Underserved Communities Receive Hep C Treatment in Jail

Ingrid Hein

September 17, 2019

MONTREAL — Inmates awaiting trial or serving sentences of less than a year can be effectively treated for hepatitis C during their incarceration, new research shows.

Jail is a setting in which underserved groups can receive care, said Justin Chan, MD MPH, director of viral hepatitis services in the correctional health services division of NYC Health + Hospitals in New York City.

In a retrospective observational study of the hepatitis C cascade of care in New York City jails, Chan and his colleagues showed that long-stay and HIV-positive prisoners were more likely to be tested and treated for hepatitis C than inmates who are detained for less than 3 months.

"Short-stay patients were underserved," Chan reported here at the International Conference on Hepatitis Care in Substance Users 2019.

Previous research showed that the rate of seropositivity was just over 20.0% in inmates the New York City jail system (Am J Public Health. 2016;106:1276-1277). In contrast, an estimate of the rate in the general population of New York City was just 1.4%, according to a 2017 report on hepatitis from the New York City Department of Health and Mental Hygiene.

To assess the cascade of care for hepatitis C in the jail system, Chan's team looked at data extracted from jail health records and from the hepatitis C surveillance registry of the New York City Department of Health and Mental Hygiene. The study period — 2014 to 2017 — coincides with the widespread availability of direct-acting antiretroviral to treat hepatitis C.

"There are many barriers of care," Chan explained. "One of the most challenging is patient flow; getting to see patients when we want to see them."

Table 1. Drop Off in the Cascade of Care for Hepatitis C in the New York City Jail System
Points of Loss in the Cascade of Care n
Inmates who entered the jail system from 2014 to 2017 121,375
Inmates who underwent screening for hepatitis C 40,338
Inmates who tested positive for exposure to the virus 8,318
Inmates with detectable viral load after subsequent RNA testing 4,652
Viremic inmates who saw a hepatitis C "treater" 1,813
Viremic inmates started on direct-acting antiviral therapy 248
Treated inmates tested for response to therapy at 12 weeks 164
Treated inmates with a lab-confirmed sustained viral response at 12 weeks 147

Chan's team also looked at the cascade of care by subpopulation.

Table 2. Likelihood of Evaluation for Hepatitis C Treatment During the Study Period
Cohort Odds Ratio
Frequent-stay inmates (more than 10 separate incarcerations) 1.4
Long-stay inmates (at least one incarceration longer than 120 days) 5.7
Inmates with HIV 6.8

This research highlights the difficulty delivering treatment to a short-stay population. "Some have argued for a better focus on linkage to care," which would connect health services in jail to health services outside, Chan explained.

"Those who are discharged on treatment don't do as well" as those who complete treatment in jail, he pointed out, so at the moment, "we try to treat those who we think will finish their treatment in jail."


Patient Perceptions Play a Role

Inmates can face many barriers to accessing treatment for hepatitis C, said Matthew Akiyama, MD, from the Montefiore Medical Center in Bronx, New York. He and his team conducted semi-structured interviews with 36 short-term inmates in the New York City jail system.

The researchers found that fear of treatment, substance abuse, and competing priorities — such as legal battles and comorbidities like HIV — all play a role in the decision to seek and continue treatment.

"I don't want to have to start over," a 22-year-old black woman in the jail system told a researcher. She said she feared the result of stopping and starting therapy would mean more intensive treatment later. "And you might have to do something that's more a rigorous regimen and I just don't want to do that."

The decision to get treated for hepatitis C during a short jail term instead of in a community setting "can be complicated," Akiyama explained during his presentation at the conference.

"Patients are aware that they may not be able to continue their treatment after release," he said.

Although many inmates perceive barriers, others encourage one another. A 41-year-old inmate told researchers that his cell mate encouraged him to get treatment: "I had a roommate not too long ago. He's hep C. He said yo, get the treatment. Whatever you do, get the treatment. Don't just leave it like it is, man."

The number of inmates being treated has increased every year since 2014, Chan noted. In 2014, 11 people were treated for hepatitis C. In 2019, it is expected that 250 inmates will enter treatment.

Over the years, the budget for treatment has increased in the New York City jail system, he reported, and improvements have been made in length-of-stay predictions, linkage-to-care options, and transition clinics, all of which allow flexibility for an inmate starting treatment.

"Ultimately, what's most important is how many people we're treating," Chan said, adding that the current focus is on "improving efficiency of workup and treatment initiation."

Chan reports that the viral hepatitis program at the New York City Department of Health and Mental Hygiene (DOHMH) has received funding for public health programming and evaluation from Gilead through their fiscal agent, Public Health Solutions. Akiyama has disclosed no relevant financial relationships.

International Conference on Hepatitis Care in Substance Users (INHSU) 2019. Presented September 12, 2019.

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