Hepatitis C: A
Correctional-Public Health Opportunity
Anne S. De Groot, MD, Elizabeth Stubblefield, Joe Bick, MD
Authors and Disclosures
For a variety
of reasons, many diseases are present at a higher prevalence in
prisons and jails. Mental illness, HIV, hepatitis B and C, and
drug and alcohol addiction are just a few of the conditions that
are common in prisoners entering the correctional system. What
is often seen as an overwhelming burden to correctional
healthcare systems should more appropriately be seen as a
tremendous public health opportunity. The stark truth is that
most inmates will eventually be released from prisons and jails.
Once released, many of them either do not have access to
healthcare or fail to avail themselves of it. In focusing
healthcare resources on the incarcerated, society has the
opportunity to decrease crime rates (mental illness, addiction),
prevent transmission (HIV, hepatitis, other sexually transmitted
diseases [STDs]), and lower lifetime costs associated with
untreated diseases. This article will focus on the challenges
and opportunities associated with the treatment of hepatitis C
virus (HCV) in the incarcerated.
Epidemiology of HCV in
infection outstrips HIV in correctional settings in terms of
sheer numbers of inmates living with this infection (Table 1).
According to a recent analysis performed by Dr. Ted Hammett (Abt
Associates, Cambridge Massachusetts) and reported to Congress,
between 1.0 and 1.25 million individuals harboring chronic HCV
infection were released from prisons and jails in the United
States in 1996, or approximately 30% (29% to 32%) of the
estimated 4.5 million individuals living with chronic HCV
infection in the United States. The prevalence of HCV infection
among US prisoners is at least 10-fold higher than the estimated
prevalence of 2% in the general population.
Outside of correctional settings, 79% of current injection drug
users (IDUs) have HCV infection.
In fact, young IDUs acquire HCV infection at rates 4 times
higher than the rate of acquisition of HIV; after 5 years of
continuous injection drug use, 90% of IDUs are HCV infected.
prevalence studies in correctional settings are rare; however,
some statistics have been compiled from a number of sources by
HIV and Hepatitis in Prison Project In the Colorado
state prisons, for example, the prevalence of HCV among inmates
has been reported to be 30%.
A recent survey of Arizona reported a 31.3% prevalence rate
among inmates (Gerard Chamberlin, personal communication). In
Maryland, the prevalence of HCV among state inmates has been
noted to be slightly higher, at 38%.
One county jail in semi-rural Massachusetts recently
reported that 20.7% of its jail inmates had HCV infection
In Virginia, 30% to 40% of inmates have been reported to
have HCV infection.
Approximately the same rate has been reported in Washington
state (30% to 40%).
The prevalence of HCV among state inmates in Pennsylvania is
slightly lower, at 13%.
their higher rate of participation in HIV and HCV risk
behaviors, incarcerated women exhibit about a third higher HCV
co-infection rate than incarcerated men.
For example, in a sample of incoming inmates in California,
54% of women inmates, compared with only 40% of men inmates,
have HCV infection.
In Connecticut, 1 in 3 women (32%) incarcerated at the
only state facility for women inmates has HCV infection.
In Texas, 37% of incarcerated women and 28% of
incarcerated men have HCV infection.
Wisconsin reported HCV infection rates among women
inmates that are almost 2-fold higher than the rates among men:
21% for women, 12.4% for men, 13.2% overall.
non-Hispanic blacks have higher rates of HCV and HBV infection
and chronic disease than whites; most cases of HCV and HBV
infections are found among persons who are male, members of
minority populations, and 30 to 49 years of age.
These race- and class-related risk factors for hepatitis
infection probably contribute to the current concentration of
HCV- and HBV-infected persons in prisons and jails.
Screening for and Treating HCV in
The CDC lists
correctional institutions, HIV counseling and testing sites, and
drug and STD treatment programs as sites where hepatitis
screening and interventions should take place. (See Table 2 for
screening recommendations.) Correctional facilities that screen
for HCV and educate their inmates about HCV are performing a
significant public service, since approximately 50% of persons
with hepatitis are unaware of their hepatitis infection.
Testing for hepatitis infection informs the patient and
physician about the potential for and possible existence of
liver damage, and it should serve as an important prompt for a
discussion about risky behaviors and transmission to others.
Treatment of HCV
standard of care in community settings is to treat chronic HCV
patients who meet treatment selection criteria with a
combination of ribavirin/interferon alpha (Table 3). Most
correctional facilities have either developed protocols for
screening and treating HCV-infected inmates, or are in the
process of developing these protocols. However, the criteria for
HCV treatment may vary slightly from one correctional system to
another. The CDC is in the process of developing a set of
guidelines for HCV screening and treatment that may assist
correctional facilities with their decision-making process. (A
draft of the hepatitis recommendations that are proposed for
publication in MMWR
[Morbidity and Mortality
Weekly Report] in the fall of this year can be
obtained by contacting
Rob Lyerla or
Cindy Wientraub or by calling 404-371-5460.)
eligible patients meet the following criteria: (1) have evidence
of persistent HCV infection and inflammation based on liver
function test (LFT) abnormalities and detectable virus in the
blood stream; (2) have enough time left in their sentence to
allow for completion of treatment (6-12 months) (3) are
committed to a life free from substance and alcohol abuse; (4)
are educated about potential HCV treatment side effects and
willing to adhere to an arduous course of treatment.
therapy is to provide daily treatment with ribavirin (usually
5-6 pills divided into 2 doses) and thrice-weekly
alpha-interferon injections. (See Table 3 for dosing and side
effects of treatment regimens.) Pegylated interferon, a new form
of interferon that permits once-weekly dosing, was approved by
the FDA this year. Monotherapy is currently used only if the
patient cannot take ribavirin due to toxicities or side effects.
therapy consistently yields higher rates of sustained response
compared with monotherapy. (A sustained response implies that
HCV RNA remains undetectable for 6 months or longer after
therapy stops.) With combination therapy, 40% of treatment-naive
patients respond. Patients with genotype-1 have sustained
response rates of 25% to 30% (slightly better response rates are
seen with lower baseline HCV viral loads). Non-genotype-1
patients achieve response rates of 60% to 65%.[14,15]
Other factors that increase the likelihood of a response to
therapy include age younger than 45, female gender, and mild
(rather than advanced) chronic inflammation on liver biopsy.
Histologic improvement occurs in 86% of patients who achieve a
sustained response and 39% of patients who relapse after initial
response to combination therapy.
Cost vs Benefits
As with many
other chronic medical conditions, morbidity and mortality
attributable to HCV may not manifest themselves until well after
the end of incarceration. Treatment is often ineffective, poorly
tolerated, and prohibitively expensive. Many correctional
systems, still reeling from the impact of providing HIV
treatment, have been slow to embrace wide-scale treatment of
hepatitis C. Additionally, the therapy in most cases is being
given to IDUs who are in forced institutional abstinence, have
not had and will not have drug treatment, and will therefore
probably be promptly reinfected upon release.
concerns, some state medical directors have led the way and
adopted clear protocols for the screening and treatment of HCV
in their facilities. These individuals are mindful that a year
2001 dollar spent on treatment may reduce the eventual cost (to
society) of caring for patients who may require liver
transplants in 20-30 years.[4,16]
Furthermore, combination therapy of HCV is leading to higher
rates of cure (up to 88% in carefully selected patients);
therefore, the overall cost-effectiveness of HCV interventions
in corrections is improving.
analyses have been performed. For example, medical decision
analyst J. Wong calculated that 6 months of combination therapy
resulted in net savings in the range of $400 to $3500 over the
lifetime of each HCV-infected patient.
Dr. Wong's analysis ranked combination therapy for HCV in the
same range of cost-effectiveness as stool guaiac testing,
pneumococcal vaccination, coronary bypass surgery, and
The need for
confirming the extent of damage to the liver by HCV and chronic
HBV infection is another area of debate, since obtaining liver
biopsies can be both costly and logistically complicated in
correctional settings. LFTs can be normal in patients with
rather advanced cirrhotic features. Likewise, LFTs may be
consistently elevated in hepatitis C patients with normal
histology. Some state correctional systems do not routinely
perform liver biopsies prior to initiating treatment, because of
cost and logistical difficulties. Other states (eg, Florida)
believe biopsies are the only real way to measure disease
progression over time and therefore have made arrangements to do
them on site at very reduced costs ($200 per biopsy). Depending
on the cost of obtaining a liver biopsy, electing to treat all
incarcerated individuals who meet the criteria for treatment may
be more cost-effective for society as a whole than management by
The Lowest-Cost Intervention:
lowest-cost intervention for the prevention of hepatitis
infection is education. Given the risk of acquiring HCV (not to
mention HIV), all bloodborne pathogen screening events should
lead to careful discussion of the risks of acquiring HIV, HBV,
and HCV infection (for those patients who have negative
hepatitis serologies). The risk of transmitting hepatitis should
also be made very clear (see Resources for information on
The impact of
continued drug use should also be made very clear to patients,
especially those who are not yet HCV infected. For those inmates
who are already HCV infected, education should be provided on
the impact of alcohol abuse on HCV progression (4-fold increase
in risk of progression, risk of liver damage directly correlated
with alcohol intake) and the risk of transmission to uninfected
sexual partners. Inmates who have HCV infection should, at the
very least, be educated about options for treatment even if they
are not eligible for treatment while incarcerated (see Resources
for information on expanded access programs).
low-cost (but not no-cost) intervention is vaccination. For
HCV-infected patients, vaccination against HBV and HAV is
routinely recommended, as these relatively inexpensive vaccines
may reduce the risk of fulminant liver failure and the need for
liver transplantation for HCV-infected patients. A new schedule
of HBV vaccination (3 shots at 0, 1, and 4 months) has received
approval. The first shot provides up to 50% protection, and the
series does have efficacy even if it is given over several
years, so the new CDC guidelines are expected to encourage
initiating HBV vaccination even in jail settings.
Management of HCV in Correctional
incidence of side effects to HCV combination therapy can be
relatively high and it can be difficult for incarcerated
patients to quickly gain access to their clinician to report
side effects, it is important to:
time preparing the patient for potential treatment-related
PRN medications for symptom management
following the patients in a dedicated hepatitis clinic
establishing a support group for patients under HCV
peer education programs when possible
nurse or other staff person to regularly check in with
patients who are receiving HCV treatment so that side
effects can be rapidly addressed
good support system, a high percentage of patients will fail to
complete therapy. Because of the high cost of treatment, time
spent preparing patients and supporting them while on treatment
is likely to be cost-effective. Table 4 provides guidelines for
HIV and HCV Coinfection
the effect of HCV and HIV co-infection on progression of either
disease are often confounded by concurrent risk factors for
progression. However, available data seem to indicate that HIV
infection accelerates HCV liver disease. Persons who are
co-infected (HIV/HCV) appear to have a 12- to 300-fold higher
risk of developing hepatocellular carcinoma compared with
Furthermore, antiretroviral agents can contribute to liver
inflammation, and this may be more frequent in those who have
underlying chronic hepatitis due to HCV or HBV. Ritonavir and
nevirapine appear to be the antiretroviral therapy medications
that are most commonly associated with liver inflammation in HCV/HIV
The impact of
HCV infection on HIV infection is less clear. In some studies,
HCV infection does not appear to have an effect on the
progression of HIV.
Other studies have reported an association between more rapid
progression to AIDS or death in HIV-infected patients,
particularly among those who were co-infected with HCV genotypes
1a and 1b.[21,22]
However, a report by Sulkowski
at the 8th National Conference on Retroviruses and Opportunistic
Infections (CROI), contraindicated these findings, suggesting
that risk of progression was more closely linked to lack of
access to medical care (for HIV) in his cohort of African
American patients who had HIV and HCV co-infection.
HCV therapy in individuals who also have HIV infection appears
to be equivalent to that of non-HIV-infected individuals.
A recent study in JAMA
by Sulkowski and associates
indicates that 88% of co-infected patients tolerate concurrent
HCV treatment and highly active antiretroviral therapy (HAART).
Following successful HCV treatment, co-infected patients are not
more likely to relapse after HCV treatment than are patients who
do not have concurrent HIV infection.
when exclusionary criteria are not present (see Table 2),
treatment of hepatitis C is recommended for patients when CD4
and viral load values reflect good response to antiretroviral
treatment. Although some controversy remains with regard to the
definition of a good response to HAART, a stable CD4+ T-cell
count greater than 200 with a stable viral load less than 400 is
The cost of
HCV treatment is expected to be a major barrier to wide
implementation of the guidelines in prisons and jails. There is
a concern that treatment could overwhelm some systems'
healthcare budgets. The high prevalence of hepatitis infections
among incarcerated individuals and the availability of
treatments with less than 100% efficacy force difficult decision
making in correctional health facilities.
clustering of individuals with hepatitis and other treatable
illnesses in correctional facilities creates not only challenges
but opportunities as well. With an effective public
health-correctional collaboration, the opportunity exists to
make a tremendous impact on the health of society as a whole.
Without such initiatives, many prisoners will eventually return
untreated to the communities from which they came. Prisons and
jails are an ideal site for introducing public health
interventions that will have a positive impact on hard-to-reach
communities; this opportunity to improve public health should
not be overlooked.
It must be
noted, however, that the cost savings that may accrue from
treatment of prisoners are primarily to society as a whole.
While treatment of incarcerated individuals for hepatitis and
HIV is the right thing to do and can tremendously benefit the
public health, it is not realistic to expect correctional
systems to shoulder this financial burden without assistance.
Guidelines and standards for selecting patients who are to be
treated, while providing access to care for HCV-infected
individuals regardless of incarceration status, are forthcoming
from the CDC. Correctional physicians eagerly anticipate further
guidance from state and federal health officials on supplemental
sources of funding for HCV treatment initiatives in correctional