BackgroundHepatitis C virus (HCV) infection is common in prisoner populations, particularly those with a history of injecting drug use (IDU). Previous studies of HCV incidence have been based on small case numbers and have not distinguished risk events in prison from those in the community.MethodsHCV incidence was examined in a longitudinal cohort of 488 Australian prisoners with a history of IDU and documented to be seronegative within 12 months prior to enrolment. Inmates were tested for anti-HCV antibodies and viremia, and interviewed about demographic and behavioral risk factors for transmission.ResultsThe cohort was predominantly male (65%) with high rates of prior imprisonment (72%) and tattooing (73%), as well as longstanding IDU (mean 8.5 years). Ninety-four incident HCV cases were identified (incidence 31.6 per 100 person years). Independent associations were observed between incident infection and prior imprisonment (p = 0.02) and tattooing (p = 0.03), and surprisingly also with methadone maintenance treatment (MMT) (p < 0.001).ConclusionsHigh rates of new HCV infection were found in this prisoner cohort reflecting their substantive risk behavior profile, despite having remained uninfected for many years. The association with MMT is challenging and highlights the need for better understanding of prison-specific HCV transmission risks, as well as the uptake and effectiveness of prevention programs.

Background: Limited empirical evidence exists for hepatitis C virus (HCV) treatment-asprevention. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study assessed HCV treatment-as-prevention in four Australian prisons.Methods: SToP-C is a non-randomised trial, including a pre/post analysis within a prospective longitudinal cohort of people incarcerated in two maximum-(male) and two medium-security prisons (one male, one female). All prison inmates at least 18 years were eligible for enrolment.Participants were enrolled from late-2014 to 2019. Following HCV testing, participants were monitored for risk behaviors and HCV, among three sub-populations: 1) uninfected (HCV antibody negative); 2) previously infected (HCV antibody positive, HCV RNA negative); 3) infected (HCV antibody and HCV RNA positive). Uninfected and previously infected (at-risk) participants were followed every 3-6 months for HCV primary infection and re-infection, respectively. Infected participants were assessed for treatment, initially standard of care treatment (by prison health services), followed by direct-acting antiviral (DAA) treatment scale-up from mid-2017 (12 weeks sofosbuvir/velpatasvir, through SToP-C). Participants were followed until study closure in November 2019. The primary study outcome was HCV incidence compared between pre-and post-treatment scale-up periods among participants at risk of HCV primary infection or re-infection. The trial was registered with ClinicalTrials.gov (identifier: NCT02064049) Findings: Of 3,691 participants enrolled, 719 (19%) had detectable HCV RNA and 2,965 were at-risk of primary infection (n=2,240) or re-infection (n=725) at baseline. DAA treatment was initiated in 349/499 eligible participants during the treatment scale-up period. Among at-risk population with longitudinal follow-up (n=1,643; median age 33 years; 82% male), 31% reported injecting drug use in prison. HCV incidence declined by 48%, from 8.31 to 4.35/100 person-years between pre-and post-treatment scale-up periods [Incidence Rate Ratio (IRR): 4 0.52, 95%CI: 0.36, 0.78]. Incidence of primary infection declined from 6.64 to 2.85/100 personyears (IRR: 0.43, 95%CI: 0.25, 0.74), while incidence of re-infection declined from 12.36 to 7.27/100 person-years (IRR: 0.59, 95%CI: 0.35, 1.00). Among participants reporting injecting drug use in the current imprisonment, incidence of primary infection declined from 39.08 to 14.03/100 person-years (IRR: 0.36, 95%CI: 0.16, 0.80), and incidence of re-infection declined from 15.26 to 9.34/100 person-years (IRR: 0.61, 95%CI: 0.34, 1.09). Adjusted analysis indicated a significant reduction in HCV risk between pre-and post-treatment scale-up periods (adjusted Hazard Ratio: 0.50, 95% CI: 0.33, 0.76).Interpretation: DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of HCV treatment-as-prevention. The findings support broad DAA treatment scale-up among incarcerated populations.

AimThe potential for transmission of hepatitis C virus (HCV) in prison settings is well established and directly associated with sharing of injecting and tattooing equipment, as well as physical violence. This study is one of the first to examine the circumstances surrounding the acquisition of HCV in the prison setting via inmates’ own accounts.MethodThis is a sub-study of a cohort of prison inmates in New South Wales, Australia. Cohort participants were inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. Cohort participants were monitored every 3 to 6 months for HCV antibodies and viraemia and via behavioural risk practices questionnaire. Participants with a documented HCV seroconversion were eligible to participate in in-depth interviews with a research nurse known to them.ResultsParticipants included six inmates (four men, two women) with documented within-prison HCV seroconversion. Participants reported few changes to their injecting practices or circumstances that they attributed to HCV acquisition. Participants believed that they were sharing syringes with others who were HCV negative and trusted that others would have declared their HCV status if positive. Some participants described cleaning equipment with water, but not with disinfectant. In a departure from usual routine, one participant suggested that he may have acquired HCV as a result of using a syringe pre-loaded with drugs that was given to him in return for lending a syringe to another inmate. Participants described regret at acquiring HCV and noted a number of pre- and post-release plans that this diagnosis impacted upon.ConclusionsAcquiring hepatitis C was not a neutral experience of participants but generated significant emotional reactions for some. Decisions to share injecting equipment were influenced by participants’ assumptions of the HCV status of their injecting partners. The social organisation of injecting, in trusted networks, is a challenge for HCV prevention programs and requires additional research.

AimA formal Needle and Syringe Program (NSP) is not provided in Australian prisons. Injecting equipment circulates in prisons as part of an informal and illegal economy. This paper examined how this economy generates blood-borne virus (BBV) risk and risk mitigation opportunities for inmates.MethodThe HITS-p cohort recruited New South Wales inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. For this study, qualitative interviews were conducted with 30 participants enrolled in HITS-p. Participants included 10 women and were incarcerated in 12 prisons.ResultsA needle/syringe was nominated as being typically priced in the ‘inside’ prison economy at $100-$150, with a range of $50-$350. Purchase or hire of equipment was paid for in cash (including transactions that occurred outside prison) and in exchange for drugs and other commodities. A range of other resources was required to enable successful needle/syringe economies, especially relationships with visitors and other prisoners, and violence to ensure payment of debts. Strategies to mitigate BBV risk included retaining one needle/syringe for personal use while hiring out others, keeping drug use (and ownership of equipment) “quiet”, stealing used equipment from the prison health clinic, and manufacture of syringes from other items available in the prison.ConclusionsThe provision of prison NSP would disrupt the inside economies built around contraband needles/syringes, as well as minimise BBV risk. However, any model of prison NSP should be interrogated for any unanticipated markets that could be generated as a result of its regulatory practices.

Background Transmission of hepatitis C virus (HCV) among the prisoner population is most frequently associated with sharing of non-sterile injecting equipment. Other blood-to-blood contacts such as tattooing and physical violence are also common in the prison environment, and have been associated with HCV transmission. The context of such non-injecting risk behaviours, particularly violence, is poorly studied. The modified social-ecological model (MSEM) was used to examine HCV transmission risk and violence in the prison setting considering individual, network, community and policy factors. Methods The Australian Hepatitis C Incidence and Transmission Study in prisons (HITS-p) cohort enrolled HCV uninfected prisoners with injecting and non-injecting risk behaviours, who were followed up for HCV infection from 2004–2014. Qualitative interviews were conducted within 23 participants; of whom 13 had become HCV infected. Deductive analysis was undertaken to identify violence as risk within prisons among individual, network, community, and public policy levels. Results The risk context for violence and HCV exposure varied across the MSEM. At the individual level, participants were concerned about blood contact during fights, given limited scope to use gloves to prevent blood contamination. At the network level, drug debt and informing on others to correctional authorities, were risk factors for violence and potential HCV transmission. At the community level, racial influence, social groupings, and socially maligned crimes like sexual assault of children were identified as possible triggers for violence. At the policy level, rules and regulations by prison authority influenced the concerns and occurrence of violence and potential HCV transmission. Conclusion Contextual concerns regarding violence and HCV transmission were evident at each level of the MSEM. Further evidence-based interventions targeted across the MSEM may reduce prison violence, provide opportunities for HCV prevention when violence occurs and subsequent HCV exposure.