28 November 2023
According to UNODC data, one in four people in prison are living with hepatitis C. This year, at the International Conference on Health and Hepatitis in Substance Users, several sessions addressed healthcare in prisons, providing an opportunity to share the latest research and innovations in prison models of care.
Below are the key findings from prisons-related sessions at INHSU 2023, held in Geneva in October. If you’re interested in the health and well-being of people who use drugs in carceral settings, you can join our special interest group, INHSU Prisons, here.
Session K, Health service delivery in prison
Global best practice examples of prison-based models of care
Joaquin Cabezas, University Hospital Marques De Valdecilla, Spain
Cabezas discussed how prisons offer a unique opportunity to engage marginalised individuals into healthcare and the lasting impacts this could have on hepatitis C epidemiology in the prison setting but also in the wider community.
This opportunity starts with political will, with Cabezas urging for the penitentiary setting to be included in national plans for hepatitis C elimination. In Spain, the national plan includes people in prisons as a priority population.
Analysing best practice for hepatitis C models globally, it is clear that models should include effective and systematic screening programs, unrestricted access to direct-acting antivirals (DAAs), education programs, universal screening of infection, simplified strategies to hepatitis C diagnosis – including rapid test with liver evaluation in a single visit, universal and immediate linkage to care, a multidisciplinary care team, telemedicine, and harm reduction programs.
Enhancing Blood-Borne Virus and Harm Reduction Measures in Prisons
Rick Altice, Yale University School of Medicine
Altice highlighted the disparity in HIV and hepatitis C prevalence in prisons in Eastern Europe and Central Asia. HIV prevalence currently stands at 4.4 per cent—six times higher than in the general community, with hepatitis C even higher, at 17.7 per cent.
These figures are, in part, a consequence of laws and policing practices that disproportionately affect individuals with poor health status or heightened risk for HIV, TB, or viral hepatitis, and there is a clear need to address this pressing public health challenge.
Altice shared a toolkit of prevention and treatment measures, including antiretroviral therapy (ART), pre-exposure prophylaxis (PReP), DAAs, drug consumption rooms, syringe services programs, and Opioid Agonist implementation post-release. Issues of adoption and scalability was a theme throughout this year’s conference, and it appears it is no different within the prison environment.
One of the key areas Altice addressed was the implementation of OAT and challenges that impede progress, such as attitudes of patients, informal prison hierarchies among persons deprived of liberty, lack of addiction and HIV expertise among medical staff, and the concerns of custodial staff related to safety and negative attitudes.
Speaking of intervention implementation, Altice stressed the importance of simplicity, speed, and cost-effectiveness. Fundamental principles for successful implementation and scalability were presented, including understanding and involving the customer, selecting a powerful change leader, and employing rapid cycle testing.
Community-led models for improving care in prisons: successes and challenges
Julia Sheehan, National Women’s Criminal Justice Manager, Hepatitis C Trust
Sheehan presented on community-led approaches to enhance prison care in the United Kingdom. Established in 2000, the Hepatitis C Trust, staffed predominantly by people with personal experience of hepatitis C or drug use, and the legal system, introduced a community peer model in 2010, expanding it to prisons nationally in 2018.
They have since screened 97,000 individuals and helped over 15,000 start treatment in the past four years. The success of the program stems from key partnerships, including prison staff, healthcare providers, and mental health services, alongside thorough staff training, national funding, support from the Department of Health, and strong peer involvement at every stage.
Like most programs, there have, of course, been challenges and barriers along the way, including competing priorities, prison schedules, vetting procedures, and testing options. Staffing shortages and garnering buy-in were also mentioned as hurdles.
For others looking to take inspiration from the model, Sheehan emphasised the need for sustained funding, support from the Department of Health, and backing from the legal system and prison governors. It is also vital that there is continuity of care from prison to community.
Session M, INHSU Prisons Abstract Session
Viral hepatitis micro-elimination: models of care and barriers to implementation in 5 EU/EEA prisons
Prison settings often have suboptimal coverage of essential prevention and control services for viral hepatitis and lack adequate monitoring schemes. However, targeted interventions have proven effective in reducing the burden of viral hepatitis among incarcerated individuals and in the broader community.
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) identified several effective models of care for viral hepatitis elimination in prisons. These models included micro-elimination programs, transitional care for treatment, tailored services for specific groups like women, and vaccination programs for HBV or HAV/HBV in prison settings.
Despite the innovative models collected, barrier remained across all, including:
- Engagement of people living in prison
- Prison governance structure
- Availability of infrastructural and human resources
- Daily prison organisation
- Inter-sectorial collaboration within prison and between prison and community services
- Training for prison staff
- Lack of systematic monitoring
To foster inclusion of prison settings within national elimination programs, EMCDDA suggests evidence-based interventions, intra-EU benchmarking for resource allocation and impact monitoring, and promoting awareness as essential steps.
Bridging the prison to community gap in hepatitis C treatment
Sean Cox, director of Prison Services at the Hepatitis C Trust
People diagnosed with hepatitis C in prison who are then released or transferred are often not started on treatment. Problems with medication transfer, referrals to community healthcare, and homelessness on release are common.
This often means patients disengage or cannot complete treatment. In 2019, The Hepatitis C Trust established the ‘Follow Me through the Gate’ model to ensure people in prison are not lost to follow-up.
Their model involves establishing information-sharing protocols among healthcare entities, utilising peer support before release, and gathering critical information about the individual’s potential whereabouts post-release. This proactive outreach approach is geared towards finding and supporting patients even in situations of sudden or unexpected release.
In 2022-3, the program received 553 referrals and to date, 317 have started treatment. Despite this success, locating and re-engaging with individuals post-release, particularly when releases happen suddenly, remains a time-consuming challenge despite prisoners’ eagerness to engage.
Overall, the success of this program relies heavily on building and maintaining strong, trusting relationships between peers, people in prison, NGOs, prison staff, and healthcare services. The critical support provided around hepatitis C during the vulnerable period of prison release can have far-reaching effects, potentially reducing overdose risks and blood-borne virus infections within the community.
Understanding availability and barriers to scaling up prison-based hepatitis C services and perceived advocacy needs globally to inform a prison-based advocacy toolkit: The INHSU Prisons Advocacy Toolkit Project
Nadine Kronfli, McGill University, Canada
The INHSU Prisons Advocacy Toolkit Project aims to enhance hepatitis C care in carceral settings. This mapping study discovered disparities in hepatitis C testing and treatment availability across socioeconomic strata, notably in services like testing, RNA testing, fibrosis assessment, and access to DAAs, especially between high-income and lower-income nations.
The primary barrier identified across all countries was inadequate healthcare resources within prisons, notably the high cost of DAAs and insufficient support from policymakers and funders. Tailored advocacy tools, such as case studies, infographics, and social media templates, were deemed crucial in addressing these barriers and advancing hepatitis C care in prisons, particularly in low and lower-middle-income countries. This study will inform the creation of the new toolkit.
To be informed of its release, sign up for the INHSU Prisons newsletter here.
INHSU Prisons pre-conference workshop
Country overviews of hepatitis C testing, treatment, and prevention services in prisons
A full report of this session and other workshop sessions will be released soon. Sign up for the INHSU Prisons newsletter here to be alerted if its release.
At the INHSU Prisons Workshop, an annual pre-conference event hosted by INHSU Prisons, speakers from across Europe presented their existing models of hepatitis C care in prisons and discussed the challenges hindering treatment access:
Portugal
- The prison environment is seen as a promising avenue for hepatitis C elimination. Several NGOs operate in this field, conducting testing and referring individuals for treatment. Additionally, numerous hospital initiatives and a hemodialysis elimination program exists
- However, there is a notable absence of a National Practical and Centralised Strategy toward elimination
- Innovative models include Madeira Island, where a program embedded within emergency rooms resulted in 38,000 screening tests over three years. This effort led to 57 new diagnoses of chronic hepatitis C infection, 356 previously treated cases, and 158 known untreated infections
Italy
- High BBV prevalence persists in Italian prisons, primarily due to screening, linkage, and retention challenges, especially during transitions between prison and the community
- To enhance hepatitis C micro-elimination, a patient-centered focus—beyond just DAAs—considering mental health and addiction issues is crucial
- Establishing strong connections between prisons, addiction centres, and hospitals is essential for a patient-centered approach to eliminate hepatitis C among incarcerated individuals and people who use drugs
- Advocacy with policymakers is also vital
Romania
- In Romania, people in prison have the access to hepatitis C testing, treatment and prevention services
- However, a lack of infectious disease doctors means testing and treatment is not always possible. This is compounded by a lack of willingness from prisoners to get treated
- There is a call for advocacy within the country to attract doctors to the prison environment but also to educate people in prison for the need to get tested and treated
- Peer support, telemedicine, and training of prisons staff are all initiatives with hope to improve access
The need for ongoing, effective advocacy emerged as a critical requirement across the European models showcased at the INHSU Prisons Workshop. From Portugal’s decentralised but promising initiatives to Romania’s lack of doctors hindering treatment initiatives, the emphasis on a patient-centred approach and the need for interconnectedness between prisons, addiction centres, and hospitals underscored advocacy’s vital role in driving policy changes, resource allocation, and engagement.
More prisons related abstracts
- Prevalence of blood-borne viruses, hepatitis C testing and treatment, and implementation barriers and facilitators in a prison-based surveillance system in Australia: The AusHep study
- Enhancing treatment uptake for hepatitis C virus infection through high-intensity point-of-care HEPATITIS C testing in prisons in Queensland, Australia
- The impact of incarceration on injecting-related injuries and diseases: a longitudinal cohort study
- Drug use behavioral trajectories and hepatitis C incidence among people who are incarcerated
- Best interest of the child: a global assessment of conditions of detention and age restrictions
Conclusion
Hepatitis C rates in prisons continue to be higher than in the general population, but as countries like the UK and Portugal demonstrate, this setting is also ideal for micro-elimination. There is a wide range of successful models of care to draw inspiration from, but funding and strong advocacy is lacking in many regions. Hepatitis C testing and treatment in prisons must also be combined with post-release follow-up and support to fight against re-infection.
