Estelle v. Gamble ruled that prisons are legally responsible for treating inmates’ health conditions.
About 30% of all people with hepatitis C in the U.S. spend part of their lives in a prison.
20% to 55% of inmates have a history of injection drug use.

The topic of hepatitis C in prisons has always been hotly debated. But like it or not, if we are ever going to eliminate hepatitis C, we are going to have to test and treat prisoners. In this article, I will discuss what we know, and what we don’t know. I will discuss screening, prevalence and treatment of incarcerated people infected with hepatitis C. Finally, I will discuss some solutions that have been suggested to solve the problem of hepatitis C in American jails and prisons.

Jails
Jails are funded and staffed by local and state governments. People are housed in jails for being accused of a crime or who are waiting for a trial whether they are innocent or guilty. The length of time that people are held in jails can be up to one year or longer. Jails typically have a more transient population. Jails offer educational, substance abuse, and vocational (work) programs.

Jails do not routinely screen for hepatitis C and seldom, if ever, offer treatment. But jails would be a good place to test and provide referrals to local agencies.

Prisons
People who are convicted of a felony and generally sentenced for a year or more, are sent to a prison. State and federal governments operate prisons or contract with the private prison industry. A person who is convicted of a crime and who is incarcerated in a prison is a felon. Prisons can have a minimum, medium, and maximum security. There are also halfway houses, work related programs, and community restitution programs.

The average length of time a person who is incarcerated is a couple of years.

Screening
The Federal Bureau of Prisons (FBOP) recommends opting-out of hepatitis C testing for all inmates during the prevention baseline visit. See complete guideline www.bop.gov/resources/pdfs/hepatitis_c.pdf. Screening for hepatitis C in state prisons is not uniform and it is conducted on a state-by-state basis.

Prisons offer an optimal place to test, manage and treat hepatitis C.

Prevalence
Hepatitis C is the most common blood-borne pathogen in the United States and the Correctional Systems. In a study conducted by the Centers for Disease Control and Prevention (CDC) it was estimated that 9.6% to 41.1% of inmates in the prison system are infected with hepatitis C. The CDC took these numbers, averaged them out and estimated the number at 17.4% nationally.


New York and Maryland contributed to the CDC study and noted that their hepatitis C rates in prisons were declining. Two states that were not included in the CDC report, California and Rhode Island, also reported declining rates of hepatitis C infections in prisons.

The Annals of Epidemiology published a study on the ethnic and racial prevalence of the hepatitis C populations in correctional facilities. Non-Hispanic whites had the highest percentage of entrants followed by Hispanics then non-Hispanic Blacks. The racial comprise reported in the Annals of Epidemiology is in stark contrast to the racial and ethnic make-up of the groups who make up the general prison population. This difference may reflect the emergence of the new HCV infections from the current opioid epidemic.

Treatment
There are many reasons that prisons do not treat every prisoner with hepatitis C. In the past the cost of hepatitis C medications, the length of treatment, lack of prison medical staff, and the public reaction to spending large sums of money on the general prisoner health budget.


Now, the cost of treatment is coming down. The most recent treatment approved was AbbVie’s Mavyret. The most common treatment period is 8 weeks. The indication for the 8-week treatment period is for people with mild cirrhosis or no cirrhosis. The cost for the 8-week treatment period is $26,400. This is before negotiations that could drive down the cost even further. The other treatment periods are 12 and 16 weeks. Still public opinion, the number of prisoners times the cost of the HCV medications, and the lack of medical staff are major barriers to treating all prisoners.

Some Possible Solutions
Changing Public Opinion: Most people believe that all prisoners are hardened criminals, but many people who are incarcerated are convicted for crimes such as using drugs or committing crimes to support their drug use. As previously mentioned, the average time spent in prison is 2 years.


Ex-prisoners are all around us in the community and we are interacting with them on a daily basis.

Treating prisoners accomplishes many goals. If we can treat and cure prisoners we can stop the HCV epidemic from spreading into the community at-large. It will help to lower the future disease burden and overall future health care costs. It will also be a big step to eventually eliminating hepatitis C.

Lack of Prison Medical Staff: There have been studies showing that telemedicine can successfully manage and treat prisoners. The ease of treatment of hepatitis C, one pill-once-a-day for 8, 12 or 16 weeks is relatively easy for most patients. People with more advanced liver disease will need more care and support that will require an

in-house physician that could consult with a telemedicine expert, an in-house expert or a local expert.

Cost of HCV Medicines: There was an interesting idea put forth in an article that appeared in the National Academy of Sciences. The authors proposed buying licensing rights to hepatitis C drugs that could cost $2 billion dollars. The states would pay roughly 140 million dollars each to treat 700,000 Medicaid beneficiaries and prisoners. This is just one innovative idea. We need more ideas like this to solve such an important and expensive problem.

A final note
There is contradicting information coming from the White House. The Justice Department led by the Attorney General, Jeff Sessions, is basically reinstituting the “War on Drugs.” This will mean that there will be mandatory minimum sentences for drug offenses even small ones. These policies will increase the number of people incarcerated, and the government will spend large sums of money on law enforcement, trials, jails, prisons and prisoners instead of services to help people with addiction.

In August, the Trump Administration announced that there was a national emergency due to the opioid crisis. The declaration should mean that more resources will be allocated towards fighting the opioid epidemic.


Resources:
• National Hepatitis Corrections Network – An Initiative of the Hepatitis Education Project www.hcvinprison.org and www.hepeducation.org
Sources:
• Varan, Aiden K. “Hepatitis C Seroprevalence Among Prison Inmates Since 2001: Still High but Declining” Public Health Reports March-April Volume 129: (2014): 187-195.
• Larney, Sarah “A systematic review and meta-analysis of racial and ethnic disparities of hepatitis C antibody prevalence in United States correctional
populations” Annuals of Epidemiology 26 (2016): 570-576.
• He, Tianhua “Prevention of Hepatitis C by Screening and Treatment in U.S. Prisons” Annuals of Internal Medicine (2016): 84-92

Alan Franciscus is the Executive Director of the Hepatitis C Support Project and the Editor-in-Chief of the HCV Advocate website. This first appeared in the HCV Advocate, and is reprinted with permission.