Introduction Hepatitis C virus (HCV) is common in the prison population, with reported prevalence of up to 19%1. High rates of injecting drug use (IDU) coupled with in-prison sharing of needles, tattoo and shaving equipment are thought responsible. Incarceration is considered an ideal opportunity to treat “hard-to-reach” groups due to reduced alcohol/drug use, and lack of financial or geographical barriers to engagement. We have delivered a prison treatment service for several years, and sought to compare HCV management in this group (PC) with the standard outpatient setting (OC).
Method A retrospective cohort study was conducted of referrals from 2013–2016. Since all 5 prisons in our catchment area are male-only, we excluded females from the OC group. Data were anlaysed with regard to demographics, clinical assessment and access to treatment.
Results Demographics: 369 male patients were referred over 3 years (82 PC; 287°C). Median age was 40 (23-60) in PC and 44 (22-80) in OC. Genotype 1 was commonest in both groups (PC 40/82 [48.78%]; OC 134/287 [46.69%]), followed by genotype 3 (PC 29/82 [35.37%]; OC 93/287 [32.40%]). The vast majority acquired HCV via IDU (PC 74/82 [90.24%]; OC 234/287 [81.53%]). Rates of non-attendance were far higher than expected in PC, but still significantly lower than OC (16/82 [19.51%] vs. 90/287 [31.36%], p=0.0365). In several cases, prison notes documented patient unwillingness to enter treatment. Assessment: Almost all patients across both cohorts had appropriate blood testing performed (PC 78/82 [95.12%]; OP 275/287 [95.82%]). Non-invasive assessment of liver fibrosis was offered to all patients attending an appointment; but significantly fewer PC attended for scan (PC 36/82 [43.90%]; OC 169/287 [58.89%], p=0.01596). The disparity is partly explained by lack of an in-house prison Fibroscan until 2015, with poor attendance to hospital for elastography prior to that. Longstanding prison organisational issues were also felt to impact attendance, even within prison. Treatment: Despite significantly more OC being offered anti-viral therapy (PC 20/82 [24.39%]; OC 108/287 [37.63%], p=0.02), successful completion of treatment was more likely in the PC group, although this did not quite reach significance (PC 11/20 [55.00%]; OC 35/108 [32.41%], p=0.053).
Conclusion Prison-based management is associated with greater engagement and ultimately more successful for those commencing treatment than standard care. Non-attendance remains a major barrier, even in a controlled environment. Whilst poor organisation may have prevented some attendances, many were patient-driven indicating that reasons for non-attendance go beyond logistical issues. A greater understanding of these factors is required if eradication of HCV is to be achieved.
. Addressing hepatitis C in prisons and other places of detention: Recommendations by NHS England2013
Disclosure of Interest None Declared
- viral hepatitis