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

Elimination of hepatitis C virus in a prison: An 18-year experience

INTRODUCTION

Despite the decrease of hepatitis C in Spanish prisons in the last years, it still remains a reservoir for infection. The aim of this work is to analyze the characteristics of these patients and the response to antiviral treatment over the last 18 years.

METHODS

Retrospective observational study in inmates of Araba penitentiary center diagnosed with HCV infection between 2002 and 2020. A descriptive analysis of patient characteristics and the response to the three antiviral treatment modalities was performed: peg-interferon and ribavirin, peg-interferon, ribavirin and a first-generation protease inhibitor and different combinations of direct-acting antivirals.

RESULTS

A total of 248 antiviral treatments were prescribed. Treatment response rate up to 2015 was 65% and 93,7% after that year. Interferon non-responders were the main cause of non-response to treatment in periods 1 and 2 (40%-50%). Conversely, in period 3 viral breakthrough (67%) was the main culprit.

CONCLUSION

After 18 years, active hepatitis C infection in prison inmates has resolved with treatment according to clinical criteria. Therefore, the stay in prison may represent an opportunity to reduce the reservoir of the disease in the community, together with continued health care for those released from prison.

Liver diseases: Perspective from the Philippines

Liver diseases are a major cause of morbidity and mortality globally. In the Philippines, a lower middle-income country in Southeast Asia, liver diseases accounted for 27.3 cases per 1000 deaths. In this review, we discussed the prevalence, risk factors, and management of hepatitis B, hepatitis C and other viral hepatitis, non-alcoholic fatty liver disease, alcohol-associated liver disease, liver cirrhosis, and hepatocellular carcinoma. The true burden of liver disease in the Philippines is likely underestimated due to limited epidemiological studies. Thus, surveillance of liver disease should be strengthened. Clinical practice guidelines tailored to the local needs of the country have been developed for important liver diseases. Multisectoral cooperation among different stakeholders is needed to manage the burden of liver disease in the Philippines.

What does it take to achieve microelimination of hepatitis C among incarcerated individuals in Haryana, India?

Content available: Audio Recording.

Is Illicit Substance Use Gender-Specific? The Basic Points of Mental and Health Disorders

Among the groups of users of illicit substances, a high percentage are persons deprived of their liberty; at the same time, each social and age group is also affected, to one degree or another. The purpose of this study is to provide general data on the relationship between different psychostimulants, clinical and socio-demographic studies, and gender, both among the general population and in one of the most at-risk groups. This review identifies the use of illicit substances as gender-specific in the general population. A detailed study of the causal relationship between the use of illicit substances and gender was carried out. Electronic databases Academic Search Complete, PubMed, HealthCare, Web of Science, and Google Scholar were searched for relevant studies up to 2022 associated with drug abuse and mental and health disorders. The analysis indicated that the human population showed significant differences between the sex of the consumer as to the type of drug consumers, development of addiction, and relapse. We focus on the pathological changes caused by drug use, the personal and physiological individual traits that influence drug choice, and the extent of use in one of the most affected groups of individuals. The study may provide some guidance in developing gender-specific treatment and prevention, including response to some pharmacological and behavioral therapies. The review is intended for a wide audience of social workers, toxicologists, and pharmacologists.

Epidemiology of Hepatitis C virus infection among incarcerated populations in North Dakota

This retrospective cohort study was conducted to determine the prevalence of HCV infections among individuals incarcerated in a state prison system and identify potential contributing factors to HCV infection. North Dakota Department of Corrections and Rehabilitation (NDDOCR) data from 2009 to 2018 was used and period prevalence was calculated for this 10-year time period. The period prevalence of HCV infection was (15.13% (95% CI 14.39–15.90) with a marginally significant (p-value: 0.0542) increasing linear trend in annual prevalence over this period. Multivariate logistic regression analysis was used to identify risk factors associated with HCV infection. The main significant independent risk factors for HCV infection in this incarcerated population were age >40 years [OR: 1.78 (1.37–2.32)]; sex [OR: 1.21 (1.03–1.43)]; race/ethnicity [OR: 1.97 (1.69–2.29)]; history of intravenous drug use (IVDU) [OR: 7.36 (6.41–8.44)]; history of needle or syringe sharing [OR: 7.57 (6.62–8.67)]; and alcohol use [OR: 0.87 (0.77–0.99)]. Study limitations include uncollected information on sexual history, frequency or duration of injection drug use and blood transfusion history of the incarcerated population. Considering the high prevalence of HCV infection and its associated risk factors, it is important to implement prevention programs such as syringe/needle exchanges and counsel with imprisoned IVD users.

Global prevalence of hepatitis C in prisoners: a comprehensive systematic review and meta-analysis

Hepatitis C virus (HCV), one of the most significant causes of liver inflammation, has a high annual mortality rate. The unfavorable hygiene conditions and inadequate health monitoring in many prisons increase the risk of blood-borne infections such as hepatitis C. The growing incidence of this disease among prisoners results in overspill transmission to the general population from undiagnosed prisoners that have been released. Therefore, the aim of this study was to investigate the prevalence of hepatitis C among the world's prison population. A systematic review and meta-analysis of studies on the prevalence of hepatitis C was carried out using the keywords "Prevalence", "Hepatitis C", and "Prisoner" in the Iranian and international databases SID, MagIran, Iran Doc, Science Direct, Scopus, PubMed, and Web of Science (WoS) from January 1990 to September 2020. After transferring the articles to the information management software EndNote and eliminating duplicate studies, the remaining studies were reviewed based on inclusion and exclusion criteria, three stages of primary and secondary evaluation, and qualitative evaluation. Comprehensive meta-analysis software and Begg and Mazumdar and I² tests were used for data analysis and assessment of dissemination bias, and heterogeneity, respectively. Out of 93 studies (22 from Asia, 26 from Europe, seven from Africa, 29 from America, and nine from Australia) with a total sample size of 145,823 subjects, the prevalence of hepatitis C in prisoners worldwide was estimated to be 17.7% (95% confidence interval, 15-20.7%). The highest prevalence of hepatitis C on the continents included in this study was reported in prisoners incarcerated in Australia and Oceania, with 28.4% (95% CI: 21.6-36.4) in nine studies, and Europe, with 25.1% (95% CI: 19.4-31.8) in 26 studies. All studies used an ELISA test for the detection of HCV antibodies. The results showed a prevalence of HCV of 17.7% in prisoners worldwide, ranging between 10 and 30% over five continents (Asia, Europe, America, Africa, and Australia and Oceania). The highest prevalence was reported in Australia and Oceania (28.4%), indicating the need to pay more attention to this issue on the continent. It is necessary to reduce the incidence of the disease in prisons by appropriate policy-making and the development of accurate and practical programs, including the distribution of free syringes and examination, testing, and screening of prisoners.

Telemedicine in Hepatology: Current Applications and Future Directions

Telemedicine refers to the use of information and communication technologies for providing health care at a distance. Through the use of telecommunication technologies such as cell phones, computers, and other electronic devices, health care providers are able to conduct patient visits, mentor/train other providers, and monitor patients' chronic diseases remotely, potentially hundreds or thousands of miles away. Over the past 2 decades, the use of telemedicine has grown in the field of hepatology. In this review, we provide a focused primer on telemedicine and its current applications in hepatology. In particular, we discuss the use of telemedicine in the management of chronic hepatitis C, the complications of liver disease, as well as preliver transplantation evaluation and posttransplantation care. In addition, we provide a synopsis of the effect of the coronavirus disease 2019 (COVID-19) pandemic on the use of telemedicine in hepatology.

Milestones to reach Hepatitis C Virus (HCV) elimination in Italy: From free-of-charge screening to regional roadmaps for an HCV-free nation

Although Italy has been on track for Hepatitis C Virus (HCV) elimination since 2019, it fell off track due to the decrease in the number of treated patients. HCV elimination in Italy will be possible if immediate action is taken. A health policy was implemented beginning in 2021, consisting of screening among key populations and birth cohorts (1969-1989), estimated to have a high prevalence of undiagnosed individuals. The active screening requires regional governance that manages the processes' complexity integrating a well-organized network between territory assistance and hospital to achieve an effective HCV care cascade. This document aims to support the regional decision-making process by defining paths for screening and linkage-to-care. Implementing active screening strategies beyond a risk-based approach is required as a General Practitioners' task. Simplified paths must be drawn for the key populations screening. The infrastructure built for COVID-19 vaccination could be used also for HCV screening. According to a multidisciplinary care delivery, screening should be supplemented with rapid linkage-to-care and treatment of newly diagnosed patients. The realization of the proactive screening during the first two years is vital because it will define the tracks for the whole HCV cost-effective screening of 1948-1988 birth cohorts in Italy.

A mathematical model by route of transmission and fibrosis progression to estimate undiagnosed individuals with HCV in different Italian regions

BACKGROUND

Although an increase in hepatitis C virus (HCV) prevalence from Northern to Southern Italy has been reported, the burden of asymptomatic individuals in different Italian regions is currently unknown.

METHODS

A probabilistic approach, including a Markov chain for liver disease progression, was applied to estimate current HCV viraemic burden. The model defined prevalence by geographic area using an estimated annual historical HCV incidence by age, treatment rate, and migration rate from the Italian National database. Viraemic infection by age group was estimated for each region by main HCV transmission routes of individuals for stage F0-F3 (i.e. patients without liver cirrhosis and thus potentially asymptomatic) and F4 (patients with liver cirrhosis, thus potentially symptomatic).

RESULTS

By January 2020, it was estimated that there were 409,184 Italian individuals with HCV (prevalence of 0.68%; 95% CI: 0.54-0.82%), of which 300,171 (0.50%; 95% CI: 0.4-0.6%) were stage F0-F3. Considering all individuals with HCV in stage F0-F3, the geographical distributions (expressed as the proportion of HCV infected individuals by macroarea within the overall estimated number of F0-F3 individuals and prevalence values, expressed as the percentage of individuals with HCV versus the overall number of individuals for each macroarea) were as follows: North 42.1% (0.45%; 95% CI: 0.36-0.55%), Central 24.1% (0.61%; 95% CI: 0.48-0.74%), South 23.2% (0.50%; 95% CI: 0.4-0.61%), and the Isles 10.6% (0.49%; 95% CI: 0.39-0.59%). The population of people who inject drugs accounted for 50.4% of all individuals infected (F0-F3). Undiagnosed individuals (F0-F3) were ~ 15 years younger (⁓ 50 years) compared with patients with stage F4 (⁓ 65 years), with similar age distributions across macroareas. In contrast to what has been reported on HCV epidemiology in Italy, an increasing trend in the proportion of potentially undiagnosed individuals with HCV (absolute number within the F0-F3) from South (23.2%) to North (42.1%) emerged, independent of similar regional prevalence values.

CONCLUSION

This targeted approach, which addresses the specific profile of undiagnosed individuals, is helpful in planning effective elimination strategies by region in Italy and could be a useful methodology for other countries in implementing their elimination plans.

Seroprevalence and associated factors of HIV and Hepatitis C in Brazilian high-security prisons: A state-wide epidemiological study

The prevalence of hepatitis C virus (HCV) and the acquired immunodeficiency virus (HIV) is much higher in prisons than in community settings. Some explanatory factors for this burden include putative aspects of the prison environment, such as unprotected sexual relations and sexual violence, use of injectable drugs and syringe sharing. Nonetheless, efforts in better understanding the dynamics of both HCV and HIV are scarce in developing countries such as Brazil, which poses a risk not only to the inmates but to the community as well. In this investigation, we sought to determine the seroprevalence and sociodemographic and behavioral risk factors associated with HIV and anti-HCV antibodies among men detained at high-security institutions. This is an epidemiological, proportionally stratified observational study including 1,132 inmates aged 18 to 79 years-old (M_age = 32.58±10.18) from eleven high-security prisons located in the State of Paraná, Brazil. We found that HIV and anti-HCV prevalence were 1.6% (95% CI: 1.0–2.5) and 2.7% (95% CI: 1.0–2.5), respectively. Risk factors associated with HIV included not receiving intimate visits (OR = 8.80, 95% CI: 1.15–66.88), already having another sexually transmitted infection (OR = 3.89, 95% CI: 1.47–10.29), and reporting attendance in HIV preventive campaigns (OR = 4.24, 95% CI: 1.58–11.36). Moreover, anti-HCV seroprevalence was associated with higher age (OR = 4.03, 95% CI: 1.61–10.07), criminal recidivism (OR = 2.58, 95% CI 1.02–6.52), and the use of injectable drugs (OR = 7.32, 95% CI 3.36–15.92). Although prisons might increase the risk for acquiring and transmitting HIV and HCV, the adoption of permanent epidemiological surveillance programs could help reducing the circulation of viruses, involving strategies focusing on screening, treating, and preventing infections to assure proper prisoner health. Moreover, these policies need to take place inside and outside the prison environment to offer continued assistance to former prisoners once they leave the institution.

Hepatitis B and Hepatitis C Viral Infections and Associated Factors Among Prisoners in Northeast Ethiopia

BACKGROUND

Hepatitis is an inflammation of the liver and often caused by viruses. Hepatitis viruses are the leading causes of liver-related morbidity and mortality worldwide, with Hepatitis B and C viruses share the great majority. Studies have shown that prison settings are one of the high-risk environments for the transmission of these viruses. However, there is limited information on the seroprevalence and associated factors of hepatitis B and C viral infection among Ethiopian prisoners.

METHODS

A facility-based cross-sectional study was conducted among 339 prisoners in Dessie town, Ethiopia from February to April 2020. Hepatitis B surface antigen and antibody against hepatitis C virus in serum were determined using Enzyme-Linked Immunosorbent Assay. We imputed the data using "EpiData 3.1" software and exported it to Statistical Package for Social Sciences version 20.0 for analysis, and a p-value of <0.05 was considered statistically significant.

RESULTS

The overall seroprevalence of hepatitis B surface antigen and anti-hepatitis C virus among prisoners was 22/339 (6.5%) (95% CI = 3.8-9.4), and 4/339 (1.2%) (95% CI = 0.0-2.4), respectively. Multiple sexual partners, previous imprisonment, body tattooing, and contact with the jaundiced patient were independently associated with hepatitis B virus infection. Prisoners who had a history of blood transfusion, and dental extraction were independently associated with hepatitis C virus infection.

CONCLUSION

The seroprevalence of hepatitis B and hepatitis C viral infection among Dessie town prisoners was intermediate and low, respectively. The finding of a significant association between the presence of Hepatitis B surface antigen and hepatitis C virus antibodies among prisoners and factors calls for the need of serological testing for both Hepatitis B and C viruses to high-risk individuals. Strengthening screening strategies and prevention programs in prison settings is advisable to prevent disease transmission.

Pilot study using the ECHO model to enhance linkage to care for patients with hepatitis C in the custodial setting

Prisoners in most countries have a higher prevalence of HCV than the general population, but their access to treatment is very limited. Our aim was to evaluate a pilot programme using the ECHO model to enhance linkage to care in patients with HCV in 3 Argentinean prisons between October 2018 and January 2020. All inmates were invited to participate, and data were collected through a personal interview. We then estimated HCV prevalence with dried blood spot and performed a logistic regression analysis to identify risk behaviours associated with HCV infection. Finally, HCV management was assessed and monitored through ECHO. Overall, 1141 inmates agreed to participate, representing 39.7% of the total prison population. Anti-HCV prevalence was estimated at 1.58% (CI 0.93; 2.48), being significantly higher in women 2.98% (CI 1.4;5.6) than in men 1.07% (CI 0.5; 2.0); P = .03. Patients with anti-HCV were significantly older than those who tested negative, 42.3 years (CI 37.6;47.1) vs 30.1 years (CI 30.6;31.2), P < .001, respectively. Multiple logistic regression analysis, identified age OR 1.07 (CI 1.03;1.12, P = .001), history of sexually transmitted disease OR 3.08 (CI 0.97;9.82, P = .057) and intravenous drug use OR 12.6 (CI 3.31;48.53, P < .001) as risk factors associated with anti-HCV. Treatment was initiated in all the patients with specialist physician support utilizing ECHO model. In conclusion, our pilot study reported a low prevalence of anti-HCV in the studied population. Incarceration provides an ideal opportunity for testing and treating HCV. ECHO model arises as a useful tool to support assessment and treatment for inmates with chronic HCV.

Cost-effectiveness of strategies to improve HCV screening, linkage-to-care and treatment in remand prison settings in England

BACKGROUND

A simplified cascade-of-care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost-effectiveness of traditional and simplified screening and treatment in a London remand prison.

METHODS

Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base-case scenario. This compared two alternative strategies; (a) general prison population screening and treatment and (b) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47%-90%), linkage-to-care (60%-86%) and treatment (21%-85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were as follows: screening, treatment and disease-related costs per admitted individual, quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted.

RESULTS

In our cohort of 5239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3565-10 300) fell below the national willingness to pay threshold (£30 000). Increased successful treatment (7%-54%) was observed by an optimising cascade-of-care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value.

CONCLUSION

In our remand setting, optimising adherence to the cascade-of-care is cost-effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost-effective.

The civil society monitoring of hepatitis C response related to the WHO 2030 elimination goals in 35 European countries

BACKGROUND

People who inject drugs (PWID) account for the majority of new cases of hepatitis C virus (HCV) infection in Europe; however, HCV testing, and treatment for PWID remain suboptimal. With the advent of direct acting antivirals (DAAs) the World Health Organization (WHO) adopted a strategy to eliminate HCV as public health threat by 2030. To achieve this, key policies for PWID must be implemented and HCV continuum of care needs to be monitored. This study presents results of the first monitoring led by civil society that provide harm reduction services for PWID.

METHODS

In 2019, harm reduction civil society organizations representing focal points of Correlation-European Harm Reduction Network in 36 European countries were invited to complete a 27-item online survey on four strategic fields: use/impact of guidelines on HCV testing and treatment for PWID, availability/functioning of continuum of care, changes compared to the previous year and, the role of harm reduction services and non-governmental organizations (NGOs) of PWID. A descriptive analysis of the responses was undertaken.

RESULTS

The response rate was 97.2%. Six countries reported having no guidelines on HCV treatment (17.1%). Twenty-three (65.7%) reported having treatment guidelines with specific measures for PWID; guidelines that impact on accessibility to HCV testing/treatment and improve access to harm reduction services in 95.6% and 86.3% of them, respectively. DAAs were available in 97.1% of countries; in 26.4% of them they were contraindicated for active drug users. HCV screening/confirmatory tests performed at harm reduction services/community centers, prisons and drug dependence clinics were reported from 80.0%/25.7%, 60.0%/48.6%, and 62.9%/34.3% of countries, respectively. Provision of DAAs at drug dependence clinics and prisons was reported from 34.3 to 42.9% of countries, respectively. Compared to the previous year, HCV awareness campaigns, testing and treatment on service providers' own locations were reported to increase in 42.9%, 51.4% and 42.9% of countries, respectively. NGOs of PWID conducted awareness campaigns on HCV interventions in 68.9% of countries, and 25.7% of countries had no such support.

CONCLUSION

Further improvements in continuum-of-care interventions for PWID are needed, which could be achieved by including harm reduction and PWID organizations in strategic planning of testing and treatment and in efforts to monitor progress toward WHO 2030 elimination goal.

Hepatitis C virus infection and its associated factors among prisoners in a Nigerian prison

Background

The prison population is considered at high risk of acquiring infectious diseases due to confined conditions, behavioral factors, injection drug use, unprotected sexual activity, non-professional tattooing and scarification, and needle sharing. Hepatitis C virus (HCV) is a blood borne pathogen mostly transmitted via percutaneous exposure that results in inflammation of the liver. It is one of the public health problem worldwide and is the principal cause of parenterally transmitted non-A, non-B hepatitis. The study was aimed at evaluating the prevalence of HCV among prison inmates in Calabar, Cross River State, Nigeria and the associated factors.

Methods

The study took a descriptive cross sectional approach using multi-stage sampling technique. One hundred and forty-two (142) prison inmates within the age range of 18–50 years and above were recruited for this study.

Result

Forty two (42); [29.6%] of the participating prison inmates were seropositive for HCV. Gender stratification showed that 31.0% of the males were seropositive for HCV while 15.4% of the females were seropositive for HCV. Fisher exact test showed that gender, age, marital status, occupation and level of education had no association in distribution of seroprevalence of HCV (p > 0.05) but the duration in prison was significantly associated with distribution of seropositivity of HCV in the studied population (p < 0.05). Bivariate logistic regression showed that tattoo/scarification, injection drug use, history of blood transfusion, sexual experience, shaving equipment sharing and multiple sexual partners were not risk factor for distribution of HCV prevalence in the studied population (p > 0.05). However, 23.5% who had tattoo/scarification, 29.6% who used injection drug, 33.3% who had history of blood transfusion, 29.8% who had sexual experience, 21.2% who shared shaving equipment, and 28.3% who had multiple sex partners were seropositive for HCV.

Conclusion

Approximately 29.6% prevalence of Hepatitis C virus infection observed among inmates studied is high and calls for concern. Attitude and behaviors by inmates such as tattooing/scarification, injection drugs use, sharing of shaving equipment, multiple sexual partners should be discouraged.

A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South

BACKGROUND

Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States.

METHODS

We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care.

RESULTS

Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care.

CONCLUSIONS

Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Microelimination of Chronic Hepatitis C by Universal Screening Plus Direct-Acting Antivirals for Incarcerated Persons in Taiwan

Background

Incarcerated persons are a special population with higher hepatitis C virus (HCV) prevalence and should be prioritized for microelimination. In this study, we investigate the seroprevalence and evaluate the effectiveness and safety of direct-acting antiviral (DAA) therapy in custodial settings.

Methods

Incarcerated persons in Yunlin Prison were recruited to receive anti-HCV antibody screening. Patients with positive HCV ribonucleic acid (RNA) were treated with glecaprevir/pibrentasvir (GLE/PIB) in our special chronic hepatitis C (CHC) clinic in prison. The primary endpoint was sustained virologic response at week 12 off therapy (SVR12).

Results

A total of 1402 incarcerated persons were invited to anti-HCV screening and 824 (58.7%) accepted. The prevalence of anti-HCV positivity was 33.5% (276 of 824), and the viremic rate (detectable HCV RNA) was 69.2% (191 of 276). According to fibrosis index based on 4 factors, patients with F3 stage were 6 (3.1%), but none met the criteria of F4 stage. However, 6 (3.1%) had liver cirrhosis with splenomegaly, confirmed by findings of ultrasonography. The median log₁₀ HCV RNA level at baseline was 6.235 (2.394–7.403). Genotype (GT) 6 was predominant (39.3%), followed by GT 1a (22.0%) and 1b (14.1%). Mixed GT HCV infection accounted for 3.6% of total infections. In total, 165 patients received GLE/PIB therapy. The overall SVR12 rates were 100%.

Conclusions

Direct-acting antiviral therapy is highly effective and safe for incarcerated patients in Taiwan. Our special prison-based CHC clinic, linking universal screening to medical care, can serve as a model for microelimination of HCV in custodial settings.

Hepatitis C virus infection in jail: Difficult-to-reach, not to-treat. Results of a point-of-care screening and treatment program

BACKGROUND

An unmet objective in the pursuit of HCV elimination is the creation of a simple and fast operating model to identify difficult-to-treat populations, like prisoners. Of many obstacles, the first is represented by the poor knowledge of inmates HCV-Ab prevalence. Moreover, due to the peculiar status of conviction, often their access to antiviral therapy is neglected.

AIMS

To evaluate the prevalence of HCV infection in a penitentiary Institution of Southern Italy through a point-of-care screening and treatment program.

METHODS

We conducted a prospective observational study in two phases: first, we reviewed all the prisoners' clinical records, to verify HCV-Ab execution. Subsequently, we performed a universal point-of-care screening and treatment program.

RESULTS

We enrolled 670 patients. Overall, 310(46.27%) were already HCV-Ab tested. At the screening initiation, 23.28% patients were discharged, whereas 8.35% refused. Of the remaining 458 subjects, 58(12.67%) were HCV-Ab positive and 46 HCVRNA positive. All these underwent DAA, obtaining 100% SVR. At the end of the program, a total of 491(73.28%) subjects had HCV-Ab available. Sixty-nine (14.05%) were positive. A total of 214(31.94%) subjects were lost to follow-up.

CONCLUSIONS

We revealed a prevalence of 14.05% of HCV-Ab in conviction. Antiviral treatment was safe and efficacious. More efforts are advisable to provide screening for HCV-Ab in conviction.

A systematic review and meta-analysis of the prevalence of hepatitis C virus infection in people who inject drugs in Iran

BACKGROUND

Hepatitis C virus (HCV) infection is one of the major public health challenges generating a relevant burden. High-risk groups, including people who inject drugs (PWID), are at serious risk for developing HCV. In recent years, several investigations have been conducted in Iran to assess the prevalence e of HCV among PWID. The aim of the present study was to synthesize the literature performing a comprehensive search and meta-analysis.

METHODS

A comprehensive literature search was carried out from January 2000 to September 2019. Several international databases, namely Scopus, PubMed/MEDLINE, Embase, ISI/Web of Science, PsycINFO, CINAHL, the Cochrane Library and the Directory of Open Access Journals (DOAJ), as well as Iranian databases (Barakathns, SID and MagIran), were consulted. Eligible studies were identified according to the following PECOS (population, exposure, comparison/comparator, outcome and study type) criteria: i) population: Iranian population; ii) exposure: injection drug users; iii) comparison/comparator: type of substance injected and level of substance use, iv) outcome: HCV prevalence; and v) study type: cross-sectional study. After finding potentially related studies, authors extracted relevant data and information based on an ad hoc Excel spreadsheet. Extracted data included the surname of the first author, the study journal, the year of publication, the number of participants examined, the type of diagnostic test performed, the number of positive HCV patients, the number of participants stratified by gender, the reported prevalence, the duration of drug injection practice and the history of using a shared syringe.

RESULTS

Forty-two studies were included. 15,072 PWID were assessed for determining the prevalence of HCV. The overall prevalence of HCV among PWID in Iran was computed to be 47% (CI 95: 39-56). The prevalence ranged between 7 and 96%. Men and subjects using a common/shared syringe were 1.46 and 3.95 times more likely to be at risk, respectively.

CONCLUSION

The findings of the present study showed that the prevalence of HCV among PWIDs in Iran is high. The support and implementation of ad hoc health-related policies and programs that reduce this should be put into action.

Time matters: Point of care screening and streamlined linkage to care dramatically improves hepatitis C treatment uptake in prisoners in England

BACKGROUND

In England, opt-out dry blood spot prison screening for HIV, hepatitis B and hepatitis C (HCV) has been introduced to scale-up access to care. Recent advances in point-of-care HCV diagnostics provide an opportunity to improve diagnosis and treatment uptake. We compared the retention along and time intervals between each aspect of the HCV care continuum for an alternative rapid point-of-care-testing and simplified treatment strategy with existing national opt-out HCV dry blood spot testing and treatment at a large remand prison in West London.

METHODS

Between September 2017 and December 2018 universal opt-out dry blood spot HCV testing, clinical assessment and treatment uptake were recorded at Her Majesty's Prison Wormwood Scrubs. Outcomes were compared to a point-of-care-based (salivary Oraquick® anti-HCV screening and Xpert® HCV fingerstick viral load) screening and streamlined treatment pathway offered to all new arrivals to the HMP Wormwood Scrubs substance misuse unit, which ran in parallel to dry blood spot testing between September and December 2018.

RESULTS

During the study period 2442 out of 5239 inmates (46.6%) underwent dry blood spot screening, resulting in 62 (2.6%) HCV RNA positive cases. Thirteen (21.3%) individuals commenced therapy and no viral relapse cases were observed to date. In comparison, 162 out of 181 (89.5%) inmates admitted to the substance misuse unit agreed to rapid point-of-care testing; 20 (12.3%) HCV RNA positive cases. Seventeen (85.0%) of eligible inmates commenced treatment. The median length of stay (90 vs 30 days), time to screening (6 vs 2 days), assessment (14 vs 3 days) and treatment (36 vs 1 day) were shorter for the rapid point-of-care screen-and-treat group.

CONCLUSION

Current scaling-up of prison dry blood spot HCV screening and treatment in England is sub-optimal. In our setting, the cascade of care is time and resource sensitive and is greatly improved by the introduction of a simplified screen-and-treat strategy.

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.

Demonstration of Near-Elimination of Hepatitis C Virus Among a Prison Population: The Lotus Glen Correctional Centre Hepatitis C Treatment Project

Micro-elimination of hepatitis C virus (HCV) infection through rapid uptake of government-funded direct-acting antiviral therapy within an Australian prison setting is demonstrated. During a 22-month period, 119 patients initiated treatment for chronic HCV infection, with HCV in-prison viremic prevalence declining from 12% to 1%.

Clustering of hepatitis C virus antibody positivity within households and communities in Punjab, India

To better understand hepatitis C virus (HCV) epidemiology in Punjab state, India, we estimated the distribution of HCV antibody positivity (anti-HCV+) using a 2013-2014 HCV household seroprevalence survey. Household anti-HCV+ clustering was investigated (a) by individual-level multivariable logistic regression, and (b) comparing the observed frequency of households with multiple anti-HCV+ persons against the expected, simulated frequency assuming anti-HCV+ persons are randomly distributed. Village/ward-level clustering was investigated similarly. We estimated household-level associations between exposures and the number of anti-HCV+ members in a household (N = 1593 households) using multivariable ordered logistic regression. Anti-HCV+ prevalence was 3.6% (95% confidence interval 3.0-4.2%). Individual-level regression (N = 5543 participants) found an odds ratio of 3.19 (2.25-4.50) for someone being anti-HCV+ if another household member was anti-HCV+. Thirty households surveyed had ⩾2 anti-HCV+ members, whereas 0/1000 (P < 0.001) simulations had ⩾30 such households. Excess village-level clustering was evident: 10 villages had ⩾6 anti-HCV+ members, occurring in 31/1000 simulations (P = 0.031). The household-level model indicated the number of household members, living in southern Punjab, lower socio-economic score, and a higher proportion having ever used opium/bhuki were associated with a household's number of anti-HCV+ members. Anti-HCV+ clusters within households and villages in Punjab, India. These data should be used to inform screening efforts.

Hepatitis B and C prevalence and incidence in key population groups with multiple risk factors in the EU/EEA: a systematic review

BackgroundPeople living with HIV (PLHIV) and people in prison are population groups with a potentially high risk and/or prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection.AimWe conducted a systematic review in order to find prevalence and incidence estimates in these populations in the European Union/European Economic Area (EU/EEA).MethodsOriginal research articles published between January 2005 and February 2017 were retrieved from PubMed and Embase in February 2017.ResultsFifty-two articles were included, providing 97 estimates of HBV/HCV infection prevalence or incidence. Estimates of HBV infection prevalence ranged between 2.9% and43.4% in PLHIV and 0.0% and 25.2% in people in prison. Estimates of HCV infection prevalence ranged from 2.9% to 43.4% in PLHIV and 0.0% to 25.2% in people in prison. Incidence estimates ranged between 0.0 and 2.5 cases per 100 person-years for HBV infection in PLHIV. No such data was available for people in prison. HCV infection incidence ranged between 0.3 and 0.9 cases per 100 person-years in PLHIV and between 1 and 1.2 cases per 100 person-years in people in prison. Prevalence estimates were generally higher than in the general population, especially for HCV infection and among groups with multiple risk factors.ConclusionsPLHIV, people in prison and groups with multiple risk factors, have a high prevalence of HBV and HCV and may be at ongoing risk of infection. These groups should be among the populations prioritised and targeted for active case finding and prevention programmes in the EU/EEA.

Characteristics associated with anti-HCV serological markers in prisoners in the state of Paraná, Brazil: a case-control study

Background

The prison system in Paraná, Brazil, is experiencing serious problems related to the increasing number of prisoners. Control of hepatitis C virus (HCV) has become more intense because the incarcerated population is considered a high-risk group for contagious diseases due to the favorable conditions found in prisons for the spread of these morbidities. The objective of this study was to identify features associated with hepatitis C infection among male prisoners in correctional institutions of Paraná state, Brazil.

Methods

This was a case-control study (27 cases and 54 controls) of men incarcerated in 11 penitentiaries in Paraná, Brazil. Information was obtained through a questionnaire in a cross-sectional epidemiological survey on HCV infection during the period from May 2015 to December 2016. Eligible men were recruited after testing positive for anti-HCV antibodies. Cases and controls were selected based on serological results of enzyme-linked immunosorbent assays and were matched by age, location of the penitentiary, and time in prison. Logistic regression analysis was used to identify risk factors for HCV seropositivity.

Results

The main significant independent risk factor for the acquisition of HCV infection was the use of injectable drugs (OR = 4.00; 95%CI:1.41–11.35; p < 0.001).

Conclusions

This study provides evidence that HCV infection is associated with drug use by this population. This information is pivotal for tailoring prevention programs and guiding specific socioeducational measures that aim to reduce or prevent HCV transmission within the prison setting.

Hepatitis C virus screening and treatment in Irish prisons from nurse managers' perspectives - a qualitative exploration

BACKGROUND

Prisoners carry a greater burden of physical, communicable and psychiatric disease compared to the general population. Prison health care structures are complex and provide challenges and opportunities to engage a marginalised and poorly served group with health care including Hepatitis C Virus (HCV) screening, assessment and treatment. Optimising HCV management in prisons is a public health priority. Nurses are the primary healthcare providers in most prisons globally. Understanding the barriers and facilitators to prisoners engaging in HCV care from the perspectives of nurses is the first step in implementing effective strategies to eliminate HCV from prison settings. The aim of this study was to identify the barriers and facilitators to HCV screening and treatment in Irish prisons from a nurse perspective and inform the implementation of a national prison-based HCV screening program.

METHODS

A qualitative study using focus group methodology underpinned by grounded theory for analysis in a national group of nurse managers (n = 12).

RESULTS

The following themes emerged from the analysis; security and safety requirements impacting patient access, staffing and rostering issues, prison nurses' skill set and concerns around phlebotomy, conflict between maintaining confidentiality and concerns for personal safety, peer workers, prisoners' lack of knowledge, fear of treatment and stigma, inter-prison variations in prisoner health needs and health service delivery and priority, linkage to care, timing of screening and stability of prison life.

CONCLUSIONS

Prison nurses are uniquely placed to identify barriers and facilitators to HCV screening and treatment in prisoners and inform changes to health care practice and policy that will optimise the public health opportunity that incarceration provides.

A cross-sectional evaluation of opt-in testing for sexually transmitted and blood-borne infections in three Canadian provincial correctional facilities: a missed opportunity for public health?

PURPOSE

Incarceration provides an opportunity for screening and treatment of sexually transmitted and blood-borne infections (STBBIs) in high-risk groups. The purpose of this paper is to determine positivity rates of STBBI screening within correctional facilities using opt-in strategies and estimate the proportion of admissions tested.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional, retrospective review of testing data from January 2012 to August 2015 from three provincial correctional facilities located in Alberta, Canada was completed. Analysis variables included STBBI, gender, facility, collection year and age. STBBI-stratified analysis was performed to identify correlates for positivity using univariate and logistic regressions.

FINDINGS

Overall prevalence of chlamydia was 11.2 percent and gonorrhea was 3.5 percent; correlates for both were younger age and facility type. The syphilis prevalence rate was 3.2 percent; correlates included being female, older age, adult facilities, with later years being protective. In total, 14 (0.3 percent) newly diagnosed HIV cases were found, prevalence increased with age. HBV prevalence was 1.7 percent with no significant correlations. Nearly one-tenth (n=422) of those screened for HCV antibody were positive; all variables were significantly correlated. Overall estimates of the proportion of admissions tested by STBBI were low and ranged from 4.8 to 16.1 percent.

ORIGINALITY/VALUE

This study found high rates of STBBI in correctional facilities and showed that only a small proportion of the population was tested using an opt-in strategy. Shifting to an "opt-out" strategy may be warranted.

Family Practitioner-Directed Hepatitis C Therapy With Direct-Acting Antivirals Achieves High-Sustained Virologic Response in Prison Population

The burden of hepatitis C virus (HCV) infection is disproportionately high in U.S. federal and state prisons. This offers a unique opportunity for targeted HCV screening and treatment. New, highly effective, oral direct-acting antiviral (DAA) agents have the potential to eliminate many of the hurdles previously imposed by older interferon-based therapies. However, a relative deficit of providers motivated or empowered to treat HCV, along with a lack of treatment data on use of DAAs in prisons, greatly restricts the ability to treat the prison population. Here, we present a retrospective chart review of HCV treatment with DAAs by a family practitioner in a California state prison. Our data demonstrate that focused treatment by a primary care practitioner can achieve high HCV cure rates even in historically difficult to treat populations. Treatment of prison populations per local and national guidelines by family practitioners should be pursued to facilitate the eradication of hepatitis C in the United States.

Offering HCV treatment to prisoners is an important opportunity: key principles based on policy and practice assessment in Europe

Background

Prisoners have a high prevalence of hepatitis C virus (HCV) infection but may find it difficult to access healthcare services. This may be related to risk behaviour including history of injecting drugs and marginalisation related to problem drug use/ opioid use disorder (OUD). Direct-acting antiviral products with superior efficacy and safety compared to interferon-based regimens offer HCV cure. Many citizens in Europe have been treated, although few received therapy in prisons.

Methods

Analysis of prisoner HCV treatment need and policy determinants of clinical practice was completed for 5 EU countries. Evidence was collected from national statistical sources and peer-reviewed publications to describe prison populations and HCV prevalence, to map national prison/ HCV health policy or guidance. A consensus of important principles for prisoner HCV care was developed.

Results

Data from published sources describing prisoner HCV prevalence is limited. Prisoner population requiring HCV treatment is not known; estimated numbers based on analysis of evidence: England and Wales, 9000, France, 8000, Spain, 6000, Italy, 6000, Germany, 6000. Treatment access: national law defines right to equivalent care in all countries implying access to HCV therapy in prison similar to community; useful prisoner HCV guidance facilitating treatment decisions present in: 4 of 5 national/ regional HCV policy documents, 4 of 5 national prison healthcare policies. Four of five had practical prison HCV clinical guidelines. Despite existence of policy, implementation of guidance, and so HCV treatment, is suboptimal in many locations.

Conclusions

Prison is an important location to detect, address and treat HCV infection in people who may be underserved for healthcare and find it difficult to navigate community treatment pathways. This is often related to problems with OUD and resulting social inequity. HCV management in prisons must be improved. Policy and clinical practice guidance must be set to promote treatment, and practical steps to make treatment easy should be followed including education to promote engagement, set-up of optimal screening and work up processes with modern tools to reduce time needed/ achieve efficiency; programs to make it easier to get specialists’ input include remote working and nurse-led services.

Previous incarceration impacts access to hepatitis C virus (HCV) treatment among HIV-HCV co-infected patients in Canada

INTRODUCTION

The prevalence of hepatitis C virus (HCV) is far higher in prison settings than in the general population; thus, micro-elimination strategies must target people in prison to eliminate HCV. We aimed to examine incarceration patterns and determine whether incarceration impacts HCV treatment uptake among Canadian HIV-HCV co-infected individuals in the direct-acting antiviral (DAA) era.

METHODS

The Canadian Co-Infection Cohort prospectively follows HIV-HCV co-infected people from 18 centres. HCV RNA-positive participants with available baseline information on incarceration history were included and followed from 21 November 2013 (when second-generation DAAs were approved by Health Canada) until 30 June 2017. A Cox proportional hazards model was used to assess the effect of time-updated incarceration status on time to treatment uptake, adjusting for patient-level characteristics known to be associated with treatment uptake in the DAA era.

RESULTS

Overall, 1433 participants (1032/72% men) were included; 67% had a history of incarceration and 39% were re-incarcerated at least once. Compared to those never incarcerated, previously incarcerated participants were more likely to be Indigenous, earn <$1500 CAD/month, report current or past injection drug use and have poorly controlled HIV. There were 339 second-generation DAA treatment initiations during follow-up (18/100 person-years). Overall, 48% of participants never incarcerated were treated (27/100 person-years) compared to only 31% of previously incarcerated participants (15/100 person-years). Sustained virologic response (SVR) rates at 12 weeks were 95% and 92% respectively. After adjusting for other factors, participants with a history of incarceration (adjusted hazard ratio (aHR): 0.7, 95% CI: 0.5 to 0.9) were less likely to initiate treatment, as were those with a monthly income <$1500 (aHR: 0.7, 95% CI: 0.5 to 0.9) or who reported current injection drug use (aHR: 0.7, 95% CI: 0.4 to 1.0). Participants with undetectable HIV RNA (aHR: 2.1, 95% CI: 1.6 to 2.9) or significant fibrosis (aHR: 1.5, 95% CI: 1.2 to 1.9) were more likely to initiate treatment.

CONCLUSIONS

The majority of HIV-HCV co-infected persons had a history of incarceration. Those previously incarcerated were 30% less likely to access treatment in the DAA era even after accounting for several patient-level characteristics. With SVR rates above 90%, HCV elimination may be possible if treatment is expanded for this vulnerable and neglected group.

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.

Telementoring for hepatitis C treatment in correctional facilities

Introduction

Prevalence of hepatitis C virus (HCV) is substantially higher among prisoners than the general population. In Australia until recently, only a small proportion of prisoners with HCV received antiviral therapy. The direct-acting antivirals (DAAs) for HCV are highly effective, with a low burden of side effects. Since 2016, DAAs are available to all Australians with HCV. However, currently in Australia, they can only be prescribed by or in consultation with experienced prescribers. This study evaluated a telementoring service to upskill doctors and nurse practitioners working in correctional facilities.

Methods

The telementoring service was implemented in five correctional facilities. Qualitative interviews were used to examine the perceived clinical effectiveness and organisational impacts of the service. Content analysis of the interviews was used to identify key themes.

Results

In the first ten months of the service, there were 16 telementoring sessions with 173 patients discussed. Sixteen staff participated in qualitative interviews. From these, three key themes were identified: access to antiviral therapy; organisational impacts (cost, increased staff knowledge and confidence, staff time, and workload); and, adaptations of the care model and future opportunities.

Conclusion

Telementoring is an effective method to facilitate eligible prescriber status to medical doctors and upskill other clinicians in correctional facilities to increase capacity to treat HCV.

Evaluation of cost-effectiveness of peginterferon plus ribavirin for chronic hepatitis C treatment and direct-acting antiviral agents among HIV-infected patients in the prison and community settings

BACKGROUND

In Taiwan, the majority of chronic hepatitis C carriers with HIV co-infection are intravenous drug users and inmates in correctional facilities. Peginterferon and ribavirin (PegIFN/RBV) have been the standard-of-care for chronic hepatitis C virus (HCV) infection more than decades. We evaluated the estimated cost-effectiveness of PegIFN/RBV from the National Health Insurance Research Database, covering the population of Taiwan from 1998 to 2013.

MATERIALS AND METHODS

This is an observational study, and study during was 2010-2016 and a total of 239 patients were treated with PegIFN/RBV. Of them, 156 patients were treated in the correctional facilities of Taipei, Taoyuan, Taichung and Taitung prisons, and 83 patients were treated in communities. The cost-effectiveness was analyzed in regimens of PegIFN/RBV and direct-acting antiviral agents.

RESULTS

By multivariate analysis, the patients completed PegIFN/RBV in prison (adjusted odds ratio [aOR]: 4.56, 95% confidence interval [CI]: 1.58-13.12, p = 0.005), HCV RNA level <800,000 IU/mL (aOR: 4.0, 95% CI: 1.27-12.66, p = 0.02) at baseline, and the presence of early virologic response (EVR) (aOR: 7.67, 95% CI: 1.89-31.06, p = 0.004) were independent predictors for sustained virologic response (SVR). For the subgroups of prisoners, HIV-infected prisoners and HIV-infected patients in communities, the SVR rate was 73.8%, 72.0% and 36.8%, and the average medical-care cost was US$7,701, $7,893, and $15,443 per SVR achieved, respectively. Also, the estimated medical-care cost for genotype 6 was US$9211.

CONCLUSIONS

Chronic HCV/HIV co-infected patients with genotype 1 and 6 in the community setting could benefit from DAAs in Taiwan.

Direct-acting antiviral treatment of acute hepatitis C virus infections

INTRODUCTION

Hepatitis C contributes to significant morbidity and mortality worldwide. AHCV is defined as documented infection within 6 months of exposure. Treating acute hepatitis C virus (AHCV) with direct-acting antiviral agents in persons who inject drugs, HIV-positive men who have sex with men, and patients who acquire HCV nosocomially can contribute to the elimination of disease globally, preclude the morbidity and mortality of chronic disease, and prevent further transmission. Areas covered: In this review, we describe the epidemiology of AHCV, its natural history, the considerations involved in the decision of whether to treat AHCV, and the most current DAA therapy guidelines. PubMed was queried using key words and bibliographies were evaluated for relevant articles. Expert commentary: Despite the obvious benefits of AHCV treatment, clinical management is limited by the ability to identify asymptomatic cases and the absence of fully supported guidelines. However, clinical research is advancing and identifying specific regimens, decreasing treatment durations, and creating strategies to target at risk groups and screen for AHCV.

Exploring Lifetime Accumulation of Criminal Justice Involvement and Associated Health and Social Outcomes in a Community-Based Sample of Women who Use Drugs

Among people who use illegal drugs, engagement with the criminal justice (CJ) system often involves an ongoing, intermittent series of arrests, incarcerations, and periods of community supervision. The potential associations between the lifetime accumulation of CJ involvement and social and health outcomes is largely unexplored. In a cross-sectional sample of women who use crack, heroin, and/ or methamphetamine recruited from communities in Oakland, CA (N = 624), we developed an approach to characterize CJ accumulation. We used latent class analysis (LCA), a multivariate person-centered method that assumes an unobserved categorical variable that divides a population into a small number of mutually exclusive and exhaustive classes. Using observed measures of incarceration and community supervision as indicator variables, we developed a model of CJ accumulation that elucidates patterns of involvement as lived by the women in the sample. Based on model fit statistics, we selected a three-class model and labeled the classes "low," "medium," and "high." We then explored associations between the classes of CJ accumulation and health and health-related outcomes using logistic regression. The odds of homelessness (p for trend = 0.004), transience (p for trend = 0.017), and recent victimization (p for trend = 0.023) were higher among women in higher accumulation classes. Higher class of CJ accumulation was associated with higher odds of reporting unmet need for physical health care (p for trend < 0.001) and mental health care (p for trend = 0.002). The odds of physical health conditions, such as hepatitis C infection (p for trend < 0.001) and mental health conditions, such as depression (p for trend = 0.003), also increased with higher class of accumulation. While the findings described here are limited by the cross-sectional nature of the study, they suggest that CJ accumulation is a potentially meaningful concept for assessing associations between the CJ system and health-related issues.

Hepatitis C seropositivity among newly incarcerated prisoners in Estonia: data analysis of electronic health records from 2014 to 2015

Background

Hepatitis C virus (HCV) infection is a widespread problem in prisons. The present study aimed to assess the prevalence of HCV seropositivity, HCV genotypes, factors associated with HCV seropositivity in newly incarcerated prisoners and to report experiences of treatment with pegylated interferon/ribavirin for HCV-positive inmates.

Methods

Patient data were extracted from the Estonian prison medical information system (Vanglate meditsiiniline infosüsteem) databases.

Results

Among 1845 prisoners newly incarcerated from January 2014 to January 2015, the overall prevalence of HCV was 56.3% (95% CI: 54 to 59), and 25.5% (95% CI: 23.5 to 27.6%) had HIV (39.0% had neither). The all-inclusive HCV testing strategy identified 37.7% more HCV infected prisoners than the risk-based (drug use history, HIV status) case finding. Factors associated with HCV seropositivity included history of drug use (aOR 6.51 95%CI 5.12–8.28), HIV co-infection (aOR 2.56 95%CI 1.92–3.43), previous incarceration (aOR 3.61 95%CI 2.48–4.04), and increasing age. The main HCV genotypes were 3a (n = 172, 44.4%) and 1b (n = 135, 35.2%). Twenty-five prisoners received HCV treatment: 60% (n = 15) were cured, 16% (n = 4) relapsed (3 with genotype 3a, one with 1b), and 12% (n = 3) were unresponsive (all with genotype 3a).

Conclusions

HCV seropositivity rate is high and HCV tretment rate is very low in Estonian prisons. Optimizing case finding and scaling up treatment is critical to addressing the health needs of prisoners and meeting public health goals.

Treatment with direct-acting antivirals in a multicenter cohort of HCV-infected inmates in Italy

BACKGROUND

People who are incarcerated have a significantly higher prevalence of HCV infection than the general population. Given their high-risk behavior, they represent a reservoir of HCV infection for the whole community.

METHODS

We evaluated all HCV-infected people who were incarcerated in 25 Italian prisons starting direct-acting antivirals (DAAs) treatment between May 2015 and October 2016. We collected information on demographic characteristics, liver disease, HCV-related aspects, anti-HCV treatment, HIV or HBV co-infection.

RESULTS

We enrolled 142 incarcerated people treated with DAAs. They were mostly Italians (93.7%) and males (98.6%). Median age was 50 years and 108/142 (76.1%) were cirrhotic patients. Prevalent genotypes were 1a (35.9%) and 3 (35.9%). Two patients were HBV co-infected, twenty-one patients (14.8%) were HIV co-infected and almost all (95.2%) received antiretroviral therapy. 118/142 (83.1%) DAAs-based regimens included sofosbuvir. Treatment completion rate was 94.4%. There were eight (5.6%) discontinuations, one (0.7%) due to an adverse reaction, one due to death (0.7%) and six (5.6%) due to release from prison. SVR12 was achieved in 90.8%. Four patients relapsed but no breakthrough occurred.

CONCLUSIONS

Our study shows that in Italian penitentiary settings DAAs treatment is feasible and effective. This intervention is crucial for reducing HCV circulation with possible benefits to the general population.

Prevalence and risk factors for HBV and HCV in prisoners in Iran: a national bio-behavioural surveillance survey in 2015

OBJECTIVES

To provide more accurate estimates of the prevalence of Hepatitis B (HBV) and Hepatitis C (HCV) and their contributing factors among prisoners in Iran.

METHODS

Cross-sectional study of 6200 Iranian prisoners in 2015. Data were collected through questionnaires and interviews. HBV infection and HCV exposure status of the participants was determined by HBsAg and HCV antibodies blood tests using enzyme-linked immunosorbent assay (ELISA). Data were analysed in STATA-12.

RESULT

Prevalence of HCV exposure was 9.48% (95% CI: 8.73-10.27), and prevalence of HBV was 2.48% (95% CI: 2.07-2.89) in the general prison population. In multivariate analysis, the most important risk factor for HBV was a history of drug use in lifetime (adjusted odds ratio, AOR: 1.8, 95% CI: 1.17-3.02). The main risk factors for HCV exposure were a history of drug use in lifetime (AOR: 4.08, CI: 2.56-6.27), age over 30 (AOR: 2.68, CI: 2.01-3.56), and having tattoos (AOR = 1.67, CI: 1.35-2.07).

CONCLUSION

Although vaccination is used to control HBV among prisoners, prevalence of HCV exposure is alarming in the prison population of Iran, especially among people who inject drugs. Eliminating viral hepatitis in Iran by 2030 requires a national commitment and rapid measures for targeting this high-risk group. Given the increased efficiency of HCV treatment in recent years, prisons provide an opportunity to access patients for treatment.

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.

Prevalence of hepatitis C virus infection among prisoners in Iran: a systematic review and meta-analysis

Background

Hepatitis C virus (HCV) is one of the major public health problems both in developed and developing countries. Prison represents a high-risk environment for prisoners, in that it is characterized by high-risk behaviors such as injecting drug use (IDU), tattooing, unprotected sexual intercourses, or sharing syringes. The aim of this study was to quantitatively evaluate the prevalence of HCV among Iranian prisoners conducting a systematic review and meta-analysis.

Methods

We searched different scholarly databases including Embase, PubMed/MEDLINE, ISI/Web of Sciences, the Cochrane library, Scopus, CINAHL, and PsycINFO as well as Iranian bibliographic thesauri (namely, Barakatns, MagIran, and SID) up to December 2017. The Newcastle Ottawa Scale (NOS) was used to assess the quality of the studies included. HCV prevalence rate with its 95% confidence interval (CI) was estimated using the DerSimonian-Laird random-effects model, with Freeman-Tukey double arcsine transformation. Egger’s regression test was used to evaluate publication bias.

Results

Finally, 17 articles were selected based on inclusion and exclusion criteria. Overall, 18,693 prisoners were tested. Based on the random-effects model, the prevalence of HCV among Iranian prisoners was 28% (CI 95% 21–36) with heterogeneity of I² = 99.3% (p = 0.00). All studies used an ELISA test for the evaluation of HCV antibodies. The findings of this study showed that the highest prevalence rate (53%) was among prisoners who inject drugs.

Conclusion

The findings of our study showed that the prevalence of HCV among Iranian prisoners is dramatically high. Managing this issue in Iran’s prisons requires careful attention to the availability of health facilities and instruments, such as screening, and harm reduction policies, such as giving sterile syringes and needles to prisoners. An integrated program of training for prisoners, prison personnel and medical staff is also needed to improve the level of health condition in prisons.

Interventions to increase testing, linkage to care and treatment of hepatitis C virus (HCV) infection among people in prisons: A systematic review

BACKGROUND

While the burden of chronic hepatitis C virus (HCV) infection is significantly higher among people in prisons compared to the general population, testing and treatment uptake remain suboptimal. The aim of this systematic review was to synthesize evidence on the effectiveness of interventions to increase HCV testing, linkage to care and treatment uptake among people in prisons.

METHODS

We searched Medline (Ovid 1996-present), Embase (Ovid 1996-present), and the Cochrane Central Register of Controlled Trials for English language articles published between January 2007 and November 2017. Studies evaluating interventions to enhance HCV testing, linkage to care and treatment uptake for people in prison were included. Two independent reviewers evaluated articles selected for full-text review. Disagreements were resolved by consensus.

RESULTS

A total of 475 unique articles were identified, 29 were eligible for full text review, and six studies were included. All but one study was conducted in the pre-direct-acting antiviral (DAA) era; no studies were conducted in low- or middle-income countries. Of the six studies, all but one focused on testing. Only two were randomised controlled trials; the remaining were single arm studies. Interventions to enhance HCV testing in prison settings included combination risk-based and birth-cohort screening strategies, on-site nurse-led opt-in screening clinics with pre-test counselling and education, and systematic dried blood spot testing. All interventions increased HCV testing, but risk of study bias was high in all studies. Interventions to enhance linkage to care included facilitated referral for HCV assessment and scheduling of specialist appointments; however, risk of study bias was critical.

CONCLUSIONS

There is a lack of recent data on interventions to improve the HCV care cascade in people in prisons. With the introduction of short-course, well-tolerated DAAs, rigorous controlled studies evaluating interventions to improve testing, linkage and treatment uptake for people in prison are necessary.

Epidemiological features of chronic hepatitis C infection caused by remunerated blood donors: A nearly 27-year period survey

AIM

To understand the prevalence of hepatitis C virus (HCV) infection in blood donors over a nearly 27-year interval and to explore the factors that affect the outcome of HCV infection.

METHODS

A retrospective and cross-sectional study was conducted. The participants, mostly plasma donors, were selected from three administrative villages in the Jiangsu province in Eastern China. A questionnaire was administered among the villagers who had a history of blood donation from the late 1980s to the early 1990s. All participants underwent physical examination, liver B-ultrasonography, and liver stiffness measurement. In addition, 10 mL of blood was collected from each participant to measure simple liver function parameters (albumin, alanine aminotransferase, aspirate aminotransferase), blood factors (platelet), and for hepatitis B surface antigen, antiHCV, and antihuman immunodeficiency virus detection. HCV RNA detection, HCV genotyping, and other tests were carried out in antiHCV-positive patients.

RESULTS

After a median of 27 years (25-31 years) from the last blood donation to the time of survey, a total of 1694 participants were investigated, and the antiHCV-positive individuals were categorized into three groups: blood donors (n = 12, 3.3%), plasma donors (n = 534, 68.5%), and mixed donors (n = 324, 58.8%). A total of 592 (68.05%) patients had detectable HCV RNA, and 91.9% had genotype 1b. A total of 161 (27.2%, 161/592) patients with chronic HCV were considered to have cirrhosis with a liver stiffness measurement level higher than 12 kPa. Multiple logistic (binary) regression analysis results showed that platelet and IgG levels were associated with cirrhosis.

CONCLUSION

The nearly 27-year interval investigation revealed that chronic hepatitis C infection is a very serious public health problem in Eastern China. Plasma donation and subsequent return of blood cells to the donor are the main causes of hepatitis C infection. The main HCV genotype is 1b. Nearly 28% of cases progressed to cirrhosis. Age, especially over 60 years, and regular drinking habits were risk factors associated with cirrhosis.

Genotype distribution and treatment response among incarcerated drug-dependent patients with chronic hepatitis C infection

The prevalence of hepatitis C virus (HCV) infection is disproportionately high among prisoners, especially among those who are drug-dependent. However, current screening and treatment recommendations are inconsistent for this population, and appropriate care is not reliably provided. To address these problems, the present study aimed to identify unique characteristics and clinical manifestations of incarcerated patients with HCV infection. We included incarcerated patients who received treatment with pegylated-interferon combined with ribavirin at Mackay Memorial Hospital in Taitung and were serving sentences at either the Taiyuan Skill Training Institute or the Yanwan Training Institute. HCV genotypes 1 (41.4%), 3 (25.9%), and 6 (24.1%) were the most prevalent in the incarcerated patients. During the study period, we analyzed treatment response among 58 incarcerated patients and compared obtained results with treatment response among 52 patients who were living in the community. Higher sustained virological response rate was observed among patients with incarceration and HCV genotype other than 1. The odds ratios (corresponding 95% confidence intervals) for incarceration and genotype 1 were 2.75 (1.06–7.11) and 0.37 (0.14–0.99), respectively. Better treatment compliance among incarcerated patients might partially explain these results. The results of this study suggest that treatment of prisoners with HCV infection is feasible and effective. More appropriate and timely methods are needed to prevent HCV transmission among injection drug users inside prisons.

HCV infection and drug use in Italian detainees: results of validation of EQDP (European Questionnaire on Drug Use in Prison)

Purpose: The aim of this paper is to describe the results of a survey conducted in Italy amongst detainees by administering a specific questionnaire (EQDP, European Questionnaire on Drug Use in Prison), in order to investigate drug use in prison, any sharing of used needles and, lastly, the degree of self-awareness regarding health (more specifically, in terms of HIV, HBV and HCV infection). Structure of the article: The article is split into three parts. The first provides an overview of the methodological guidelines for the EQDP, which were issued in March 2017 by the European Monitoring Centre for Drugs and Drug Addiction. The second describes the structure of the EQDP questionnaire (Italian version). The third provides the results of a survey conducted in Italy using this questionnaire and the health-related implications for the prison community, in particular regarding HCV, HIV and HBV. Results: The data were collected by the self-administration of the questionnaire to groups of a sample consisting of 40 male detainees under in normal prisons. In this type of custody, fewer subjects were substance abusers during previous prison terms than amongst subjects in open prisons. The most common forms of dependence (tobacco, alcohol, THC, cocaine, psychostimulants, hallucinogens, opioids, sedatives) detected were significantly different between the two types of imprisonment and they were easier to identify in the open-prison system. The analysis of the state of health with regard to the above viruses demonstrated that, in open-prison conditions, a higher percentage of subjects have been tested for HIV, HBV and HCV, whereas detainees in normal prison conditions were almost all unaware of their infection status and had a poorer awareness of their health in general. Conclusions:Health status (HBV, HCV, HIV) is not declared amongst normal detainees, who are less aware of their health conditions and receive less risk-reduction intervention. Amongst open-prison detainees, however, all substance users are subject to risk reduction interventions, which are efficacious in improving self-awareness in terms of a greater use of blood tests and treatments for infectious diseases. (www.actabiomedica.it)

For a program of eradication of hepatitis C in the populations at risk (drug users and convicts)

Injection drugs are the greater source for HCV infection. About 60% of drug users and about 20-30% of convicts are infected with HCV. HCV infection is often associated with behavioral disorders and drug use. At present, few subjects with HCV belonging to risk groups have been treated with Direct-Acting Antivirals (DAAs). SerDs and prisons should implement the screening for HCV. HCV populations at risk can be successfully treated with DAAs. The primary objective of the linkage to care is the holistic and integrated treatment, and the prevention of reinfections is a priority and essential part of the treatment goals. The removal of the barriers to treatment is a primary goal of the linkage-to-care models and integrated systems; the main action to be undertaken for the linkage to care of the HCV population at risk are screening, referral, treatment and prevention of reinfection. All HCV RNA+ patients may be eligible for treatment, and those with the clinical criteria for starting treatment should be treated with DAAs. All patients should receive a structured harm-reduction program (with skill training). The prevention of the infection is of paramount importance in the linkage to care of the HCV population at risk and is an element which should always be associated with the drug treatment. (www.actabiomedica.it)

Risk Factor Analysis Between Newly Screened and Established Hepatitis C in GI and Hepatology Clinics

BACKGROUND

Several studies show inconsistencies in the rate of hepatitis C virus (HCV) detection among baby boomers (born 1945-1965). We conducted a cross-sectional HCV screening followed by a case-controlled comparison of the newly screened population with established HCV subjects.

METHOD

Enrollment was offered to subjects aged 40-75 at our gastroenterology and hepatology clinics. Demographic data and potential risk factors were obtained, and HCV antibody test was offered to those who had never been screened and compared with a group with established HCV. Logistic regression analysis and Fisher's exact test were performed.

RESULTS

Six hundred and seventy-five patients were offered participation, of whom 128 declined while 50 consented to participate but did not perform the HCV antibody test. Of 497 enrolled subjects, 252 patients had HCV, while 245 subjects (188 patients among "baby boomer") underwent screening for HCV. There were more females (62.4 vs. 41.7%) and immigrants (34.7 vs. 22.2%) among the newly screened group. Among the screened population, five patients had HCV antibody (2.04%), and two of them had positive viral load (0.82%) of whom only one fell in the baby boomer category (0.53%). Compared to HCV group, screened group had significantly lower-risk factors, such as IV drug use (1.22 vs. 43.3%), intranasal cocaine use (14.3 vs. 49.6%), and blood transfusion (18.8 vs. 32.5%).

CONCLUSION

We found a slightly lower but similar prevalence of HCV antibody when screening based on birth cohort as compared to larger baby boomer studies. Future studies evaluating addition of other screening strategies or possibly universal screening may be needed.

High variability of TB, HIV, hepatitis C treatment and opioid substitution therapy among prisoners in Germany

BACKGROUND

In Germany, medical care of prisoners is completely separated from extramural health care. The extent and quality of medical care among prisoners in Germany are therefore largely unknown. We performed a secondary data analysis of pharmacy sales data for tuberculosis (TB), HIV, hepatitis C (HCV) and opioid substitution treatment (OST) delivered to prisons in 11 federal states (FS) in Germany between 01/2012 and 03/2013. The aims of this study were to assess (i) the treatment availability for the selected diseases and OST in German prisons, (ii) the proportion of prisoners treated per FS and overall for TB, HIV, HCV and OST during the study period.

METHODS

Substances unique to or typically used for the treatment of each disease were defined as marker substances with defined daily doses (DDD). For each marker substance we assessed the cumulative number of DDD, the average daily number of DDD (DDD_d) and average treatment prevalence per day in percent (adTP). Accordingly, the DDD_d represents one person treated per day and the adTP means the proportion of prisoners treated per day. We compared the adTP of the diseases with previously measured prevalences.

RESULTS

We obtained data from pharmacies supplying prisons in 11 of 16 German FS. Of the included prisons, 41% were supplied with medicines for TB, 71% for HIV and 58% for HCV and OST. Twice as many delivered marker substances for TB were indicated for the continuation phase and chemoprevention than the intensive phase. The HIV adTP ranged from 0.06% to 0.94%, HCV adTP ranged from 0.03% to 0.59% and OST adTP ranged from 0% to 7.90%. The overall adTP for the respective treatment was 0.39% for HIV, 0.12% for HCV and 2.18% for OST.

CONCLUSIONS

According to our findings treatment rates for TB were consistent with the expected TB prevalence, at least in Berlin. HIV treatment seems to be offered to an adequate proportion of estimated infected prisoners. In contrast, the HCV treatment prevalence was low. High variation among FS in provision of all treatments, particularly of OST, point to inconsistent treatment practices, although nationwide extramural treatment guidelines for Germany exist.