Recently (just before the Covid-19 tsunami hit) I was privileged to chair the American College of Correctional Physicians (ACCP) committee tasked with writing an official position paper on the treatment of Hepatitis C infection in corrections. The exact wording of the paper required some delicacy because treating Hepatitis C in incarcerated inmates can be controversial. No one disagrees that patients with Hepatitis C infection should be treated, whether incarcerated or in the free world, but because the drugs used to treat Hepatitis C are so horrifically expensive. Some state legislatures, which authorize funds for inmate medical care in their prison systems, have been reluctant to fully fund Hepatitis C treatment. More on this in a future post. In the meantime. I believe this is an important document that all correctional medical professionals should read.
It is estimated that between 15-40% of inmates incarcerated in in the United States have chronic hepatitis C infection (HCV), compared to 1-2% of the general population. Over time, HCV can lead to complications of end-stage liver disease, including cirrhosis, liver transplantation, cancer, and death. Direct Acting Anti-viral agents (DAAs) used to treat HCV are highly effective in eradicating HCV infection and preventing the progression of liver disease in most patients. When used appropriately, DAAs have minor, if any, side effects. Unfortunately, barriers to treatment remain both in corrections and in the community, including inadequate financial support, shortages of medical resources and incarceration periods too short to allow the full process of diagnosis, staging and treatment.
Correctional facilities (including prisons, jails and juvenile facilities) offer unique opportunities to identify and treat patients with HCV, housing a subset of patients that have proven nearly impossible to reach in the community due to homelessness, mental illness, substance abuse, lack of medical coverage and other factors. Beside achieving the best patient outcome, treating the HCV-infected population is also important from a public health perspective by reducing transmission of the Hepatitis C virus from infected to uninfected individuals.
The American College of Correctional Physicians (ACCP) believes that all prison inmates should be screened for HCV unless the patient declines (“opt-out” testing). Screening should include, at least, an HCV antibody test with a reflex HCV viral load when reactive. Since most jail patients are released back into the community before screening and treatment can be accomplished, ACCP encourages jails to form a partnership with their local public health agencies to offer HCV screening to jail patients and to mobilize community resources for those found to be infected.
Because of the medical and public health benefits of HCV treatment, the ACCP agrees with the recommendations of the AASLD/IDSA (www.hcvguidelines.org) that all patients with HCV should be treated, with few exceptions, whether in the community or in a correctional facility. At this time, the evidence-based practice of HCV treatment regardless of hepatic fibrosis stage leads to the best clinical outcomes known to date for morbidity, mortality, and cost-effectiveness.
ACCP believes that prison systems should establish a multidisciplinary HCV committee to incorporate the evidence-based standard of care into treatment plans for patients, similar to hospital tumor boards. Ideally, the committee should be chaired by an Infectious Disease specialist or Hepatologist and include a correctional physician, correctional nurse, pharmacist, a security administrator and other members as deemed advisable. When creating treatment plans for individual patients, the committee would consider the stage of liver disease, comorbid conditions (such as Hepatitis B and HIV), available resources, expected length of incarceration, and the willingness of the patient to adhere to institutional and treatment protocols. Patients entering a correctional facility already receiving treatment for HCV should have their treatment completed, if possible.
ACCP strongly encourages federal, state and local governments to provide adequate funds to their correctional facilities for the screening, staging and treatment of all incarcerated patients with HCV. ACCP believes that all state and federal agencies should practice the same standard of care for HCV patients, whether incarcerated or in the community.
Treating any offender [with Hep C] that is incarcerated for the duration of the course of treatment [jail or prison] should be the standard – exceptions as noted similar to community standards. Yet, not only are we ‘blessed’ with a higher percentage of Hep C patients – we are similarly blessed with a much higher rate of substance abusers. The concern not only that they will return to abuse of substances but that they will be exposed to re-infection. It does not seem effective in that situation to treat aggressively (at all?). While not aware of and data on successful treatment of Hep C and re-infection upon relapse – would think it should be out there (or should be done).
Truly, cost is an issue – use of manufacturer cost reduction programs, grants and partnering with organizations may be of some help. Perhaps some situation, like Texas – UTMB that provides health care to prisons could accomplish the study noted above with a grant.
On another note; Covid-19 being the hot topic, it seems that we keep reinventing the wheel. Over time there have been a number of ***demic illnesses (SARS, MERS, Hantavirus, Swine / Bird Flu) and the response is to rebuild the infection control process again. Or is it just me…
Thanks, Al! Great comment as usual. Yes, some of the HepC patients treated and cured of HepC in a prison will re-infect themselves. But most won’t. We don’t deny treatment for HIV or chlamydia based on the possibility of the patient getting reinfected. It all comes down to cost. More on that later!
I’ve been interested in this issue for a while. Has the new ACCP Position Paper on Hep C been published? The ACCP website still lists the 2014 position. Thanks!
The newly written ACCP Position Paper will be published there soon . . .
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