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Prison Breakthrough
With one in six inmates infected with HCV, testing and treating this population presents an ideal opportunity for infection control.
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The US prison population provides an opportunity to battle the current epidemic of hepatitis C virus infection because inmates have a high prevalence of infection and are readily reachable for testing and treatment, experts claimed in a recent article published in The New England Journal of Medicine.
“Stemming the epidemic of HCV-related disease requires a national strategy … and 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; it could also prevent ongoing viral spread,” Josiah D. Rich, MD, MPH, Scott A. Allen, MD, and Brie A. Williams, MD, wrote.
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, professor of medicine and epidemiology at the Warren Alpert Medical School of Brown University and the Center for Prisoner Health and Human Rights at The Miriam Hospital in Providence, R.I. Rich laid out the arguments in an interview with HCV Next.
“In a nutshell, the United States has become the world’s largest incarcerator,” Rich said. “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.”
Josiah D. Rich
The numbers are undeniable. About 10 million people rotate through US correctional facilities each year. On any given day, around 2 million people are incarcerated in US prisons.
“About one in every six prisoners is infected with HCV, according to the best available data. In some localities, that number can exceed one in three. It is estimated that one of every three individuals in the community who is infected with HCV rotates through a jail or prison each year,” Allen, professor of medicine and associate dean of academic affairs at the University of California, Riverside, School of Medicine, and also co-director of the Center for Prisoner Health and Human Rights, told HCV Next.
The data support this claim. In a recent Public Health Reports study, Varan and colleagues surveyed all US state correctional departments to determine compliance rates of routine HCV screening since 2001. Results indicated seroprevalence rates ranging from 9.6% to 41.1% in at least 12 states that performed routine testing from 2001 to 2012. Based on these estimates, the national seroprevalence rate for HCV infection in correctional facilities in 2006 was 17.4%. The researchers noted that correctional populations may account for about 30% of the HCV burden in the United States. But, with an influx of new patients expected as a result of improved direct-acting antiviral therapies and anticipated increases in routine testing of baby boomers, these numbers could change sharply in the next decade.
Target of Opportunity
For many in the clinical community, the reaction to these numbers should be obvious.
Scott A. Allen
“The high prevalence within US 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.
Allen 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 US hepatitis C epidemic, I reply: ‘Because that’s where the disease is,’” Allen said.
“In short, 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,” Rich told HCV Next.
However, there are challenges in targeting the US prison population. Political and clinical obstacles exist and, as with any current discussion of HCV, the cost of currently approved DAAs is embedded within the argument. HCV Next addressed the questions of why resources should be devoted to this population, and what might happen if no action is taken.
Treatment Debate
Rich described the situation among prisoners as reaching “epidemic proportions,” which should be reason enough to intervene, he said. But some outside of the health care community have suggested that resources should be devoted to unincarcerated populations 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. 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,” Allen said.
Then there are the sheer numbers, millions of patients or potential patients in and out of prisons and jails. But, the NEJM authors suggest that the task of dealing with 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 US 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 US 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 US 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 US 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 National Strategy
A national strategy is necessary to meet the clinical challenges of testing and treating the US 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 set 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.”
Barriers, Challenges Exist
New therapies have changed the standard of care for HCV and have also raised a number of questions that need to be addressed to develop a public health strategy, according to the authors.
One question surrounds the issue of the cost to treat prisoners with newer HCV therapies. Based on the current costs of the new DAAs and the number of individuals who rotate through jails and prisons per year, “if we estimate that 17% of people incarcerated today have HCV and aim to treat them all, the cost will be $33 billion,” or five times as much as treating only those incarcerated on a given day. “If we treat even half the people with HCV who pass through corrections facilities in a year, the cost will be $76 billion,” or roughly 2.5 times as much as treating those present on a given day, the researchers wrote in NEJM.
“The criminal justice system cannot be expected to shoulder the prohibitive costs of hepatitis C treatments alone,” Williams, associate professor of medicine at the University of California, San Francisco, said in a press release. “Recognizing that infectious disease epidemics cannot be contained behind prison walls, we must develop a national strategy for responding to them that includes financial support and an infrastructure to test and treat prisoners, both within prisons and jails and after they return to our communities.”
Brie A. Williams
Another question the authors raised is whether all prisoners should be screened and treated for HCV, particularly in light of the fact that more than 95% of prisoners 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.
Beyond cost, there are also challenges at the individual doctor-patient level. Although the once-daily, oral formulation of many new DAAs make them much less difficult to administer than pegylated interferon and ribavirin, providers still need to be trained and gain experience with the new therapies.
“We will also need to provide appropriate incentives to make the prisoners want to get treated, and resources to prevent reinfection,” Rich said. “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.” But, this too is a problem that can be solved, according to Rich. “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,” he 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 US 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 in response to epidemics, a standard that necessitates deploying external emergency funding to optimize both correctional- and community-based treatment.”
Allen also suggested that timely action in prison populations should become a permanent component of the US 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 United States, 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
References:
Rich JD. N Engl J Med. 2014;370:1871-1874.Varan AK. Public Health Rep. 2014;129:187-195.
For more information:
Scott A. Allen, MD, can be reached at University of California, Riverside, 900 University Ave., Riverside, CA 92521; email: scott.allen@ucr.edu.Josiah D. Rich, MD, MPH, can be reached at the Miriam Hospital, 164 Summit Ave., Providence, RI 02906; email: josiah_rich@brown.edu.
Brie A. Williams, MD, can be reached at University of California, San Francisco, School of Medicine, 3333 Calif. St., Laurel Heights, San Francisco, CA 94143; email: brie.williams@ucsf.edu.
Disclosures: Allen and Williams report no relevant financial disclosures. Rich reports associations with Gilead.