Background:
Optimizing prison-based test-and-treat models is crucial for hepatitis C (HCV) micro-elimination. We analyzed a streamlined model implemented in two major prisons in Kedah, Malaysia (June 2022 and December 2023) to identify key determinants acting as facilitators and barriers at two critical stages: treatment initiation and treatment completion.
Methods:
Data from the model’s implementation was analyzed. The first model assessed determinants for treatment uptake among all 655 participants with confirmed hepatitis C infection. The second model assessed determinants for treatment completion among the 319 participants who initiated direct-acting antiviral (DAA) therapy. Predictors for each outcome were identified using univariable and multivariable logistic regression.
Results:
Of 655 participants diagnosed with HCV, 319 (48.7%) initiated treatment. Of these, 165 (51.7%) completed the full course. In the multivariable analysis for treatment uptake, participants with a remaining sentence of <1 year had significantly lower odds of initiating treatment compared to those with long-term sentences (Adjusted Odds Ratio [aOR]: 0.15, p<0.001). This was often due to in-prison medical officers’ reluctance to start DAA for participants with short remaining sentences. Participants without cirrhosis had higher odds of starting treatment (aOR: 3.71, p<0.001), as cirrhotic cases were deemed to require more advanced management. For treatment completion, sentence duration was no longer a significant factor. Instead, age was the sole independent predictor, with participants ≥40 years having higher odds of completing treatment (aOR: 1.80, p=0.016).
Conclusion:
The determinants for success differ profoundly across the HCV care cascade. Treatment initiation is dictated by systemic barriers, namely short sentence duration, and clinical complexity. Successful completion is driven by individual factors, specifically age, which may reflect greater maturity or health motivation in older participants. Optimizing the cascade requires a dual approach: addressing systemic barriers to improve access for short-sentence participants and providing targeted adherence support for younger patients. |