Incidence and prevalence of hepatitis C in prisons and other closed settings: Results of a systematic review and meta-analysis

Abstract

People detained in prisons and other closed settings are at elevated risk of infection with hepatitis C virus (HCV). We undertook a systematic review and meta-analysis with the aim of determining the rate of incident HCV infection and the prevalence of anti-HCV among detainees of closed settings. We systematically searched databases of peer-reviewed literature and widely distributed a call for unpublished data. We calculated summary estimates of incidence and prevalence among general population detainees and detainees with a history of injecting drug use (IDU), and explored heterogeneity through stratification and meta-regression. The summary prevalence estimates were used to estimate the number of anti-HCV positive prisoners globally. HCV incidence among general detainees was 1·4 per 100 person-years (py; 95% CI: 0·1, 2·7; k=4), and 16·4 per 100py (95% CI: 0·8, 32·1; k=3) among detainees with a history of IDU. The summary prevalence estimate of anti-HCV in general detainees was 26% (95% CI: 23%, 29%; k=93), and in detainees with a history of IDU, 64% (95% CI: 58%, 70%; k=51). The regions of highest prevalence were Central Asia (38%; 95% CI 32%, 43%; k=1) and Australasia (35%; 95% CI: 28%, 43%; k=9). We estimate that 2·2 million (range: 1·4 million – 2·9 million) detainees globally are anti-HCV positive, with the largest populations in North America (668,500; range: 553,500–784,000) and East and Southeast Asia (638,000; range: 332,000–970,000). Conclusion HCV is a significant concern in detained populations, with one in four detainees anti-HCV positive. Epidemiological data on the extent of HCV infection in detained populations is lacking in many countries. Greater attention towards prevention, diagnosis and treatment of HCV infection among detained populations is urgently required.

Reply

“…We commend Larney et al 1 for their recent review, which provides much needed global and regional estimates of HCV prevalence among detainees, confirms the occurrence of HCV transmission in closed settings, 2 and stratifies estimates by injection drug use (IDU) history. Incidence rates are critical when evaluating the full effect these settings may have on HCV epidemics.…”

“…Larney et al attempt to evaluate HCV incidence rates among detainees globally, but concerns arise regarding the investigators' estimation and interpretation of these estimates. 1 In their pooled analysis of incidence rates in prisons, Larney et al included three studies that did not control for the HCV antibody seroconversion window (page 5 of Supporting Materials). 1 These studies recruited an unknown number of subjects who could have been infected before detention and thus might have biased HCV seroconversion rates upward.…”

“…1 In their pooled analysis of incidence rates in prisons, Larney et al included three studies that did not control for the HCV antibody seroconversion window (page 5 of Supporting Materials). 1 These studies recruited an unknown number of subjects who could have been infected before detention and thus might have biased HCV seroconversion rates upward. If these studies are excluded from the analysis, the incidence rates are reduced in both general detainees (from 1. .…”

“…Gough et al raise concerns regarding our estimates of hepatitis C virus (HCV) incidence among continuously incarcerated persons, 1 arguing that the inclusion of studies that do not account for the HCV seroconversion window period may result in overestimation of incidence rates. We accept that this is a valid point, but note that even when the studies in question are excluded from the summary estimate, HCV incidence among detainees with a history of injection drug use (IDU) remains many times higher than that for general detainee samples (6.6 per 100 person-years versus 0.4 per 100 person-years), albeit with overlapping confidence intervals.…”

“…With great interest, we read the study by Arena et al 1 showing an increase in liver stiffness 15 to 45 minutes after the intake of a standardized liquid meal lowering the accuracy of fibrosis assessment by transient elastography (TE). These results are in line with another study using liquid meals 2 and our previous findings obtained under "real-life" conditions using standardized solid meals.…”