Essay Sample on Interventions on Reducing HCV Prevalence in the Incarcerated Population

According to the United Nations Basic Principles for the Treatment of Prisoners, it is imperative for prisoners to gain access to health services available in the subject country without discrimination because of their legal situation. Unfortunately, the basic principle has not been applied as frequently in real life, as prisoners are still having lesser access to care and assistance when compared to the other citizens in many countries. Hepatitis C virus (HCV) infection is evidently more prevalent in the incarcerated population than in the general population, with the highest prevalence detected in Australasia (35%) and Central Asia (38%). In the United States, the prevalence of HCV in the general population is estimated at 1%. In comparison, the corresponding prevalence in United States prisons is estimated at 17.3%. Also, about 30% of individuals infected with HCV in the US spend a part of their life in correctional facilities (He, Li, Roberts, Spaulding, Ayer, Grefenstette, Chatwal, 2016). The need to come up with an intervention of reducing the burden of HCV in prisons has emerged with the recent availability of applicable measures.

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Proper treatment of HCV in prison is still a rare practice due to certain educational and social reasons, and, at least, not due to most incarcerated individuals with HCV infection remaining unaware of their virology condition. Many other barriers also prevent HCV inmates from being admitted for treatment, thus preventing the reduction of HCV prevalence in prisons (Zampino, Coppola, Sagnelli, Caprio, Sagnelli, 2015). Some of these include personal problems such as stress, drug abuse, lack of confidence, fear, as well as social problems like discrimination, stigma, and a difficulty in relating to the health personnel. Other obstacles include a lack of specialists such as a liver disease specialist in prison, an issue that may be overcome using telemedicine.

Although numerous prisoners are incarcerated for long periods, the overall period of stay in prison can be weeks or months in some cases, and this makes it a challenge to complete the clinical itinerary from screening to post-treatment follow-ups. Physicians and prison authorities need to implement strategies in improving the therapeutic approach in HCV for prisoners, the general screening for anti-HCV antibody as being the initial step in the approach (Zampino, Coppola, Sagnelli, Caprio, & Sagnelli, 2015). Prisoners having chronic HCV infection should go through a full diagnostic procedure as well as clinical staging prior to being considered for treatment, as inmates having HCV-related chronic hepatitis may achieve a sustained virology response having the same frequency as free patients.

HCV prevalence reduction measures used in correctional facilities in the past include providing sterile equipment for injection, opioid substitution therapy in minimizing injection and HCV treatments as a way of eliminating the infection. Further, reducing the number of individuals that can transmit hepatitis C. Screening for hepatitis has proved to be essential as a way of raising awareness on the risk and obtain appropriate medical treatment. Hep-CORE study what 16 countries reported in HCV screening policy for prisoners. Only nine European states have identified prisoners as a population in minimizing drug injecting and HCV treatment in eliminating the infection and reducing the number of individuals that can transmit HCV (Baker, Barnett, Gomez, 2015). Screening for HCV is important in raising awareness of the risks and obtaining the necessary medical treatment.

An applicable intervention in reducing the HCV burden in prisons include the use of oral antiviral agents that act directly in a highly effective manner. The treatment includes a treatment duration of 8-24 weeks, with a few contradictions, and more than 90% of patients having achieved a cure. The high price has proved to draw criticism from numerous stakeholders. Even with their high price, the treatment of HCV in prisons is feasible and meets the standard criteria of cost-effectiveness.

However, there is a likelihood of the treatment reducing disease burden in the case of HCV patients being identified in the first place. In the U.S, 75% of state prisons neither offer to screen nor targeted testing of inmates reporting high-risk behavior, and this may miss numerous potential patients (He, et al., 2016). According to past rulings in the US Supreme Court, prisons may not have a deliberate indifference to medical needs. Therefore, after a diagnosis is made, a provider can find it a challenge to justify in not treating those diagnosed. Due to the treatment being expensive and prison budgets often being limited, there can be an incentive in not testing for HCV.

The first step to take in the intervention includes simulating a sample number of heterogeneous persons representing the incarcerated population and the general population. The patients' characteristic can include gender, age, drug use behavior, and imprisonment status. The case can include assumptions such as 25% of HCV patients being in prisons, half of who had been aware of disease status, whether through previous prison or community screening. It should also be considered that the infected inmates could transmit the virus to unaffected persons every month (Zampino, Coppola, Sagnelli, Caprio, & Sagnelli, 2015). Two types of transmission models can be used, the ones related to IDU and everything else, that is, those separately in the community and prisons. The probability of transmission may depend on factors such as active injection drug use, awareness status, history of injection of drug use, and previous HCV treatment.

The second step of the intervention is HCV screening. Unaware inmate patients can be diagnosed through HCV testing. About 5 screening scenarios can be evaluated, each on an annual basis. Some of the possible assumptions include the uptake rates of risk-based screening being around 75%, those opting out of the HCV screening being 90% like that of HIV opting out screening in screening prisons (He, et al., 2016). For the general population, a combination of risk-based screening and birth-cohort can be implemented.

The third step in the intervention is on the treatment of HCV. The inmates diagnosed with HCV will be eligible for treatment. In the case's base, it can be assumed that the only the ones with fibrosis scores F3 and F4 can receive treatment and others can wait due to limited resources. Patients can then be assigned treatment with oral DAAs. Due to the SVR rates of the available oral drugs can be like one another, the SVR rates in sofosbuvir-based therapies can be used as references (He, et al., 2016). Treatment regimens will depend on HCV genotype, before treatment outcomes, as well as the presence of cirrhosis. It can be assumed that by 2030, more generic drugs will be available and that all patients can be eligible in treatment with some low-cost drugs even with their fibrosis stage.

During the admission and release of inmates. Movement of people can be simulated from the community to prison and vice versa. The chances of being incarcerated and the lengths of the sentence at admission can be estimated from the gathered data (Zampino, Coppola, Sagnelli, Caprio, & Sagnelli, 2015).

Other factors to consider in the intervention include utilities and costs. The used model can include the cost of HCV testing, management of chronic HCV disease, and antiviral treatment. Screening costs can include the cost of HCV antibody, HCV genotype tests, HCV RNA, and FibroSure test. Costs of treatment include the wholesale acquisition cost of sofosbuvir, ledispavir, and ribavirin, as well as considering drug discounts in a sensitivity analysis (Alcorn, 2018). The management of HCV disease cost can include the costs associated with chronic HCV infection, hepatocellular carcinoma, decompensated cirrhosis, and liver transplant.

Some of the outcomes of the intervention include the number of HCV cases diagnosed, the number of new HCV infections because of releasing the untreated inmates infected with HCV, quality-adjusted life years (QALYs), a total cost to society and prisons, inclusive of the cost of HCV screening, the treatment and expense related to HCV disease and its sequelae. It includes cases of decompensated cirrhosis, liver transplant, liver-related and liver transplants deaths (Zampino, Coppola, Sagnelli, Caprio, & Sagnelli, 2015). There can also be a further estimation of incremental cost-effectiveness ratios (ICERs) of all screening scenarios. A standard 3% of annual discount rate to all the future costs can be applied; the model ran 40 times to estimate confidence intervals of the outcomes.

In gauging the intervention's credibility, external validation of Tap HCV model results with known data. The natural history of HCV can particularly be validated in the model through in comparing the projected incidence rates of hepatitis C sequelae of the reported range of a large clinical study. There can also be a validation of the expected number of admissions in the sampled prisons (He, et al., 2016).

Conclusively, correctional facilities need to strive towards removing substantial institutional, economic, and bureaucratic barriers that hamper an appropriate approach in the management of HCV infection among incarcerated prisons (Baker, Barnett, & Gomez, 2015). These institutions indeed have a great responsibility as well as a fundamental role in the organization of health care systems for the prisoners. Reducing interventions such as the one above need to observe necessary common practices like performing screening for anti-HCV is indeed commendable, as this may prove to be cost-effective, and is particularly valid for prisoners that have risk factors for HCV infections (He, et al., 2016). Improvement of the access to treatment and follow-up processes for prisoners with HCV is also a commendable move to make in the intervention. Goodwill, sensitivity and the willingness in cooperating with healthcare authorities, prison authorities, as well as personnel are necessary.

References

Alcorn, K. (2018, May 31). Harm reduction measures for HCV prevention and treatment lacking in Europe's prisons, survey finds. Retrieved Oct 10, 2018, from http://www.infohep.org/Harm-reduction-measures-for-HCV-prevention-and-treatment-lacking-in-Europes-prisons-survey-finds/page/3278108/

Baker, S., Barnett, J., & Gomez, J. L. (2015, July). Strategies for Addressing Hepatitis C Prevalence. Retrieved Oct 10, 2018, from https://wws.princeton.edu/sites/default/files/content/Domestic%20Workshop%20Report%202015.pdf

He, T., Li, K., Roberts, M. S., Spaulding, A. C., Ayer, T., Grefenstette, J. J., & Chhatwal, J. (2016, Jan 19). Prevention of Hepatitis C by Screening and Treatment in United States Prisons. Ann Intern Med, 164(2), 84-92. Retrieved Oct 8, 2018

Zampino, R., Coppola, N., Sagnelli, C., Caprio, G. D., & Sagnelli, E. (2015, Sept 28). Hepatitis C virus infection and prisoners: Epidemiology, outcome, and treatment. World Journal of Hepatology, 7(21), 2323-2330. Retrieved Oct 8, 2018