New opportunities for the management and therapy of hepatitis C in correctional settings

Comparison of effectiveness and discontinuation of interferon-free therapy for hepatitis C in prison inmates and noninmates

Chronic hepatitis C treatment with direct acting antiviral (DAA) therapy during incarceration is an attractive option, due to its short duration and to the possibility of directly observed treatment or supervision. The aim of this study is to compare the effectiveness and rates of discontinuation of DAA treatment in prisoners and nonprisoners. We studied all patients treated in the 10 prisons of Catalonia and at 3 public hospitals in the Barcelona area between 1 January 2015 and 30 April 2016. We analysed sustained viral response (SVR) and rates of discontinuation through intention-to-treat and modified-intention-to-treat analyses, the latter excluding discontinuations due to release from prison. One hundred and eighty-eight inmates and 862 noninmates were included. Prisoners were significantly younger than nonprisoners, with higher proportions of men, drug users, HIV infection, genotypes 1a and 3 and more treatment with psychiatric drugs. Overall, 98.4% of patients completed treatment. The discontinuation rate was low, but higher in inmates (3.7% vs 1.2% noninmates; P = .003) and in community patients >65 years old (2.8% vs 1.2% in under 65 seconds; P = .008). Among the inmates, 7 (42.8%) discontinuations were due to release. SVR was 93.1% in inmates vs 96.5% in noninmates (P = .08) by intention-to-treat and 95.1% vs 96.5% (P = .37) by modified intention-to-treat. Virologic failure rates were similar (3.8% vs 3% in noninmates; P = .60). SVR, virologic failure and discontinuation rates were similar in inmates and noninmates. Currently, prisons are considered a priority for the implementation of DAA. Improved coordination between penitentiary and community health systems would help to ensure therapeutic continuity in released prisoners.

"Seek, test, treat and retain" for hepatitis C in the United States criminal justice system

PURPOSE

The purpose of this paper is to consider the potential benefits and challenges of applying a strategy of "seek, test, treat and retain" (STTR) to hepatitis C virus (HCV) in the US criminal justice system.

DESIGN/METHODOLOGY/APPROACH

The authors draw on the published literature to illustrate how each component of STTR could be applied to HCV in the US criminal justice system, and describe challenges to the implementation of this strategy.

FINDINGS

The burden of morbidity and mortality associated with chronic HCV infection in the USA is increasing and without significantly increased treatment uptake, will likely continue to do so for several decades. The authors argue that the US criminal justice system is an ideal focus for HCV case finding and treatment due to a high prevalence of infection and large volume of individuals in contact with this system. STTR would identify large numbers of HCV infections, leading to opportunities for secondary prevention and primary care. Important challenges to the implementation of STTR include treatment costs and training of prison medical providers.

ORIGINALITY/VALUE

This paper highlights opportunities to address HCV in the US criminal justice system.

Hepatitis C virus infection and prisoners: Epidemiology, outcome and treatment

The studies on hepatitis C virus (HCV) infection in prison populations are few and mostly cross-sectional. We analyzed prevalently the articles appearing on PubMed in the last ten years. HCV infection is frequent in prisoners, prevalences ranging from 3.1% to 38% according to the HCV endemicity in the geographical location of the prison and in the countries of origin of the foreign prisoners and to the prevalence of intravenous drug use, which is the most important risk factor for HCV infection, followed by an older age of prisoners and previous prison terms. HCV replication in anti-HCV-positive cases varies from 45% to 90% in different studies, and the most common HCV genotypes are generally 1 and 3. The response to antiviral treatment is similar in prisoners to that of the general population. Unfortunately, treatment is administered less frequently to prisoners because of the difficulties in management and follow-up. The new directly acting antivirals offer a good therapy option for inmates because of their good efficacy, short duration of treatment and low incidence of side effects. The efforts of the prison authorities and medical staff should be focused on reducing the spread of HCV infection in prisons by extending the possibility of follow-up and treatment to more prisoners with chronic hepatitis C.

Lack of health insurance limits the benefits of hepatitis C virus screening: insights from the National Health and Nutrition Examination Hepatitis C follow-up study

OBJECTIVES

Identifying barriers to access to hepatitis C virus (HCV) treatment among screen detected subjects is critical for any public health strategy aimed at controlling HCV infection in the general population.

METHODS

Data from the National Health and Nutrition Examination Survey HCV Follow-up study from 2001 to 2010 were used. Participants who tested positive for HCV were sent a letter informing them of their test results and advised to pursue further evaluation. Information on HCV transmission and its potential complications was also provided to all positive participants. These subjects were recontacted 6 months after notification to determine what action they had taken regarding the positive result.

RESULTS

Of 38,025 participants, 502 tested positive for HCV infection, giving a prevalence of 1.3% (95% confidence interval (CI) 0.8%, 1.8%). A total of 205 subjects participated in the 6-month follow-up interview. Those who could not be reached were more likely to be less educated, injecting drugs, and not to have health insurance. Half (50.2%) of the positive individuals were not aware of their status before notification. A total of 166 (81%) had pursued further evaluation. Only 18 (26.9%) received therapy. The main reason for not receiving treatment was high cost (19.4%). In adjusted analysis, the only barrier to pursuing downstream HCV care was the lack of health insurance (2.76, 95% CI 1.54, 7.69; P=0.007).

CONCLUSIONS

This study suggests that the lack of health insurance may attenuate the theoretical benefits of a screening program that identifies asymptomatic HCV-infected individuals who are less likely to pursue downstream care.

A Budget Impact Analysis of Newly Available Hepatitis C Therapeutics and the Financial Burden on a State Correctional System

Hepatitis C virus (HCV) infection continues to disproportionately affect incarcerated populations. New HCV drugs present opportunities and challenges to address HCV in corrections. The goal of this study was to evaluate the impact of the treatment costs for HCV infection in a state correctional population through a budget impact analysis comparing differing treatment strategies. Electronic and paper medical records were reviewed to estimate the prevalence of hepatitis C within the Rhode Island Department of Corrections. Three treatment strategies were evaluated as follows: (1) treating all chronically infected persons, (2) treating only patients with demonstrated fibrosis, and (3) treating only patients with advanced fibrosis. Budget impact was computed as the percentage of pharmacy and overall healthcare expenditures accrued by total drug costs assuming entirely interferon-free therapy. Sensitivity analyses assessed potential variance in costs related to variability in HCV prevalence, genotype, estimated variation in market pricing, length of stay for the sentenced population, and uptake of newly available regimens. Chronic HCV prevalence was estimated at 17% of the total population. Treating all sentenced inmates with at least 6 months remaining of their sentence would cost about $34 million-13 times the pharmacy budget and almost twice the overall healthcare budget. Treating inmates with advanced fibrosis would cost about $15 million. A hypothetical 50% reduction in total drug costs for future therapies could cost $17 million to treat all eligible inmates. With immense costs projected with new treatment, it is unlikely that correctional facilities will have the capacity to treat all those afflicted with HCV. Alternative payment strategies in collaboration with outside programs may be necessary to curb this epidemic. In order to improve care and treatment delivery, drug costs also need to be seriously reevaluated to be more accessible and equitable now that HCV is more curable.

Survey of US Correctional Institutions for Routine HCV Testing

To ascertain HCV testing practices among US prisons and jails, we conducted a survey study in 2012, consisting of medical directors of all US state prisons and 40 of the largest US jails, that demonstrated a minority of US prisons and jails conduct routine HCV testing. Routine voluntary HCV testing in correctional facilities is urgently needed to increase diagnosis, enable risk-reduction counseling and preventive health care, and facilitate evaluation for antiviral treatment.

Hepatitis C in European prisons: a call for an evidence-informed response

Globally, over 10 million people are held in prisons and other places of detention at any given time. People who inject drugs (PWID) comprise 10-48% of male and 30-60% of female prisoners. The spread of hepatitis C in prisons is clearly driven by injection drug use, with many infected prisoners unaware of their infection status. Risk behaviour for acquisition of hepatitis C via common use of injecting equipment is widespread in many prison settings. In custodial settings, effective and efficient prevention models applied in the community are very rarely implemented. Only approximately 60 out of more than 10,000 prisons worldwide provide needle exchange. Thus, HCV prevention is almost exclusively limited to verbal advice, leaflets and other measures directed to cognitive behavioural change. Although the outcome of HCV antiviral treatment is comparable to non-substance users and substance users out of prison, the uptake for antiviral treatment is extremely low. Based on a literature review to assess the spread of hepatitis C among prisoners and to learn more about the impact for the prison system, recommendations regarding hepatitis C prevention, screening and treatment in prisons have been formulated in this article.

Expression of soluble and active interferon consensus in SUMO fusion expression system in E. coli

Protein production can be improved if methods for soluble protein expression are developed. Interferon consensus (IFN-con) is used to treat hepatitis C. IFN-con has superior activity compared to other clinically used interferon α subtypes. However IFN-con is a challenging protein to produce in a soluble form using an Escherichia coli expression system. Here we describe the expression of soluble and active recombinant IFN-con in E. coli. The IFN-con gene sequence was optimised for expression in E. coli, which was then cloned into the Champion™ pET SUMO expression vector downstream of the SUMO fusion protein and under strong T7lac promoter. The SUMO-IFN-con fusion protein was efficiently expressed using the SHuffle™ E. coli strain and existed in soluble form as 86-88% of the total IFN-con. After removal of the SUMO fusion partner, approximately 50mg of recombinant IFN-con of at least 98% purity (by RP-HPLC) was obtained from a 1L fermentation culture. Using an A549/EMCV antiviral assay, the specific activity of the recombinant IFN-con was determined to be 960×10(6) IU/mg as calculated to NIBSC standard for IFN-con (3×10(5)pfu/mL virus titre). Comparison of the antiviral activity of the produced IFN-con to IFN α-2a showed that IFN-con displays 2.8 times greater activity, which is in good agreement with what has been reported in the literature for pure protein. IFN-con expression in a soluble form from E. coli allowed us to use a simple, two-step purification process to yield highly pure and active IFN-con which is more efficient than obtaining IFN-con from inclusion bodies.

Enhancing assessment and treatment of hepatitis C in the custodial setting

Acute and chronic hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. This disparity between the burden of disease and hepatitis service delivery reflects the marginalized patient population, which features high rates of injection drug use and poor mental health. In addition, the prison environment is intended for deprivation of liberty and not healthcare. Screening for HCV infections is provided in most jurisdictions, but uptake rates remain low. Assessment and treatment of inmates is often provided only by community-based services. Despite these challenges, assessment and treatment of inmates with chronic HCV via prison-based services has been shown to be feasible and effective. These services offer the potential to substantively increase HCV treatment uptake and reduce the burden of disease for the community at large. Improvements in the efficacy of HCV therapies via direct-acting antivirals, which also offer reduced treatment duration and decreased toxicities, mean that prison health services will be well placed for the treatment of large numbers of people with HCV who do not access health services in the community.

Hepatitis C virus reinfection among prisoners with sustained virological response after treatment for chronic hepatitis C

BACKGROUND & AIMS

We estimated HCV reinfection rate and its associated risk factors in inmates with chronic hepatitis C who had achieved sustained virological response (SVR) after completing combination therapy while in prison.

METHODS

Individuals who had achieved an SVR after treatment provided from January 2003 to December 2009 at four prisons in Catalonia, had been tested annually for HCV RNA and were in prison during 2010, were invited to complete a questionnaire regarding risk factors for reinfection. Incidence rate was calculated as 100 person-years of follow-up. Risk factors potentially associated with reinfection were evaluated by bivariate log-rank test and multivariate Cox regression analysis.

RESULTS

One hundred and nineteen subjects who had achieved an SVR agreed to participate. 98% were male, with a median age of 33.3 ± 6.3 years and 81% had a history of injection drug use (IDU). After a mean follow-up of 1.4 years, HCV reinfection was identified in nine former IDUs, seven with HCV genotype switch, for an overall reinfection rate of 5.27 cases per 100 person-years. Reinfection incidence was significantly higher among active drug users (HR=12.47; 95% CI: 2.90-53.71), HIV co-infected (HR=9.95; 95% CI: 1.73-57.34), and those engaging in more than one risk behaviors after treatment (HR=7.47; 95% CI: 1.19-46.89).

CONCLUSIONS

HCV reinfection among inmates after successful treatment is high especially in those with ongoing IDU. Preventative interventions at diagnosis and during and after HCV treatment should be strongly reinforced.

An update on the management of hepatitis C: consensus guidelines from the Canadian Association for the Study of the Liver

Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last consensus conference on the management of chronic hepatitis C, major advances have warranted a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed, and several single nucleotide polymorphisms associated with an increased probability of spontaneous and treatment-induced viral clearance have been identified. In light of this new evidence, a consensus development conference was held in November 2011; the present document highlights the results of the presentations and discussions surrounding these issues. It reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved protease inhibitors (boceprevir and telaprevir), including those who have previously failed pegylated interferon and ribavirin therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.

Public health and the epidemic of incarceration

An unprecedented number of Americans have been incarcerated in the past generation. In addition, arrests are concentrated in low-income, predominantly nonwhite communities where people are more likely to be medically underserved. As a result, rates of physical and mental illnesses are far higher among prison and jail inmates than among the general public. We review the health profiles of the incarcerated; health care in correctional facilities; and incarceration's repercussions for public health in the communities to which inmates return upon release. The review concludes with recommendations that public health and medical practitioners capitalize on the public health opportunities provided by correctional settings to reach medically underserved communities, while simultaneously advocating for fundamental system change to reduce unnecessary incarceration.