Part One
ACCP Position on Hepatitis C Infection
It is estimated that between 15-40% of inmates incarcerated in in the United States have chronic hepatitis C infection (HCV), compared to 1-2% of the general population. Over time, HCV can lead to complications of end-stage liver disease, including cirrhosis, liver transplantation, cancer, and death. Direct Acting Anti-viral agents (DAAs) used to treat HCV are highly effective in eradicating HCV infection and preventing the progression of liver disease in most patients. When used appropriately, DAAs have minor, if any, side effects. Unfortunately, barriers to treatment remain both in corrections and in the community, including inadequate financial support, shortages of medical resources and incarceration periods too short to allow the full process of diagnosis, staging and treatment.
Correctional facilities (including prisons, jails and juvenile facilities) offer unique opportunities to identify and treat patients with HCV, housing a subset of patients that have proven nearly impossible to reach in the community due to homelessness, mental illness, substance abuse, lack of medical coverage and other factors. Beside achieving the best patient outcome, treating the HCV-infected population is also important from a public health perspective by reducing transmission of the Hepatitis C virus from infected to uninfected individuals.
The American College of Correctional Physicians (ACCP) believes that all prison inmates should be screened for HCV unless the patient declines (“opt-out” testing). Screening should include, at least, an HCV antibody test with a reflex HCV viral load when reactive. Since most jail patients are released back into the community before screening and treatment can be accomplished, ACCP encourages jails to form a partnership with their local public health agencies to offer HCV screening to jail patients and to mobilize community resources for those found to be infected.
Because of the medical and public health benefits of HCV treatment, the ACCP agrees with the recommendations of the AASLD/IDSA (www.hcvguidelines.org) that all patients with HCV should be treated, with few exceptions, whether in the community or in a correctional facility. At this time, the evidence-based practice of HCV treatment regardless of hepatic fibrosis stage leads to the best clinical outcomes known to date for morbidity, mortality, and cost-effectiveness.
ACCP believes that prison systems should establish a multidisciplinary HCV committee to incorporate the evidence-based standard of care into treatment plans for patients, similar to hospital tumor boards. Ideally, the committee should be chaired by an Infectious Disease specialist or Hepatologist and include a correctional physician, correctional nurse, pharmacist, a security administrator and other members as deemed advisable. When creating treatment plans for individual patients, the committee would consider the stage of liver disease, comorbid conditions (such as Hepatitis B and HIV), available resources, expected length of incarceration, and the willingness of the patient to adhere to institutional and treatment protocols. Patients entering a correctional facility already receiving treatment for HCV should have their treatment completed, if possible.
ACCP strongly encourages federal, state and local governments to provide adequate funds to their correctional facilities for the screening, staging and treatment of all incarcerated patients with HCV. ACCP believes that all state and federal agencies should practice the same standard of care for HCV patients, whether incarcerated or in the community.
Part Two
ACCP Position on the Funding of Hepatitis C Treatment
Because of the medical and public health benefits of HCV treatment, it is the position of the American College of Correctional Physicians (ACCP) that all patients with chronic Hepatitis C infection (HCV) should be treated, with few exceptions, whether in the community or in a correctional facility (ACCP Position Paper on Hepatitis C Infection).
The most important barrier to accomplishing this goal has been a lack of sufficient funding for HCV treatment from many state legislatures, the Federal Government and others responsible for inmate medical care. ACCP believes that these funding agencies have an ethical responsibility to fund treatment for HCV infection. There is compelling medical, public health, legal and fiscal evidence to support treatment of inmates with HCV infection.
HCV is caused by a virus that, over time, causes progressive liver disease, often leading to liver failure, hepatic cancer, liver transplantation and death. Treatment of HCV infection using Direct Acting Antiviral agents (DAAs) results in complete eradication of the virus over a few weeks with minimal, if any, side effects in well over 90% of patients. Research has shown that HCV treatment with DAAs reduces mortality and morbidity at all stages of the disease. Based on the fact that we have a well-tolerated cure for a serious disease, there is unanimous agreement among various medical societies that all HCV patients (with few exceptions) should be offered this therapy.
Hepatitis C is a communicable disease. Untreated HCV patients transmit HCV to other people. Eradicating the virus in patients who have HCV will prevent these individuals from transmitting the disease to others. Since the incidence of HCV infection is much higher in incarcerated inmates (15-40%) versus the general public (1-2%), jails and prisons are an ideal place to find HCV patients through routine screening, to supervise their treatment and to verify virologic cure. Successfully treated HCV patients will then not infect others when released from jail or prison.
The Courts have long established that incarcerated inmates have a right to medical care of serious medical conditions. More recently, class action lawsuits have been filed in many states arguing that failing to treat HCV infections is a violation of inmate rights. These have generally been successful in forcing states to treat more inmates for HCV infection.
The cost of treating HCV with DAAs has fallen markedly since DAAs were first introduced. The evidence shows that treating incarcerated inmates with DAAs will save money in the long term by preventing the complications of progressive liver disease, cancer, liver transplant and end of life care (https://www.hcvguidelines.org/evaluate/cost). Also, treating inmates with HCV now will reduce substantial legal costs by avoiding needless defense of inevitable lawsuits. In addition, some jails and prisons have been able to negotiate even lower prices by participating in pharmaceutical supplier contracts.
Underfunding HCV treatment also puts correctional medical professionals in a position of having to ration medical care. It is unethical and wrong for those funding correctional health care to require correctional physicians to make such decisions. Correctional practitioners are not asked to do such rationing for other chronic disease states such as HIV or cancer.
The American College of Correctional Physicians strongly encourages full funding of treatment for inmates with chronic Hepatitis C infection.
