Hepatitis C Among Offenders--Correctional Challenge and Public
Author(s): Allen, Scott A.
Rich, Josiah D.
Friedmann, Peter D.
Source: Federal Probation; Sep2003, Vol. 67 Issue 2, p22, 5p
CHRONIC INFECTION WITH hepatitis C virus (Hepatitis C Virus) is the most
blood-borne illness in the United States, affecting nearly 2
all Americans, or an estimated 4-5 million individuals (Alter
1999). While most individuals with chronic infection are not
progress to end-stage liver disease or death, hepatitis C is
common indication for liver transplantation in the U.S., and
responsible for 10,000 deaths annually (NIH Consensus
Management of Hepatitis C, 2002). Although Hepatitis C Virus can be
through blood and blood product transfusions, hemodialysis and
sexual practices, the leading risk factor for Hepatitis C Virus infection is
drug use (IDU) (Alter, 1997).
While the hepatitis C epidemic is substantial in the country
as a whole,
it has become a major concern in correctional settings.
Hepatitis C Virus infection in prisons is 8- to 20-fold higher than in the
with infection rates between 16-41 percent and evidence of
infection in 12-35 percent (Centers for Disease Control and
2003). An estimated one out of three Americans with chronic
infection rotate through correctional facilities annually
al., 1997). Despite slow progression of most infections,
death within correctional systems is already substantial,
explained by a large number of infections acquired decades
Hepatitis C infection is a leading cause of illness and death
in-custody inmates in some correctional facilities (Allen,
Reiger, personal communication, 2002) and an emerging cause in
(J. Paris, personal communication, 2003).
Natural History of the Disease and Treatment Options
Hepatitis C virus primarily affects the liver. Over time, the
cause inflammation, which can lead to scarring (fibrosis or
and in some cases, liver cancer or end-stage liver failure.
The hepatitis C virus was only identified a little over a
Consequently, accurate information regarding the natural
untreated disease is limited to a number of epidemiologic
analyses. The most widely accepted models state that between
percent of individuals initially infected will spontaneously
virus without any treatment. The majority of those infected,
percent, will go on to have chronic infection (Alter, 2000).
Fortunately for those with chronic infection, progression
over years--typically decades. In a well respected model, in a
period following initial infection, 20 percent of individuals
hepatitis C will develop late-stage scarring of the liver (or
and only 3-5 percent will develop fatal complications such as
decompensated liver disease of liver cancer (hepatocellular
(Alter, 2000). Co-infection with HIV can cause acceleration of
process, as can regular heavy alcohol use.
While the disease can be staged (determining how advanced the
is) by means of blood work and a liver biopsy, current
the disease does not allow clinicians to accurately predict
progress to end-stage complications. For that reason, most
established disease and evidence of scarring on liver biopsy
potential candidates for anti-viral therapy.
Over the past decade, anti-viral treatments have become
have steadily improved. Initially, standard interferon
in successful eradication of virus in roughly 20 percent of
treated. With the addition of ribavarin, treatment response
roughly 40 percent. With the current therapy, pegylated
ribavarin has been associated with a response rate in excess
percent, with a response rate as high as 80 percent for some
the virus. No effective vaccine is currently available.
Unfortunately, despite improvements in response to therapy,
side effects limit the utility of treatment. Unlike HIV, where
may continue for an indefinite period, current hepatitis C
are either 24 or 48 weeks, depending on the strain of the
initial response to treatment. Side effects of ribavirin may
significant drops in blood counts, resulting in anemia,
shortness of breath. In addition, pegylated interferon can
flu-like symptoms including fever, muscle aches, headache and
plus a host of possible reactions including eye problems,
dysfunction and lung abnormalities. Significant psychiatric
effects of the treatment include irritability, depression and
suicidality. Therapy for hepatitis C is contraindicated in a
conditions, including pregnancy, advanced liver disease,
disease (such as Lupus) and uncontrolled psychiatric illness,
In combination with the slow smoldering course of disease, the
effect profile of available medications, and the expectation
treatment with higher efficacy and improved side effect
profiles in the
next 3 to 5 years, patient selection for treatment is highly
individualized within treatment guidelines. Treatment
take into consideration a number of factors, including stage
(as established by clinical factors such as blood tests and
biopsy) and co-existing chronic disease such as HIV, diabetes,
disease and psychiatric illness. Finally, treatment requires
informed consent of the patient regarding the risks and
In the correctional setting, duration of incarceration is
often used to
determine eligibility for anti-viral therapy (Proceedings of
of Hepatitis C in Prisons Conference, 2003). As interruption
can adversely affect effectiveness, treatment while
typically reserved for those patients who will remain
for the complete period of anti-viral therapy (24 or 48 weeks
on genotype). Treatment for patients with shorter sentences is
safely deferred to the community.
Unfortunately for the large number of inmates being released
correctional facilities with hepatitis C, resources for
management of this disease are scarce in the community. Public
agencies have generally not been funded to address the high
disease in the largely uninsured, post-correctional
Response to Hepatitis C in Corrections
Despite the high prevalence of hepatitis C in corrections,
correctional institutions has been measured. Most facilities
difficulty in accessing sub-specialty evaluation for the large
patients who are infected. While some states have developed
for evaluation and treatment by general internists (Allen et
others have to date failed to offer any treatment at all.
limited or no access to treatment have been subjected to class
lawsuits seeking access to care for infected inmates. At this
states and the Federal Bureau of Prisons are in the process of
guidelines and protocols for evaluation and management of
hepatitis C in
the correctional setting (Proceedings of Management of
Hepatitis C in
Prisons Conference, 2003). In January 2003, the Centers for
Control and the National Commission of Correctional Healthcare
a meeting of state and federal correctional healthcare
encourage the sharing of data, treatment experience and
correctional settings (Allen, 2003).
In rare cases, clinically advanced disease can lead to major
potentially fatal complications, with implications for
classification, probation and parole. In the majority of
chronic hepatitis C can be safely managed within the prison
provided hepatitis C evaluation and treatment are accessible.
inmates undergoing active treatment--typically for 24 or 48
significant side effects of therapy can impact on the
to participate in work and recreational activities.
of therapy and work assignment needs coordination.
Costs of Treatment
In addition to the human cost of treatment-related side
potential financial impact on stressed correctional budgets is
public policy concern. Funding for medical care of inmates is
almost entirely by public funds under a constitutional
provide care (Estelle v. Gamble, 1976). Cost for a course of
ranges between a low estimate of $7,000 and a high estimate of
Legitimate logistic constraints resulting from short periods
incarceration result in deferral of treatment until after
the majority of individuals incarcerated with Hepatitis C Virus infection
personal communication, 2003; Allen et al., 2003). Other
criteria and informed consent resulting in patient decision to
therapy further reduce the pool of candidates for treatment
period of incarceration. While correctional facilities have
been able to
take advantage of reduced cost drugs in some settings, the
cost impacts are considerable (Spaulding et al., 1999). For
foreseeable future, correctional systems will struggle to
cost-effective care while not unreasonably limiting access to
Anticipation of newer therapies with greater effectiveness and
side-effect profiles can be expected to be more costly than
Associated issues: Substance Abuse and Mental Health
The strong association between remote and/or current injection
(IDU) and hepatitis C infection has already been described. In
the vast majority of Hepatitis C Virus infected patients acquired their
drug-related risk behaviors. In addition, alcoholism can have
accelerating effect on the clinical course of the infection (Schiff,
1999) and may help explain some of the more advanced clinical
fibrosis and cirrhosis found in some incarcerated patients.
A history of substance abuse had long been considered a
contraindication to treatment for Hepatitis C Virus infection. However, a
review of published experience has demonstrated little
justification for withholding treatment to Hepatitis C Virus patients with a
of substance abuse (Edlin, 2001). In 2002, the NIH Consensus
on Hepatitis C removed substance abuse from the list of
contraindications for anti-viral therapy. The forced sobriety
also provides for a window of opportunity for safe and
treatment (Allen et al., 2003) that, when coupled with
treatment--including methadone (Tomasino et al.), education,
reduction counseling and intervention--has the potential to
risk of re-infection. Furthermore, fears about re-infection
largely theoretical; there are only two confirmed cases of
re-infecting themselves by drug injection after successful
with interferon and ribavirin (Kao et al., 2001; Dalgard et
Still, efforts aimed at addressing Hepatitis C Virus in corrections need to
coupled with treatment and referral for the health problem of
dependence. While no longer considered a prerequisite for
treatment, responsible treatment protocols include counseling,
and treatment for substance-abuse-related issues as part of
their Hepatitis C Virus
program. Given the persistently high cost of medical
for Hepatitis C Virus for the minority of incarcerated infected patients who
eligible, broader efforts aimed at dealing with the activity
closely associated with transmission of infection are
Because the side effects of interferon-based anti-viral
include significant psychiatric side effects including major
(Zdilar et al., 2000), caution must be exercised when
interferon in patients with a history of psychiatric illness.
for possible treatment should include screening for history of
depression, suicidality and other significant psychiatric
Mental illness, including depression, anxiety, and
disorder, is encountered more commonly in correctional
in the general public (Ditton, 1999; Beck and Maruschak,
interferon-related depression does respond to anti-depressant
(Hauser, 2002). Concerns about adverse psychiatric effects in
individuals with histories of psychiatric disorders are
from studies reporting psychiatric side effects in patients
psychiatric diagnoses who were treated for hepatitis C
(Schaefer et al.,
2003). In fact, a growing body of literature supports the
treating hepatitis C in individuals with a history of
diagnoses (Relault et al., 1987). Hepatitis C treatment can be
initiated in patients with a history of mental illness
illness is stable, a psychiatrist has evaluated and cleared
and the medical and psychiatric teams collaborate closely
treatment period. In correctional settings where there are
mental health services, the controlled and monitored
environment of a
correctional facility may provide one of the safest settings
interferon therapies can be undertaken in those with mental
(Allen et al., 2003).
Have We Been Here Before? The HIV Experience
Corrections has faced the challenge of an epidemic of a
blood-borne infectious disease prior to the recognition of the
C epidemic with HIV, the virus that causes AIDS. There are
that may be useful to consider, and factors that make these
quite distinct. The risk factors for HIV and Hepatitis C Virus are similar,
corrections, injection drug use accounts for the majority of
infections (Centers for Disease Control and Prevention, 2003).
Hepatitis C Virus is more effectively transmitted, and is consequently much
common. HIV prevalence among releasees from correctional
estimated to be 2-3 percent, compared to 17-18.6 percent for
Hepatitis C Virus
(National Commission on Correctional Health Care, 2002). While
majority of individuals infected with Hepatitis C Virus will not progress to
complications of liver failure, cancer and death even if
majority of HIV-infected individuals would face fatal outcome
Still, there is much to learn about the current Hepatitis C Virus epidemic
HIV experience in corrections. First, HIV treatment programs
that inmates who are engaged in well-designed longitudinal
programs have lower recidivism rates and are more likely to
health-conscious behaviors (Conklin et al., 1998). Second, in
days of antiretroviral therapy for HIV, providers were often
to prescribe these life-saving medications to drug users and
with mental illness because of fears of non-adherence and
interactions (Clarke and Mulcahy, 2000). However, in the
programs that specifically address the unique needs of these
(Mitty et al., 2002), including adherence programs for
persons (Kirkland et al., 2002), drug users and persons with
illness are consistently safely and successfully treated for
A Public Health Opportunity
Many observers understandably look at the large concentration
hepatitis C within prisons as a daunting medical and fiscal
state and federal correctional systems, which indeed it is. At
time, it is also a significant public health opportunity.
Americans with a clinically silent and often undiagnosed
infectious disease are congregating in jails and prisons. The
of these individuals will return to the community. The Centers
Disease Control and Prevention estimate that 1.3 million
with hepatitis C, or 39 percent of all Americans with this
released from correctional facilities each year. Once back in
community, infected individuals may continue to transmit the
particularly if they remain undiagnosed and untreated. This
presents a rare opportunity for targeted interventions aimed
spread of the virus. Including the incarcerated population in
impact the burden of infectious disease is a valid and
approach, and is now recognized as an important strategy by
corrections and public health agencies (Glaser and Greifinger,
Association of State and Territorial Health Officials, 2002).
While medical treatment of Hepatitis C Virus has the theoretical effect of
the size of the infectious pool for those returning to the
other preventive interventions, such as diagnosis of the
education and counseling about transmission, education about
reduction through clean needle access, and referral and
substance abuse make sense from a public health and safety
Related cost-effective interventions, such as vaccination of
Hepatitis C Virus-infected inmates against hepatitis B (whose co-infection
accelerate liver failure) would also save money and lives for
localities (Rich et al., 2003).
Hepatitis C is a significant problem for individuals involved
correctional justice system nationally. This epidemic has
policy and fiscal implications, and correctional institutions
are in the
early stages of developing systematic responses to the
significant minority (39 percent) of Americans infected with
congregates in correctional institutions. This situation
unique opportunity to diagnose, educate and treat appropriate
individuals, and to reduce transmission in the community upon
While diagnosis, evaluation and treatment has significant
implications for individual patients, access to proper medical
after prison also has the potential to influence future
behavior. Linkage of incarcerated HIV-seropositive patients to
care upon prison release has been associated with improved
health services and reduced recidivism (Flanigan et al., 1996;
al., 1997). Addressing the factors that influence the ability
tolerate Hepatitis C Virus treatment (substance abuse, stable mental health,
support) will likely also reduce recidivism. In substance
treatment settings, linkage to medical care is associated with
addiction-related outcomes (Friedmann et al., 2003). The same
effect on recidivism and addiction outcomes will likely accrue
drug-involved prison releasees who become motivated to address
their Hepatitis C Virus
infection. Continuity of care will help the drug-involved
develop "trust in the system" work toward
rehabilitative goals and
community readjustment (Mitty et al., 1998), and address
and substance abuse issues as part of community management of
Hepatitis C Virus.
Systematic approaches to the hepatitis C epidemic in
needed. Unlike the early days of the HW epidemic, which
spawned a highly
organized, politically influential constituency, incarcerated
individuals with substance abuse histories have few advocates.
result, the public and legislative response to hepatitis C in
corrections has been muted. The public health and fiscal
this epidemic, however, warrant a more proactive response.
Cost-effective interventions, such as targeted screening,
education and individual counseling, clean needle access,
against hepatitis B and substance abuse treatment, should form
foundation of that response.
The work described was supported, in part, by grant number
from the National Institutes of Health, Center for AIDS
CFAR); and by grant number H79-TI-014562 from The Center for
Abuse Treatment of the Substance Abuse and Mental Health
Administration (SAMHSA CSAT)and U01-DA016191-01 from the
Institute on Drug Abuse. Its contents are solely the
the authors and do not necessarily represent the official
views of the
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By Scott A. Allen, M.D.; Josiah D. Rich, M.D., M.P.H.; Beth
Schwartzapfel and Peter D. Friedmann, M.D., M.P.H.
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Source: Federal Probation, Sep2003, Vol. 67 Issue 2, p22, 5p