HCV treatment as prevention in prison: Key issues
Authors: Natasha K. Martin, Peter Vickerman, David Goldberg, Matthew Hickman
Journal: Hepatology (2014)

There are high numbers and proportions of people who inject drugs (PWID) among the prison population—and therefore, inevitably high rates of hepatitis C virus (HCV) among prisoners.1 Therefore, the proposal of using HCV treatment as prevention in prison settings is compelling. Indeed, our theoretical modeling studies have indicated that treatment of those with ongoing HCV transmission risk could prevent onward transmission and reduce HCV chronic prevalence.2, 3 In their letter ("The Ethics of Hepatitis C 'Treatment as Prevention' Among Prisoners"), Levy and Larney rightly highlight the need for truly voluntary HCV testing. We would also like to emphasize that voluntary HCV testing is not enough; our recent cost-effectiveness analysis4 of HCV testing and treatment in the prison health systems highlighted the need to also ensure that infected individuals are referred to treatment and remain in referral contact or on treatment after release or transfer. The high turnover of incarcerated populations and frequent prison transfers in some prison settings therefore poses a challenge. Systems to ensure effective referral into treatment and continuity of care are often not in place, which can substantially limit the effectiveness and cost-effectiveness of a prison-based treatment as prevention strategy. Levy and Larney also call for greater access to harm reduction interventions within prison for those who successfully complete treatment to protect themselves against reinfection, and caution that reinfection may limit the effectiveness of treatment as prevention in prisons. In a recent study in Scotland the risk of HCV transmission in prisons was lower than the community, due primarily to widespread access to opiate substitution treatment (OST).5 We agree that greater access to OST is required within prisons, and that if HCV incidence remains high then further harm reduction interventions should be made available for all individuals, not just those who undergo treatment. However, it should be remembered that the time in prison is comparatively short in relation to the overall duration of injecting risk in the community, so the risk of reinfection may well be greater in the community than in prison. We have shown that a combination prevention approach (OST, needle and syringe programs, and HCV treatment) could have a substantial impact on the HCV epidemic in the population.6 HCV case finding and treatment in prison could provide a substantial boost to "treatment as prevention" in the community, precisely because individuals with an ongoing risk of transmitting infection to others may be detected and treated. To date, however, the duration of HCV treatment, problems of ensuring continuity of care in the community, and average durations of imprisonment have mitigated against scaling up HCV treatment in the prison setting. Many of these issues could be overcome with the advent of highly potent all-oral, interferon-free, direct-acting antiviral regimens for HCV. In particular, these shorter-course treatments with much reduced side effects may substantially increase the feasibility of increasing HCV treatment availability within prison settings. To inform policy, evaluations are needed to gauge the effectiveness and acceptability, particularly from an ethical perspective, of HCV treatment among prisoners, for both individual and population benefit. Natasha K. Martin, D.Phil.,1,2Peter Vickerman, D.Phil.,1,2David Goldberg, FRSE,3Matthew Hickman, Ph.D.1 1School of Social and Community Medicine University of Bristol Bristol, UK 2Department for Global Health and Development London School of Hygiene and Tropical Medicine London, UK3Health Protection Scotland Glasgow, UK