Opportunities & Challenges in Addressing HCV in the Criminal Justice System

Cross-posted from the HHS.gov Hepatitis blog

Hepatitis C virus (HCV) is a major public health challenge among justice-involved people in the United States. For decades, individuals with substance use disorders have been concentrated in the criminal justice system leading to HCV prevalence rates that are 10-20 times higher than surrounding communities. Since the majority of justice-involved people will return to the community, correctional settings are crucial sites to address all phases of the HCV care cascade (screening, linkage to care, treatment, and prevention of reinfection).

As the first step in the cascade, screening and confirmation of chronic infection using HCV RNA testing are important to make individuals aware of their infection. Opt-out HCV antibody screening of all inmates was recommended by the Federal Bureau of Prisons in 2016; however, screening practices still vary from institution to institution. Screening and confirmation of chronic infection in correctional settings can also been complicated by stigma, medical mistrust, and the logistics of providing test results, among other factors. Effective strategies are needed to promote testing and diagnosis in this high-risk population.

Once the diagnosis is made, the time spent in correctional settings can be used as an opportunity to provide needed HCV care. This includes assessment of the stage of liver disease; provision of hepatitis A and B vaccines; and counseling about liver health, HCV transmission, and the risk of reinfection. While counseling and vaccination are important, an emphasis should also be placed on making curative treatment available to all who are diagnosed. Data are limited on rates of HCV treatment in correctional settings, but as of 2015 less than 1% of HCV-positive inmates were being treated in state prisons. Treatment is further complicated in jails where the median length of stay is 15 days or less in the majority of U.S. jails making treatment completion prior to release impossible.

When treatment is not possible during detainment or incarceration, linkage to care for HCV treatment in the community is critical. Yet, the period following release can be a very challenging time for individuals reentering the community. There are many barriers during this period related to social and physical determinants of health such as social support and housing, as well as relapse to active substance use. Indeed, the time following release is likely highest risk for relapse to active substance use and HCV transmission. Comprehensive strategies to address these social and physical determinants are needed to improve linkage to HCV care following release from correctional settings.

A Call to Action

Due to the high volume of people living with HCV in the criminal justice system, HCV-associated economic and healthcare delivery challenges are magnified in this setting. Despite the challenges, correctional settings present a number of opportunities to advance individuals living with HCV along the care cascade, during this time of relative stability from competing priorities and active substance use. Direct-acting antiviral (DAA) HCV therapy has already been shown to be cost effective in correctional settings. With the price of DAAs falling, there are increasing opportunities to deliver HCV care and curative treatment to this key population that bears a disproportionate burden of HCV infection.

Scaling up HCV care and curative treatment in the criminal justice system presents an opportunity to have a major impact on HCV health outcomes among a key population with a high prevalence of infection. Failure to effectively intervene may lead to progression of liver disease on an individual level and facilitate ongoing HCV transmission in the neighborhoods to which detainees return. Improving the HCV care cascade among justice-involved individuals will be crucial to achieving national goals for reducing new HCV infections, improving health outcomes for people living with HCV, preventing deaths, and reducing HCV-related health disparities.

Matthew Akiyama is an Assistant Professor of Medicine at Montefiore Medical Center, Albert Einstein College of Medicine and clinician-investigator who conducts research on HCV among socioeconomically marginalized populations with particular emphasis on the intersection of HCV in the criminal justice system. He is also a member of the NY Governor’s Hepatitis C Elimination task force.