, and treatment. Participants proposed that consensus in the following areas would support a rational framework for the management of hepatitis C for infected prison inmates. Testing for HCV Infection in Prisons Would Identify Many Infected Americans Of all persons infected with HCV, approximately 29% to 43% pass through a correctional system each year (25). It is currently recommended that incarcerated persons with risk factors for HCV infection be screened (4). Although 49 states have at least 1 prison that tests inmates, only 10 states offer routine testing in all facilities. Of 1584 state prison facilities, 4% offer risk-factorbased HCV testing to incoming inmates and 5% offer testing to inmates already in custody (26). Routine HCV testing for all inmates is less common than routine HIV testing, which was performed for inmates at entrance in 19 state prison systems in 2000 (27). Although court rulings have granted prisoners access to health care, correctional systems are not obligated to seek potential medical problems (28, 29). Medical conditions identified for screening have been selected for the following reasons: 1) They are amenable to treatment; 2) they interfere with activities of daily living; 3) they could progress without treatment during the duration of incarceration; or 4) they pose a risk for infection transmission. Although hepatitis C can be easily identified by testing, it has not been considered a correctional health priority because it does not meet these criteria. Recommended screening strategies maximize identification of individuals infected with HCV while avoiding the cost of universal testing (4). In Wisconsin, 91% of anti-HCVpositive inmates were identified through testing the 27% of the population with a history of injection drug use, serologic evidence or a history of hepatitis B virus infection, or elevated alanine aminotransferase (ALT) levels (30, 31). Risk-based screening programs in the Federal Bureau of Prisons and Washington State prisons identified 6% and 15% of their populations, respectively, as anti-HCVpositive. However, the