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It is crucial to upscale testing and treatment for hepatitis C infection among Australia’s prisoner population if we are to achieve the goal of elimination by 2030, writes Chris Wallis.
Hepatitis C prevalence remains high among incarcerated individuals due to large numbers of prisoners with a history of illicit substance use, along with the common practices of needle sharing and amateur tattooing while in custody (here). Corrective services agencies across the country spend a large amount of time and resources attempting to slow the rate of drugs and other contraband from entering the prison environment, though often providing very little in the way of practical measures to reduce the harm associated with injecting drug use (here). The acute consequences of injecting drug use are well documented (skin abscess/boils, sepsis, osteomyelitis, endocarditis, viral hepatitis infection) (here), though the impact of chronic hepatitis C virus (HCV) infection 20–30 years later can be far more devastating to a person’s quality of life (here), and indeed also, the crippling effects on the wider health care system.
In people living with chronic HCV infection for more than 20 years, up to 30% will develop liver cirrhosis, which is a risk factor for the development of hepatocellular carcinoma (HCC) as upwards of 5% of people with liver cirrhosis will develop HCC (here). Liver transplant rates in Australia and internationally are driven predominantly by advanced cirrhosis in the context of chronic HCV infection and/or alcohol misuse (here).
Although I often lament with my fellow colleagues the frustrations of trying to deliver health care in a custodial setting, there has also been a great deal of progress made in the steady march towards eliminating hepatitis C as a public health threat in Australia by the year 2030, particularly within the prison environment (here).
The recent consensus statement endorsed by the National Prisons Hepatitis Network (NPHN) outlines the importance of an increase in testing and treatment for hepatitis C in Australian prisons (here). Labour intensive and often painful blood collection techniques used to confirm the presence of chronic HCV infection have now been replaced in many prison settings by newer point-of-care modalities, allowing same-day testing, diagnosis and commencement of antiviral treatments (here). The latest hepatitis C point-of-care testing (POCT) methods include fingerstick blood collection for HCV antibody, with results available in as little as 60 seconds, and GeneXpert HCV polymerase chain reaction (PCR) RNA quantitative testing that confirms presence of chronic infection in under 60 minutes (here).
Large scale hepatitis C screening in the prison setting has traditionally relied on HCV IgG antibody serology to confirm previous exposure and a reflexive HCV PCR RNA quantitative to detect current viraemia, with curative treatment being offered many weeks to months later (here). Many prisoners by that time had been released from custody before commencing antiviral therapy, which, as we know now, is a completely avoidable situation if treatment is offered at the time of diagnosis. Recent Australian studies have shown POCT testing to be welcomed by people who are incarcerated (here and here).
Testing the theory of HCV micro-elimination
In early 2021, West Moreton Prison Health Services partnered with Gilead Sciences, Queensland Injectors Health Network (QUIHN), Hepatitis Queensland and Kombi Clinic to test the theory of “HCV micro-elimination” within a high security prison (here).
Before this project, GeneXpert POCT technology was only being used in small numbers across Australian prisons to test prison entrants rather than the whole prison population, with antiviral treatment not always offered on the same day.
Testing was conducted over a three-day period for 211 of a possible 244 prisoners in custody for the duration of the project. This resulted in 17 prisoners (8%) having detectable HCV RNA in blood samples, of whom 14 were reviewed and commenced antiviral therapy within one week of testing. Upon review of relevant blood pathology for those who did not consent for testing or were not available for testing during the project, most of these prisoners had recent negative HCV serology.
Based on the overall numbers of negative serology results and rapid antiviral treatment for prisoners found to be HCV positive, it is highly likely that the prevalence of HCV within the prison was dramatically reduced to near zero at that point in time.
At the time of completion, we believe this was the first project offering hepatitis C testing and treatment to an entire consenting prison population in Australia. The experience gained during this project has highlighted the impact of POCT screening technology in supporting hepatitis C elimination goals throughout Australian prisons and the wider community. Analysis of available pathology results for prisoners who did not give consent or request testing provided a stronger argument that micro-elimination of HCV is very possible within correctional settings.
Unfortunately, hepatitis C elimination in this setting can only maintained with a continued focus on screening and treatment. This was shown to be the case at another Queensland prison in 2018, where micro-elimination was achieved through rapid scale-up of HCV antiviral treatments, only to experience a rebound of newly acquired hepatitis C cases in the following year (here).
Conclusion
The NPHN consensus recommendations have endorsed several strategies to address the ongoing challenges with HCV transmission in prisons, including universal opt-out testing, POCT use, simpler assessment protocols and earlier linkage to antiviral treatments.
If Australia is to meet the 2030 World Health Organization goal of hepatitis C elimination, federal and state governments must continue to increase their support for upscaling of rapid hepatitis C testing and treatment within the prison setting.
With established high efficacy antiviral treatments available on the Pharmaceutical Benefits Scheme to all Australians, no one in this country should have to live with chronic HCV infection and risk potentially life-shortening cirrhosis or liver carcinoma.
POCT technology is a proven weapon in the fight against hepatitis C and should be used across all correctional facilities in Australia to support increased linkage to care for people affected by this disease.
Chris Wallis is a Nurse Practitioner in Prison Health Services at West Moreton Hospital and Health Service in Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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It is with mixed feelings that national peak community organisation Hepatitis Australia replies to published by MJA InSight+ (Issue 45) on 27 November 2023 (https://insightplus.mja.com.au/2023/45/urgent-need-for-hepatitis-c-testing-in-australias-prisoner-population/ ). We agree on many points but take issue with some selective conclusions.
People affected by hepatitis C are resilient, diverse, and dispersed with many of them yet to be effectively reached and receive the support they want and need from the national response.
The goal of eliminating hepatitis C by 2030 in Australia rests on a knife edge. Despite progress in areas with adequate allocation of focus and resourcing, Australia remains behind in its pursuit of national targets and global commitments. Business-as-usual has taken us this far yet we are not on track to achieve elimination. What’s more, we won’t get on track to achieving elimination without hard conversations about inconvenient truths. One such inconvenient truth is that we cannot ignore prevention and hope to simply test and treat our way to elimination. This fact was echoed so clearly by stakeholders in the response at the National Prisons Hepatitis Network Annual Forum in November 2023, including from the Australian Department of Health and Hepatitis Australia.
In 2022 an estimated 35% of all hepatitis C treatment episodes nationally were initiated in prisons. This has increased steadily as a proportion of all treatment nationally, up from 25% in 2019 made possible by the availability of direct-acting antivirals and more recently innovative and more efficient testing modalities.
Just as the Wallis article has done, the afore-mentioned increasing proportion of treatment episodes initiated in prisons is often lauded as “progress” and “key to elimination.” It seems important to note that while in-prison treatment is increasing as a proportion of hepatitis C treatment nationally, this is not because the rate of treatment is increasing in prisons. The rate of in-prison treatment is declining in real terms, just at a slower rate than in the community.
Highlighting testing and treatment in prisons as key to “achieve the goal of elimination by 2030” at the exclusion of evidence-based harm reduction strategies (including prison needle and syringe programs) cherry picks interventions, ignores available evidence, and ignores calls from community for comprehensive prevention measures. Squibbing the argument is unhelpful and ignores the human rights of people in prison to access evidence-based hepatitis C prevention strategies equivalent to those available in the community.
Lotus Glen prison in Queensland (the first Australian prison to claim micro-elimination of hepatitis C, in 2018, following rapid scale-up of direct-acting antiviral therapy) should remind us about the importance of prevention. With an absence of implementing prevention/harm reduction strategies, in sixteen months following micro-elimination there were 250 new and reinfected cases of in-prison hepatitis C transmission. See here for further information https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13238.
The first strategic priority of the draft (next) National Hepatitis C Strategy 2023-2030 is to implement needle and syringe programs to ensure regulated access to sterile injecting equipment in corrections settings and other places of held detention, alongside the full suite of other hepatitis C harm reduction and prevention measures. Please see here for the new National Hepatitis C Strategy https://www.health.gov.au/sites/default/files/2023-05/sixth-national-hepatitis-c-strategy-2023-2030.pdf .
Hepatitis Australia thanks author Chris Wallis and MJA InSight+ for highlighting the critical link between prisons and the elimination of hepatitis C by 2030. We also applaud the article for identifying injecting-related injury and disease beyond hepatitis C (such as sepsis, osteomyelitis, and endocarditis). These serious and potentially fatal conditions are often overlooked in debate about the rights of people in prison to access preventive healthcare equivalent to that available in the community (see The United Nations Standard Minimum Rules for the Treatment of Prisoners here https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf).
Prisons are priority settings for the national hepatitis C response because of increased prevalence, elevated incidence, myriad risk factors, ongoing inaction on prevention, and the opportunity to offer comprehensive healthcare.