For Australia to meet the World Health Organization’s target of eliminating hepatitis C by 2030, comprehensive changes in how the disease is managed and treated in Australian prisons are required, according to Australian researchers.

A consensus statement published in today’s The Medical Journal of Australia has recommended an increase in testing and treatment of hepatitis C in prisons to help eliminate the disease from the general population.

Monash University Senior Research Officer Rebecca Winter and Kirby Institute Research Project Manager Yumi Sheehan told InSight+ that persistent hepatitis C among Australia’s prison population risks preventing elimination of the disease.

“Australia is a world leader on the path to hepatitis C elimination,” they said.

“The Australian Government’s subsidy of hepatitis C treatments via the Pharmaceutical Benefits Scheme makes a cure available to all Australians … However, Australia is now at a point where we need to apply novel and innovative strategies to identify and offer treatment to the 117 000 people remaining to be treated.”

Eliminating Hepatitis C in Australian Prisons
Consensus Statement co-author Yumi Sheehan, Kirby Institute Research Project Manager

Research shows hepatitis C is most often acquired through injecting drug use. Due to the criminalisation of injecting drug use, Kirby Institute research shows there is a high prevalence of hepatitis C in prison populations (approximately 20%).

Incidental hepatitis C infection is also high in prisons due to lack of prevention measures and the sharing of needles.

Hepatitis can be cured with direct acting anti-viral (DAA) therapy, which has revolutionised hepatitis C care. Curing hepatitis C improves quality of life, regresses liver fibrosis, reduces the risk of liver failure, liver cancer and other liver related mortality, as well as preventing onward transmission.

Without a national strategy or framework for treating hepatitis C in prisons, Australia will struggle to meet its hepatitis C elimination goals, the authors said.

The consensus statement was prompted by advocacy from the National Prisons Hepatitis Network (NPHN) and identified significant gaps in the Australian policy landscape, with different prison operating practices across the eight jurisdictions.

There are also differences between how public and private prisons are run. It says variations in budget allocations, health service contracts and health service availability affect the rollout of hepatitis C treatments.

Logistical constraints such as frequent prisoner movements and attitudinal barries among correctional and health care providers add another layer of complexity, Winter and Sheehan wrote.

“We know that over 40% of all hepatitis C treatment initiations in Australia originate from prison hepatitis services,” they said.

“Prison settings need continued resourcing to ensure that comprehensive hepatitis C care is available to all people in prison through primary care-led services. In tandem, community services need bolstering.”

The consensus statement highlighted the following suggestions:

  • implement high coverage testing strategies that are timely and efficient such as testing all newly incarcerated people unless they choose to opt out;
  • streamline DAA treatment pathways, to improve continuity of care when a person is moving between prisons and in community settings;
  • improve coverage of opioid agonist therapy, which can reduce the frequency of injection episodes and needle sharing (here, here and here); and
  • regulate prison needle and syringe programs to reduce the spread of hepatitis C in prison populations.

Testing all newly incarcerated people unless they choose to opt out is one suggested strategy for improving hepatitis C management

Authors Winter and Sheehan said:

“The approach to reducing hepatitis C infection and re-infection in Australian prisons is three-pronged:

  • first, prevention strategies must be implemented;
  • second, new and existing infections need to be detected through timely testing; and
  • third, people diagnosed with hepatitis C infection must be offered comprehensive and timely care including DAA treatments.”

They also referenced a recent protocol in New South Wales, the SToP-C study, which demonstrated that by increasing treatment in prisons, the rate of new infections decreases.

In an interview, Hepatitis Australia Chief Executive Carrie Fowlie welcomed the findings of the consensus statement.

“Hepatitis C is a preventable and curable disease, it is also one of the strongest examples of a socially determined disease,” Ms Fowlie told InSight+.

“Transmission of hepatitis C happens when people do not have access to preventive health measures. Australian prisons do not provide the health services needed to prevent hepatitis C transmission … As a result we are seeing what is being coined as a ‘merry-go-round’ of hepatitis C transmission, where people are unable to prevent reinfection and the changeover of people incarcerated leads to new infections.

“Nationally, Australia has a comprehensive and evidence-based set of approaches to eliminate hepatitis C in the community … However, this approach is not reflected in prisons, which conflicts with Australia’s international human rights obligations and, specifically, the position that no person should leave prison in a worse state of health.”

The article’s authors hope the consensus statement will provide state and territory policymakers with valuable guidance towards implementing real change.

“The statement summarises best practice standards for the management of hep C in Australia’s prisons and provides aspirational targets for the delivery of care,” said Winter and Sheehan.

“The document can therefore act as guidance for health professionals and policymakers working in custodial settings, as well as provide shared goals across jurisdictions.”

If Australia is to meet the WHO targets of eliminating hepatitis C by 2030, the article’s authors emphasise the importance of equitable health care within prisons and the community.

“We as co-authors are passionate about the equivalence of care principle: that people in prison should have access to health services that are equivalent to those available in the community, and we are committed to devising models of care which meet the needs of people in prison, a marginalised and stigmatised group.”

Hepatitis Australia agreed, with Ms Fowlie stating, “All people living with or at risk of hepatitis C are entitled to quality health services, regardless of if they are in the community or in prison.”

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