Managing Hepatitis C in Our Prisons: Promises and Challenges
By Owen J. Murray, DO, John Pulvino, PA, Jacques Baillargeon, PhD,
David Paar, MD, and Ben G. Raimer, MD

http://www.ncchc.org/pubs/CC/managing_hcv.html

America’s prisons and jails bear a disproportionate share of the total U.S. population infected with HCV. Epidemiologic studies show that the prevalence of HCV infection in correctional facilities (15% to 40%) is significantly higher than that for the general population (1.6%). Translated into actual numbers, these prevalence rates suggest that between 300,000 and 400,000 HCV-infected persons are incarcerated in U.S. prisons or jails at any point in time.

Since the vast majority of these individuals will eventually be released into the community, the degree to which correctional health care providers are able to control and manage this infectious disease has enormous public health implications.

Prevalence data suggest that at least one-third of all HCV-infected persons in the United States pass through a correctional facility in any given year. Consequently, some health policy analysts have argued that prison systems are optimal venues for implementing comprehensive HCV prevention and medical management programs because they can efficiently target a high concentration of infected persons.

Unfortunately, most correctional institutions are confronting unprecedented challenges in their attempts to address the growing HCV epidemic. These challenges primarily revolve around financial and logistical impediments to evaluating and treating such a large number of patients, as well as the absence of a clear consensus about how to best manage the disease in the unique environment of a prison.

A related challenge is the general scarcity of follow-up care available in the community once an inmate with HCV is released. The Texas prison system, which holds one of the largest groups of HCV-infected inmates in the nation, offers an illustrative snapshot of both the promises and challenges of managing HCV in the correctional environment.

HCV In the Texas Prison System
The Texas Department of Criminal Justice (TDCJ) houses more than 153,000 convicted inmates in prison units, state jails and substance abuse felony punishment facilities. A recent seroprevalence survey of nearly 4,000 adults entering a TDCJ facility showed that about 29% of the new inmates were HCV positive. This finding suggests that more than 40,000 inmates in the custody of TDCJ may be infected with the virus.

All medical, dental and psychiatric care for TDCJ inmates is provided by two of the state’s academic medical centers. Evaluating and caring for a cohort of HCV-infected inmates that is larger than the total population of most state prison systems has proved to be a daunting task, requiring health care providers to do more with less in the face of soaring medical costs and finite government funding.

Identification and Evaluation
To identify inmates who are HCV-positive, TDCJ uses voluntary serologic screening targeted at inmates with risk factors for the infection (e.g., history of injection drug use, known HIV seropositivity or high-risk sexual activity). Although some infectious disease experts advocate universal HCV screening, such an approach is probably not cost-effective and would likely decimate the health care budgets of many prison systems.

Approximately 20,000 HCV-positive inmates in TDCJ have been identified and are being managed by a network of medical professionals.

All newly diagnosed inmates undergo a comprehensive medical evaluation by a physician or midlevel provider. They also receive extensive education about the disease process, medical management and treatment options, and methods to prevent transmission of the virus and minimize disease progression.

Asymptomatic patients with an elevated alanine aminotransferase (ALT) level but no laboratory evidence of advanced liver disease are monitored and undergo repeat ALT testing at three-month intervals for the first 12 to 15 months after diagnosis.

Symptomatic patients are typically enrolled in a chronic care clinic where their condition can be more closely monitored during the initial evaluation period. Criteria for selecting potential candidates for antiviral therapy are based on clinical practice guidelines formulated by an internal pharmacy and therapeutics committee comprised of health care professionals from TDCJ and the two medical centers. These guidelines mirror national consensus recommendations but are tailored to accommodate the special circumstances of managing chronic HCV infection in a large prison system.

Antiviral Therapy
Combination therapy with pegylated interferon and ribavirin represents a major advance in the management of hepatitis C, with an overall sustained virologic response rate of 40% to 50%. Successful eradication of the virus eliminates the potential for HCV transmission and prevents or significantly delays further liver damage and associated complications. Unfortunately, correctional health care providers are able to provide antiviral therapy to only a minority of the HCV-infected inmates due to several unresolved stumbling blocks.

Because of the amount of time required for evaluation and treatment of HCV, a major determinant of eligibility for antiviral therapy in the correctional setting is the expected duration of an inmate’s incarceration. Most inmates who are released are uninsured and cannot afford to pay for costly medical services. And with few exceptions, public health agencies do not have the resources to provide treatment for the indigent HCV population in the community.

This harsh reality has left correctional health administrators with little choice other than to exclude inmates with short sentences from consideration for antiviral therapy since partial treatment provides little clinical benefit and is an inefficient use of limited resources. The effects of this policy are especially profound for HCV-infected inmates in state jails and other short-term detention facilities since few if any of them are eligible for treatment.

Cost is another major obstacle to providing treatment for HCV-infection. Antiviral therapy is expensive, with recent estimates for a course of treatment ranging from a low of $7,000 to a high of $20,000. Correctional health care is paid for almost entirely by government appropriations, which typically do not provide sufficient funds for managing the large numbers of inmates with HCV. Consequently, providers have had little choice but to limit antiviral therapy to those patients who are most likely to benefit from treatment.

Aggressive Cost Control
Between September 2005 and August 2006, more than 300 TDCJ inmates completed a course of combination therapy with interferon and ribavirin. Treatment for this sizeable group of patients was possible because of several aggressive initiatives to control costs. These include the use of clinical protocols and case management strategies to reduce the inappropriate use of expensive resources while improving overall clinical outcomes.

Telemedicine has also proved to be an effective strategy for reducing costs associated with HCV treatment. Because most TDCJ units are in rural areas, telemedicine enables specialty providers to monitor patients remotely for potentially serious side effects during the course of antiviral therapy.

The most significant savings in treating HCV-infected inmates have been achieved through the participation of one of the medical centers (University of Texas Medical Branch) in the 340B Drug Pricing Program. Created under the Veterans Health Care Act of 1992, this program provides substantial discounts on covered outpatient drugs (including antiviral medications) purchased by federally funded entities serving the most vulnerable patient populations.

HCV and End-Stage Liver Disease
Chronic HCV infection is now the leading cause of end-stage liver disease (ESLD) in TDCJ and other state prison systems, and more cases of liver failure are expected as the number of elderly inmates continues to rise. The cost of managing variceal bleeding, hepatic encephalopathy and other serious complications of liver failure is substantial.

Approximately 300 inmates with ESLD are currently incarcerated in Texas prisons. Ultimately, the only viable treatment for some of these patients will be liver transplantation. The enormous costs of liver transplantation and long-term immunosuppressive therapy are staggering and have the potential to consume most, if not all, of many correctional health care budgets.

The ethical and legal issues of providing organ transplants to prisoners have been contentiously debated for more than a decade. Thus far, only a handful of state and federal prisoners have received organ transplants. However, since organ transplantation is now an accepted standard of care and as the federal courts have begun to address the constitutionality of denying inmates access to such treatment, the number of inmates with ESLD who qualify for placement on a transplant waiting list is expected to gradually increase. Organ transplantation may very well represent the most significant financial challenge that correctional health care systems have ever had to confront.

HCV and the HIV Experience
The current challenge of managing hepatitis C in our prisons is comparable to the problems faced by correctional programs during the early days of the HIV epidemic. Comprehensive guidelines for identifying and treating HCV-infected inmates are still evolving, and expensive antiviral therapy remains a major obstacle. Nonetheless, correctional health care has successfully met the challenges of a chronic, bloodborne infectious disease before, and there is every reason to believe that cost-effective, systematic approaches to the HCV epidemic are attainable.

— About the authors: The authors are affiliated with the University of Texas Medical Branch at Galveston. Owen J. Murray, DO, is assistant vice president and chief physician executive of the UTMB Correctional Managed Care program. John Pulvino, PA, is senior director of quality and outcomes for Correctional Managed Care. Jacques Baillargeon, PhD, is an epidemiologist for Correctional Managed Care and an associate professor in the department of preventive medicine and community health. David Paar, MD, is director of clinical virology for Correctional Managed Care and an associate professor in the department of internal medicine. Ben G. Raimer, MD, is vice president of Community Health Services and a professor in the department of preventive medicine and community health.