Nurse-led treatment model for hepatitis C in state prisons
This program delivered hepatitis C treatment in prisons in Victoria, Australia. Nurses led treatment onsite in the prisons with support from specialists for complex, higher risk cases. This observational study followed hepatitis C treatment across 14 prisons for 13 months following the implementation of this program. The program treated 74% of eligible participants and had a high cure rate (96%) for those who completed treatment during their incarceration.
People entering prison are at higher risk of contracting hepatitis C because of the overrepresentation of at-risk populations that are incarcerated, including people who use drugs. Their time in prison further increases this risk because of the lack of safe injecting, tattooing and piercing equipment and a lack of access to health care services.
The nurse-led treatment program was conducted across 14 prisons. Participants were offered “opt-in” screening for hepatitis C upon entering prison. If a participant tested positive for hepatitis C during this screening or self-reported a previous diagnosis, they met in-person with a hepatitis C program nurse at the prison. The nurse performed an initial assessment, including:
- a questionnaire about risk behaviours for hepatitis C
- a test to assess liver injury
- additional testing for hepatitis C, hepatitis B and HIV
- recording of other health issues, including psychiatric illness
After this assessment, eligible participants enrolled in the program to begin treatment. To be eligible for treatment, participants were required to have a long enough sentence duration to complete hepatitis C treatment (between eight and 24 weeks). Those with shorter sentences were ineligible, but they were referred to a healthcare service for treatment upon release into the community.
The program was staffed by:
- two full-time nurses
- three part-time hepatologists (who were accessible by telemedicine)
- a part-time pharmacist
- a part-time pharmacist technician
Treatment and care for participants who had less complex cases and no liver disease was led by a program nurse, with paper-based consultation with a physician for medication prescriptions. Participants who had more complex cases, including those with cirrhosis, received additional assessment and oversight from a hepatologist either in-person or through telemedicine appointments. Participants with cirrhosis enrolled in a monitoring program for liver disease.
The central prison hospital pharmacy couriered medications to each prison. Medication delivery moved with participants if they transferred between facilities during their treatment course. If they were released early, they were given their remaining medication to complete treatment in the community.
The study measured the success of treatment with blood tests performed 12 weeks after treatment ended, which showed whether the participant had been cured.
This observational study followed an initial group of 416 individuals who began treatment as part of the program. Of this group, 103 individuals were lost to follow-up because they were released from prison or they did not complete treatment. Of the 313 individuals who completed treatment and were tested at 12 weeks, 301 (96%) were cured. This program demonstrates that a decentralized model of nurse-led treatment was highly effective in increasing hepatitis C treatment access in prisons, with high rates of cure.
Of the participants assessed, 82% were considered to have less complex needs, with no liver disease, and they had their treatment led by a program nurse. This suggests that in a majority of cases, hepatitis C treatment in prisons can be overseen by nursing staff.
What does this mean for service providers?
To achieve elimination of hepatitis C, people in prison represent a priority population that must be addressed. Increasing treatment access is a major pillar of a Canadian elimination strategy. This program is an example of a nurse-led, decentralized model that can effectively engage a large number of people in treatment with very high cure rates.
This program demonstrates that hepatitis C treatment with direct-acting antiviral therapies has become reliable and straightforward. In many cases there is no need for specialized medical staff, and programs can be delivered by nurses working in a decentralized fashion in individual prison facilities. This can lessen the need for specialized healthcare staff or for prisoners to be transported to centralized healthcare facilities. In cases where more specialized care is needed, technology like telemedicine can help remotely link hepatologists or other specialists to patients.
Blueprint to inform hepatitis C elimination efforts in Canada (CanHepC)
Blueprint to Inform Hepatitis C Elimination Efforts in Canada: What do service providers need to know? (CATIE)
Micro-elimination of hepatitis C: A pathway to achieve national elimination goals (CATIE)
Papaluca T, Mcdonald L, Craigie A, et al. Outcomes of treatment for hepatitis C in prisoners using a nurse-led, statewide model of. Journal of Hepatology. 2019;70:839–46.