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Lafferty L, Altice FL, Leone F, Stoové M, Lloyd AR, Hajarizadeh B, Kronfli N. Using nominal group technique with people who are incarcerated in Canadian federal prisons to identify barriers and solutions to improving Prison Needle Exchange Program uptake. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 131:104549. [PMID: 39141957 DOI: 10.1016/j.drugpo.2024.104549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Prison needle exchange programs (PNEPs) are a critical component for harm reduction in prisons. Little is known about the PNEP access barriers for people who are incarcerated, but the low uptake in the Canadian program highlights these constraints. We aimed to identify the barriers and potential solutions for increasing PNEP coverage in the nine Canadian federal prisons where they operate. METHODS Eighteen focus groups were conducted in nine prisons using nominal group technique (NGT) with two stakeholders: peer advocates and people who use or identified as potential users of the PNEP. NGT uses a round-robin technique followed by generating a list of barriers to PNEP enrolment within their prison. Participants then allocated votes to rank the highest priority barriers, followed by an identical process to generate solutions to address the top three barriers. Interview transcripts describing participant narratives during this process were de-identified and coded to generated themes. Barriers and solutions receiving >10 % of votes within respective participant groups, alongside associated narratives, are discussed more fully. RESULTS Fear of repercussions due to drug use, lack of confidentiality, and fear of being targeted and sanctioned by correctional authorities were perceived by both stakeholder groups as the top barriers inhibiting PNEP enrolment. Stigma (peer advocates) and the application process for the program (PNEP users) were also ranked as a priority. Proposed solutions included education and external oversight of PNEP (i.e., not via correctional officers) by both groups. Peer advocates regarded improving participant confidentiality and a supervised/safe injection site as potential enablers for program participation, while PNEP users identified wrap-around services as likely to improve access. CONCLUSION Barriers to increasing PNEP coverage in Canadian federal prisons proposed by participants highlight the importance of trust and perceived repercussions surrounding program participation. These barriers and proposed solutions highlight a need for changes in implementation to PNEP delivery if the potential health benefits of PNEPs are to be realised.
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Affiliation(s)
- Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Level 1, Goodsell Building, Sydney NSW 2052, Australia; The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney NSW 2052, Australia
| | - Frederick L Altice
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederic Leone
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Stoové
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Road, Melbourne VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne VIC 3004, Australia; Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney NSW 2052, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney NSW 2052, Australia
| | - Nadine Kronfli
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada.
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Kronfli N, Lafferty L, Leone F, Stoové M, Hajarizadeh B, Lloyd AR, Altice FL. Using nominal group technique to identify perceived barriers and facilitators to improving uptake of the Prison Needle Exchange Program in Canadian federal prisons by correctional officers and healthcare workers. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104540. [PMID: 39079352 DOI: 10.1016/j.drugpo.2024.104540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/14/2024] [Accepted: 07/14/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Elimination of bloodborne viruses including HIV and hepatitis C virus from prisons requires high coverage of evidence-based interventions that prevent bloodborne virus transmission, including needle and syringe programs. Canada launched a Prison Needle Exchange Program (PNEP) in nine federal prisons in 2018; however, uptake among people who inject drugs in prison remains low. We aimed to explore barriers and facilitators to improving PNEP uptake identified by correctional officers and healthcare workers. METHODS Participants from nine federal prisons with PNEP completed focus groups using nominal group technique, a rapid mixed-method consensus strategy. Responses were generated, rank-ordered, and prioritized by each stakeholder group. We identified the highest-ranking responses (≥10 % of the overall votes) to questions about barriers and facilitators to PNEP uptake. RESULTS Between September 2023 and February 2024, 16 focus groups were conducted with 118 participants (n = 51 correctional officers; n = 67 healthcare workers). Among correctional officers, the top perceived barriers were bullying from peers (22 %), fear of being targeted by correctional officers (14 %), and fear of repercussions due to drug use (13 %). The top facilitators were safe injection sites (30 %), provision of wrap-around services (16 %), and education of correctional officers (10 %). Among healthcare workers, the top perceived barriers were lack of confidentiality (16 %), fear of being targeted by correctional officers (12 %), and a long and complex application process (11 %). The top facilitators were education of correctional officers (29 %), delivery of PNEP by an external provider (15 %), automatic approval for participation in the PNEP (13 %), and safe injection sites (12 %). CONCLUSION Multiple modifiable barriers and solutions to improving PNEP uptake in Canadian federal prisons were identified by correctional employees. Both participant groups identified the potential for safe injection sites and education to correctional officers as enabling PNEP uptake. These data will inform Canadian efforts to improve engagement and to expand PNEP coverage.
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Affiliation(s)
- Nadine Kronfli
- Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Level 1, Goodsell Building, Sydney, NSW 2052, Australia; The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Frederic Leone
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Stoové
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Road, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, VIC 3004, Australia; Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Frederick L Altice
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine. 135 College St., Suite 323, New Haven, CT 06510, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Aponte-Meléndez Y, Eckhardt B, Fong C, Padilla A, Trinidad-Martínez W, Maldonado-Rodríguez E, Agront N, Mateu-Gelabert P. Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209308. [PMID: 38301921 PMCID: PMC11060894 DOI: 10.1016/j.josat.2024.209308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico. METHODS The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis. RESULTS Of the 150 participants, 89 % were male; 11 % were female; 72 % identified as mixed race; and the median duration of drug injection was 17.8 years. The mean age was 43.1 years, with 64 % of the population being from 23 to 45 years old. Among study participants (n = 150), the prevalence of HCV Ab was 73 %, and HCV RNA was 53 %. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity. CONCLUSIONS Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.
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Affiliation(s)
- Yesenia Aponte-Meléndez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA; NYU Rory Meyers College of Nursing, 433 1(st) Ave., New York, NY, 10010, USA.
| | - Benjamin Eckhardt
- New York University School of Medicine, 550 First Avenue, New York, NY 10016, USA.
| | - Chunki Fong
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Adriana Padilla
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Wanda Trinidad-Martínez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Eric Maldonado-Rodríguez
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
| | - Nancy Agront
- AbbVie Corp., Paseo Caribe Building Suite 22415 Ave Munoz Rivera San Juan, 00901, Puerto Rico.
| | - Pedro Mateu-Gelabert
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125(th) street, New York, NY 10027, USA.
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Walker SJ, Shrestha LB, Lloyd AR, Dawson O, Sheehan Y, Sheehan J, Maduka NBC, Cabezas J, Akiyama MJ, Kronfli N. Barriers and advocacy needs for hepatitis C services in prisons: Informing the prisons hepatitis C advocacy toolkit. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104386. [PMID: 38492433 PMCID: PMC11106844 DOI: 10.1016/j.drugpo.2024.104386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Carceral settings are a key focus of the 2030 WHO global hepatitis C virus (HCV) elimination goals. Despite this, access to HCV testing and treatment services in prisons remains low globally, limiting opportunities to achieve these goals. Advocacy efforts are needed to address service inequities and mobilise support for enhanced HCV programs in prisons globally. INHSU Prisons, a special interest group of the International Network on Health and Hepatitis in Substance Users (INHSU) is developing a Prisons HCV Advocacy Toolkit to address this need. Here we present findings of a mixed study to inform the development of the Toolkit. METHODS The aim of this study was to inform the development of the Toolkit, including understanding barriers for scaling up prison-based HCV services globally and advocacy needs to address these. An online survey (n = 181) and in-depth interviews (n = 25) were conducted with key stakeholders from countries of different economic status globally. Quantitative data were statistically analysed using R Studio and qualitative data were analysed thematically. The data sets were merged using a convergent design. RESULTS Key barriers for enhanced prison-based HCV services included lack of political will and action, lack of prison-based healthcare resources, and poor awareness about HCV and the importance of prison-based HCV services. These findings underscore how advocacy efforts are needed to motivate policymakers to prioritise HCV healthcare in prisons and ensure funds are available for services (including diagnostic tools and treatment, healthcare teams to implement services, and systems to measure their success). Advocacy resources to raise the awareness of policy makers, people working in the prison sector, and incarcerated populations were also identified as key to increasing HCV service uptake. CONCLUSION The Toolkit has the potential to support advocacy efforts for reaching HCV elimination targets. By understanding the advocacy needs of potential Toolkit end-users, the findings can inform its development and increase its accessibility, acceptability, and uptake for a globally diverse audience.
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Affiliation(s)
- Shelley J Walker
- National Drug Research Institute, Curtin University, Perth, Australia; Burnet Institute, Melbourne, Australia; Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
| | - Lok B Shrestha
- The Kirby Institute, University of New South Wales (UNSW), Sydney, Australia; School of Biomedical Sciences, University of New South Wales (UNSW), Sydney, Australia
| | - Andrew R Lloyd
- The Kirby Institute, University of New South Wales (UNSW), Sydney, Australia
| | - Olivia Dawson
- The International Network on Health and Hepatitis in Substance Users (INHSU)
| | - Yumi Sheehan
- The Kirby Institute, University of New South Wales (UNSW), Sydney, Australia
| | | | | | - Joaquin Cabezas
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Santander, Spain
| | - Matthew J Akiyama
- Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Centre, New York, USA
| | - Nadine Kronfli
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University Health Centre, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
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Snell G, Marshall AD, van Gennip J, Bonn M, Butler-McPhee J, Cooper CL, Kronfli N, Williams S, Bruneau J, Feld JJ, Janjua NZ, Klein M, Cunningham N, Grebely J, Bartlett SR. Public reimbursement policies in Canada for direct-acting antiviral treatment of hepatitis C virus infection: A descriptive study. CANADIAN LIVER JOURNAL 2023; 6:190-200. [PMID: 37503523 PMCID: PMC10370724 DOI: 10.3138/canlivj-2022-0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/28/2023] [Indexed: 07/29/2023]
Abstract
Background Direct-acting antiviral (DAA) therapies have simplified HCV treatment, and publicly funded Canadian drug plans have eliminated disease-stage restrictions for reimbursement of DAA therapies. However other policies which complicate, delay, or prevent treatment initiation still persist. We aim to describe these plans' existing reimbursement criteria and appraise whether they hinder treatment access. Methods We reviewed DAA reimbursement policies of 16 publicly funded drug plans published online and provided by contacts with in-depth knowledge of prescribing criteria. Data were collected from May to July 2022. Primary outcomes were: (1) if plans have arranged to accept point-of-care HCV RNA testing for diagnosis; testing requirements for (2) HCV genotype, (3) fibrosis stage, and (4) chronic infection; (5) time taken and method used to approve reimbursement requests; (6) providers eligible to prescribe DAAs; and (7) restrictions on re-treatment. Results Fifteen (94%) plans have at least one policy in place which limits simplified HCV treatment. Many plans continue to require results of genotype or fibrosis staging, limit eligible prescribers, and take longer than 1 day to approve coverage requests. One plan discourages treatment for re-infection. Conclusion Reimbursement criteria set by publicly funded Canadian drug plans continue to limit timely, equitable access to HCV treatment. Eliminating clinically irrelevant pre-authorization testing, expanding eligible prescribers, expediting claims processing, and broadening coverage of treatment for reinfection will improve access to DAAs. The federal government could further enhance efforts by introducing a federal HCV elimination strategy or federal high-cost drug PharmaCare program.
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Affiliation(s)
- Gaelen Snell
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alison D Marshall
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, Nova Scotia, Canada
| | | | - Curtis L Cooper
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nadine Kronfli
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Sarah Williams
- Calgary Liver Unit, Alberta Health Services, Calgary, Alberta, Canada
| | - Julie Bruneau
- Centre Hospitalier de l’Université de Montréal Research Center, Quebec, Canada
| | - Jordan J Feld
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marina Klein
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Nance Cunningham
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jason Grebely
- The Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Reekie A, Gratrix J, Smyczek P, Woods D, Poshtar K, Courtney K, Ahmed R. A Cross-Sectional, Retrospective Evaluation of Opt-Out Sexually Transmitted Infection Screening at Admission in a Short-Term Correctional Facility in Alberta, Canada. JOURNAL OF CORRECTIONAL HEALTH CARE 2022; 28:429-438. [PMID: 36475978 DOI: 10.1089/jchc.21.08.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Alexandra Reekie
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jennifer Gratrix
- Department of STI Services, Alberta Health Services-Provincial STI Program, Edmonton, Alberta, Canada
| | - Petra Smyczek
- Department of STI Services, Alberta Health Services-Provincial STI Program, Edmonton, Alberta, Canada
| | - Dan Woods
- Department of Corrections, Alberta Health Services-Corrections Health, Edmonton, Alberta, Canada
| | - Katherine Poshtar
- Department of Corrections, Alberta Health Services-Corrections Health, Edmonton, Alberta, Canada
| | - Keith Courtney
- Department of Corrections, Alberta Health Services-Corrections Health, Edmonton, Alberta, Canada
| | - Rabia Ahmed
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Identifying barriers and enablers to opt-out hepatitis C virus screening in provincial prisons in Quebec, Canada: A multilevel, multi-theory informed qualitative study with correctional and healthcare professional stakeholders. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103837. [PMID: 36030569 DOI: 10.1016/j.drugpo.2022.103837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Diffuse implementation of hepatitis C virus (HCV) treatment is dependent on universal screening for HCV, but screening strategies are heterogenous across prisons in the province of Quebec (Canada). We sought to identify barriers and enablers to universal opt-out HCV screening and to describe the multisectoral decision-making processes related to HCV screening in Quebec provincial prisons. METHODS A multilevel, multi-theory informed qualitative descriptive approach was used to conduct semi-structured interviews. Interview guides and analyses with correctional stakeholders were informed by the Consolidated Framework for Implementation Research (CFIR) and those with healthcare professionals (HCPs) were based on the Theoretical Domains Framework (TDF). Directed content analysis was used to identify domains within CFIR and TDF reflecting barriers and enablers to opt-out HCV screening. RESULTS Sixteen interviews (correctional stakeholders: n = 8; HCPs: n = 8) were conducted in April-May 2021. Twelve CFIR constructs were identified as barriers, seven as enablers, and two as neutral factors for the implementation of opt-out HCV screening. Correctional stakeholders underscored the need for political will (construct: external policy and incentives), highlighted limited resources (construct: available resources), and expressed concerns for the lack of consideration of implementation issues (constructs: trialability, planning). Six TDF domains were identified among HCPs as relevant to the implementation of opt-out HCV screening: beliefs about consequences (mixed = enablers and barriers), environmental context and resources (barrier), social influences (barrier), optimism (mixed), emotions (mixed), and behavioural regulation (barrier). The decision-making processes vis-à-vis HCV care in Quebec correctional settings were found to be hierarchical and complex. CONCLUSIONS The use of CFIR and TDF was helpful in identifying barriers and enablers to HCV screening at multiple levels for people incarcerated in Quebec provincial prisons. Going forward, several political, structural, and organizational factors should be addressed through the engagement of stakeholders and people with lived experience of incarceration.
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Merone L, Ashton S, Harris A, Edwards WS, Preston-Thomas A, Gair R, Russell DB. A complex increase in hepatitis C virus in a correctional facility: bumps in the road. Aust N Z J Public Health 2022; 46:377-381. [PMID: 35435996 DOI: 10.1111/1753-6405.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/01/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The prevalence of hepatitis C virus (HCV) in correctional facilities in Australia among people who inject drugs is 60%, with disproportionate effects observed in Aboriginal and Torres Strait Islander people. Following the micro-elimination of HCV in a Queensland correctional facility (QCF), newly acquired cases began to increase in mid-2019. Here we discuss the public health response to increasing HCV in a QCF. METHODS Enhanced surveillance was performed to obtain contextual outbreak data on risk factors including injecting drug use, sharing of personal hygiene equipment and do-it-yourself-tattooing. RESULTS In the sixteen months, there were 250 notifications of new and re-infected HCV infections in prisoners in the QCF. Qualitative data revealed the leading factor in transmission to be injecting drug use. CONCLUSIONS Drivers for increased HCV transmission in correctional facilities include boredom, waiting lists for opioid substitution programs, changes in injecting behaviours and sharing of injecting paraphernalia. Point-of-care testing combined with education and the development of a needle and syringe program may be promising ways forward for managing HCV in correctional facilities. IMPLICATIONS FOR PUBLIC HEALTH Correctional facilities are key locations to target sexually transmitted infection (STI) and blood-borne virus (BBV) testing and treatment as well as health promotion to improve the health of inmates and the communities they return to.
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Affiliation(s)
- Lea Merone
- Tropical Public Health Services, Cairns, Queensland
| | - Sian Ashton
- Tropical Public Health Services, Cairns, Queensland.,College of Health Care Sciences, James Cook University, Queensland
| | - Andy Harris
- Cairns and Hinterland Hospital and Health Service, Queensland
| | | | | | - Richard Gair
- Tropical Public Health Services, Cairns, Queensland
| | - Darren B Russell
- College of Health Care Sciences, James Cook University, Queensland.,Cairns Sexual Health Service, Queensland
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Ortiz-Paredes D, Varsaneux O, Worthington J, Park H, MacDonald SE, Basta NE, Lebouché B, Cox J, Ismail SJ, Kronfli N. Reasons for COVID-19 vaccine refusal among people incarcerated in Canadian federal prisons. PLoS One 2022; 17:e0264145. [PMID: 35263350 PMCID: PMC8906611 DOI: 10.1371/journal.pone.0264145] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Vaccine uptake rates have been historically low in correctional settings. To better understand vaccine hesitancy in these high-risk settings, we explored reasons for COVID-19 vaccine refusal among people in federal prisons. METHODS Three maximum security all-male federal prisons in British Columbia, Alberta, and Ontario (Canada) were chosen, representing prisons with the highest proportions of COVID-19 vaccine refusal. Using a qualitative descriptive design and purposive sampling, individual semi-structured interviews were conducted with incarcerated people who had previously refused at least one COVID-19 vaccine until data saturation was achieved. An inductive-deductive thematic analysis of audio-recorded interview transcripts was conducted using the Conceptual Model of Vaccine Hesitancy. RESULTS Between May 19-July 8, 2021, 14 participants were interviewed (median age: 30 years; n = 7 Indigenous, n = 4 visible minority, n = 3 White). Individual-, interpersonal-, and system-level factors were identified. Three were particularly relevant to the correctional setting: 1) Risk perception: participants perceived that they were at lower risk of COVID-19 due to restricted visits and interactions; 2) Health care services in prison: participants reported feeling "punished" and stigmatized due to strict COVID-19 restrictions, and failed to identify personal benefits of vaccination due to the lack of incentives; 3) Universal distrust: participants expressed distrust in prison employees, including health care providers. INTERPRETATION Reasons for vaccine refusal among people in prison are multifaceted. Educational interventions could seek to address COVID-19 risk misconceptions in prison settings. However, impact may be limited if trust is not fostered and if incentives are not considered in vaccine promotion.
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Affiliation(s)
- David Ortiz-Paredes
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Hyejin Park
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Shannon E. MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole E. Basta
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joseph Cox
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Shainoor J. Ismail
- Division of Immunization Programs and Pandemic Preparedness, Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada, Ottawa, Ontario, Canada
- Metro City Medical Clinic, Edmonton, Alberta, Canada
| | - Nadine Kronfli
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Kronfli N, Dussault C, Bartlett S, Fuchs D, Kaita K, Harland K, Martin B, Whitten-Nagle C, Cox J. Disparities in hepatitis C care across Canadian provincial prisons: Implications for hepatitis C micro-elimination. CANADIAN LIVER JOURNAL 2021; 4:292-310. [PMID: 35992251 PMCID: PMC9202774 DOI: 10.3138/canlivj-2020-0035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/26/2020] [Indexed: 04/06/2024]
Abstract
Background Delivery of hepatitis C virus (HCV) care to people in prison is essential to HCV elimination. We aimed to describe current HCV care practices across Canada's adult provincial prisons. Methods One representative per provincial prison health care team (except Ontario) was invited to participate in a web-based survey from January to June 2020. The outcomes of interest were HCV screening and treatment, treatment restrictions, and harm reduction services. The government ministry responsible for health care was determined. Non-nominal data were aggregated by province and ministry; descriptive statistical analyses were used to report outcomes. Results The survey was completed by 59/65 (91%) prisons. On-demand, risk-based, opt-in, and opt-out screening are offered by 19 (32%), 10 (17%), 18 (31%), and 9 (15%) prisons, respectively; 3 prisons offer no HCV screening. Liver fibrosis assessments are rare (8 prisons access transient elastography, and 15 use aspartate aminotransferase to platelet ratio or Fibrosis-4); 20 (34%) prisons lack linkage to care programs. Only 32 (54%) prisons have ever initiated HCV treatment on site. Incarceration length and a fibrosis staging of ≥F2 are the most common eligibility restrictions for treatment. Opioid agonist therapy is available in 83% of prisons; needle and syringe programs are not available anywhere. Systematic screening and greater access to treatment and harm reduction services are more common where the Ministry of Health is responsible. Conclusions Tremendous variability exists in HCV screening and care practices across Canada's provincial prisons. To advance HCV care, adopting opt-out screening and removing eligibility restrictions may be important initial strategies.
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Affiliation(s)
- Nadine Kronfli
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Camille Dussault
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sofia Bartlett
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Dennaye Fuchs
- ID Clinic, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Kelly Kaita
- Department of Medicine, John Buhler Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kate Harland
- Centre for Research, Education and Clinical Care of At-Risk Populations, Saint John, New Brunswick, Canada
| | - Brandi Martin
- Department of Justice and Public Safety, Community and Correctional Services, Government of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Cindy Whitten-Nagle
- Department of Justice and Public Safety, Adult Corrections, Government of Newfoundland and Labrador, St. John’s, Newfoundland and Labrador, Canada
| | - Joseph Cox
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Duchesne L, Dussault C, Godin A, Maheu-Giroux M, Kronfli N. Implementing opt-out hepatitis C virus (HCV) screening in Canadian provincial prisons: A model-based cost-effectiveness analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103345. [PMID: 34176704 DOI: 10.1016/j.drugpo.2021.103345] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Implementing opt-out hepatitis C virus (HCV) screening across Canadian provincial prisons is crucial to achieving micro-elimination. Given short incarceration lengths, the most cost-effective screening strategy remains unknown. We compared the cost-effectiveness of current standard of care (venipuncture-based HCV-antibody+HCV RNA) and 13 alternative strategies in Quebec's largest provincial prison. METHODS A prison cohort was simulated with a Markov micro-simulation model. Strategies differed in the biomarkers, sampling methods, and number of tests used. The model considered incarceration lengths, time to linkage to care (LTC), nursing costs, and tests' costs, performances, acceptability and turnaround times. Outcomes included costs (Canadian dollars, CAD$), number of true positives linked to care, and incremental cost-effectiveness ratios (ICERs, additional $/additional TP-L). A one-year time horizon and health-payer perspective were adopted. RESULTS Across all analyses, three strategies consistently provided the best value for money: venipuncture-based HCV-antibody+HCV-core antigen, venipuncture-based HCV-core antigen (base-case ICER=~ $720), and point-of-care HCV-antibody+HCV RNA (base-case ICER=$4,310). However, these strategies linked only 23%-29% viremic individuals to care. Main drivers of cost-effectiveness were the seroprevalence, proportion viremic, and time to LTC. CONCLUSION Alternative strategies would be more cost-effective than standard of care for implementing opt-out screening in provincial prisons. However, interventions to maximize LTC should be explored.
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Affiliation(s)
- Léa Duchesne
- Institut de Médecine et d'Epidémiologie Appliquée, Fondation Internationale Léon Mba, Paris, France
| | - Camille Dussault
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Arnaud Godin
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Nadine Kronfli
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University Health Centre, Montréal, Québec, Canada.
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12
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Annual Meeting of the Canadian Association for the Study of the Liver (CASL), the Canadian Network on Hepatitis C (CANHEPC) and the Canadian Association of Hepatology Nurses (CAHN) 2021 Abstracts. CANADIAN LIVER JOURNAL 2021; 4:113-248. [PMID: 35991765 PMCID: PMC9204943 DOI: 10.3138/canlivj.4.2.abst] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2023]
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13
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Bartlett SR, Buxton J, Palayew A, Picchio CA, Janjua NZ, Kronfli N. Hepatitis C Virus Prevalence, Screening, and Treatment Among People Who Are Incarcerated in Canada: Leaving No One Behind in the Direct-Acting Antiviral Era. Clin Liver Dis (Hoboken) 2021; 17:75-80. [PMID: 33680440 PMCID: PMC7916434 DOI: 10.1002/cld.1023] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/21/2020] [Accepted: 08/02/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sofia R. Bartlett
- Department of Pathology and Laboratory MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBCCanada
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
- British Columbia Centre for Disease ControlProvincial Health Services AuthorityVancouverBCCanada
| | - Jane Buxton
- British Columbia Centre for Disease ControlProvincial Health Services AuthorityVancouverBCCanada
- School of Population and Public HealthFaculty of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Adam Palayew
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealQCCanada
| | - Camila A. Picchio
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Naveed Z. Janjua
- British Columbia Centre for Disease ControlProvincial Health Services AuthorityVancouverBCCanada
- School of Population and Public HealthFaculty of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Nadine Kronfli
- Department of MedicineDivision of Infectious Diseases and Chronic Viral Illness ServiceMcGill UniversityMontrealQCCanada
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Paynter MJ, Bagg ML, Heggie C. Invisible women: correctional facilities for women across Canada and proximity to maternity services. Int J Prison Health 2020. [DOI: 10.1108/ijph-06-2020-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to describe the process to create an inventory of the facilities in Canada designated to incarcerate women and girls, health service responsibility by facility, facility proximity to hospitals with maternity services and residential programmes for mothers and children to stay together. This paper creates the inventory to support health researchers, prison rights advocates and policymakers to identify, analyse and respond to sex and gender differences in health and access to health services in prisons.
Design/methodology/approach
In spring 2019, this study conducted an environmental scan to create an inventory of every facility in Canada designated for the incarceration of girls and women, including remand/pretrial custody, immigration detention, youth facilities and for provincial and federal sentences.
Findings
There are 72 facilities in the inventory. In most, women are co-located with men. Responsibility for health varies by jurisdiction. Few sites have mother-child programmes. Distance to maternity services varies from 1 to 132 km.
Research limitations/implications
This paper did not include police lock-up, courthouse cells or involuntary psychiatric units in the inventory. Information is unavailable regarding trans and non-binary persons, a priority for future work. Access to maternity hospital services is but one critical question regarding reproductive care. Maintenance of the database is challenging.
Originality/value
Incarcerated women are an invisible population. The inventory is the first of its kind and is a useful tool to support sex and gender and health research across jurisdictions.
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Kronfli N, Dussault C, Chalifoux S, Kavoukian H, Klein MB, Cox J. A randomized pilot study assessing the acceptability of rapid point-of-care hepatitis C virus (HCV) testing among male inmates in Montreal, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102921. [PMID: 32911319 DOI: 10.1016/j.drugpo.2020.102921] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/14/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The OraquickⓇ fingerprick point-of-care hepatitis C virus antibody (HCV-Ab) test is favoured to venipuncture among people who inject drugs; however, its acceptability in prison populations is unknown. We aimed to compare the acceptability of the OraquickⓇ versus standard venipuncture among people in prison. METHODS From October to December 2019, 280 sentenced male inmates at L'Établissement de Détention de Montréal (Quebec, Canada) were screened for participation, 150 excluded due to prior HCV screening, and 52 refused participation. The remaining 78 were randomized 1:1 to opt-out HCV-Ab screening with OraQuickⓇ or venipuncture (n = 39 each). Acceptability was determined by the proportion accepting to undergo screening. RESULTS The majority of participants (median age 33 years) reported a history of drug use (76%; 8% injection drug use); 47% perceived their HCV risk to be moderate/high. All inmates randomized to OraquickⓇ accepted testing while 87% accepted venipuncture. Among those who accepted OraquickⓇ vs. venipuncture, 100% vs. 97% were satisfied with the test, 97% vs. 94% would recommend the same test, and 100% vs. 76% would choose the same test again. CONCLUSION Adult incarcerated men in Canada were both more likely to accept OraquickⓇ compared to venipuncture, and to choose OraquickⓇ for future HCV screening.
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Affiliation(s)
- Nadine Kronfli
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - Camille Dussault
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sylvie Chalifoux
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Hasmig Kavoukian
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina B Klein
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; CIHR Canadian HIV Trials Network, Vancouver, Canada
| | - Joseph Cox
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Kronfli N, Dussault C, Klein MB, Lebouché B, Sebastiani G, Cox J. The hepatitis C virus cascade of care in a Quebec provincial prison: a retrospective cohort study. CMAJ Open 2019; 7:E674-E679. [PMID: 31796509 PMCID: PMC6890491 DOI: 10.9778/cmajo.20190068] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) microelimination efforts must target people in prison; however, although some inmates may qualify for treatment in provincial prisons, it may not be routinely provided. Our aim was to characterize the cascade of HCV care in Quebec's largest provincial prison. METHODS We conducted a retrospective study of all HCV-related laboratory tests requested at the Établissement de détention de Montréal (men's prison with on-demand screening), between July 1, 2017, and June 30, 2018. We defined 8 HCV care cascade steps: 1) total sentenced inmates, 2) screened for HCV (via HCV antibody [HCV Ab]), 3) HCV Ab positive, 4) tested for HCV RNA, 5) HCV RNA positive, 6) linked to care, 7) HCV treatment initiated and 8) achieved sustained virologic response. We measured proportions of inmates at each step using denominator-numerator linkage. We also calculated the proportion screened among inmates with a sentence duration of at least 1 month, during which time screening should be feasible. RESULTS Of the 4931 sentenced inmates, 344 (7%) were screened for HCV, of whom 38 (11%) were HCV Ab positive. Thirty-five (92%) of the 38 received HCV RNA testing, which showed positivity in 16 (46%). Ten (62%) of the 16 inmates were linked to care; treatment was initiated in 3 (30%), 2 of whom (67%) achieved a sustained virologic response. Among inmates with a sentence duration of at least 1 month (n = 1972), the proportion screened increased to 17%. INTERPRETATION A small proportion (7%) of men at a Canadian provincial prison with on-demand HCV testing were screened, and rates of treatment initiation were low in the absence of formal HCV cure pathways. To eliminate HCV in this subpopulation, opt-out HCV testing should be considered.
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Affiliation(s)
- Nadine Kronfli
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que.
| | - Camille Dussault
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que
| | - Marina B Klein
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que
| | - Bertrand Lebouché
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que
| | - Giada Sebastiani
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que
| | - Joseph Cox
- Division of Infectious Diseases (Kronfli, Klein, Lebouché, Sebastiani, Cox), Department of Medicine, McGill University; Chronic Viral Illness Service (Kronfli, Klein, Lebouché, Sebastiani, Cox), McGill University; Research Institute of the McGill University Health Centre (Kronfli, Dussault, Klein, Lebouché, Sebastiani, Cox), Montréal, Que
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