Despite the detailed legislative developments that have occurred within the context of prison medicine in Italy, problems of a management nature continue to affect prisoner health and management, which in turn impact the prison system’s ability to offer prisoners a real opportunity for rehabilitation. Certain behavioral aspects reported in prisons may alter and negatively impact the normal doctor-patient relationship, including elements that hinder the therapeutic alliance and impede proper clinical risk prevention and management. However, practical steps may be taken in connection with the analysis of flows and healthcare services that may enable prison administrations to bring about a true, modern restructure of the prison system.
Compared with the general population, incarcerated people have a higher prevalence of several communicable diseases, including viral hepatitis. Nevertheless, there is still a lack of literature in field. Our review aims to shed the actual knowledge on viral hepatitis among incarcerated people in Italy. We performed a comprehensive literature search, through key electronic databases (Scopus, Pubmed–MEDLINE) and search engines (Google Scholar), of peer-reviewed publications (articles and reviews), grey literature on viral hepatitis prevalence, and models proposed for active case finding and control strategies in prison settings. We found that viral hepatitis epidemiology drastically changed in the last five years, particularly on hepatitis C virus (HCV), reporting an HCV antibody (HCV-Ab) prevalence decrease from up to 38% to ˂20% in penitentiary institutes, as well as an even more important reduction in active infections. Probably, the availability of direct-acting antivirals is contributing to this scenario. However, there is a lack of data available regarding incarcerated women. For this reason, more tailored interventions are needed for this sub-population. Judiciary and regulatory bodies should be prompted to discuss and define specific regulations to optimize case active finding strategies, guarantee wide access to effective preventive and treatment options for viral hepatitis and enhance treatment management.
In Italy, a person suffering from a mental disorder who commits a crime will be given a custodial security order and serve the period of admission at a Residenza per la esecuzione delle misure di sicurezza (REMS) (Residence for the Execution of Security Measures, hereinafter “REMS”). These institutions have been established recently and though equipped with the necessary safety measures, the focus is on psychiatric therapy. Despite being present on a national scale, access is very limited in terms of capacity. Immediate remedial measures are needed, so much so that the European Court of Human Rights recently condemned Italy for this very reason. This article, through a review of the constitutive principles of these institutions, shows how they have very positive aspects such as the attention to necessary psychotherapy in order to protect the right to health and the real taking charge of the fragility of the subjects; however, it is seen how there are many negative aspects linked above all to the scarce availability of places in these structures. The article provides suggestions on a more comprehensive strategy for facilities for detainees with mental disorders.
Objective: To evaluate the cost-effectiveness of a strategy based on direct-acting antivirals (DAAs) versus no drug strategy in HCV-infected inmates, from the perspective of the Italian National Health System (iNHS). Methods: A previous Markov model was adapted to the Italian setting to evaluate the direct medical costs and health outcomes (quality-adjusted life years, QALY) throughout the life of HCV-infected inmates. Epidemiological data, patient characteristics (genotype, METAVIR classification), DAAs sustained virological response (SVR), annual likelihood of transition, treatment costs and utilities were gathered from the literature. The DAAs strategy included the administration of elbasvir/grazoprevir or sofosbuvir/velpatasvir or glecaprevir/pibrentasvir. Direct medical costs and QALYs were discounted at a 3.0% annual rate. Cost-effectiveness was evaluated as incremental cost-effectiveness ratio (€, 2019) per QALY gained. A deterministic sensitivity analysis (DSA) was performed. Results: Over a lifetime horizon, the DAAs strategy showed higher health costs per patient compared to no drugs strategy in the base-case analysis (€ 42,571 vs. € 26,119). However, it was associated with an increase of QALYs gained (21.14 vs. 15.67), showing an incremental cost-effectiveness ratio of € 3,010 per QALY. The sensitivity analysis confirmed the base-case results. Conclusions: Extending the DAAs treatment to HCV-infected inmates was estimated to be cost effective from the perspective of the Italian NHS, regardless genotype and METAVIR classification.
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