18 May 2022
On 5 May 2022, INHSU Prisons hosted a virtual event ‘Inside the Research’, which welcomed authors from research papers highlighted in the Annual INHSU Prisons Bibliography 2021.
These papers were considered to be of ‘outstanding’ or ‘exceptional’ interest by the INHSU Prisons Executive Committee.
INHSU Prisons is a special interest group focussed on improving the health and wellbeing of people in custodial settings. You can find out more about the group – and how to join – here.
Chaired by INHSU Prisons vice-chair Dr Nadine Kronfli, the authors of each paper provided an overview of their research alongside key takeaways before participating in a facilitated panel discussion.
Below is a summary of each paper, and a video of the event.
Matthew J Akiyama, presented ‘Hepatitis C elimination among people incarcerated in prisons: challenges and recommendations for action withing a health systems framework’.
Matthew J Akiyama is an Associate Professor of Medicine and Infectious Diseases at Albert Einstein College of Medicine in New York, USA. He is also a vice-chair of INHSU Prisons.
The paper presented was published in The Lancet Gastroenterology & Hepatology and included co-authors from the INHSU Prisons Executive Committee and the wider INHSU membership.
- There is a disproportionate burden of HCV in the criminal legal system – that is 10 -20 times greater that of the surrounding communities. Yet despite this, there is currently a lack of integration of the prisons system into country-specific HCV elimination plans
- The World Health Organization’s 2010 Health Systems Framework outlines building blocks to providing better healthcare, particularly within low- and middle-income countries. Prisons are among the lowest resource settings globally, and there is a need for a similar framework
- There are various prisons-specific challenges to healthcare delivery including who delivers the care – Ministries of Health, Ministries of Justice, or other entities
- The paper outlines seven domains within a Health Systems Framework to eliminating HCV in prisons and provides country-specific examples of best practices:
- Changing political will – Political leadership and stakeholder engagement in coordinating prison-based services and community-based halfway houses in Singapore
- Ensuring access to HCV diagnosis and testing – Improving access and time to care through point-of-care HCV RNA testing in the UK and a Spanish test and treat strategy including reflex testing and telehealth
- Promoting optimal models of HCV care and treatment – New Mexico’s peer education project
- Improving surveillance & monitoring of the HCV Care Cascade – Hepcorrections.org, a website showing gaps in testing and treatment in the U.S.
- Reducing stigma & tackling social determinants of health inequalities – HIV transitional care coordination in the New York City jails used as infrastructure for HCV-specific care coordination
- Implementing HCV prevention & harm reduction programs – Moldova as a pioneer in implementing needle and syringe programs in prisons
- Advancing prison-based research – Events such as these being critical to understanding best practices and developing research partnerships in prisons
Dr. Joaquin Cabezas, presented ‘Hepatitis C Micro-Elimination beyond prison walls: navigator-assisted test-and-treat strategy for subjects serving non-custodial sentences.’
Dr. Joaquin Cabezas works in the gastroenterology & hepatology department at the Marques de Valdecilla University Hospital. The paper presented was published in the Diagnostics Journal and focussed on a unique model of care within the Spanish justice system.
This model was also highlighted in the paper by Matthew Akiyama outlined above, as a best practice example.
- Dr. Cabezas spoke about the justice system in Spain, one of the few countries who use local health specialist care system to support health in prisons
- The project focused specifically on people serving their sentences outside of the correctional setting but still needing to regularly check into specific facilities as part of their sentence
- The model of care resulted in 92% of patients being screened, which demonstrated an 8% HCV prevalence. Of this 8%, 81.2% were treated and cured
- The model included:
- Invitation to get tested for HCV included in the check-in to serve their sentence
- Medical staff/navigator provided a HCV test as part of a health assessment – this was incentivized including lunch tickets, transport tickets, medical appointments arrangements treatment supervision and harm reduction program engagement
- Reflex test used – with point-of-care tools including the OraQuick® HCV test for hepatitis C antibodies and HCV RNA testing on the GeneXpert System.
- Telemedicine was used to prescribe and as follow-up to ensure treatment delivery
- In Spain, it is allowed by law for non-custodial sentences to be reduced in certain cases if people follow the health programs
“Micro elimination programs like this using rapid diagnostics tests, telemedicine, and the ‘navigator’ figure are necessary for these vulnerable and hard to reach populations,” concluded Cabezas.
Behzad Hajarizadeh, presented ‘Evaluation of hepatitis C treatment-as-prevention withing Australian prisons: The SToP-C study’.
Behzad Hajarizadeh, MD, PhD, from the Kirby Institute, University of New South Wales, presented a study first published in The Lancet Gastroenterology & Hepatology. The SToP-C study was led by Professors Andrew Lloyd and Greg Dore from the Kirby Institute. Professor Lloyd is the Chair of INHSU Prisons.
- Treatment as prevention was initially used in the context of HIV therapy, but mathematical modelling demonstrated the potential for HCV treatment as prevention
- The Surveillance and Treatment of Prisoners with Hepatitis C (SToP-C) evaluated the impact of Direct Acting Antiviral (DAA) treatment scale up in four Australian prisons, to help provide empirical data of the feasibility and effectiveness of HCV treatment as prevention
- It was hypothesized that rapid DAA-based treatment scale-up in prison would reduce HCV transmission
- Four prisons were included in the study. All prison inmates over the age of 18 were included irrespective of HCV infection status or risk behaviours
- HCV testing at enrolment led to three core groups; HCV infected, previously infected, and uninfected
- Those infected were referred directly for treatment with the other two groups tested every 3-6 months for detection of incident HCV infections
- 3691 participants were enrolled, with 19% testing positive for HCV RNA. Of 719 participants with HCV RNA positive, just over 300 individuals received no follow-up, mainly due to being released from prison or transfer to other prisons. Of the 340 individuals who had a follow up, there was a 70% treatment uptake
- HCV incidence decreased from 8.3 per 100 person-years before DAA treatment scale-up to 4.4 per 100 person-years after treatment scale-up
“SToP-C was the first HCV treatment-as-prevention study in the prison setting and the largest in any setting,” explained Hajarizadeh. “It provides empirical evidence of the HCV treatment-as-prevention with the HCV incidence almost halved during rapid DAA scale-up. The impact was even larger on participants who reported injecting drugs.”
Prof. Heino Stöver presented ‘The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases’.
Prof. Heino Stöver, Professor, Frankfurt University of Applied Sciences, Frankfurt, Germany presented findings from a paper published in the Harm Reduction Journal. The paper sought to provide an overview on availability, coverage and the policy framework of prison-based harm reduction interventions in Europe.
- There are one million prisoners in Europe with 15-25% sentenced for drug offences
- One in six prisoners are people who use drugs, up to 21% of injectors initiated injecting in prison with 90% relapsing to heroin after release
- UNODC provided a list of 15 Key Interventions to address the challenges of drug use in prison, called the Comprehensive Package. These can be seen here with the three main interventions that impact HCV and HIV being condom use, Opioid Substitution Therapy, and Needle and Syringe Programs
- Stöver’s findings included:
- In 16 countries more than 75% of prisons per country provide OST for prisoners. In 3 countries 25-50% of prisons provide OST, while in 7 countries less than 25% of prisons provided such service. There is no data available for 2 countries. England was the highest performing in this intervention
- NSP is available in only 3 countries; Germany, Spain and Luxemburg with the UK and France planning to introduce NSP into the custodial setting. However, not all prisons in these countries offer it, which leaves a lot of work to do. For example, in Germany, only 1 out of 180 prisons offer NSP services. Spain is the highest performing of the 30 countries analysed, with over half of prisons offering the service
- Other interventions highlighted in the study include Naloxone distribution upon release and education on risks to help minimise exposure to infectious diseases and many others
“Drug user and dependent prisoners are doubly discriminated and are not benefitting from the progresses in drug treatments and harm reduction that have been achieved in the community,” explained Stöver. “There should also be a shift in responsibility of healthcare from justice to the ministry in charge of healthcare – this would lead to more and efficient healthcare closely connected to community services.”
Dr Win Min Han, presented ‘HCV Universal Test-and-Treat with Direct Acting Antivirals for Prisoners: A prison health care workers-led model’
Dr Win Min Han is a Clinical Research Physician, HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand. The paper presented was published in The Journal of Acquired Immune Deficiency Syndrome.
- The Thai prison system is one of the most overcrowded in the world, with the long duration of sentences (the median prison sentence was 25 years) putting people at high risk of infection and transmission
- There is limited data available for HCV and BBVs in Thailand, as well as limited data on DAA treatment outcomes. Most data comes from high-income countries
- This study aimed to show how a ‘test-and-treat’ approach with DAAs combined with post-release linkage to community services would facilitate micro-elimination in Thailand: Two central male prisons were included; with screening for HIV, HBC, HCV and syphilis
- Of 2,000 prisoners invited for screening, 1,028 people accepted the invitation, with the screening completed by prison healthcare workers
- Prisoners who tested positive for HCV RNA were referred for DAA treatment, with counselling on infection risks also provided
- Prison healthcare workers had no specialisation in hepatology or infectious diseases and received training as part of the study
- Of 1,028 people tested, 61 (6%) tested positive for HCV antibodies and 43 (71%) had detectable HCV RNA. 68 people received DAA treatment (25 referred from other prison sectors)
- The current test and treat program is ongoing in Klong Prem Central Prison
“Healthcare workers are not confident in treating HCV as DAA is new in Thailand,” explained Dr Win Min Han. “Some training sessions was given to physicians and to nurses to let them know DAA is simple and effective. This study has shown that universal screening with linkage to prison care for DAA treatment is highly feasible for other prisons.”
If you would like to find out more about INHSU Prisons and how to join, visit the INHSU Prisons web page.