HCV Management in the Incarcerated Population: How Do We Deliver on This Important Front?

Mixed-methods evaluation of point-of-care hepatitis C virus RNA testing in a Scottish prison

OBJECTIVES

Hepatitis C virus (HCV) poses a global public health threat. Prisons are a focus of prevention efforts due to high infection burdens. Expedition of treatment for incarcerated people is critical, as many are short-term sentenced. We evaluated point-of-care (PoC) HCV RNA testing in a maximum-security Scottish prison and assessed its impact on transition to treatment. We also evaluated costs and determinants of implementation.

DESIGN

Mixed-methods evaluation of a single-centre care pathway pilot using National Health Service (NHS) data from 2018 to 2021. Descriptive statistics and survival analysis were undertaken. Cost analysis was assessed from a provider perspective. Healthcare staff participated in semistructured interviews and thematic analysis with a deductive approach was undertaken to identify implementation determinants.

SETTING

A large maximum-security Scottish prison health centre administered by the NHS.

PARTICIPANTS

296 incarcerated NHS patients (all men) and six NHS staff members (two men and four women).

INTERVENTIONS

HCV testing using the Cepheid GeneXpert platform with Xpert HCV VL Fingerstick assay.

OUTCOME MEASURES

The main outcome was survival (in days) from HCV test to treatment initiation. Secondary outcomes were cost-per-cure obtained and implementation determinants.

RESULTS

During the pilot, 167 Xpert tests were administered, with an 84% completion rate, and treatment transition was superior for those who received it (p=0.014). Where PoC tests were administered, shorter survival to treatment was observed (19 vs 33 days: adjusted HR (aHR) 1.91 (1.03-3.55), p=0.040; 19 vs 50 days; aHR 3.76 (1.67-8.46), p=0.001). PoC was costlier than conventional testing. In qualitative analysis, most facilitators were observed among characteristics of individual domain while most barriers were noted in the inner setting.

CONCLUSIONS

Integrating PoC HCV RNA diagnosis into nurse-led HCV care in a maximum-security prison health centre shortens survival to HCV treatment. However, there are cost implications to this approach and multiple determinants that impact on implementation should be addressed.

Hepatitis C elimination among people incarcerated in prisons: challenges and recommendations for action within a health systems framework

Hepatitis C virus (HCV) is a global public health problem in correctional settings. The International Network on Health and Hepatitis in Substance Users-Prisons Network is a special interest group committed to advancing scientific knowledge exchange and advocacy for HCV prevention and care in correctional settings. In this Review, we highlight seven priority areas and best practices for improving HCV care in correctional settings: changing political will, ensuring access to HCV diagnosis and testing, promoting optimal models of HCV care and treatment, improving surveillance and monitoring of the HCV care cascade, reducing stigma and tackling the social determinants of health inequalities, implementing HCV prevention and harm reduction programmes, and advancing prison-based research.

Telemedicine efficiently improves access to hepatitis C management to achieve HCV elimination in the penitentiary setting

INTRODUCTION

Linkage to care for hepatitis C includes a new tool: teleconsultation. Micro-elimination in prison is a recommendation and is feasible. An economic evaluation of telemedicine for hepatitis C virus (HCV) treatment in prisons has not yet been performed. This study aimed to provide a cost-minimization analysis comparing two strategies of HCV treatment in a prison: telemedicine clinical practice (TCP) and the usual clinical practice (UCP).

METHODS

An observational cost-minimization study was carried out on a cohort of inmates who received anti-HCV treatment in El Dueso prison (May 2016-November 2017). A decision tree was constructed, incorporating different clinical profiles according to the severity of the disease, the results of diagnostic tests, and treatment outcomes as well as the costs of each profile. Satisfaction with telemedicine was evaluated through an 11-question questionnaire with a 5-point Likert scale.

RESULTS

Seventy-five inmates were treated and underwent TCP with a follow-up of one year. The average cost per patient with the TCP strategy was €1,172 (€1,151 direct costs). Had UCP been carried out, the cost would have been €1,687 (€1,630 direct). Telemedicine consultation practice produced savings of €516 (30.6%) per patient, with total savings of €38,677. The transfer costs from prison to hospital represented the most important saving item, accounting for 99.3% of the TCP-related savings. The questionnaire revealed high levels of satisfaction with TCP, with a median score of 5 in each question. Sustained virological response rates were 94.7% after the first treatment and 100% after retreatment of the four relapses.

CONCLUSION

Telemedicine consultation practice is a more efficient strategy than UCP, mainly due to the reduction of transfer costs while preserving effectiveness and user satisfaction.