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

  

Infections Behind Bars
Hepatitis C: A Correctional-Public Health Opportunity
Anne S. De Groot, MD, Elizabeth Stubblefield, Joe Bick, MD
[Medscape Infectious Diseases, 2001. © 2001 Medscape, Inc.]

Introduction
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 (Hepatitis C Virus) in the
incarcerated.

Epidemiology of Hepatitis C Virus in Correctional Settings
Hepatitis C 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,[1] between 1.0 and 1.25 million
individuals harboring chronic Hepatitis C Virus 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 Hepatitis C Virus infection in the
United States. The prevalence of Hepatitis C Virus infection among US prisoners is at least
10-fold higher than the estimated prevalence of 2% in the general
population.[2] Outside of correctional settings, 79% of current injection
drug users (IDUs) have Hepatitis C Virus infection.[3] In fact, young IDUs acquire Hepatitis C Virus
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 Hepatitis C Virus infected.
Hepatitis C Virus 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 Hepatitis C Virus among inmates has been reported to be 30%.[4] A recent survey of
Arizona reported a 31.3% prevalence rate among inmates (Gerard Chamberlin,
personal communication). In Maryland, the prevalence of Hepatitis C Virus among state
inmates has been noted to be slightly higher, at 38%.[5] One county jail in
semi-rural Massachusetts recently reported that 20.7% of its jail inmates had
Hepatitis C Virus infection (Hampden County).[6] In Virginia, 30% to 40% of inmates have
been reported to have Hepatitis C Virus infection.[7] Approximately the same rate has been
reported in Washington state (30% to 40%).[8] The prevalence of Hepatitis C Virus among
state inmates in Pennsylvania is slightly lower, at 13%.[9]
Reflecting their higher rate of participation in HIV and Hepatitis C Virus risk behaviors,
incarcerated women exhibit about a third higher Hepatitis C Virus co-infection rate than
incarcerated men.[10] For example, in a sample of incoming inmates in
California, 54% of women inmates, compared with only 40% of men inmates, have
Hepatitis C Virus infection.[11] In Connecticut, 1 in 3 women (32%) incarcerated at the
only state facility for women inmates has Hepatitis C Virus infection.[12] In Texas, 37% of
incarcerated women and 28% of incarcerated men have Hepatitis C Virus infection.[3]
Wisconsin reported Hepatitis C Virus 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.[13]
Hispanics and non-Hispanic blacks have higher rates of Hepatitis C Virus and HBV infection
and chronic disease than whites; most cases of Hepatitis C Virus and HBV infections are
found among persons who are male, members of minority populations, and 30 to
49 years of age.[3] These race- and class-related risk factors for hepatitis
infection probably contribute to the current concentration of Hepatitis C Virus- and
HBV-infected persons in prisons and jails.

Screening for and Treating Hepatitis C Virus in Correctional Facilities
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 Hepatitis C Virus and educate their inmates about
Hepatitis C Virus are performing a significant public service, since approximately 50% of
persons with hepatitis are unaware of their hepatitis infection.[1] 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.[1]

Treatment of Hepatitis C Virus
The current standard of care in community settings is to treat chronic Hepatitis C Virus
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 Hepatitis C Virus-infected inmates,
or are in the process of developing these protocols. However, the criteria
for Hepatitis C Virus treatment may vary slightly from one correctional system to another.
The CDC is in the process of developing a set of guidelines for Hepatitis C Virus 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.)
In general, eligible patients meet the following criteria: (1) have evidence
of persistent Hepatitis C Virus 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 Hepatitis C Virus treatment side effects and willing to
adhere to an arduous course of treatment.
Standard 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.

 

    

Response Rates
Combination therapy consistently yields higher rates of sustained response
compared with monotherapy. (A sustained response implies that Hepatitis C Virus 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 Hepatitis C Virus 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.[15]

Cost vs Benefits
As with many other chronic medical conditions, morbidity and mortality
attributable to Hepatitis C Virus 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.
Despite these concerns, some state medical directors have led the way and
adopted clear protocols for the screening and treatment of Hepatitis C Virus 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 Hepatitis C Virus is leading to higher rates of cure (up to 88% in
carefully selected patients); therefore, the overall cost-effectiveness of
Hepatitis C Virus interventions in corrections is improving.
Cost-benefit 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
Hepatitis C Virus-infected patient.[17] Dr. Wong's analysis ranked combination therapy for
Hepatitis C Virus in the same range of cost-effectiveness as stool guaiac testing,
pneumococcal vaccination, coronary bypass surgery, and mammography.[17]

Liver Biopsy
The need for confirming the extent of damage to the liver by Hepatitis C Virus 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 biopsy.[17]

The Lowest-Cost Intervention: Education
The lowest-cost intervention for the prevention of hepatitis infection is
education. Given the risk of acquiring Hepatitis C Virus (not to mention HIV), all
bloodborne pathogen screening events should lead to careful discussion of the
risks of acquiring HIV, HBV, and Hepatitis C Virus 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 educational
materials).
The impact of continued drug use should also be made very clear to patients,
especially those who are not yet Hepatitis C Virus infected. For those inmates who are
already Hepatitis C Virus infected, education should be provided on the impact of alcohol
abuse on Hepatitis C Virus 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 Hepatitis C Virus 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).

 

    

Additional Considerations
Another low-cost (but not no-cost) intervention is vaccination. For
Hepatitis C Virus-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
Hepatitis C Virus-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 Hepatitis C Virus in Correctional Settings
Since the incidence of side effects to Hepatitis C Virus 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:
·   Spend time preparing the patient for potential treatment-related side
effects
·   Prescribe PRN medications for symptom management
·   Consider following the patients in a dedicated hepatitis clinic
·   Consider establishing a support group for patients under Hepatitis C Virus treatment
·   Utilize peer education programs when possible
·   Use a nurse or other staff person to regularly check in with patients who
are receiving Hepatitis C Virus treatment so that side effects can be rapidly addressed
Without a 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 monitoring treatment.

HIV and Hepatitis C Virus Coinfection
Analyses of the effect of Hepatitis C Virus 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 Hepatitis C Virus
liver disease. Persons who are co-infected (HIV/Hepatitis C Virus) appear to have a 12- to
300-fold higher risk of developing hepatocellular carcinoma compared with
noncarriers.[18] Furthermore, antiretroviral agents can contribute to liver
inflammation, and this may be more frequent in those who have underlying
chronic hepatitis due to Hepatitis C Virus or HBV. Ritonavir and nevirapine appear to be
the antiretroviral therapy medications that are most commonly associated with
liver inflammation in Hepatitis C Virus/HIV co-infected patients.[19]
The impact of Hepatitis C Virus infection on HIV infection is less clear. In some studies,
Hepatitis C Virus infection does not appear to have an effect on the progression of
HIV.[20] 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 Hepatitis C Virus genotypes 1a and 1b.[21,22] However, a
report by Sulkowski[23] 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 Hepatitis C Virus
co-infection.
Response to Hepatitis C Virus therapy in individuals who also have HIV infection appears to
be equivalent to that of non-HIV-infected individuals.[24] A recent study in
JAMA by Sulkowski and associates[19] indicates that 88% of co-infected
patients tolerate concurrent Hepatitis C Virus treatment and highly active antiretroviral
therapy (HAART). Following successful Hepatitis C Virus treatment, co-infected patients are
not more likely to relapse after Hepatitis C Virus treatment than are patients who do not
have concurrent HIV infection.
Currently, 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 generally accepted.[25]

Conclusion
The cost of Hepatitis C Virus 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.
The 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 Hepatitis C Virus-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 Hepatitis C Virus treatment initiatives in
correctional settings.

Acknowledgements
This article is modified from an article by Anne S. De Groot entitled Hepatitis C Virus:
The Correctional Conundrum, published in HEPP News, Vol. 4 (4), April 2001.
Available at: http://www.hivcorrections.org/archives/april01/.