October 13, 2016
Jail and prison officials often say the high cost of HCV management and treatment forces them to create guidelines so those with the greatest degree disease progression get care first. Such actions lead to rationing which results in people being unaware they have HCV, or discovering they can't get health care when they ask for it. Rationing occurs throughout the U.S but is likely to be worse in rural counties where there is less moneyfor inmate health care.
To provide a context in discussing HCV management and care, we need to quickly look at the differences between jails and prisons.
Jails temporarily house people under suspicion of committing a crime. People will stay in jail long enough to be sentenced and then they will either go to a prison or home. Transitioning so quickly in and out of jail makes providing health care more challenging. The money for jails to run and provide care to inmates comes from local cities and counties. Management and treatment can become a strain on small rural communities forcing them to make difficult choices on how to stretch what little they have.
Prisons house people with sentences that range from a few years to life. State and federal prisons hold more inmates and have more robust budgets than jails. They also house a larger number of inmates who are HCV+. Prisons can have greater success at HCV management and care than jails because of an inmate's length of stay.
The CDC and U.S. Preventative Task Force (USPSTF) recommend screening for all people with a history of injection drug use and those who were born between 1945 and 1965.1-3 Many of people who go into prison or jail are likely to be in one of those two recommended categories. Although high cost is frequently brought up in the discussion of HCV treatment, we know that treating more inmates with HCV will actually prevent transmission in the general population.4,5 Many states do in fact provide some level of HCV services to inmates, although there are only three that provide universal screening.6
Many people are aware of the high baseline cost of the new 12-week regimens. Each state does possess the ability to negotiate prices and come to a bulk price agreement. According to a recent Wall Street Journal article Indiana pays $80,000 per treatment placing it the third most expensive state per inmate for Harvoni. Indiana does provide routine HCV screening and education in state prisons. This is not the case in jails where currently there isn't a blanket policy to offer opt out HCV screening.
Some jails are resistant to carrying out HCV screening because many people won't be there long enough to complete treatment. Cost related issues such as these have led some jails to privatize their medical services, or reduce different parts of current HCV screening services. In Indiana, all but two of the jails I work in have had their medical services privatized.
Although this may improve care overall by removing the financial burden off of cities and counties, specifically treating HIV/HCV is still the responsibility of the county the jail resides in. This "hot potato" approach to infectious disease management does almost nothing to address the growing epidemic. These services being expensive does not justify limiting access to HCV screening and treatment. Regardless of cost inmates need to be given information on and unrestricted access to HCV care.
Understanding the challenges faced in successfully providing HCV management and care, the Federal Bureau of Prisons (BOP) released Evaluation and Management of Chronic Hepatitis C Infection, as guidance to jails and prisons. The recommendations give information on incorporating HCV screening, evaluation, education and treatment among inmates. The BOP recommends HCV screening for all sentenced inmates, all inmates with certain clinical conditions, and any inmate who asks for a screening.7
Improving the overall health of HCV + people will be most successful when working together to find innovative ways of improving management and treatment. We can create robust training programs that give the necessary tools to medical staff and correctional employees to provide HCV care. We can create peer education groups inside of jails and prisons where inmates can learn and educate each other fostering an environment where both health and empowerment improves together. We can focus on creating exit protocols between jails and local communities where people can access services on release which will reduce the likelihood of someone falling out of care entirely.
All of those things will help the overall health of inmates living with HCV, but the biggest achievement to HCV management and care while reducing long term economic cost, is to either increase funding for jails and prisons or begin applying pressure on them to carry out price negotiations on their own.
We must begin to create a framework for HCV services that is as robust and embedded as current HIV services. Many of the individuals currently contracting HCV are people who use substances and inject drugs. This makes accessing them in care whenever possible even more important to the improvement of overall health. If we do none of these things faster than we currently are, we'll wake up in 20 years with economic costs and strains on the medical system that will dwarf what we are currently experiencing.
Matthew Zielske currently works as a HIV/HCV special populations prevention specialist at an HIV services organization. He utilizes a harm reduction model in his work with the substance use population focusing pointedly on persons who inject drugs. He is currently conducting research on Health Literacy and hepatitis C for his Master's Thesis in Communications. www.umbrellaway.org
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