About hepatitis C testing, treatment, and prevention in prisons

Hepatitis C virus is a blood-borne infection that affects millions of people around the world. A person can unknowingly live with chronic hepatitis C virus for many years before symptoms appear. When symptoms do appear, they are often serious – the virus can cause liver inflammation, cirrhosis (i.e. scarring of the liver), liver failure, liver cancer, and death.

These outcomes pose a significant health burden for the person living with hepatitis C, as well as for society and health care systems as a whole. However, hepatitis C is easily treated with antiviral medications, which offer cure rates of over 95%. Around the world, there is growing recognition that treating hepatitis C will improve morbidity and mortality, and reduce the long-term burden on health systems. Consequently, the World Health Organisation (WHO) has set a target for eliminating hepatitis C as a public health threat by 2030.

Included in the United Nations’ Sustainable Development Goals (SDGs): Goal 3.3 is to “End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”.

As a blood-borne virus, hepatitis C is strongly associated with injection drug use and sharing unsterile injecting equipment is a leading cause of hepatitis C transmission worldwide. In low- and middle-income countries, transmission also occurs through exposure to unsterile medical equipment and contaminated blood products. To eliminate hepatitis C, we need to ensure that people living with, and at risk of hepatitis C have access to education, testing, treatment, and prevention services. Hepatitis C is more common among people in prison than the general population and so elimination efforts must prioritise addressing hepatitis C in prisons.

The United Nations has set Sustainable Development Goals (SDGs) that guide its 160 member states’ governments, funders and partners on areas of focus. The third sustainable development goal relates to population health and well-being and, within that, target 3.3. is defined as:

“By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”

The World Health Organisation’s (WHO) global hepatitis strategy, endorsed by all WHO Member States, aims to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030 (1). This includes hepatitis B and C, and is aligned with the SDGs.

WHO has outlined comprehensive Global health sector strategies 2022-2030 that outline recommendations for how to deal with viral hepatitis.

Overall, 194 countries have committed to meeting the WHO’s elimination targets, but many are not on track to do so by 2030. You can track progress by viewing the country-level data and elimination profiles developed by the Coalition for Global Hepatitis Elimination. However, there are also many examples of successful programs which have led to elimination in some settings globally, including in prisons – all made possible with the right support from advocates and decision-makers. 

Hepatitis C affects people in prison at a disproportionate rate compared to those in the general population. It is estimated that around a quarter of people in prison have been exposed to hepatitis C virus (2). Often, this is because drug use and possession are criminalised and people who inject drugs are disproportionately incarcerated. While high-risk practices like injection drug use and tattooing continue in prisons, lack of access to sterile equipment increases the risk that hepatitis C will be transmitted among people in prison.

Equally, incarceration provides an opportunity for people to access health care that may not be easily available outside prison. Treatment for hepatitis C also has positive individual-level benefits, with improved quality of life and overall health outcomes associated with cure.

By offering hepatitis C testing, treatment and prevention services in prisons, healthcare staff and administrators can help prevent the spread of hepatitis C both within prison and within the surrounding communities following release.

The WHO recognises that treatment of hepatitis C in people in prisons is vital to elimination efforts and, along with the United Nations Office on Drugs and Crime (UNODC) and other partners, supports the implementation of comprehensive hepatitis C services for people in prisons and other closed settings (2).

Hepatitis C is easily treated and cured with direct-acting antiviral medications (DAAs), which were first made available as an all-oral regimen in 2014. Prior to 2014, hepatitis C treatments were less effective and had more side effects. With the use of DAAs, treatment can be delivered via a simple regimen of daily tablets (usually 1-3) taken for 8-12 weeks. There are minimal side effects and they cure 95% of people.

As DAAs are relatively new, some people may remain unaware of the changes in treatment options over the last decade. For example, people who have seen others receive treatment pre-DAAs, or decision-makers who have considered past proposals for treatment, may only know of the old interferon era that pre-dated DAAs when the treatments had side-effects and weren’t very effective. This may influence their expectations of current treatment options, so it is important to improve their understanding and assumptions around treatment options, including the possibility of re-treatment.

While current treatment regimens are straightforward, accessing medications is not always equally as simple, especially in under-resourced settings. In many low- and middle-income countries, the high cost of DAAs is often considered a barrier to enhancing prison-based hepatitis C treatment. DAAs may also not be listed on the essential medicines list, may be hard to access, and/or may frequently be out of stock.

Advocates may need to explore options for accessing additional funding to increase the availability of DAAs in prison. Additionally, prison-based healthcare workers may require additional education on hepatitis C treatment and managing follow-up. The resources linked below may be helpful.