Prison officers' views about hepatitis C testing and treatment: a qualitative enquiry

Development of an evidence-based hepatitis C education program to enhance public health literacy in the Australian prison sector: The Hepatitis in Prisons Education program (HepPEd)

BACKGROUND

Australia's prisons have a high chronic hepatitis C (HCV) prevalence (8 %). Antiviral therapies and prison-based hepatitis services are available, but only a minority of those eligible are being treated. Improving the HCV public health literacy of the prison sector via targeted education may overcome key barriers to scale-up treatment. This paper describes the: i) HCV public health literacy of the prison setting; ii) barriers and solutions for HCV education and service engagement; iii) HCV education program co-design and development processes; and iv) HepPEd resources.

METHODS

A national needs assessment was conducted to analyse the HCV public health literacy of the target audience groups in the prisons (healthcare providers; custodial officers; people in prison) to inform development of a prison-specific HCV education program (HepPEd). Structured interviews were conducted with key informants (n = 40). Three National Steering Committees, one for each target group, were convened to co-design and develop HepPEd.

RESULTS

Only healthcare providers involved with hepatitis care were considered to have 'good' to 'very good' HCV health literacy (including knowledge, attitudes, and capabilities), with all other groups considered less favourably. Key barriers identified included being time poor (healthcare providers), poor motivation (custodial officers) and stigma (people in prison). Peer education delivery was considered a key facilitator for custodial officers and people in prison. A suite of multi-modal resources addressing the perceived gaps in HCV health literacy was developed, with a broad theme of 'Let's talk about hep C'. Delivery of HepPEd was designed to overcome key barriers and utilise facilitators for each group.

CONCLUSIONS

Significant gaps in HCV health literacy were perceived amongst the target audience groups. The comprehensive co-design and development processes utilised in HepPEd suggest the program will be well-placed to improve the HCV public health literacy of the prison sector and thereby enhance HCV testing and treatment rates amongst people in prison.

Reducing barriers to the hepatitis C care cascade in prison via point-of-care RNA testing: a qualitative exploration of men in prison using an integrated framework

BACKGROUND AND AIMS

Hepatitis C virus (HCV) is highly prevalent within the prison setting. Although HCV testing and treatment are available within prisons, system barriers can impede progress along the HCV care cascade for those who are incarcerated. The PIVOT intervention used a 'one-stop-shop' model (i.e. point-of-care HCV RNA testing, Fibroscan-based liver disease assessment and treatment) at a reception prison in New South Wales, Australia. This analysis sought to understand the role of point-of-care HCV RNA testing at intake in reducing barriers to the HCV care cascade within the male prison setting.

DESIGN AND SETTING

Qualitative analysis using semi-structured interviews in a reception prison in Australia.

PARTICIPANTS

Twenty-four men enrolled in the PIVOT study; all participants had undergone HCV point-of-care testing in the intervention arm.

MEASUREMENTS

Høj's Integrated Framework informed this analysis.

FINDINGS

Participants widely expressed the view that point-of-care HCV RNA testing on entry was beneficial for care engagement. Point-of-care testing was perceived as timely (compared with standard pathology) and reduced opportunities for adjudication by correctional officers due to fewer clinic visits for testing and results. Adoption of routine opt-out testing at prison intake was regarded as an important strategy for normalising HCV testing (and likely to increase pathways to treatment uptake) and fostered patient candidacy (i.e. self-perceived eligibility to access care).

CONCLUSION

Twenty-four men in prison in New South Wales, Australia, who underwent opt-out point-of-care HCV RNA testing on entry into prison, widely supported the programme as a means of overcoming barriers to HCV testing and treatment in the prison setting, as well as providing public health benefits through early detection of HCV infection among people entering into custody.

How do people in prison feel about opt-out hepatitis C virus testing?

The prison population is central to the campaign to eliminate hepatitis C virus as a public health threat. In the UK, this has led to the introduction of a national 'opt-out' policy, requiring people in prison to be tested for HCV unless they decline, with a target to test 75% of those admitted. However, in a representative prison estate in the East Midlands of England (20,000 prison entrants per annum) testing rates were only 13.4%. This qualitative study explains why the rates of test uptake are so far short of target. This qualitative study examines the experiences of 45 people in prison about hepatitis C virus testing in an English category C (low security) prison. The data collection method was semi-structured interviews. The data were coded and analysed according to the research questions, and interpretation of the data was aided by the use of a thematic network approach. The themes Fear, Insufficient Knowledge, Stigma, Privacy, Choice and Prison Life emerged as the principal barriers to test uptake. Test Uptake Facilitators that promoted testing were identified by participants and benefits presented of prison health care being a Health Farm. In order to increase hepatitis C virus test uptake, significant changes and flexibility in the timing, location, and staff deployed to test are required. Providing information to people in prison about hepatitis C virus transmission and treatment may reduce fears and enable the test uptake target to be met and sustained.

Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol)

INTRODUCTION

Hepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV 'Treatment as Prevention' (TasP) in PWID.

METHODS AND ANALYSIS

We plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome - chronic HCV prevalence in PWID - is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a 'virtual cohort' of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes.

ETHICS AND DISSEMINATION

Extending HCV community care pathways is covered by ethics (ERADICATE C, ISRCTN27564683, Super DOT C Trial clinicaltrials.gov: NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.

Testing for hepatitis C virus infection in UK prisons: What actually happens?

Prisons are a key demographic in the drive to eradicate hepatitis C virus (HCV) as a major public health threat. We have assessed the impact of the recently introduced national opt-out policy on the current status of HCV testing in 14 prisons in the East Midlands (UK). We analysed testing rates pre- and post-introduction of opt-out testing, together with face-to-face interviews with prison healthcare and management staff in each prison. In the year pre-opt-out, 1972 people in prison (PIP) were tested, compared to 3440 in the year following opt-out. From July 2016 to June 2017, 2706 people were tested, representing 13.5% of all prison entrants (median 16.6%, range 7.6%-40.7%). Factors correlating with testing rates were as follows: pre-admission location of the PIP (another prison or the community, OR 2.2, 95% CI 1.9-2.3, P < 0.001); whether the PIP could access health care independently of prison officers (OR 1.7, 95% CI 1.5-1.8, P < 0.001); the absence of out-reach services for HCV treatment (OR 1.3, 95% CI 1.2-1.5, P < 0.001), whether >50% of PIP reported ease of access to a nurse (OR 2.0, 95% CI 1.8-2.2, P < 0.001), and whether prison health care was supplied by private or NHS providers (OR 1.3, 95% CI 1.2-1.5, P < 0.001). Testing rates remained far below the minimum national opt-out target of 50%. Inadequacy of healthcare facilities and constraints imposed by adherence to prison regimens were cited by healthcare and management staff at all prisons. Without radical change, the prison estate may be intrinsically incapable of supporting NHSE to deliver the HCV elimination strategy.

Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review

BACKGROUND

Prisons represent a unique opportunity to diagnose blood-borne viruses. Opt-out testing is receiving increasing interest, as a result of mounting evidence to suggest that the manner in which a test offer is delivered, affects test uptake. Although the effectiveness of opt-out testing within the prison setting has been established, robust explanations are required for the variation in outcomes reported.

METHODS

Rapid-realist review methodology was used to synthesise the literature on prison-based opt-out testing. The review was carried out in three phases. Phase one: An expert panel provided literature relevant to the implementation of opt-out testing within the English prison estate. Unstructured searches were also conducted to identify other social programmes where "opt-out" had been used to increase uptake. Phase two: a systematic search of six peer-review and five grey literature databases was carried out to identify empirical data on opt-out testing within the prison setting. Phase three: Additional non-exhaustive searches were carried out to identify literature that reinforced emergent concepts. The development of programme theory took place with each iteration and was validated in consultation with stakeholders.

RESULTS

Programme theory was constructed for two outcomes: the proportion of intake offered a test and the proportion offered that accepted testing. The proportion of intake offered testing was influenced by the timing of the test offer, which was often delayed due to barriers to prisoner access. The decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner's personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer.

CONCLUSIONS

This review identified important implementation considerations that moderate the effectiveness of opt-out testing programmes. It also highlighted a lack of appreciation for the theoretical underpinnings of opt-out programmes and tension around how to implement testing in a manner that adheres to both default theory and informed consent. It is anticipated that results will be used to inform the design and implementation of subsequent versions of these programmes, as well as catalyse further in-depth analysis into their operation within the unique context of prison.

REVIEW REGISTRATION

CRD42017068342 .

Increased diagnosis and treatment of hepatitis C in prison by universal offer of testing and use of telemedicine

With recent advances in antiviral therapy, there is an opportunity to eliminate hepatitis C virus (HCV) from the UK population. HCV is common in incarcerated individuals, with previous estimates suggesting ~7% of the UK prison population is anti-HCV antibody positive. Increasing diagnosis and treatment of HCV in prison is a priority in seeking to eliminate transmission in the general population. Thus the study aimed to assess the impact implementation of: (a) A universal offer of blood borne virus testing (UOBBVT) using dry blood spot testing for prisoners at reception to increase diagnosis; (b) Telemedicine clinics (TC) within North East England (NEE) prisons to increase HCV treatment rates. UOBBVT was initially implemented at Her Majesty's Prison (HMP) Durham, commencing March 2016. From March 2016 to February 2017, 2831 of 4280 (66%) new receptions were offered blood borne virus (BBV) testing. Of these, 1495 (53% of offered) accepted BBV testing, of whom 95 (6.4%) were HCV antibody positive, with 47 of those 95 (49.5%) HCV RNA positive, suggesting a prevalence of active infection in the tested population of 3.1% (95% CI 2.4%-4.2%). Between August 2015 and October 2017, 80 individuals were seen in the TC and 57 (71%) commenced antiviral therapy. Of those with known outcome (n = 29), 100% achieved sustained virological response. In the year prior to implementation, only four patients received HCV treatment. In conclusion, a universal offer of BBV testing to inmates presenting at HMP reception coupled with linkage into specialist care via TC can substantially increase rates of testing, diagnosis and treatment of HCV in this high-prevalence population.

Hepatitis C virus screening and treatment in Irish prisons from a governor and prison officer perspective - a qualitative exploration

BACKGROUND

Prisons are a key location to access Hepatitis C Virus (HCV) infected people who inject drugs (PWID). Prison health care structures are complex and optimising health care delivery to this high need, marginalised and underserved population remains challenging. Despite international guidelines recommending that prisons are a priority location for HCV screening and treatment levels of prisoner engagement in HCV care remain low. Competing priorities between security and healthcare is a key feature of prison health care. A collaborative approach to health care delivery in prisons can maximise the benefits for prisoners, staff and the wider community.

AIM

To identify the barriers and enablers to HCV screening and treatment in Irish prisons and inform the implementation of a HCV screening program within the Irish Prison Services (IPS).

METHODS

Qualitative study using focus group methodology underpinned by grounded theory.

RESULTS

The following themes emerged from the analysis: priority of safety and security, staffing and resources, concerns about personal risk, lack of knowledge, concerns around confidentiality, prisoners' fear of treatment and stigma, timing of screening, use of peer workers, in-reach hepatology and fibroscanning services. The primary role of prison security is to ensure the safety of staff and prisoners with a secondary but important supporting role in health care delivery. Maintaining adequate staffing levels and the provision of training and education were seen as priorities and impacted on prison officers' fear for personal safety and risk of HCV transmission. Opt-out screening and peer support workers had high levels of support among participants.

CONCLUSION

Upscaling HCV management in prisons requires an in-depth understanding of all barriers and facilitators to HCV screening and treatment. Engaging prison officers in the planning and delivery of health care initiatives is a key strategy to optimising the public health opportunity that prisons provides.