Beyond Prison Walls (BPW) uses a multidisciplinary care model to link individuals recently released from prison to hepatitis C treatment in the community. BPW begins before the person is released from prison, where pre-treatment bloodwork is completed by a nurse and discharge planning is completed by a social worker and a patient navigator. Upon release, a patient navigator supports linkage to care by scheduling appointments, accompanying people to appointments and following up to help participants start treatment. Individuals who participated in BPW were 70% more likely to successfully be linked to care than individuals who received the standard of care.
Program description
People with prison experience are disproportionately impacted by hepatitis C in Canada. Barriers to care in prison and competing priorities after release (e.g., unstable housing) leave people undiagnosed and untreated. Beyond Prison Walls (BPW) was developed to enhance linkage to hepatitis C care for individuals being released from l’Établissement de détention de Montréal (EDM), the largest provincial men’s prison in Quebec. BPW employed a multidisciplinary team, consisting of a nurse, social worker and patient navigator, to facilitate linkage to hepatitis C care after release. Participants were eligible if they were 18 years of age or older and expected to stay at EDM between two and 12 weeks — long enough to confirm a current infection at EDM, but typically not long enough to complete treatment in prison.
Pre-release hepatitis C testing, bloodwork and linkage to care planning
While incarcerated, participants are offered opt-out point-of-care hepatitis C antibody testing by the nurse. Those who test positive have their blood drawn for RNA testing on the spot, with the nurse providing results and post-test counselling at a second visit. Individuals with a current infection also complete pre-treatment bloodwork (e.g., liver function, HIV and hepatitis B testing) and review treatment options with the nurse during the second visit.
The social worker conducts a needs assessment with the individual to identify barriers that could impact linkage to care (e.g., housing, health coverage), assesses their harm reduction needs (e.g., supporting safer drug use) and organizes community referrals for after their release. Before a participant is released from EDM, the patient navigator attempts to meet with them at least twice and schedules their treatment initiation appointment to occur within 30 days after they re-enter the community. Individuals are linked with their existing physician when possible, or another conveniently located provider. Participants consent to share their medical records, allowing community providers to receive pre-treatment bloodwork and the BPW team to confirm treatment start and completion. As many individuals lack access to a phone after release, the patient navigator also collects contact information for participants’ networks of emergency contacts — including family members, peers and healthcare workers — and provides participants with the BPW phone number to encourage them to maintain contact with the team after their release.
Linkage to care after release and ongoing navigation
Once a participant has returned to the community, the patient navigator contacts them either directly or through their network of emergency contacts one week before their hepatitis C appointment; participants are considered lost to follow-up if the patient navigator could not establish contact within three attempts, each 24 hours apart. Participants with whom the patient navigator is successfully able to connect receive an appointment reminder and are offered accompaniment to their appointment. The patient navigator provides a second reminder to all participants 24 hours before their appointment, regardless of their choice of whether or not to receive accompaniment.
Individuals who accept accompaniment meet with the patient navigator at a predetermined location and are escorted primarily using public transportation (all fees are covered). Baseline bloodwork results are provided to community providers at the time of the appointment to allow for same-day treatment initiation; however, treatment decisions are left to the providers’ discretion. The patient navigator schedules additional appointments and offers appointment accompaniment until the participant starts treatment. Individuals who are reincarcerated within 90 days of release have continued access to patient navigation and linkage services. In the event treatment is initiated in the community, individuals who are reincarcerated have continued access to treatment at EDM.
Results
In a quasi-experimental study, two sequential groups were recruited using convenience sampling to compare linkage to care within 90 days of release between BPW and the standard of care (on-demand testing, full panel pre-treatment bloodwork and a pre-release discharge appointment with a community-based provider).
In the standard of care arm, 300 participants agreed to participate, of whom 48 (15%) received hepatitis C antibody testing. Half of those tested (24) were antibody positive, and of those who were antibody positive, 79% (19) were RNA positive.
In the BPW arm, 644 participants agreed to participate and all received hepatitis C point-of-care antibody testing. Nine percent (56) were antibody positive, and of those who were antibody positive, 36% (20) were RNA positive.
The participants in the standard of care and BPW arms had similar average ages (46 vs. 45 years), housing instability (42% vs. 50%) and mental health diagnoses (42% vs. 55%). All participants reported a history of injection drug use and most participants (62%) lacked a primary care provider.
Among the 20 RNA-positive individuals in the BPW arm, 80% (16) were linked to care within 90 days of release, compared with only 11% (two) of the RNA-positive individuals in the standard of care arm. Among the 20 RNA-positive individuals in the BPW arm, 65% (13) started treatment and 40% (eight of 20) completed treatment and were cured. In the BPW arm, the patient navigator successfully established contact with 95% (19) of the RNA-positive participants (one did not provide contact information). Of these, 74% (14) desired accompaniment to hepatitis C care appointments from the patient navigator and a median of two appointments were scheduled for participants by the patient navigator.
In comparing BPW with the standard of care, BPW participants were 70% more likely to be linked to care than people who received the standard of care. Among those in BPW, linkage to care was associated with contact by the patient navigator after release; BPW participants who were successfully contacted by the patient navigator were 64% more likely to be linked to care than those who were not. Participants who accepted appointment accompaniment were also 27% more likely to be linked to care than those who did not.
What does this mean for service providers?
Findings from this study suggest that a multidisciplinary model of care that incorporates pre-release discharge planning and follow-up after release is effective in linking people who are incarcerated to hepatitis C care in the community. In particular, patient navigators play a crucial role in supporting the linkage process. Considerable follow-up may be required to facilitate linkage to care. However, establishing successful contact in the community was key to ensuring individuals were not lost to follow-up while they were managing competing priorities after release. Further, as reincarceration can be a reality for people with prison experience, collaboration between corrections and community providers can help reduce barriers to care and minimize care disruptions.
Related resources
Patient navigator services needed to link people to hepatitis C care and treatment after release from incarceration – CATIE News
Unlocking the Gates: From corrections to community – CATIE Blog
Strengthening hepatitis C care from corrections to community – CATIE Webinar
Reference
Kronfli N, Mambro A, O’Brien A et al. A pre-post study of the impact of a multidisciplinary model of care on linkage to hepatitis C care following release from prison: the Beyond Prison Walls study. International Journal of Drug Policy. 2025 Sep 1;143:104873.