Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date. A diverse group of correctional health care professionals from prisons and jails, federal representatives, academics, hepatitis C experts, lawyers, and public health advocates gathered recently for a key meeting on managing hepatitis C in prisons ("Management of Hepatitis C in Prisons 2003," January 25-26, 2003, San Antonio, Texas). The official goals of the conference were to describe the prevalence of hepatitis C virus (HCV) in prisons and understand how two recently released federal documents on the diagnosis and treatment of HCV pertain to prison populations.(1, 2)
However, as Anne Spaulding, MD, of the Centers for Disease Control (CDC) Division of Viral Hepatitis made clear in her opening statement, the goal of many of the professionals present at the meeting was to establish a new consensus on the treatment of HCV in correctional settings. She described plans to publish the proceedings in a monograph that would help establish national guidelines for the management of HCV in correctional settings.
While it was difficult to reach a consensus, different approaches were shared (and debated) with the goal of better understanding the epidemic facing the nation's prisons and creating effective approaches to managing it. The conference focused on the management of HCV in prisons; adequately discussing management of HCV in jails was thought too large a scope for the meeting.
The first session was devoted to reviews of scientific data on the pathogenesis, and treatment of HCV. Stanley Lemon, MD, of the University of Texas Medical Branch (UTMB) summarized virological aspects and contrasted the prognosis and management of HIV and HCV (Figure 1).
Ted Hammett, PhD, (Abt Associates) presented data from studies supported by the National Commission on Correctional Health Care (NCCHC), the CDC, the National Institute of Justice (NIJ), and the Bureau of Justice Statistics (BJS) on the prevalence of HCV in corrections. He presented revised estimates based on these studies suggesting that 17% to 25% of inmates in the nation's correctional facilities have chronic HCV infection. Based on these data, Dr. Hammett estimated that 1.3 to 1.9 million individuals passing through correctional facilities every year have HCV infection, representing 29% to 42% of the total number of HCV-infected persons in the United States (estimated at 4.5 million). This means that the correctional population provides a remarkable opportunity to diagnose, educate patients, and treat HCV in the United States. He also discussed the "ripple effect" of this blood-borne infection on public health following the return of HCV-infected inmates to their home community.
Two approaches to testing were discussed: universal and targeted. As discussed by Dean Reiger, MD, of the Indiana Department of Corrections, HCV testing became universal in Indiana prisons in July 2002 despite objections relating to fiscal concerns (there was no additional funding allotted with the legislation). Indiana now performs three separate tests for each offender: HIV, HCV, and syphilis. Initial results show that 13% of inmates in Indiana prisons are HCV-positive.
David Burnett, MD, of the Wisconsin Department of Corrections discussed targeted HCV testing now practiced in Wisconsin. The conclusion of a study commissioned by the Division of Public Health found that targeted testing based on self-identified risk factors as well as routinely available laboratory findings would require testing less than 30% of inmates, but would capture almost 90% of those with HCV infection. Risk factors for targeted screening include a history of IDU, liver disease, elevated ALT, HBV-positive, a history of blood or blood product transfusion, hemodialysis, or organ/tissue transplantation.
Dr. Jay Hoofnagle of the National Institute of Diabetes and Digestive and Kidney Diseases reminded the participants that HCV - unlike HIV - can be cured (with combination therapy). Based on available evidence, the best response to therapy occurs when patients are treated early, are relatively young, have low levels of HCV RNA, show less fibrosis on biopsy, and stop drinking before therapy. Hoofnagle advised that the level of the HCV viral RNA alone does not predict the response to therapy. Response to combination therapy using pegylated interferon and ribivarin is generally 42% - 46% for patients who have genotype 1 and 76% - 82% in patients who have genotypes 2 and 3.
There was still some debate about what constitutes the "best" possible care (given the toxicity of treatment and the less-than-optimal response rates in patients with genotype 1). However, for those individuals who meet treatment criteria, Hoofnagle stated that the standard of care is combination therapy with pegylated interferon and ribivarin. Others pointed out that the number of inmates that can be treated with combination therapy while incarcerated is a small percentage of the number testing positive for HCV - and that the real "standard of care" is to make sure that all inmates are properly screened, tested and counseled. Still others objected to establishing a standard of care for HCV treatment in correctional settings without sufficient support in terms of resources and funding from the public health sector.
The question of how to pay for hepatitis C testing, treatment, and education (without sacrificing other essential health services) was discussed at nearly every session. Of the few firm areas of consensus reached, nearly everyone agreed that there isn't currently enough money to screen, treat and educate inmates on HCV - and there is no expectation that this will change anytime soon. Some believe that lawsuits will force the issue - and others suggest that litigation might be the only catalyst large enough to make a change in legislative and public opinion.
In the opinion of many attendees to the breakout session on resources, the public health system, which has not yet begun to adequately fill the need for HCV aftercare, needs to work with correctional health care professionals and legislatures to develop effective ways to deal with HCV and other infectious diseases. Community and community-based organizations (CBOs) need to play a role and find ways to educate and treat in collaboration with corrections. With some exceptions, CBOs have been silent on this issue, according to health care professionals at the conference.
A large barrier to effectively treating HCV after release from prison is the lack of an equivalent to the Ryan White CARE Act. The very real epidemic in the U.S. - not just in correctional facilities - needs attention from legislators (and the public) who can work to implement funding and other components of support for managing HCV. Some at the meeting suggest that correctional officials need to work with their legislators and other elected officials to explain the needs and issues facing corrections in order to allocate the necessary funds to correctional health care budgets and ensure effective aftercare in the community.
* Nothing to disclose
1. NIH Consensus Statement: http://consensus.nih.gov/cons/116/091202116cdc_statement.htm.
2. CDC. Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings MMWR Jan 24, 2003 / 52(RR01);1-33 .
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©1997,1998,1999,2000,2001,2002, 2003. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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