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Hepatitis C Challenges The Prison System: Issues of
Testing and Treatment for Prisoners with Hepatitis C Virus Will Tax
Correctional Facilities for Years
By Alan Franciscus
Editor
Recent estimates indicate that between 40-60% of the US
prison
population in the United States is infected with Hepatitis C Virus
and that 1/3 of
the estimated 4 million Americans infected with Hepatitis C Virus
pass through the
prison system each year. A disproportionate number of
prisoners are
people of color; many are locked up for drug-related
crimes. In view
of the fact that new Hepatitis C Virus infections are most frequently
spread by
sharing drug injection works (needles, cottons,
cookers, etc) and
minorities
have a higher rate of Hepatitis C Virus infection, it is easy to see why
prisons have such a large population infected with Hepatitis C Virus.
Now, many
prisons around the country are just starting to address
the enormous
financial and ethical issues that threaten to bankrupt
many state
budgets.
Many prison systems are starting to tackle the problems
of testing and
treating
Hepatitis C Virus. California, Texas, New York, Florida, Virginia and
Pennsylvania have adopted testing policies. The larger
and more
important issue is treatment guidelines on Hepatitis C Virus. Many
prisons have
adopted the treatment guidelines based on the National
Institutes of
Health (NIH) Consensus guidelines, but have added more
restrictions
within their prison system. The big challenge will be
instituting these
adopted medical guidelines in states with a large
prison population
such as California, New York and Texas.
Testing
There has been sporadic testing in some states to
establish Hepatitis C Virus
prevalence rate. However, routine testing of Hepatitis C Virus in
prison does not
currently exist. When routine testing does become
available it is hoped
that counseling will be included. "Ideally, there
should be pre and post
counseling around testing" comments Judy
Greenspan, 47,
Chairperson of the HIV in Prison Committee of
California Prison
Focus. "Unfortunately, this is not being done. In
fact, some prisoners
have been tested and were not told they are Hepatitis C Virus+ until
years later".
This seems to be a recurring theme in letters received
by the Hepatitis
C Support Project (HCSP) from prisoners. "Many
prisoners write
that when they inquire about being tested for Hepatitis C Virus, they
are told that
a test had already been performed
years earlier, but they were never
told they tested positive for Hepatitis C Virus", comments
Marie, 74, a volunteer
with the HCSP. Marie receives between 10-15 letters a
week from
prisoners around the country. "It's very sad,
because many prisoners
we hear from are infected with Hepatitis C Virus, and are living in
complete fear."
This is in large part due to the lack of education
about Hepatitis C Virus.
In California, testing for prisoners or the staff is
not routine. According
to the California Department of Corrections (CDC),
inmates are
medically evaluated upon entry and are periodically
monitored for
ongoing health conditions, and may request medical
attention when
they have health questions or concerns. Hepatitis
testing is done when
medically
appropriate as indicated by history, physical examination,
laboratory testing showing abnormalities, or by inmate
request.
Involuntary testing of an inmate may be ordered under
California
Penal Code 4501.1, if an inmate has been involved in
"gassing"
(throwing of body fluids) at an employee. CDC prison
staff is given
annual and periodic staff education on all blood-borne
pathogens,
which includes hepatitis.
CDC is planning a pilot project using a new Hepatitis C Virus
screening test
process with $1 million appropriated by the
Legislature. The CDC
hopes this program will help to evaluate the
cost-effectiveness and
efficiency of the screening process in reception
(incoming) centers and
subsequent treatment prevention measures and costs.
Prevention
Effective disease prevention strategies that include
harm reduction
models that use bleach and condoms are virtually
non-existent in the
nation's
prisons. Since hepatitis C is most commonly transmitted by
sharing Hepatitis C Virus infected needles and any drug paraphernalia
it is
impossible to implement these types of effective
prevention measures
while inmates are locked up.
Education
Very little attention has been focused on educating
inmates or the
prison staff. Most prisoners and the general prison
staff know very
little about this disease and are not being informed
about the general
issues of transmission, prevention or how to live with
Hepatitis C Virus.
This may change in California as Centerforce gears up
to provide
education to prisoners and prison staff. Centerforce, a
San Francisco
based non-profit, contracts with the State of
California, Department of
Corrections
to provide services for visitor centers and prison health
services. The health services piece provides education,
prevention and
case management to the prison population. These
services are broken
into three basic educational components-reception
(incoming)
prisoners, workshops to the general prison population
and re-entry
services for inmates prior to release. "Centerforce
has incorporated
hepatitis C prevention into its existing health
education prevention
programs. This includes hosting Hepatitis C specific
workshops for
men and women, who are about to be released from
custody, with
messages on prevention, testing, and treatment, as well
as basic
hepatitis information to all inmates entering the
prison system"
comments
Mick Gardner, Program Director of Centerforce Health
Programs Division.
Treatment
Historically, medical care in prisons has been less
than optimal. Prison
officials generally chalk this up to limited funding
and an under trained
staff. Conversely, prison activists claim that it is
due to a general
disinterest and malice on the part of the prison
administration.
Currently, it is believed that 20-25% of people
infected with Hepatitis C Virus
have serious illness or disease progression and these
people may
require medical treatment. The majority of people
(75%-80%)
infected with Hepatitis C Virus do not have serious disease
progression and
treatment for these individuals is usually not
recommended. If medical
treatment is deemed
appropriate - the standard medical treatments for
Hepatitis C Virus include interferon and the combination of
interferon and
ribavirin. Most medical authorities believe that
individuals with
elevated liver enzymes, mild to moderate disease
progression, low
viral load (under 2 million), younger age and a short
duration of
infection will have a more favorable response to
treatment.
Exclusionary criteria usually include - severe
uncontrolled psychiatric
disorders, decompensated (end stage liver disease)
cirrhosis,
underlying autoimmune disease, underlying
cardiovascular disease and
recent alcohol/ illegal drug use. As well, individuals
with an
uncontrolled major illness are excluded from treatment.
Additionally,
most prisons will not start a person on Hepatitis C Virus medication
unless the will
be incarcerated for the entire length of treatment.
Cost and Effectiveness of Treating Hepatitis C Virus
Cost and effectiveness of treating Hepatitis C Virus has long been
debated, but it
has been proven that treatment is cost effective.
Additionally,
combination therapy produces long term response rates
up to 45%.
Thus treatment can lower future patient care
costs and lower Hepatitis C Virus
transmission. Two FDA approved treatment protocols are
currently
available. Interferon mono-therapy (3 mu, injected 3
times a week)
and
the combination of interferon (3mu, injected 3 times a week
and
ribavirin (1,00-1,2000 mg pill taken daily). The
sustained response
rate (clear the virus during and at the end of
treatment) for
mono-therapy is 10-15% while the sustained response
rate of
combination therapy is approximately 40-45%. Most
physicians agree
that since the response rate is so low for
mono-therapy, most
individuals should be treated with the combination
therapy unless
contra-indicated for medical reasons.
The cost of mono-therapy is approximately $4,800/yr,
while
combination therapy averages approximately $16,000 -
$18,000 a
year. These figures do not include the additional
expense of extra
medical personnel and the cost of monitoring patients
on treatment for
side effects from these potent drugs.
Treating Hepatitis C Virus with interferon or the combination therapy
involves
many complex issues, complicated even further if the
patient is in
prison. For instance, managing the side effects of
interferon requires
monitoring blood work for signs of potential adverse
effects such as
interferon induced auto-immune disease, low white blood
counts and
anemia. Ribavirin can increase the side effects
experienced with
interferon with an additional risk of severe anemia.
The physical side
effects
vary from patient to patient but many patients require pain
medications to help ease some of the potential side
effects such as
headaches and muscle/joint pain. The physical side
effects seem to
diminish with time. However, psychological side effects
from these
medications can be very difficult to control.
Depression, anxiety and
suicidal ideation can occur and patients need to be
monitored
carefully. Treatment with anti-depressants and/or
anti-anxiety drugs
may need to be initiated. In prisons, all mediations
and
over-the-counter drugs are closely monitored. In some,
prisoners
must be observed as they take each medication. Taking
into account
the amount of medications needed to treat the disease
and side
effects, and the potential number of prisoners needing
treatment, the
implications are staggering.
California's prison system is currently treating about
400 patients per
month, but has not tracked the number of inmates who
have
completed treatment. The funds allocated for Hepatitis C Virus is
$485K while
the budget only allows for $325K - the remainder $165k
is taken
from the general health care budget
which is used for all medical needs
and treatments. The CDC estimates that treatment costs
could be
greater than $8 million as screening tests continue to
be done and as
patient numbers continue to rise. The CDC also
estimates that a
comprehensive program for diagnosis, treatment,
prevention, training
and education of Hepatitis C Virus could climb to an estimated
$60,000,000. This
would be a big chunk out of the CDC health care
services budget of
$585,080,000 for fiscal year 2000-2001.
Part of the solution to California's problem may come
from Senator
Polanco's SB 1256 - a bill that will help fund the
Hepatitis C
Education, Screening, and Treatment Act. A portion of
the funds will
be targeted for Hepatitis C Virus in prisons. It has passed the
California
Legislature and is waiting for signature from Governor
Gray Davis.
Some critics of this measure fear that the CDC will
emphasize testing,
not treatment and education, thus increasing prisoner's
fear without
providing any meaningful solutions.
"As the broader community struggles with the
pressing issues
surrounding Hepatitis C Virus testing and treatment", Cynthia
Skow, (42), of the
HIV in Prison Committee of California Prison Focus
says, "special
care must be taken to ensure that people in prison have
access to
competent,
compassionate care."
Sources: California Department of Corrections Health
Services Division
HEPP News, June 2000 Vol. 3, Issue 6
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