CATIE News

11 September 2020 

Exploring the role of interventions to eliminate hepatitis C virus (HCV) in Montreal prisons

  • Researchers in Quebec simulated strategies to eliminate hepatitis C among prisoners
  • Offering more testing and treatment would reduce hepatitis C in prisons 50% by 2030
  • Combined with harm reduction outside prison, researchers projected a 96% decrease

Hepatitis C virus (HCV) infects the liver and as the infection progresses it can inflame and degrade this vital organ. Over time, as the liver becomes increasingly injured, healthy liver tissue is replaced by useless scar tissue. As a result, the liver becomes increasingly dysfunctional and complications can ensue. HCV also increases the risk for liver failure, liver cancer and death.

Treatment for HCV is taken orally, usually for eight to 12 weeks, and is highly effective, resulting in more than 95% of people being cured.

Due to the potency and general tolerability of HCV treatment, the World Health Organization (WHO) has encouraged countries and regions to help eliminate HCV infection as a public health issue by 2030. To do this in Canada and other high-income countries, offers of testing and treatment as well as access to harm reduction services will need to be enhanced.

In Quebec

A team of researchers in Montreal and Quebec City have developed a computer simulation to assess the possibility of eliminating HCV as a public health issue in people who have been imprisoned. The researchers found that a package of interventions—including offers of HCV testing and treatment in prisons, helping prisoners connect with health care once they are released into the community, and enhancing the availability of harm reduction and HCV testing and treatment in the community—had the highest projected impact on curing people and reducing the spread of HCV.

Study details

Researchers at McGill University in Montreal, Université Laval in Quebec City and the Institut National de Santé Publique du Quebec (also in Quebec City) cooperated and developed a dynamic computer simulation. They input data from previous studies and surveys so that they could model HCV transmission in and out of prison and the effects of different interventions.

Results

Prisoners are eventually released into the community, so it is important to understand the spread of HCV both in prisons and in the community.

In the community

The researchers found that if offers of HCV testing and treatment are scaled up in the community, the computer simulation predicted that “substantial decreases” in existing HCV infections (by 88%) and new infections (by 84%) would occur by 2030.

In prisons

The researchers stated that if offers of HCV testing and treatment were increased in prisons—such that 90% of inmates were tested and 75% of those who were diagnosed with chronic HCV received treatment—there would be a nearly 50% reduction of HCV in prisons by 2030 compared to levels in 2018. These interventions would reduce new infections in the community by 22% (once people left prisons).

Alternatively, researchers found that if authorities offered HCV treatment in the community once people had left prison—such that 75% of people who inject drugs and who have chronic HCV infection are successfully linked to treatment after release—“a relative reduction in [new infections] of 36% is expected [by] 2030, as compared to 2018.”

Combining a prison-based HCV test-and-treat strategy with enhanced offering of testing and treatment together with harm reduction services in the community decreased new HCV infections by 96% vs. the rate of decrease seen in 2018. 

From simulation to reality

The researchers noted that while their findings are based on computer models, there are existing real-world examples that could be implemented to achieve a tremendous reduction in HCV infections, including the following:

The researchers underscored studies where “nurse-led interventions in prison have helped increase treatment [adherence], reduce risk behaviours and manage disease burden: lessons from these successes could be applied for interventions in the post-release period.”

“Similarly, peer navigator programs could reduce the risk of injecting drug use post-release and enhance engagement in the healthcare system by increasing trust, reducing perceived stigma, and improving social determinants of health, such as housing and employment.”

Although the simulation was powerful and dynamic and likely closely mimicked the spread of HCV in Montreal, it may have had minor shortcomings. For instance, researchers used data from previous studies and surveys that included information about injecting drugs and so on. Since such behaviour, particularly in prisons, is stigmatized, it is plausible that information on drug and needle use may have been under-reported. The researchers stated that cocaine is the main street drug that is injected in Montreal. However, the use of injected crack and opioids is increasing. Such changes in the drugs used could lead to changes in the spread of HCV that were not captured by the simulation.

Bear in mind

The interesting work by the researchers in Quebec provides a path forward to mobilize resources for interventions in prisons and in the community to help eliminate HCV as a public health issue in the coming decade.

––Sean R. Hosein

Resources

Researchers project that Canada could eliminate hepatitis CCATIE News

Canadian trends in hepatitis C virus treatment for people co-infected with HCV and HIV – CATIE News

Progress made in the hepatitis C virus cascade of care but more work lies ahead in B.C. – CATIE News

Improved health when treatment for both hepatitis C and opioid use disorder are offered – CATIE News

Assessing the cascade of care for opioid use disorder in British Columbia – CATIE News

Trends in deaths among people with hepatitis C virus in British Columbia – CATIE News

The cascade of hepatitis C virus care in Alberta – CATIE News

Blueprint to inform hepatitis C elimination efforts in Canada Canadian Network on Hepatitis C (CanHepC)

REFERENCES:

  1. Godin A, Kronfli N, Cox J, et al. The role of prison-based interventions for hepatitis C virus (HCV) micro-elimination among people who inject drugs in Montréal, Canada. International Journal of Drug Policy. 2020; in press.
  2. Binka M, Janjua NZ, Grebely J, et al. Assessment of treatment strategies to achieve hepatitis C elimination in Canada using a validated model. JAMA Network Open. 2020;3(5):e204192.
  3. Dore GJ, Trooskin S. People with hepatitis C who inject drugs—underserved, not undeserving. New England Journal of Medicine. 2020; 383:608-611.