Hepatitis C virus (HCV) transmission to uninfected individuals entering the prison system is a significant problem. An incidence of 34.2 per 100 person years in entrants to the New South Wales (NSW), Australia prison system has been reported by Dolan et al.1 and this figure should be seen as unacceptable. A total of 36% of the population in this study continued to inject in prison, which is not surprising because many individuals in prisons are there because of drug-related crimes. No prison system has yet succeeded in remaining drug free, and as a result, prisoners with a dependent drug habit continue to inject these substances during their incarceration. Although injections in gaol may be less frequent, in most situations, prisoners have to use and share unsterile injecting equipment. This places them at a high risk of acquiring HCV because the background prevalence of HCV in prisons ranges from 10% to 70%.2–7
Much has been done recently to address the subject of HCV in prisons. A major thrust has been that of reducing HCV transmission and harm from hepatitis C in prisons. However, the issue of drug use in prison is a highly emotive one, and steps that might reduce HCV transmission from injection drug use can be very difficult to implement, despite evidence for their efficacy. Such steps include:
- 1Reducing the incarceration rate of those who have committed drug offences of a non-indictable type. In NSW, the Magistrates Early Referral into Treatment program has been established to divert those committing less serious offences away from the penal system into a treatment environment. Early evaluation suggests this approach can be effective (NSW Health, Mental Health Drug and Alcohol Office, pers. comm., 2007).
- 2Ensuring that those with an injecting drug habit are offered optimal treatment while in prison. This does not include providing opioids, such as methadone or buprenorphine, to non-opioid-dependent individuals.
- 3Considering the provision of sterile injecting equipment to those who wish to inject while in prison. A number of jurisdictions have made sterile injecting equipment available in prisons (needle and syringe exchange programs; NSP), and the outcomes have been summarized in a number of reports.8–11
The first-established prison-based NSP was in Switzerland in 1992, and there are now NSP in over 60 prisons in Spain, Germany, Moldova, the Kyrgyz Republic, Belarus, Armenia, Luxemburg, and Iran.12 Generally, evaluations of prison-based NSP have been positive. The major findings are summarized in Table 1.
|A significant reduction in needle and syringe sharing (with the exception of one prison, where there was insufficient supply of needles and syringes)|
|No new cases of HIV in prisoners participating in the needle and syringe exchange programs (unfortunately data for hepatitis C virus are lacking)|
|A decrease in the incidence of drug overdose and deaths|
|An increase in referral to drug treatment programs|
|Increased awareness of transmission risk behaviours|
|A decrease in injection site abscesses|
|No incidents where needles or syringes have been used as weapons against fellow prisoners or guards|
|No increase in injecting drug use among prisoners|
Given these data, it is difficult to understand why NSP have not been introduced to any prison in Australia to date, and they appear to be rare in Asian countries.
All prison systems should now be in a position to test for HCV and to then fully evaluate the person who is diagnosed with the condition for the first time. All HCV-positive individuals should also be able to receive treatment if their disease warrants it, or if they themselves believe it would be helpful while in prison to have treatment for their own sake or the sake of their family. Until recently, little attention has been paid to the family members and other social contacts of incarcerated individuals. These folk are at risk of transmission of HCV if the inmate remains infected upon release from prison. A return to the community often means a return to injecting drug use, unprotected sexual activity, and also a higher level of domestic violence than experienced by a never-incarcerated individual. Thus, treatment in the prison setting can be regarded as a general public health measure.
Treatment has been offered in prison settings now for a number of years.13–17 Outcomes have been shown to be equivalent to those achieved in the non-prison setting,13,14 but concern has been expressed that these individuals may become reinfected upon release from prison, or even while still in prison. The risk of HCV reinfection in those previously infected and either spontaneously or via treatment, clear the virus now appears real; it may be even greater than in the naïve to HCV population!17–19
In this issue of the Journal of Gastroenterology and Hepatology, Bate and colleagues17 highlight the risk of HCV reinfection in patients treated in prison in South Australia over a 12-year period up to December 2008. Seventy-four treated prisoners were followed for a mean of 1243 days, a remarkable achievement given the mobility of this patient group. A sustained virus response (SVR) was achieved in 53 patients. The reinfection rate in this retrospective study was 17%, a figure which cautions against unthinking provision of treatment simply because the person has HCV. A significantly higher HCV incidence rate was measured in previously-infected injection drug user (IDU) (47% per year) compared with HCV-naïve IDU (16% per year) by Aitken et al.18 The hazard ratio for previously-infected IDU compared to HCV-naïve IDU, after adjustment for time-dependent covariates, was 2.54 (95% confidence interval, 1.11–5.78, P > |z| < 0.05).16 In a further series,19 multiple HCV infections were detected in 23/59 (39%) seroconverters; seven had HCV reinfections, 14 were superinfected, and two had reinfection followed by superinfection. In total, the authors identified 93 different HCV infections, varying from one to four infections per seroconverter. Multiple HCV infections were observed in 10/24 seroconverters with spontaneous HCV clearance (11 reinfections, three superinfections).19
In another recent study in this month's issue of the Journal of Gastroenterology and Hepatology, Grebely et al. report an HCV reinfection rate of 5.3 per 100 person years in 16 treated patients who continued to inject drugs.20 In any treatment program, the risk of re-exposure should be identified before treatment is commenced. The ultimate social and biological significance of these results remains unclear; many more detailed studies of the viral/immune interactions allowing reinfection are required. Answers should be sought to questions such as:
- 1Which individual characteristics predict reinfection?
- 2Why do some individuals clear an HCV infection without seroconversion?
- 3What is the impact on the liver of repeated infection with new strains and genotypes of the virus?
Despite concerns that treatment may not be safe or effective in prison settings, SVR rates are similar in this group of patients to those in major liver units worldwide. Bate et al.17 and others have highlighted the several factors that should be taken account before HCV treatment is offered in prison settings, and these are tabulated (Table 2).
|Full resourcing for monitoring treatment effectively|
|Patient access to acute hospital and psychological support if complications of treatment arise|
|Treatment should only be offered if it is likely to be completed before the individual is released from prison. There is a real risk that upon release from prison, the person no longer regards treatment as of high priority, and therefore, fails to complete the prescribed course. Often, despite careful planning, release from prison comes unexpectedly and appointments for follow up in clinics in the community cannot be made before the individual leaves the prison|
|Where injecting drug use remains a major issue for the individual, attention should be primarily directed to this issue rather than to the hepatitis C virus because injecting upon release increases the chance of reinfection|
In summary, data from these and a growing number of other publications indicate that treatment for HCV in prison should be routinely available and offered under standard guidelines that should be equivalent across jurisdictions in and outside of the corrections system. What is the way forward? The answer is reducing the public (and government) ignorance about HCV and increasing the availability of treatment for those with a dependent drug use pattern of life. Ensuring ready access to clean needles and syringes is critical, despite some recent evidence that HCV transmission may not necessarily be reduced.21,22 This is especially so in prison settings. It is hoped that at least one correctional setting in Australia will accept the challenge and provide a NSP in a prison which can be evaluate effectively.