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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



                             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


                          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


                          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.


                          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.


                          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.


                          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.


                          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