Hepatitis C Virus Infection in United States Correctional Institutions
Frederick L. Altice, MD and R. Douglas Bruce, MD
Current Hepatitis Reports- August 2004, 3:112-118
In the United States, over 6 million people are under correctional supervision and over 2 million are in custody and receiving health care. Prisoners are overrepresented by individuals with high risk for hepatitis C virus (HCV) infection, including injection drug users, the sexual partners of injection drug users, and people living with HIV or AIDS and mental illness. As such, it is estimated that approximately 30% of all prisoners are infected with HCV. Despite this high prevalence, little has been done to implement effective therapy for treating this potentially curable infection in this setting. Correctional settings, with their structured environment and managed care approach, are ideal settings to screen, evaluate, and provide treatment and promote risk reduction interventions that will contribute to society's improved public health.
The overlapping epidemics of incarceration, illicit drug use, and viral infections continue to grow in the United States, with each epidemic compounding and negatively impacting the other. Prisoners are at exceptional risk for viral hepatitis because of the association between injection drug use (IDU) and incarceration. Women prisoners are at additional risk for viral hepatitis as a consequence of being more likely to be drug users and engaging in commercial sex work. This article reviews the following issues associated with viral hepatitis in prisoners: epidemiology; transmission; managing comorbid conditions; and institutional constraints, including prison policies and practices, prevention, and the role of educational programs and issues surrounding the transition of prisoners to a community setting.
By 2002, 6 million people in the United States lived under the jurisdiction of the criminal justice system, and 2.1 million were in jail or prison. The United States imprisons its population at the highest known rate in the world, at 686 per 100,000. In 1998, 11.5 million people were released from jails and prisons to communities in the United States. These figures, which increase daily, indicate the country"s devotion to a formidable social policy of imprisonment, and the huge public health impact of prisoners" health on the community at large. Prison populations have multiplied in recent decades, primarily because incarceration has been the central tactic of the "war on drugs" in the United States. The millions of intermittently incarcerated people in America, many of whom are illicit drug users, are among the most difficult people to reach with critical health information (1, 2, 30.
Persons incarcerated in correctional systems have a disproportionately greater burden of infectious diseases, including infections with hepatitis viruses and other infections of public health importance (eg, HIV, sexually transmitted disease, and tuberculosis) [4**]. Recent estimates indicate 12% to 39% of all Americans with chronic hepatitis B virus or hepatitis C virus (HCV) infections were released from prison during the previous year [4**].
The significance of including incarcerated populations in community-based disease prevention and control strategies is now recognized by public health and correctional professionals [5, 6]. Improved access to medical care and prevention services for incarcerated populations can benefit communities by reducing disease transmission and medical costs [7, 8, 9, 10, 11]. Inmates who participate in health-related programs while incarcerated have lower recidivism rates and are more likely to maintain health-conscious behaviors . Finally, because incarcerated persons have a high frequency of infection with hepatitis viruses, community efforts to prevent and control these infections require inclusion of the correctional population [12, 13, 14]. The implementation of preventive health programs for incarcerated persons, however, faces substantial challenges.
Epidemiology of HCV in Correctional Settings
Hepatitis C virus is the most common of the chronic blood-borne infections in the United States . HCV is primarily transmitted parenterally, yet sexual transmission does occur. Because HCV is associated with IDU, the prevalence of HCV is higher in geographical sites where IDU is more frequent (eg, the Northeast). Therefore, it is not surprising that the prevalence of HCV among prisoners in these regions is high, with a significant number of inmates who are coinfected with HIV. It is estimated that the prevalence of HCV in state and federal correctional facilities is between 16% to 59%; rates vary by geographic region, method of screening, and year of data collection (Fig. 1) [16, 17, 18, 19, 20]. This rate is significantly greater than found within the general US population (1.8%) [21**], and in other countries [22, 23].
This high HCV prevalence in correctional facilities results in approximately 30% of all released prisoners having HCV infection, making prisons important sites for detection and treatment of this disease. The prevalence of HCV among female prisoners, similar to the increased HIV prevalence among incarcerated women, ranges from 35% to almost 50%, likely due to the increased risk behaviors associated with IDU and commercial sex work. Unlike the case for HIV, the prevalence of HCV among African-American persons is lower than found among white persons in one prison system in Texas . This is atypical, however, because most reports of HCV infection occur in men aged 30 to 49 who are members of a racial minority .
Screening for HCV
The period of incarceration provides an important window of opportunity to diagnose and educate those at risk for HCV infection. The Centers for Disease Control (CDC) has recently published recommendations on the prevention and control of hepatitis viral infections in correctional settings, which begins with increased screening efforts . This has resulted in increased interest by correctional administrators and physicians to determine how to better manage HCV in the correctional environment . Unfortunately, this interest has not been implemented in correctional settings, due to the lack of expertise and resources to pay for treatment. The identification of infected individuals has the potential to reduce subsequent transmission in the community through the provision of treatment and risk-reduction counseling.
Screening for liver disease due to HCV infection and determining who should undergo treatment, although recommended by the CDC, has not been adopted by all correctional systems in the United States. Some states have adopted routine HCV screening for all prisoners (eg, Indiana), whereas others have adopted a targeted approach using known risk factors (eg, Wisconsin). The CDC currently recommends routine screening for HCV among prisoners who meet the following criteria: 1) have ever used injection drugs; 2) have received clotting factor concentrate before 1987; 3) have ever received long-term hemodialysis; 4) have evidence of chronic liver disease, including persistently elevated hepatic transaminases; 5) have received a transfusion of blood or blood components or transplant before 1992; and 6) anyone with documented HIV infection . The Federal Bureau of Prisons guidelines also recommend routine screening for inmates who received tattoos or body piercing while incarcerated . Virginia has implemented a management strategy and actively offers HCV antibody testing for all inmates, followed by HCV-RNA confirmation of infection and liver biopsy. Only patients with stages 2 through 4 liver disease are offered treatment. According to official estimates, Virginia saves almost $125,000 per 100 patients using this algorithm . Liver biopsies are recommended for all genotype-1 HCV-infected patients. Because genotypes 2 and 3 have a markedly higher rate of response and often require a shorter duration of treatment, treatment is often offered without liver biopsy.
Despite the very recent recognition of the epidemic, available information suggests that the HCV epidemic among the incarcerated is decades old. Data from liver biopsies in several correctional systems (including Virginia  and Louisiana ) show that many patients already have advanced fibrosis and cirrhosis, consistent with long-standing infection. In other facilities, HCV infection has emerged as a leading cause of in-custody death (Reiger, Personal communication) . End-stage liver disease is now recognized as the leading cause of death in HIV-infected populations, especially in those patients who are responsive to highly active antiretroviral therapy . Given the prevalence of HCV in corrections and considering projections from the CDC regarding anticipated cases of cirrhosis, end-stage liver disease, and hepatocellular carcinoma, correctional communities should anticipate rising morbidity and mortality from HCV-related disease in the near future. At a minimum, correctional facilities should have a systematic plan for screening based on risk factors and disease prevalence in the facility. Such plans must incorporate standardized assessments of risk that include a combination of risk behavior questions and routine testing of hepatic transaminases.
Evaluation of HCV Infection
Evaluation and treatment of HCV in correctional settings should be consistent with the community standard of care. Correctional settings have been slow to respond to the challenges set by local communities because of inadequate funding and expertise . The first challenge is for correctional settings to develop treatment guidelines. In recognition that HCV is typically a slowly progressive disease, a number of issues unique to correctional settings must be considered during the development of treatment guidelines, which are summarized in Table 1.
Table 1. Essential Elements in treatment guidelines for Correctional Settings
--Persistent AST/ALT elevated for at least 6 months with detectable HCV RNA
--Rule out etiologies of liver disease (eg. Hemochromatosis, autoimmune hepatitis, wilson's disease, and so forth)
--Stability of other chronic illnesses (eg, CD4 >200 with low HIV RNA [ideally <50 copies/ml])
--Otherwise medically stable:
Albumin >3.5 mg/dL with INR <1.2
Creatinine <1.5 mg/dL
Normal thyroid studies
--Pretreatment mental health screening with evidence of stable mental health
--sufficient prison sentence to obtain liver biopsy (about 3 months) and complete treatment while incarcerated:
9 months for genotypes 2 & 3
15 months for all other genotypes
--Inmate motivated to defer early-release programs (eg, halfway houses, parole) until treatment has been fully completed
--Inmate willingness to be transferred to another prison where physician and nursing expertise in treating HCV is available
--Willingness of inmate to enroll in prison-based drug treatment programs, if readily available
--Linkage to community drug treatment programs and opiate agonist treatment (eg, buprenorphine or methadone) upon release to reduce recurrence of substance use and reinfection with HCV
Typically, there should be demonstration of elevated transaminases separated by 6 months or more during the current or previous incarcerations. This is particularly true because transaminases ordered upon incarceration may reflect recent alcohol or illicit drug use that typically improves if it is not HCV related. At a minimum during this time period, vaccination for hepatitis A virus and hepatitis B virus should be completed per national treatment guidelines. Adequate time to complete HCV treatment within the correctional setting is essential. Treatment is unlikely to be completed after release to the community because health insurance entitlements are often not available immediately after release and could result in lapses in therapy.
Current guidelines suggest 6 months of treatment for genotypes 2 and 3 and 12 months for all other genotypes in HCV-monoinfected patients. To allow adequate time for biopsy, a prisoner should have at least 9 months of confirmed confinement for genotypes 2 and 3 and 15 months for all other genotypes. Because treatment should be completed while within the correctional system, inmates should also be voluntarily ineligible for early release programs until the full treatment has been completed. This would include deferring parole or transfer to a halfway house or drug treatment program until HCV treatment is completed. When possible, the correctional setting should make effective drug treatment programs available while incarcerated. However, correctional-based drug treatment programs are not widely available and, therefore, completion of such programs should not be a requirement for HCV treatment. Lastly, the correctional setting should, wherever possible, establish linkages to drug treatment programs in the community (including opiate agonist treatment programs such as methadone maintenance and buprenorphine treatment) to reduce relapse to substance use and reinfection with HCV.
The high prevalence of mental illness among prisoners in general , and among drug users specifically , requires pretreatment screening and treatment for any unstable mental illness before initiating therapy. This should be accomplished before considering liver biopsy. Mental illness, particularly depression, may develop or exacerbate during treatment with interferon and should be routinely followed during treatment [36, 37].
Another consideration for treatment protocol development is the availability of appropriate levels of health care. Some correctional facilities have 24-hour medical coverage, whereas others may have only minimal health care services. Although patients in the community are treated in the outpatient setting, due to healthcare liability, patients being treated for HCV should be housed where there is adequate access to skilled providers throughout the course of treatment.
Coinfection with HIV and HCV
Coinfection with HCV has important implications for the management of HIV. Although chronic HCV infection results in progression to cirrhosis in approximately 10% per decade of infection among individuals not infected with HIV, patients coinfected with both viruses are likely to progress to end-stage liver disease and death as rapidly as 7 years [38, 39]. End-stage liver disease due to HCV is now recognized as the leading cause of death in HIV-infected persons in the general community, as well as in many custody-related deaths . Therefore, it is now recommended to actively assess all HIV-infected persons for HCV infection and treat if appropriate.
Although HIV infection is not a contraindication for treatment of HCV, the use of pegylated interferon and ribavirin may complicate treatment with antiretroviral therapy with adverse events, such as transaminitis with fulminate hepatic failure, anemia, thrombocytopenia, neutropenia, drug-drug interactions (eg, ribavirin and didanosine), and weight loss. Furthermore, interferon can exacerbate comorbid psychiatric diseases including depression, a common co-occurring disorder among HIV-infected prisoners. This can cause difficulty with adherence to both therapies and potentially increase morbidity if there is not a rigorously controlled program instituted in each correctional facility to provide appropriate screening and follow-up care of coinfected inmates. In correctional systems that provide mental health treatment, coordination of treatment of HCV-infected persons with mental health problems should be carefully integrated.
Treatment of HCV Infection
Few data are available for the treatment of HCV in correctional settings. In the Rhode Island Department of Corrections, 90 HCV-monoinfected patients were treated with directly observed standard interferon alfa-2b (3 MIU three times a week) and ribavirin (dosage based on weight) from 1997 to 2001 [21**]. Only 17 (19%) had the more responsive genotypes 2 or 3. Efficacy was determined by measurement of HCV RNA 6 months into treatment. Fifty-five percent (50/90) of the patients completed treatment; 72% of these (39/50) had an undetectable HCV-RNA level at end of treatment; and 34% (17/50) had an undetectable HCV-RNA level at 1 year after the end of treatment. The current accepted treatment of hepatitis C in mono- and coinfected adults in the community is pegylated interferon plus ribavirin for 6 to 12 months of therapy . Unfortunately, there are no current data on the use of pegylated interferon and ribavirin in correctional settings.
The major reason that HCV infection has not been treated systematically in correctional settings has been the concern about the lack of available expertise in the correctional setting, costs for treatment, and potential toxicity of treatment of coinfected patients among a group already with significant comorbidity from HIV and mental illness, both of which may result in increased complications with therapy and decreased benefit. It is incumbent on the leaders in the area of correctional health care to develop appropriate guidelines and expertise for the treatment of HIV- and HCV-infected patients in this structured settings, where patients are often free from active drug use and have universal access to medical and mental health services.
The Role of Correctional Institutions in Preventing HCV Infection
One of CDC"s national strategies to prevent HCV infection includes the prevention of HCV transmission during high-risk activities (eg, IDU and unprotected sex with multiple partners) through risk-reduction counseling, testing, and appropriate medical management of infected persons. Primary prevention is directed at lowering the incidence of HCV infection. Of the estimated 25,000 to 40,000 persons newly infected with HCV annually during the past 5 years, approximately 60% acquired their infection through IDU . Because no vaccine exists to prevent HCV infection, prevention must focus on risk reduction through counseling of persons who have admitted to or are at risk for illicit drug use or high-risk sexual practices. Counseling and testing to prevent HCV infection should be conducted in settings where persons at high risk are identified, including correctional health programs . Prisons, with their structured environment, are ideal settings to educate and initiate risk-reduction interventions. To be effective, risk reduction among this population often requires a multidisciplinary approach to address drug use, as well as other medical, psychological, social, vocational, and legal problems . Understanding that IDU is the main mode of HCV transmission, risk reductions are not limited to, but may include, the provision of and linkage to effective drug treatment programs, including opiate agonist therapy with either methadone maintenance or buprenorphine for prisoners with opiate dependence or abuse [43*]. The high prevalence of HCV infection and risk associated with HCV infection among inmates requires inclusion of HCV prevention activities in correctional settings. These types of programs would be effective for both primary and secondary prevention efforts.
Health Education and Release Planning
Health education directed toward prevention of viral hepatitis includes information related to the disease, routes of transmission, risk factors for infection, methods of prevention, disease outcomes, and treatment options. Such information does not promote risk taking, but rather educates the inmate on how to prevent the transmission of viral infections to other individuals or how to protect the inmate from acquiring such infections.
During incarceration, numerous educational opportunities exist (eg, at entry, or in HIV education and other classes). Education can take different forms, including videos, brochures, and formal classroom presentations. However, repeated face-to-face sessions have been determined the most effective means with the highest retention [44, 45, 46]. Model programs use peer health educators in workshops for incoming inmates, and community educators to discuss risk assessment, risk reduction, and referrals for soon-to-be-released inmates.
Health education programs that focus on primary prevention of HCV should include discussion of hepatitis A and B prevention, hygiene practices, and the significance of vaccination for persons at risk for infection. Curricula addressing HCV infection include information concerning the modes of transmission and means for prevention, and information about hepatitis A and B vaccination and risk reduction. Such information can also be incorporated into health education programs for the prevention of HIV and AIDS. Integrating risk-reduction interventions would be cost-effective and serve a dual purpose.
The identification of HCV-infected persons is required to initiate secondary and tertiary prevention activities to reduce the risks for HCV transmission and chronic liver disease . HCV-infected persons require further evaluation for chronic HCV infection and liver disease, and persons with chronic hepatitis C require evaluation for possible antiviral therapy and the need for further medical management. Treatment of HCV infection is one of many ways to implement secondary and tertiary prevention.
Persons at risk for HCV infection or those chronically infected with HCV can benefit from health education on topics that include 1) substance-abuse treatment where appropriate, with or without opiate agonist therapy (eg, methadone or buprenorphine), 2) clean needle and syringe use, 3) risks of sharing drug paraphernalia, and 4) condom use. Counseling and educational materials should include information concerning reducing further liver damage, as well as treatment options for those with chronic liver disease. Release planning should include substance-abuse treatment referrals for IDUs and medical referrals to specialists for future medical management and treatment.
Release planning for inmates with chronic medical conditions has gained increasing acceptance as a new component of health care management for incarcerated persons. The majority of medical release and discharge planning programs in prison facilities have focused on HIV aftercare [47, 48, 49, 50], but management of other chronic infections can result in the same beneficial outcomes. Comprehensive release planning includes transitional housing, continued access to discharge medications and immunizations, and coordination and case-management of long-term specialized care for persons with chronic conditions.
Hepatitis C virus infection is common among inmates in correctional settings, especially in demographic areas with a high prevalence of IDU. Correctional facilities offer an excellent opportunity to screen individuals for HCV infection. Screening provides a basis for further risk reduction through identification of individuals with or at risk for HCV infection. Risk reduction can begin with teaching inmates about the importance of reducing or eliminating alcohol and illicit drug use. For those unable to adhere to abstinence, condom use and safe injection practices (eg, using sterile injection equipment) should be integrated into such programs. Such information does not promote risk taking, but rather educates the inmate on how to prevent the transmission of viral infections to other individuals or how to protect the inmate from acquiring such infections. Finally, screening for HCV allows for the provision of treatment. HCV is potentially a curable infection. The provision of treatment for HCV to the correctional population affords an opportunity to provide secondary prevention throughout a community. The fewer individuals infected with HCV, the fewer who are able to transmit the infection to others through IDU and sex. It is through comprehensive risk-reduction counseling and the provision of treatment of HCV infection that public health will be promoted at a societal level.
References and Recommended Reading
Recently published papers of particular interest have been highlighted as:
* Of importance
** Of major importance
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