All around the world, people in prisons are at high risk for contracting the hepatitis C virus (HCV). But for most, screening, testing and curative treatment are unavailable or inaccessible. Awareness is rising: In recent months, global headlines—including stories in the Guardian, the New York Times, Dawn and Stat—have highlighted this alarming situation and urgent need. The public interest is welcome, if overdue, to those of us working to reduce the harms.
There is a clear moral imperative to provide health care to people in prisons. What’s more, lack of access to HCV care in prisons threatens to derail worldwide efforts to eliminate the disease.
In 2016, the World Health Organization set global goals for HCV elimination. But so far, only about one in five people who have hepatitis C have been diagnosed, and only 13 percent of those living with HCV have received treatment. As countries develop national HCV elimination strategies, seeking to scale up access to testing and treatment, a cornerstone of their programs must be reaching everyone in need—and people who are incarcerated must be central to these plans.
A key tenet of disease elimination is health equity. Hepatitis C elimination cannot be achieved unless everyone is able to benefit from its promise.
Hepatitis C rates among people in prisons are among the highest in the world: up to 10-to-25 times higher than in the general population.* The blood-borne virus is most often transmitted through sharing of injecting equipment in drug use—in the absence of access to sterile supplies. Left untreated, chronic hepatitis C can lead to severe health consequences, including liver damage, cirrhosis (liver scarring), liver cancer and death.
Safe oral medications, taken for two or three months, cure over 95 percent of people treated. Unfortunately, people in prison often face the greatest obstacles to accessing this lifesaving treatment. Barriers include lack of policies for testing and treatment, lack of financing for HCV care in prisons, low awareness of effective HCV testing and treatment strategies in these settings, and biases against incarcerated people in general and people who inject drugs in particular.
A key tenet of disease elimination is health equity. Hepatitis C elimination cannot be achieved unless everyone is able to benefit from its promise. The ideals known as the “Mandela Rules,” which have been adopted by the UN as a global standard, state that human rights for people who are incarcerated should be equivalent to everyone else. Denying access to HCV medicines in prison settings may be against local laws in some cases; in all cases, it is a clear violation of human rights.
In October 2022, to develop a roadmap for concerted global action on expanding HCV care in prisons, INHSU Prisons (a Special Interest Group of the International Network on Health and Hepatitis in Substance Users) and the Coalition for Global Hepatitis Elimination (CGHE, a program of the Task Force for Global Health), convened a workshop. Held in Glasgow, Scotland, it was a satellite meeting alongside the 10th International Conference on Health and Hepatitis Care in Substance Users.
Providers, community advocates, researchers and people with lived experience of hepatitis C and/or prison came together. We sought both to identify the most pressing real-world barriers to the provision of prison-based HCV care, and to share practicable solutions to overcome them.
Many people’s lives and health depend on our continuing, urgent attention to this issue.
The global recommendations proposed in this workshop have now been compiled in a new report: “Expanding Access to hepatitis C prevention, testing and treatment in prisons: Recommendations from the 2022 INHSU Prisons Workshop.”
The final report offers 10 recommendations to expand access in prison settings. They’re geared at policymakers and those involved in the implementation of HCV testing and treatment services.
These recommendations include:
* Invest in strong surveillance systems that track the number of HCV infections, persons screened, and persons treated for HCV in prison setting
* Adopt routine, opt-out HCV screening policies upon entry to prison settings and invest in person-centered training for staff
* Expand needle-syringe exchange and opioid agonist therapy programs within prison settings to reduce transmission of HCV and other blood-borne infections
* Set global, national, and local targets for HCV screening and treatment in prison settings and track progress
* Implement point-of-care HCV testing, reflex HCV RNA testing, peer navigation programs, rapid treatment initiation initiatives, and linkage to care programs postrelease to ensure all persons progress along the cascade of care to cure
* Expand HCV prescribing beyond specialists in prison settings
* Explore innovative financing approaches to ensure access to HCV treatment in prison settings
* Present economic, public health, human rights, and legal cases to policymakers and prison officials for financing HCV care for persons who are incarcerated
* Address stigma and discrimination through investing in strong patient advocacy, peer navigators, and prison staff education and training
* Spread the message that “prison health is community health” and prison-based HCV testing and treatment is a key determinant of national HCV elimination
The recommendations are based on real-world experiences shared by a global network of contributors with lived experience, along with researchers, clinicians and community advocates. The full workshop report features a summary of the presentations, discussions, and case studies informing the recommendations, and is available on the CGHE website.
The report will be a novel resource to support global and local efforts for scaling up HCV prison initiatives, with case studies on addressing challenges in a wide range of settings, from countries at all income levels—including both those with no access to HCV treatment in prisons and those with established programs looking to improve.
The Coalition for Global Hepatitis Elimination and INHSU Prisons will continue to promote HCV elimination among people who are incarcerated and share data and experiences on progress happening around the world. Many people’s lives and health depend on our continuing, urgent attention to this issue.
*Larney et al., 2013; Dolan et al., 2016; Moradi et al., 2018; Salari et al., 2022
To learn more about the Coalition for Global Hepatitis Elimination, visit its website or contact firstname.lastname@example.org. To learn more about INHSU and INHSU Prisons, visit their website or contact email@example.com.