In June 2019, a narrative review article from the Canadian Liver Journal looked at evidence-based strategies to eliminate hepatitis C in Canadian federal and provincial/territorial prisons.1 Prisons are unique environments for hepatitis C care that require specific approaches and coordination from a range of stakeholders, including health policy makers, corrections staff, care providers, community members and researchers. The Blueprint to inform hepatitis C elimination efforts in Canada, a policy recommendation document, prioritizes prisons as a key area of action to eliminate hepatitis C in Canada. This following article summarizes the challenges associated with hepatitis C in Canadian prisons and strategies to address them.
Canada’s prison systems and hepatitis C
There are two types of prison facilities in Canada: federal and provincial/territorial. Federal prisons hold people who have been sentenced to serve two or more years in prison. Provincial and territorial prisons hold people who are sentenced to serve less than two years and those who are awaiting trial.1 In 2018, there were almost 248,923 people in Canada’s federal and provincial/territorial prisons.2 It has been estimated that 25% of people in correctional facilities in Canada in 2011 have been exposed to hepatitis C, a rate that is 40 times higher than in the general population.1
This review states that the criminalization of drug use creates an over-representation of people who use drugs in prisons, particularly those who inject drugs. A lack of harm reduction and substance use treatment services in prisons exacerbates risks such as sharing needles and unsafe tattooing. These are practices that increase rates of hepatitis C.
A number of strategies, including universal screening, linkage to care, the use of non-specialist treatment models and telemedicine, and access to harm reduction measures, may help eliminate hepatitis C within the prison setting. The goal of these strategies is the “micro-elimination” of hepatitis C in prisons. Micro-elimination is defined as elimination in a defined segment of the population (in this case, among people who are incarcerated). For more information on micro-elimination, see this Prevention in Focus article.
Universal screening for all people in prisons improves detection and diagnosis
This review recommends universal screening as a cost-effective way to improve testing rates and case identification. In provincial and territorial prisons, screening is often provided only upon request (known as “on demand” screening), missing a large proportion of cases. Universal (“opt-out”) screening programs offer testing to all individuals, with the option to decline testing. Systematic opt-out testing improves diagnosis rates of hepatitis C, which is important because a large proportion of individuals in prisons are unaware of their status. Even though the opt-out model involves testing more people than the on-demand model, it is cost-effective because it streamlines the process of linking individuals to hepatitis C treatment and care.
Linkage to care in the community increases cure rates
Hepatitis C treatment is provided within federal prisons because inmates have longer sentences than in other prison settings, but the review describes treatment in provincial prisons as challenging. The average incarceration time in provincial or territorial prisons is four weeks and the minimum duration of hepatitis C treatment is eight weeks, which means that it is difficult for inmates to complete treatment during incarceration. It is therefore important to link individuals to community-based hepatitis C treatment and care upon release. Studies from select state prisons systems in the United States show that up to two out of three people who are linked to care upon release will go on to complete treatment.3,4
Ten percent of people remain in custody longer than six months in provincial and territorial prisons. The authors suggest that consideration should be given to providing treatment during incarceration for these individuals. Once strong linkage to care programs are in place, all inmates could be considered for treatment regardless of their sentence length, as they could continue treatment in the community upon release.
Non-specialist treatment models and telemedicine simplify the treatment process
The review proposes that treatment led by non-specialist health care providers rather than physician specialists can be an effective strategy to increase treatment numbers. Modern direct-acting antiretroviral therapies require much shorter courses of treatment, are highly effective and are less complicated to administer than older therapies. If non-specialists are allowed to initiate treatment, this reduces costs and increases access, especially if all clinical services can be provided onsite at the prison. Other jurisdictions, such as Australia, have seen success with nurse-led models in particular.5
Telemedicine can also connect patients to specialists and avoid the time and expense involved in transporting people to health care centres. In addition, telemedicine is a valuable tool to remotely train and support clinicians already working in correctional facilities to treat hepatitis C.6
Increasing access to harm reduction measures reduces risk of transmission
Substance use in prisons and the lack of harm reduction measures increase risk for hepatitis C, particularly through riskier injection practices such as reusing equipment. Currently, many prisons in Canada provide only bleach to use with injecting equipment; however, this has been shown to offer little benefit in preventing hepatitis C transmission. The review identified prison-based needle and syringe programs as an evidence-based strategy to reduce risk of transmission; however, such programs are unavailable in provincial and territorial prisons and at the time of writing, most federal prisons. In other countries, needle and syringe programs did not increase drug consumption and actually improved institutional safety for staff and prisoners,7 two common concerns.
Opioid substitution therapy (OST) programs are another evidence-based harm reduction measure. They help to reduce reliance on injection and the need to share needles, especially where needle and syringe programs do not exist. Currently, OST is available in most provincial and territorial prison systems and all federal institutions, depending on regional policies. Harm reduction pilot projects have been introduced in federal institutions, such as a safer tattooing program, which has since been terminated, and a pilot needle exchange program. Since this review was published, additional needle exchange sites and other harm reduction programs have opened in some federal institutions, including one overdose prevention service.8,9 However, many prisoner rights advocates continue to be critical of how these programs are delivered, citing issues such as concerns around confidentiality.10
Community organizations are critical partners in creating effective programs
Community organizations are essential partners for developing programs and policies to support hepatitis C care in prisons; the voices of people with lived experience are particularly important. Community-led organizations, such as Prisoners with HIV/AIDS Support Action Network (PASAN), John Howard Societies and Elizabeth Fry Societies, are also key resources in supporting individuals in the community after release. Collaboration with community organizations provides necessary perspective in prisons to develop effective and acceptable programs, advocate for prisoner rights, reduce hepatitis C stigma, and potentially assist with human resource requirements for the delivery of programs.
Implications for policy and practice
A large gap remains in Canada’s efforts to eliminate hepatitis C in prisons. Evidence exists to inform strategies to:
- increase testing and diagnosis
- increase access to treatment
- prevent new cases through harm reduction measures
- engage community members in the response
There is a role for healthcare providers and community organizations to play in continuing to advocate for change within the prison system and to support those in the prison system upon release. Policy-makers and prison administrations have a role to play in acknowledging the burden of hepatitis C, and they should take steps to implement evidence-based strategies within their institutions. Only through collective action can Canada eliminate hepatitis C within our prison systems.
For more information, see the full article in the Canadian Liver Journal.
Staying Healthy Behind the Walls: Hepatitis C, HIV and You (CATIE & PASAN)
Staying Healthy Behind the Walls: Tattooing, Piercing and You (CATIE & PASAN)
- Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Malakieh J. Adult correctional statistics in Canada, 2017/2018 [Internet]. Catalogue no. 85-002-X. Ottawa: Canadian Centre for Justice Statistics, Statistics Canada; May 2019. Available from: https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2019001/article/00010-eng.pdf?st=tDpt0-9v
- Hochstatter KR, Stockman LJ, Holzmacher R, et al. The continuum of hepatitis C care for criminal justice involved adults in the DAA era: a retrospective cohort study demonstrating limited treatment uptake and inconsistent linkage to community-based care. Health Justice. 2017;5(1):10 as cited in Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Schoenbachler BT, Smith BD, Sena AC, et al. Hepatitis C virus testing and linkage to care in North Carolina and South Carolina jails, 2012–2014. Public Health Report. 2016;131(Suppl 2):98-104 as cited in Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Post JJ, Arain A, Lloyd AR. Enhancing assessment and treatment of hepatitis C in the custodial setting. Clinical Infectious Diseases. 2013;57(Suppl 2):S70-4 as cited in Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine. 2011;364(23):2199-207 as cited in Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Stöver H, Nelles J. Ten years of experience with needle and syringe exchange programmes in European prisons. International Journal of Drug Policy. 2003;14(5-6):43744 as cited in Kronfli N, Buxton JA, Jennings L, et al. Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be? Canadian Liver Journal. 2020;2(4):171-83.
- Correctional Service Canada. The Overdose Prevention Service. Ottawa: Correctional Service Canada; 2019. Available from: https://www.csc-scc.gc.ca/health/002006-2002-en.shtml
- Correctional Service Canada. The Prison Needle Exchange Program. Ottawa: Correctional Service Canada; 2019. Available from: https://www.csc-scc.gc.ca/health/002006-2004-en.shtml
- Canadian HIV/AIDS Legal Network. News Release: Prison Needle and Syringe Program. Toronto: Canadian HIV/AIDS Legal Network; 2020. http://www.aidslaw.ca/site/news-release-prison-needle-and-syringe-program-2/?lang=en
About the author(s)
Christopher Hoy is CATIE’s knowledge specialist, hepatitis C community health programming and works to build hepatitis C programming capacity for frontline service providers. Christopher has previously worked in public health communications and policy roles and has a Master of Public Health.