Australian prisoners urgently need hepatitis C testing

Large-scale testing and treatment of hepatitis C infection among Australia’s prisoner population is vital if we are to meet our target of eliminating hepatitis C by 2030, writes Chris Wallis.

Prevalence of hepatitis C remains high among incarcerated people due to the large number of prisoners with a history of illicit drug use and the common practice of needle sharing and amateur tattooing in custody ( here ). Correctional institutions across the country spend considerable time and resources trying to slow the rate at which drugs and other contraband enter prison settings, although often little practical steps are taken to reduce the harm caused by injection drug use ( here ). The acute consequences of injection drug use are well documented (skin abscesses/boils, sepsis, osteomyelitis, endocarditis, viral hepatitis infection) (here), although chronic hepatitis C virus (HCV) infection 20-30 years later The effects can be far more devastating to a person’s quality of life (here) and actually have serious consequences for the wider healthcare system.

Up to 30% of people with chronic HCV infection for more than 20 years will develop cirrhosis, which is a risk factor for the development of hepatocellular carcinoma (HCC), as more than 5% of patients with cirrhosis will develop HCC. here). Liver transplant rates in Australia and internationally are driven primarily by advanced cirrhosis caused by chronic HCV infection and/or alcohol abuse (here).

While I often join my colleagues in lamenting the frustrations of trying to deliver health care in custodial settings, much progress has been made towards the elimination of hepatitis C as a public health threat in Australia by 2030, particularly in prisons environment (here).

A recently signed consensus statement by the National Prison Hepatitis Network (NPHN) outlines the importance of increasing hepatitis C testing and treatment in Australian prisons ( here ). In many prison settings, the labor-intensive and often painful blood-drawing technology used to confirm the presence of chronic hepatitis C virus (HCV) has now been replaced by newer point-of-care models that allow same-day testing, diagnosis, and initiation of antiviral therapy Treatment (here). The latest hepatitis C point-of-care testing (POCT) methods include finger-prick blood testing for HCV antibodies, which provides results in just 60 seconds, and the GeneXpert HCV polymerase chain reaction (PCR) RNA quantification test, which can confirm the presence of chronic infection60 within minutes (here).

Large-scale hepatitis C screening in prison settings has traditionally relied on HCV IgG antibody serology to confirm previous exposure and reflective HCV PCR RNA quantification to detect current viremia, available weeks to months later Curative treatment (here). Many prisoners at that time were released before starting antiviral treatment, which we now know was completely avoidable if treatment had been provided at the time of diagnosis. Recent studies in Australia suggest POCT testing is popular with incarcerated people ( here and here ).

Testing the HCV microelimination theory

In early 2021, West Moreton Prison Health Service partnered with Gilead Sciences, Queensland Injector Health Network (QUIHN), Hepatitis Queensland and Kombi Clinic to test the ‘HCV micro-elimination’ theory within a high security prison ( here ).

Prior to this project, GeneXpert POCT technology had only been used sparingly in Australian prisons to test prison inmates rather than the entire prison population, and antiviral treatment was not always provided on the same day.

During the project, out of a possible 244 inmates in custody, 211 were tested over three days. As a result, 17 prisoners (8%) had detectable HCV RNA in their blood samples, 14 of whom were tested and started antiviral treatment within one week of detection. Relevant hematopathology review of those who did not consent to testing or who were unavailable for testing during the program revealed that the majority of prisoners had recent negative HCV serology.

Based on the total number of negative serology results and the rapid antiviral treatment of HCV-positive inmates, it is likely that the prevalence of HCV in prisons dropped sharply to near zero at that time.

When completed, we believe this is the first program to provide hepatitis C testing and treatment to the entire consenting prison population in Australia. Experience gained during this project highlights the impact of POCT screening technology in supporting hepatitis C elimination goals across Australian prisons and the wider community. Analysis of available pathology results from inmates who did not consent or request testing provides stronger evidence that microelimination of HCV in correctional settings is very possible.

Unfortunately, in this setting, hepatitis C elimination can only be sustained with a continued focus on screening and treatment. This was the case in another Queensland prison in 2018, which achieved micro-elimination through rapid scale-up of HCV antiviral treatment, only to see a rebound in new hepatitis C infections the following year (here).

in conclusion

NPHN consensus recommendations endorse several strategies to address the ongoing challenge of HCV transmission in prisons, including universal opt-out testing, POCT use, simpler assessment protocols, and earlier linkage to antiviral treatment.

If Australia is to meet the World Health Organization’s 2030 goal of eliminating hepatitis C, federal and state governments must continue to increase support for scaling up rapid hepatitis C testing and treatment in prison settings.

With established, highly effective antiviral treatments available to all Australians through the Pharmaceutical Benefits Scheme, no one in this country should live with chronic HCV infection and be at risk of life-shortening cirrhosis or liver cancer.

POCT technology is an effective weapon in the fight against hepatitis C and should be used in all Australian correctional facilities to support improved linkages with care for people affected by this disease.

Chris Wallis is a Nurse Practitioner in the Prison Health Service at Westmoreton Hospital and Health Service in Queensland.

The statements or opinions expressed in this article reflect the views of the author and do not necessarily represent those of the AMA, Massachusetts JA or Insight+ Unless so stated.

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