Clinical Outcomes of Hepatitis C Treatment in a Prison Setting: Feasibility and Effectiveness for Challenging Treatment Populations

Hepatitis C virus (HCV) is the most prevalent chronic, bloodborne infection in the United States, affecting >4 million people. HCV infection causes ~10,000 deaths per year [1], yielding direct health care costs that exceed $1 billion annually [2]. Nowhere is the burden of HCV infection greater than in the nation’s correctional facilities [3]. Seroprevalences of chronic HCV infection in correctional facilities range from 16% to 49% [4–7], and it is estimated that more than one-third of all patients with chronic HCV infection in the United States pass through correctional facilities each year [4]. Prisons—and the correctional system in general—are among the cornerstones of public health in the United States [8–12]. By 2007, 7 million people in the United States lived under the jurisdiction of the criminal justice system [13], and 2.5 million individuals (or 1 in 100) were in jail or prison [14]. The millions of intermittently incarcerated people in America, many of whom have substance use disorders and profound psychiatric comorbidities, are among the most difficult people to reach with critical health information and treatment in community settings [3, 9, 15]. Improved diagnosis and access to medical care and prevention services for incarcerated populations, recognized as a public health disease-control strategy [13–15], can benefit communities by reducing disease transmission and medical costs [9, 16–18]. Inmates who participate in health-related programs while incarcerated have lower recidivism rates and are more likely to maintain health-conscious behavior [17]. Because the prevalence of HCV infection is high among incarcerated persons, community efforts to diagnose, treat, and prevent these infections require inclusion of the correctional population [19]. Antiviral treatment with combination pegylated IFN and ribavirin (PEG-RBV) is now the preferred treatment for HCV infection and is a crucial component of the public health response to the epidemic [20–22]. This strategy can result in achievement of a sustained virological response (SVR; defined as a nondetectable HCV load 6 months after completion of treatment) in >50% of treated subjects [23, 24]. Patients who achieve SVR experience slower rates of progression of liver disease. Unfortunately, adverse effects, difficulties with adherence to treatment, comorbid psychiatric and substance use disorders, and lack of access to clinicians experienced in the treatment of HCV infection have limited the full expansion of this strategy [25, 26]. In community settings, patients with alcohol dependence, other drug dependence, or mental illness typically do not receive treatment [27–34]. Although the feasibility of treating HCV-infected prisoners with standard thrice-weekly IFN has been demonstrated [35–37], there are, to our knowledge, no published reports on the efficacy of the contemporary and more efficacious therapy with PEG-RBV and on treatment outcomes among prisoners who receive PEG-RBV. The purpose of this retrospective, longitudinal study is to address the feasibility and effectiveness of use of PEG-RBV treatment in the correctional setting. Data from the Connecticut Department of Correction (CTDOC) HCV Management Program were analyzed using both primary outcomes (intention-to-treat SVR) and secondary outcomes (determinants of SVR and the use of additional pharmaceutical agents and hospitalizations) during treatment.