Advocating for prison-based hepatitis C programs

Identifying the right stakeholders will be critical to your advocacy efforts, but it can be challenging to identify the decision-makers and stakeholders who who are in a position to influence prison-based hepatitis C care. While each country and region will be unique, here are some ideas you may want to explore to identify the stakeholders you need to reach.

Prisons sit at a complex nexus of corrections and health bureaucratic structures. Health care in prisons may be administered via local, state or federal agencies, may be within a correctional authority or separate, and each prison can be funded and managed in very different ways. You will need to identify prisons you wish to target and understand how they are managed and funded.

You may consider engaging with influencers and decision-makers, such as:

• National or regional politicians
• Administrators of health and prison services
• Prison-based healthcare providers

• Relevant non-governmental consumer agencies and advocates

It is also recommended that, before engaging with stakeholders, you have a clear understanding of the prevalence of hepatitis C in the prison – even if prevalence needs to be inferred from available data from local or surrounding communities. Doing this will help you create a persuasive case for implementing or scaling up hepatitis C services in prisons, as you can demonstrate how the program will contribute to meeting national hepatitis C elimination goals.

It is key to work with these stakeholders to develop a framework for the prison-based hepatitis C program, including agreeing on how you will monitor and evaluate the progress of the program over time. In addition, there are a number of successful case studies of prison-based hepatitis C programs (including micro-elimination programs to end hepatitis C in a particular prison), that can also help persuade stakeholders of the value of your proposal.

In planning the implementation of a prison-based hepatitis C program, you need to be aware of the unique logistical and resourcing challenges that exist in this setting. Demonstrating your understanding of these constraints, and offering solutions to overcome them, will be critical to persuading your stakeholders that the program will be feasible and a worthwhile investment.

There are many factors to consider, including:

• Prisons are not health care facilities, their primary purpose is incarceration, so they are designed and operate for security and not for health care
• Staff availability to move individuals around the facility – e.g. if there is a requirement to take each person from their cell to the health care centre for daily medications, this would substantially increase the workload of prison officers
• Continuity of care – people frequently move between prison centers or are released from prison, so what support exists for people in prison if they are not incarcerated for the duration of their entire treatment course? What additional support will they need if they are released into the community?

• Confidentiality – how will you ensure that the diagnosis and treatment of people in prison remains confidential?

These are just a few of the unique challenges you will need to consider in designing and advocating for a prison-based hepatitis C program, but it is important that you are informed and prepared to respond to questions from stakeholders.

An implementation toolkit, which was developed as part of the SToP-C study in Australia, describes the rationale and outlines the steps of planning, implementation and evaluation of programs designed to scale-up hepatitis C testing and treatment among people in prison. The SToP-C Implementation Toolkit may be a useful tool to support you as you consider how best to design and implement your own model of care

Demonstrating cost-effectiveness will be key to your advocacy efforts, and there is a substantial body of research demonstrating that prison-based hepatitis C care is highly cost-effective and should be a priority in national elimination strategies.

Studies have shown that prison-based hepatitis C care is cost-effective in reducing prevalence and preventing long-term disease. For example, a Canadian study compared the cost-effectiveness of various methods of hepatitis C screening in prisons, including the current standard of care – venepuncture. This study identified that implementing opt-out hepatitis C screening strategies based on point-of-care or laboratory hepatitis C core antigen testing were likely to be the most reliable and cost-effective screening approaches, but both needed to ensure people were linked with care if they received a positive result (2).

One Spanish study demonstrated that if hepatitis C treatment was scaled up to treat all people in prison living with hepatitis C, irrespective of their sentence length, it would prevent 10,200 new cases of hepatitis C, and 8,300 hepatitis C-related deaths between 2019-2050. Ninety per cent of these prevented deaths would have occurred in the community (3).

Similarly, modelling in Australian prisons demonstrated that it was highly cost-effective to scale up DAA treatment for the majority of people in prison who are infected with hepatitis C. Increased levels of testing and treatment increased the cost-effectiveness of the intervention (4).

These studies all demonstrate that prison-based hepatitis C testing and treatment are cost-effective for the health care system as a whole. While the costs of programs, including diagnostic tools and DAAs, will vary depending on your country, there is an opportunity for countries to invest in population health by treating hepatitis C in prisons, and to prevent long-term health costs.