Testing for hepatitis C virus infection in UK prisons: What actually happens?

Abstract

Organization in 2016 1 and given an accelerated target of 2025 in the UK this year. 2 The success of this campaign will depend on a comprehensive and efficient testing process for the diagnosis of HCV in high-risk groups and engagement of infected individuals with viral eradication therapy. The prison population has a higher prevalence of HCV infection than the general community due to the proportion of people in prison (PIP) sentenced for crimes related to the use or distribution of drugs. In support of this, a Health and Justice Report 3 found that during 2014 seropositivity in prisons in the England and Wales estate was 1.5% for hepatitis B virus (HBV), 8% for HCV and 0.6% for human immunodeficiency virus (HIV) and a recent review estimated that 15.4% of PIP in Europe SummaryPrisons are a key demographic in the drive to eradicate hepatitis C virus (HCV) as a major public health threat. We have assessed the impact of the recently introduced national opt-out policy on the current status of HCV testing in 14 prisons in the East Midlands (UK). We analysed testing rates pre-and post-introduction of opt-out testing, together with face-to-face interviews with prison healthcare and management staff in each prison. In the year pre-opt-out, 1972 people in prison (PIP) were tested, compared to 3440 in the year following opt-out. From people were tested, representing 13.5% of all prison entrants (median 16.6%, range 7.6%-40.7%). Factors correlating with testing rates were as follows: pre-admission location of the PIP (another prison or the community, OR 2.2, 95% CI 1.9-2.3, P < 0.001); whether the PIP could access health care independently of prison officers (OR 1.7, 95% CI 1.5-1.8, P < 0.001); the absence of out-reach services for HCV treatment (OR 1.3, 95% CI 1.2-1.5, P < 0.001), whether >50% of PIP reported ease of access to a nurse (OR 2.0, 95% CI 1.8-2.2, P < 0.001), and whether prison health care was supplied by private or NHS providers (OR 1.3, 95% CI 1.2-1.5, P < 0.001). Testing rates remained far below the minimum national opt-out target of 50%. Inadequacy of healthcare facilities and constraints imposed by adherence to prison regimens were cited by healthcare and management staff at all prisons. Without radical change, the prison estate may be intrinsically incapable of supporting NHSE to deliver the HCV elimination strategy. K E Y W O R D Schronic viral hepatitis, diagnostic virology, hepatitis C, prisons

Detection, stratification and treatment of hepatitis C–positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

“…The difference in HCV RNA prevalence between Phase‐1 (7.2%) and Phase‐2 (3.9%) was also significant. Phase‐2 test positivity was comparable to the HCV seroprevalence reported during an audit of opt‐out testing in a North‐eastern English prison, 30 but was lower than a recent study looking at BBV testing across West Midland prisons (anti‐HCV = 9.3%) 31 and national sentinel surveillance testing from 2013 (9.4%) to 2017 (8.0%) 32‐35 . This decline could have occurred if targeted testing rather than screening was taking place during Phase‐1, if the prison experienced a change in incarceration patterns, or if pathway reconfiguration, as well as other contextual changes, resulted in the underrepresentation of high‐risk prisoners during Phase‐2.…”

Hepatitis B virus infection in EU/EEA and United Kingdom prisons: a descriptive analysis

“…Despite the higher prevalence of HBV infection in prison populations, the asymptomatic nature of the disease coupled with suboptimal access to healthcare may hinder diagnosis of HBV. Opt-out testing is a provider initiated service where testing is conducted unless an individual explicitly declines [19], and there is evidence to show this method has a higher uptake than other modalities for human immunodeficiency virus (HIV) and HCV [20, 21]. Recent guidance published by ECDC recommends universal opt-out testing in prisons to ensure timely diagnosis, together with vaccination and/or linkage to appropriate care to prevent the risk of further disease transmission both in and out of the prison setting [11, 22].…”

Cost‐effectiveness of strategies to improve HCV screening, linkage‐to‐care and treatment in remand prison settings in England

“…Although it may be preferable to adopt universal HCV screening in prison settings in England, existing clinical and security priorities, combined with a lack of healthcare personnel, can present significant obstacles to its implementation 27 . Thus, in our model we explored the cost‐effectiveness of an ‘imperfect’ intervention by implementing the simplified pathway among PWID being initiated on OST, while continuing a either existing (47%) or enhanced (90%) levels of DBS screening without improvement in linkage‐to‐care or treatment (strategies E and F).…”