Opt-out HIV and Hepatitis C Testing at the Dallas County Jail: Uptake, Prevalence, and Demographic Characteristics of Testers

Estimating hepatitis C prevalence in the United States, 2017-2020

BACKGROUND AND AIMS

The National Health and Nutrition Examination Survey (NHANES) underestimates the true prevalence of HCV infection. By accounting for populations inadequately represented in NHANES, we created 2 models to estimate the national hepatitis C prevalence among US adults during 2017-2020.

APPROACH AND RESULTS

The first approach (NHANES+) replicated previous methodology by supplementing hepatitis C prevalence estimates among the US noninstitutionalized civilian population with a literature review and meta-analysis of hepatitis C prevalence among populations not included in the NHANES sampling frame. In the second approach (persons who injected drugs [PWID] adjustment), we developed a model to account for the underrepresentation of PWID in NHANES by incorporating the estimated number of adult PWID in the United States and applying PWID-specific hepatitis C prevalence estimates. Using the NHANES+ model, we estimated HCV RNA prevalence of 1.0% (95% CI: 0.5%-1.4%) among US adults in 2017-2020, corresponding to 2,463,700 (95% CI: 1,321,700-3,629,400) current HCV infections. Using the PWID adjustment model, we estimated HCV RNA prevalence of 1.6% (95% CI: 0.9%-2.2%), corresponding to 4,043,200 (95% CI: 2,401,800-5,607,100) current HCV infections.

CONCLUSIONS

Despite years of an effective cure, the estimated prevalence of hepatitis C in 2017-2020 remains unchanged from 2013 to 2016 when using a comparable methodology. When accounting for increased injection drug use, the estimated prevalence of hepatitis C is substantially higher than previously reported. National action is urgently needed to expand testing, increase access to treatment, and improve surveillance, especially among medically underserved populations, to support hepatitis C elimination goals.

Racial differences in testing for infectious diseases: An analysis of jail intake data

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

Hepatitis C in Black Individuals in the US: A Review

Importance

In the US, the prevalence of hepatitis C virus (HCV) is 1.8% among people who are Black and 0.8% among people who are not Black. Mortality rates due to HCV are 5.01/100 000 among people who are Black and 2.98/100 000 among people who are White.

Observations

While people of all races and ethnicities experienced increased rates of incident HCV between 2015 and 2021, Black individuals experienced the largest percentage increase of 0.3 to 1.4/100 000 (367%) compared with 1.8 to 2.7/100 000 among American Indian/Alaska Native (50%), 0.3 to 0.9/100 000 among Hispanic (200%), and 0.9 to 1.6/100 000 among White (78%) populations. Among 47 687 persons diagnosed with HCV in 2019-2020, including 37 877 (79%) covered by Medicaid (7666 Black and 24 374 White individuals), 23.5% of Black people and 23.7% of White people with Medicaid insurance initiated HCV treatment. Strategies to increase HCV screening include electronic health record prompts for universal HCV screening, which increased screening tests from 2052/month to 4169/month in an outpatient setting. Awareness of HCV status can be increased through point-of-care testing in community-based settings, which was associated with increased likelihood of receiving HCV test results compared with referral for testing off-site (69% on-site vs 19% off-site, P < .001). Access to HCV care can be facilitated by patient navigation, in which an individual is assigned to work with a patient to help them access care and treatments; this was associated with greater likelihood of HCV care access (odds ratio, 3.7 [95% CI, 2.9-4.8]) and treatment initiation within 6 months (odds ratio, 3.2 [95% CI, 2.3-4.2]) in a public health system providing health care to individuals regardless of their insurance status or ability to pay compared with usual care. Eliminating Medicaid's HCV treatment restrictions, including removal of a requirement for advanced fibrosis or a specialist prescriber, was associated with increased treatment rates from 2.4 persons per month to 72.3 persons per month in a retrospective study of 10 336 adults with HCV with no significant difference by race (526/1388 [37.8%] for Black vs 2706/8277 [32.6%] for White patients; adjusted odds ratio, 1.02 [95% CI, 0.8-1.3]).

Conclusions and Relevance

In the US, the prevalence of HCV is higher in people who are Black than in people who are not Black. Point-of-care HCV tests, patient navigation, electronic health record prompts, and unrestricted access to HCV treatment in community-based settings have potential to increase diagnosis and treatment of HCV and improve outcomes in people who are Black.

Effectiveness of interventions to reduce sexually transmitted infections and blood-borne viruses in incarcerated adult populations: a systematic review protocol

OBJECTIVE

This review will identify, synthesize, and make recommendations regarding the effectiveness of interventions to reduce sexually transmitted infections (STIs) and blood-borne viruses (BBVs) in incarcerated adult settings.

INTRODUCTION

High-risk sexual behaviors, intravenous drug use, piercing, and tattooing are well documented within incarceration environments. Despite the World Health Organization's Global Health Sector Strategy on Sexually Transmitted Infections 2016-2021 and the Global Health Sector strategies on, respectively, HIV, viral hepatitis, and sexually transmitted infections for the period 2022-2030, STI rates within adult incarceration environments continue to rise. Identifying and implementing best-practice interventions to prevent and manage STIs and BBVs will aid infection reduction in correctional settings. The review results will inform the development of educational programs, health promotion, and policies and procedures to improve health outcomes for incarcerated populations.

INCLUSION CRITERIA

This review will consider studies in any language from any adult incarceration facility. Studies set in juvenile facilities or detention centers will be excluded. Any intervention for preventing or reducing STI and/or BBV transmission will be included.

METHODS

This review will follow the JBI methodology for systematic reviews of effectiveness. Databases to be searched will include PubMed, CINAHL (EBSCO), Ovid Library, PsycINFO (EBSCO), Cochrane CENTRAL, and Scopus. Two independent reviewers will screen titles and abstracts and assess full-text citations against the inclusion criteria. Methodological quality will be appraised using JBI's standardized critical appraisal instruments. Where possible, studies will be pooled using meta-analysis. Where statistical pooling is not possible, findings will be presented in narrative format. Certainty of evidence will be ascertained using the GRADE approach.

REVIEW REGISTRATION

PROSPERO CRD42022325077.

HCV Microelimination for High-risk Special Populations

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants. This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.

Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic

OBJECTIVES

Nearly 1 in 3 people with hepatitis C virus (HCV) infection pass through the criminal justice system annually; the system is a crucial location for HCV screening, education, and linkage to care. We aimed to (1) determine the prevalence and incidence of HCV antibody positivity and (2) evaluate the demographic characteristics of people with HCV in a large urban jail.

METHODS

We offered universal opt-out HCV testing to any person undergoing a routine blood test at the Dallas County Jail from June 2015 through December 2019 (N = 14 490). We extracted data on demographic characteristics from the electronic medical record and collected data on risk factors from people with HCV antibody positivity. We performed univariate and multivariate analyses.

RESULTS

The prevalence of HCV antibody positivity was 16.7%; the incidence was 13.5 cases per 1000 person-years. HCV antibody positivity was significantly associated with older age (P < .001), female sex (P = .004), non-Hispanic White race versus non-Hispanic Black race (P < .001), and being released to prison versus not (P < .001). Among people born after 1965, those who were HCV antibody-positive were more frequently non-Hispanic White and Hispanic women, whereas among those born in 1965 or before, those who were HCV antibody-positive were more frequently non-Hispanic Black men.

CONCLUSIONS

The high prevalence and incidence of HCV antibody positivity in a large county jail argue for routine, universal HCV testing and prevention counseling in criminal justice settings. Changing demographic characteristics mirror those of the national injection drug use epidemic and shed insight into designing interventions for risk reduction, education, linkage to care, and treatment.

A Cross-Sectional, Retrospective Evaluation of Opt-Out Sexually Transmitted Infection Screening at Admission in a Short-Term Correctional Facility in Alberta, Canada

Incarcerated populations experience higher rates of sexually transmitted infections (STIs) than the general population, alongside inconsistent testing strategies. In response, universal opt-out STIs (chlamydia, gonorrhea, syphilis, and HIV) screening was implemented at admission in a short-term correctional facility in Alberta, Canada, for individuals ≤35 years. A cross-sectional, retrospective evaluation of testing outcomes between March 2018 and February 2020 was completed. Descriptive statistics were used to stratify STIs by gender, age group, and date for univariate analysis. Despite low uptake (31.2%), opt-out screening resulted in high positivity rates (14.9%, 10.8%, 29.5%, and 0.3%, respectively) and treatment completion (93.7%) while capturing a high proportion (52.6%) of asymptomatic cases. Opt-out screening at admission is feasible and can improve STI testing in high-risk individuals experiencing incarceration in Canada.

Diagnosis, Treatment, and Prevention of HIV Infection among Detainees: A Review of the Literature

Detainees are one of the most vulnerable populations to human immunodeficiency virus (HIV). This is mostly caused by the lack of knowledge on the topic among the inmates; the lack of prophylaxis; the high percentage of risky behaviors in jail, such as sexual abuse, unprotected sexual intercourses, and injective drug use; and the generally low perception of the risk of transmission. It has also been observed that the problem does not cease to exist at the moment of release, but it also may be aggravated by the weak support system or the total absence of programs for people living with HIV/AIDS (PLWHA) to avoid discontinuation of antiretroviral drugs. Difficulty in providing housing and jobs and, therefore, a form of stability for ex-detainees, also contributes to none adherence to antiretroviral therapy. Among the detainees, there are also categories of people more susceptible to discrimination and violence and, therefore, to risky behaviors, such as black people, Hispanics, transgender people, and men who have sex with men (MSM). We reviewed the literature in order to provide a more complete picture on the situation of PLWHA in jail and to also analyze the difficulties of ex-detainees in adhering to HIV therapy.

Hepatitis C prevalence in incarcerated settings between 2013–2021: a systematic review and meta-analysis

Background

The introduction of highly effective direct-acting antiviral therapy has changed the hepatitis C virus (HCV) treatment paradigm. However, a recent update on HCV epidemiology in incarcerated settings is necessary to accurately determine the extent of the problem, provide information to policymakers and public healthcare, and meet the World Health Organization's goals by 2030. This systematic review and meta-analysis were performed to determine the prevalence of HCV Ab and RNA in incarcerated settings.

Methods

For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and Web of Science for papers published between January 2013 and August 2021. We included studies with information on the prevalence of HCV Ab or RNA in incarcerated settings. A random-effects meta-analysis was done to calculate the pooled prevalence and meta-regression to explore heterogeneity.

Results

Ninety-two unique sources reporting data for 36 countries were included. The estimated prevalence of HCV Ab ranged from 0.3% to 74.4%. HCV RNA prevalence (available in 46 sources) ranged from 0% to 56.3%. Genotypes (available in 19 sources) 1(a) and 3 were most frequently reported in incarcerated settings. HCV/HIV coinfection (available in 36 sources) was highest in Italy, Estonia, Pakistan, and Spain. Statistical analysis revealed that almost all observed heterogeneity reflects real differences in prevalence between studies, considering I² was very high in the meta-analysis.

Conclusions

HCV in incarcerated settings is still a significant problem with a higher prevalence than in the general population. It is of utmost importance to start screening for HCV (Ab and RNA) in incarcerated settings to give clear, reliable and recent figures to plan further treatment. This is all in the context of meeting the 2030 WHO targets which are only less than a decade away.

Trial registration

PROSPERO: CRD42020162616

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14623-6.

Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis

BACKGROUND

Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035.

FINDINGS

Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control.

INTERPRETATION

Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations.

FUNDING

None.

The Importance of Prisons in Achieving Hepatitis C Elimination: Insights from the Australian Experience

Following the availability of highly effective direct-acting antivirals (DAAs) to treat hepatitis C infection, the uptake of treatment by people living with hepatitis C rose dramatically in high- and middle-income countries but has since declined. To achieve the World Health Organization’s (WHO) 2030 target to eliminate hepatitis C as a public health threat among people who inject drugs, an increase in testing and treatment is required, together with improved coverage of harm reduction interventions. The population that remains to be treated in high- and middle-income countries with high hepatitis C prevalence are among the most socially disadvantaged, including people who inject drugs and are involved in the criminal justice system, a group with disproportionate hepatitis C prevalence, compared with people in the wider community. Imprisonment provides an unrivalled opportunity for screening and treating large numbers of people for hepatitis C, who may not access mainstream health services in the community. Despite some implementation challenges, evidence of the efficacy, acceptability, and cost-effectiveness of in-prison hepatitis treatment programs is increasing worldwide, and evaluations of these programs have demonstrated the capacity for treating people in high numbers. In this Perspective we argue that the scale-up of hepatitis C prevention, testing, and treatment programs in prisons, along with the investigation of new and adapted approaches, is critical to achieving WHO elimination goals in many regions; the Australian experience is highlighted as a case example. We conclude by discussing opportunities to improve access to prevention, testing, and treatment for people in prison and other justice-involved populations, including harnessing the changed practices brought about by the COVID-19 pandemic.

An opt-out approach to hepatitis C virus testing in English prisons: the literature underpinning the policy

BACKGROUND

The World Health Organization's aim to eliminate hepatitis C virus (HCV) infection as a public health threat by 2030 is dependent on testing people. HCV prevalence is higher in prisons, so to increase test uptake an 'opt-out' approach to blood-borne virus testing in English and Welsh prisons was introduced.

AIMS

This literature review examines the evidence behind the introduction of this public health policy.

METHODS

Four healthcare databases were searched for publications between January 2000 and February 2020 on the opt-out approach to blood-borne virus testing in prisons.

FINDINGS

Sixteen studies published between 2009 and 2019 were included. Analysis of their findings showed that an increase in HCV test uptake in prisons occurs when an opt-out approach is used in combination with additional interventions. Contextual differences between UK and US prisons may affect HCV test uptake.

CONCLUSION

An opt-out approach to HCV testing in prisons can increase test uptake as part of a complex of interventions.

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

Heterogeneity in Jail Nursing Medical Intake Forms: A Content Analysis

Despite high prevalence of infectious diseases and substance use disorders in jails, there are limited guidelines for the nursing intake process in this setting. We performed a content analysis of nursing intake forms used at each of the 14 Massachusetts county jails, focusing on infectious disease and substance use disorder. Only 85% of jails offered HIV testing during nursing intake and 50% of jails offered hepatitis C testing. Preventive interventions such as vaccines or pre-exposure prophylaxis therapy were infrequently offered during nursing intake. Screening for substance use disorder was present on the majority of intake forms, but only 23% of intake forms inquired about ongoing medication-assisted treatment for opioid use disorder. The results reflect heterogeneity in nursing intake forms, highlighting missed opportunities for public health interventions.

Validity of Self-Reported Hepatitis C Virus Status Among Criminal Justice-Involved Persons Living With HIV

The prevalence of HIV/hepatitis C virus (HCV) coinfection among justice-involved persons is high. The validity of self-reported HCV status in this population has important public health implications, yet has not been studied. Justice-involved persons with HIV from Washington, DC, were enrolled in a study that investigated a mobile health intervention to support HIV treatment. Self-reported and laboratory-confirmed HCV status was compared. Among 103 participants, chronic HCV prevalence was 13%. Positive predictive value of self-reported positive chronic HCV status was low at 55%, and negative predictive value was 98%. Cohen's kappa statistic was 0.60 for agreement. Two women who reported negative HCV status were found to have HCV.

A multicentre interventional study to assess blood-borne viral infections in Belgian prisons

BACKGROUND

Prevalence data on viral hepatitis B (HBV), hepatitis C (HCV), and HIV infection in prison are often scarce or outdated. There is currently no systematic screening for these blood-borne viral infections (BBV) in Belgian prisons. There is an urgency to assess the prevalence of these BBV to inform policymakers and public healthcare.

METHODS

This was a multicentre, interventional study to assess the prevalence of BBV using opt-in screening in prisons across Belgium, April 2019 - March 2020. Prisoners were tested using a finger prick and BBV risk factors were assessed using a questionnaire. A generalized linear mixed model was used to investigate the association between the various risk factors and HCV.

RESULTS

In total, 886 prisoners from 11 Belgian prisons were screened. Study uptake ranged from 16.9 to 35.4% in long-term facilities. The prevalence of HCV antibodies (Ab), hepatitis B surface antigen (Ag) and HIV Ab/Ag was 5.0% (44/886), 0.8% (7/886), and 0.2% (2/886). The adjusted odds for HCV Ab were highest in prisoners who ever injected (p < 0.001; AOR 24.6 CI 95% (5.5-215.2). The prevalence of detectable HCV RNA in the total cohort was 2.1% (19/886). Thirteen (68.4%) prisoners were redirected for follow-up of their HCV infection.

CONCLUSIONS

Opt-in testing for viral hepatitis B, C and HIV was relatively well-accepted in prisons. Compared with the general population, prisoners have a higher prevalence of infection with BBV, especially for HCV. Systematic screening for these BBV should be recommended in all prisons, preferably using opt-out to optimize screening uptake.

TRIAL REGISTRATION

Retrospectively registered at clinical trials NCT04366492 April 29, 2020.

The global and regional prevalence of hepatitis C and B co-infections among prisoners living with HIV: a systematic review and meta-analysis

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are common among individuals with human immune deficiency virus (HIV) infection worldwide. In this study, we did a systematic review and meta-analysis of the published literature to estimate the global and regional prevalence of HCV, HBV and HIV coinfections among HIV-positive prisoners.

METHODS

We searched PubMed via MEDLINE, Embase, the Cochrane Library, SCOPUS, and Web of science (ISI) to identify studies that reported the prevalence of HBV and HCV among prisoners living with HIV. We used an eight-item checklist for critically appraisal studies of prevalence/incidence of a health problem to assess the quality of publications in the included 48 cross-sectional and 4 cohort studies. We used random-effect models and meta-regression for the meta-analysis of the results of the included studies.

RESULTS

The number of the included studies were 50 for HCV-HIV, and 23 for HBV-HIV co-infections. The pooled prevalence rates of the coinfections were 12% [95% confidence interval (CI) 9.0-16.0] for HBV-HIV and 62% (95% CI 53.0-71.0) for HCV-HIV. Among HIV-positive prisoners who reported drug injection, the prevalence of HBV increased to 15% (95% CI 5.0-23.0), and the HCV prevalence increased to 78% (95% CI 51.0-100). The prevalence of HBV-HIV coinfection among prisoners ranged from 3% in the East Mediterranean region to 27% in the American region. Also, the prevalence of HCV-HIV coinfections among prisoners ranged from 6% in Europe to 98% in the East Mediterranean regions.

CONCLUSIONS

Our findings suggested that the high prevalence of HBV and HCV co-infection among HIV-positive prisoners, particularly among those with a history of drug injection, varies significantly across the globe. The results of Meta-regression analysis showed a sliding increase in the prevalence of the studied co-infections among prisoners over the past decades, rising a call for better screening and treatment programs targeting this high-risk population. To prevent the above coinfections among prisoners, aimed public health services (e.g. harm reduction via access to clean needles), human rights, equity, and ethics are to be seriously delivered or practiced in prisons. Protocol registration number: CRD42018115707 (in the PROSPERO international).

Mothering and Incarceration: A Conceptual Model Supporting Maternal Identity

Current literature expounds on community and personal factors contributing to the rapidly growing number of women involved in the criminal justice system. Contributing factors are complex and interwoven, leaving women with life patterns of trauma exposure, mental illness, and substance use disorders. Consequences of these life patterns and incarceration have a significant impact on maternal role attainment. The conceptual model Mothering and Incarceration organizes the multifaceted life patterns of incarcerated women and the influences on a woman's ability to mother her children during and following incarceration. The model has the potential to provide direction to program developers, researchers, and correctional systems to tailor programs for women. The most significant implication of the conceptual model is ending the intergenerational influences of incarceration on children.

Innovations in Hepatitis C Screening and Treatment

New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.

Opt-out Testing Pilot for Sexually Transmitted Infections Among Immigrant Detainees at 2 Immigration and Customs Enforcement Health Service Corps-Staffed Detention Facilities, 2018

OBJECTIVES

Correctional settings (prisons, jails, detention facilities) provide a unique opportunity to screen for sexually transmitted infections (STIs) among correctional populations with a high prevalence of infection. Immigrant detainees are a distinct and poorly described correctional population. The main objective of this study was to determine the feasibility of a national STI screening program for immigrant detainees.

METHODS AND MATERIALS

We developed an opt-out STI testing program that included electronic health record integration, patient education, and staff member training. We piloted this program from June 22 through August 19, 2018, at 2 detention facilities with different operational requirements and detainee demographic characteristics. We assessed STI test positivity rates, treatment outcomes, estimated cost to conduct testing and counseling, and staff member perceptions of program value and challenges to implementation.

RESULTS

Of 1041 immigrant detainees approached for testing, 526 (50.5%) declined. Of 494 detainees who were tested, 42 (8.5%) tested positive for at least 1 STI; the percentage positivity rates were 6.7% (n = 33) for chlamydia, 0.8% (n = 4) for syphilis, 0.8% (n = 4) for gonorrhea, 0.6% (n = 3) for hepatitis B, and 0.2% (n = 1) for HIV. The estimated cost to detect any STI ranged from $500 to $961; the estimated cost to identify 1 person infected with HIV ranged from $22 497 to $43 244. Forty of 42 persons who tested positive began treatment before release from custody. Medical staff members had positive views of the program but had concerns about workload.

PRACTICE IMPLICATIONS

STIs are prevalent among immigrant detainees. A routine screening program is feasible if operational aspects are carefully considered and would provide counseling, education, and treatment for this vulnerable population.

Addressing Hepatitis C in the American Incarcerated Population: Strategies for Nationwide Elimination

PURPOSE OF REVIEW

The prevalence of Hepatitis C virus (HCV) in the US incarcerated population is disproportionately high, and when inmates with infection are released back into the general population, they play a substantial role in the spread of disease. This review provides support for targeting the jail/prison population to eliminate HCV in the general population. It will also summarize various screening/treatment models to curtail the burden of disease behind and beyond bars.

RECENT FINDINGS

Transitioning from risk-based testing to opt-out testing in prisons/jails would be cost-effective through greater identification of cases and treatment to prevent complications from cirrhosis. Other innovative strategies, such as the nominal pricing mechanism or the "Netflix" DAA subscription model, have the potential to be cost-effective and to increase access to treatment. Addressing HCV in the incarcerated population is a strategy to bring the US closer to successfully eradicating the epidemic. Such findings should incentivize policymakers to implement care models that target this population.

CDC Recommendations for Hepatitis C Screening Among Adults - United States, 2020

Hepatitis C virus (HCV) infection is a major source of morbidity and mortality in the United States. HCV is transmitted primarily through parenteral exposures to infectious blood or body fluids that contain blood, most commonly through injection drug use. No vaccine against hepatitis C exists and no effective pre- or postexposure prophylaxis is available. More than half of persons who become infected with HCV will develop chronic infection. Direct-acting antiviral treatment can result in a virologic cure in most persons with 8-12 weeks of all-oral medication regimens. This report augments (i.e., updates and summarizes) previously published recommendations from CDC regarding testing for HCV infection in the United States (Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rec 2012;61[No. RR-4]). CDC is augmenting previous guidance with two new recommendations: 1) hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of HCV infection is <0.1% and 2) hepatitis C screening for all pregnant women during each pregnancy, except in settings where the prevalence of HCV infection is <0.1%. The recommendation for HCV testing that remains unchanged is regardless of age or setting prevalence, all persons with risk factors should be tested for hepatitis C, with periodic testing while risk factors persist. Any person who requests hepatitis C testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks.

Hepatitis C Virus Prevalence in 50 U.S. States and D.C. by Sex, Birth Cohort, and Race: 2013-2016

Hepatitis C virus (HCV) infection is a leading cause of liver-related morbidity and mortality, and more than 2 million adults in the United States are estimated to be currently infected. Reducing HCV burden will require an understanding of demographic disparities and targeted efforts to reduce prevalence in populations with disproportionate disease rates. We modeled state-level estimates of hepatitis C prevalence among U.S. adults by sex, birth cohort, and race during 2013-2016. National Health and Nutrition Examination Survey data were used in combination with state-level HCV-related and narcotic overdose-related mortality data from the National Vital Statistics System and estimates from external literature review on populations not sampled in the National Health and Nutrition Examination Survey. Nationally, estimated hepatitis C prevalence was 1.3% among males and 0.6% among females (prevalence ratio [PR] = 2.3). Among persons born during 1945 to 1969, prevalence was 1.6% compared with 0.5% among persons born after 1969 (PR = 3.2). Among persons born during 1945 to 1969, prevalence ranged from 0.7% in North Dakota to 3.6% in Oklahoma and 6.8% in the District of Columbia. Among persons born after 1969, prevalence was more than twice as high in Kentucky, New Mexico, Oklahoma, and West Virginia compared with the national average. Hepatitis C prevalence was 1.8% among non-Hispanic black persons and 0.8% among persons of other races (PR = 2.2), and the magnitude of this disparity varied widely across jurisdictions (PR range: 1.3-7.8). Overall, 23% of prevalent HCV infections occurred among non-Hispanic black persons, whereas 12% of the population was represented by this racial group. These estimates provide information on prevalent HCV infections that jurisdictions can use for understanding and monitoring local disease patterns and racial disparities in burden of disease.

Prevalence of Viremic hepatitis C, hepatitis B, and HIV infection, and vaccination status among prisoners in Stockholm County

BACKGROUND

Identification and knowledge of settings with high prevalence of hepatitis C virus (HCV) infection is important when aiming for elimination of HCV. The primary aim of this study was to estimate the prevalence of viremic HCV infection among Swedish prisoners. Secondary aims were to estimate the prevalence of hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV), and the proportion who have received hepatitis B virus (HBV) vaccination.

METHODS

A cross-sectional study of all incarcerated persons (n = 667) at all prisons (n = 9) in Stockholm County was conducted. All prisoners are routinely offered opt-in screening for HCV antibodies (anti-HCV), HCV RNA, HBsAg, anti-HBs, anti-HBc and HIV Ag/Ab at prison in Sweden. Data on the results of these tests and the number of received HBV vaccine doses were collected from the prison medical records. The parameters of HCV RNA, anti-HCV, and occurrence of testing for HCV were analysed in multiple logistic regression models in relation to age, sex and prison security class.

RESULTS

The median age was 35 (IQR 26-44) years, and 93.4% were men. Seventy-one percent (n = 471) had been tested for anti-HCV, 70% (n = 465) for HBsAg and 71% (n = 471) for HIV. The prevalence of anti-HCV, HCV RNA, HBsAg and HIV Ag/Ab was 17.0, 11.5, 1.9, and 0.2%, respectively among tested persons. The proportion of prisoners who had received full HBV vaccination was 40.6% (n = 271) among all study subjects.

CONCLUSIONS

The prevalence of viremic HCV infection among Swedish prisoners in Stockholm County was 11.5%, which is high in comparison to the general population. Therefore, when aiming for the WHO goal of HCV elimination, prisons could suit as a platform for identification and treatment of HCV infection. There is a need to increase testing for blood-borne viruses and to improve vaccination coverage against HBV in Swedish prisons.

Hepatitis C Virus Infection in the Dallas County Jail: Implications for Screening, Prevention, and Linkage to Care

OBJECTIVES

Screening for hepatitis C virus (HCV) infection in jail provides an opportunity to educate and offer care to a high-risk population. We aimed to (1) estimate the prevalence of HCV infection in jail; (2) describe the demographic characteristics, risk factors, and pre-incarceration health insurance status associated with HCV infection; and (3) examine the implementation of HCV screening in jail.

METHODS

We conducted a retrospective analysis of an opt-out HCV screening program with HCV RNA confirmation and patient education at the Dallas County Jail from April 1 through November 2, 2017. We extracted data on test results, demographic characteristics, and release destination from electronic medical records. A nurse navigator recorded data on patient self-reported risk factors and pre-incarceration health insurance status.

RESULTS

Of 4089 incarcerated persons screened, 708 (17.3%) had a positive HCV antibody result. Of these, 641 (90.5%) had an HCV RNA test ordered; 576 (89.9%) had RNA tests completed, of whom 413 (71.7%) had a positive HCV RNA result. Of these 413, 352 (85.2%) received patient education. Half of HCV RNA-positive incarcerated persons (n = 207, 50.1%) were born outside the birth cohort (1945-1965). Among those with HCV infection, commonly reported risk factors were injection drug use (168 of 352; 47.8%) and tattoos (82 of 352; 23.4%). Most incarcerated persons with HCV infection (284 of 350; 81.1%) did not have health insurance. HCV antibody prevalence was higher among incarcerated persons released to prison (232 of 961; 24.1%) than to outside agencies (38 of 403; 9.4%) or the community (178 of 1026; 17.4%).

CONCLUSIONS

Screening for HCV with RNA confirmation in jail provides an opportunity for disease education, transmission prevention, and navigation to HCV treatment. Future efforts should examine post-incarceration linkage to care.

Perspectives on Integrated HIV and Hepatitis C Virus Testing Among Persons Entering a Northern California Jail: A Pilot Study

BACKGROUND

Providing HIV and hepatitis C virus (HCV) testing on an "opt-out" basis is often considered the "gold standard" because it contributes to higher testing rates when compared with "opt-in" strategies. Although rates are crucial, an individual's testing preferences are also important, especially in correctional settings where legal and social factors influence a person's capacity to freely decide whether or not to test. Our study explored factors influencing HIV and HCV testing decisions and individuals' preferences and concerns regarding opt-in vs. opt-out testing at the time of jail entry.

METHODS

We conducted semistructured interviews to explore individuals' previous testing experiences, reasons to test, understanding of their health care rights, HIV and HCV knowledge, and preferences for an opt-out vs. an opt-in testing script.

RESULTS

We interviewed 30 individuals detained in the Santa Clara County Jail at intake. Participants reported that their testing decisions were influenced by their level of HIV and HCV knowledge, self-perceived risk of infection and stigma associated with infection and testing, the degree to which they felt coerced, and understanding of testing rights in a correctional setting. Most preferred the opt-in script because they valued the choice of whether or not to be tested. Participants who did prefer the opt-out script did so because they felt that the script was less likely to make people feel "singled out" for testing.

CONCLUSIONS

Our findings demonstrate that people care about how testing is offered and suggest a need for further research to see how much this influences their decision about whether to test.

Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013-2016

Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged ≥18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.

Hepatitis C elimination: challenges with under-diagnosis and under-treatment

Hepatitis C infection has affected 189 million people globally and more than 4 million in the US. Owing to remarkable advances in the therapeutic sphere, essentially all infected patients can be expected to achieve cure. This provides an unprecedented opportunity to eliminate the risk of complications from hepatitis C and to reduce the spread of the virus to others. To achieve this, a streamlined cascade of care from diagnosis to treatment may be enacted. Although great strides have been made, under-diagnosis and under-treatment remain major hurdles.

Harm reduction and viral hepatitis C in European prisons: a cross-sectional survey of 25 countries

Background

Current estimates suggest that 15% of all prisoners worldwide are chronically infected with the hepatitis C virus (HCV), and this number is even higher in regions with high rates of injecting drug use. Although harm reduction services such as opioid substitution therapy (OST) and needle and syringe programs (NSPs) are effective in preventing the further spread of HCV and HIV, the extent to which these are available in prisons varies significantly across countries.

Methods

The Hep-CORE study surveyed liver patient groups from 25 European countries in 2016 and mid-2017 on national policies related to harm reduction, testing/screening, and treatment for HCV in prison settings. Results from the cross-sectional survey were compared to the data from available reports and the peer-reviewed literature to determine the overall degree to which European countries implement evidence-based HCV recommendations in prison settings.

Results

Patient groups in nine countries (36%) identified prisoners as a high-risk population target for HCV testing/screening. Twenty-one countries (84%) provide HCV treatment in prisons. However, the extent of coverage of these treatment programs varies widely. Two countries (8%) have NSPs officially available in prisons in all parts of the country. Eleven countries (44%) provide OST in prisons in all parts of the country without additional requirements.

Conclusion

Despite the existence of evidence-based recommendations, infectious disease prevention measures such as harm reduction programs are inadequate in European prison settings. Harm reduction, HCV testing/screening, and treatment should be scaled up in prison settings in order to progress towards eliminating HCV as a public health threat.