The Importance of Prisons in Achieving Hepatitis C Elimination: Insights from the Australian Experience

Abstract

Following the availability of highly effective direct-acting antivirals (DAAs) to treat hepatitis C infection, the uptake of treatment by people living with hepatitis C rose dramatically in high- and middle-income countries but has since declined. To achieve the World Health Organization’s (WHO) 2030 target to eliminate hepatitis C as a public health threat among people who inject drugs, an increase in testing and treatment is required, together with improved coverage of harm reduction interventions. The population that remains to be treated in high- and middle-income countries with high hepatitis C prevalence are among the most socially disadvantaged, including people who inject drugs and are involved in the criminal justice system, a group with disproportionate hepatitis C prevalence, compared with people in the wider community. Imprisonment provides an unrivalled opportunity for screening and treating large numbers of people for hepatitis C, who may not access mainstream health services in the community. Despite some implementation challenges, evidence of the efficacy, acceptability, and cost-effectiveness of in-prison hepatitis treatment programs is increasing worldwide, and evaluations of these programs have demonstrated the capacity for treating people in high numbers. In this Perspective we argue that the scale-up of hepatitis C prevention, testing, and treatment programs in prisons, along with the investigation of new and adapted approaches, is critical to achieving WHO elimination goals in many regions; the Australian experience is highlighted as a case example. We conclude by discussing opportunities to improve access to prevention, testing, and treatment for people in prison and other justice-involved populations, including harnessing the changed practices brought about by the COVID-19 pandemic.

Ways to Eliminate Viral Hepatitis as a Global Health Threat

“…Despite this, there are plans for coordinated action in individual countries, as exemplified by a Hungarian study in which 28% of inmates in 2018–2019 were tested for HCV and 82% of them received DAA treatment [ 10 ]. Undoubtedly, Australia has the greatest experience in the implementation of the HCV infection control program in prisons, where in 2020 as much as 37% of all DAA treatments were conducted in prisoners [ 11 ]. As a result of the implementation of the multi-annual program, the percentage of people infected with HCV in prisons decreased by nearly a half.…”

“…As a result of the implementation of the multi-annual program, the percentage of people infected with HCV in prisons decreased by nearly a half. The article by Winter et al [ 11 ] published in our Special Issue is a kind of guide for other countries, especially those where there is strong resistance among the prison authorities against introducing HCV infection elimination programs. Additionally, the authors point to future actions involving the intensification of prevention, a further increase in the number of tests, and finally, the continuation of care for inmates after completing their sentence.…”

Reducing barriers to the hepatitis C care cascade in prison via point‐of‐care RNA testing: a qualitative exploration of men in prison using an integrated framework

“…Because of the criminalization of injecting drug use, and subsequent widespread incarceration of people who inject drugs, the HCV burden is disproportionately borne by people in prison (15% antibody prevalence globally) [ 4 ]. The World Health Organization has set targets to eliminate HCV as a global public health threat by 2030 [ 5 ], with prisons identified as a key setting [ 6 , 7 , 8 ].…”

Advancing Hepatitis C Elimination through Opt-Out Universal Screening and Treatment in Carceral Settings, United States

“…Tattooing rates during incarceration have been reported to be 8.7%–19.3% in the United States ( 6 ). Taken together, nonsterile injection practices during incarceration create opportunities for HCV infection and reinfection ( 8 ). Furthermore, cycles of reincarceration compound the risk for continued HCV transmission between previously incarcerated and nonincarcerated persons ( 8 ).…”