Who Should Receive Priority for Hepatitis C Care? Researchers Suggest Shift

The limited resources available for correctional health services guarantees that many incarcerated individuals with the hepatitis C virus (HCV) will not have access to the newer drug treatments that have revolutionized HCV care. A study suggests that the method many prison systems have used to decide who will get HCV treatment and who won't does not represent the most effective use of limited treatment capacity.

Published online last month in the journal Operations Research, the study offers an alternative decision-making model that considers multiple factors in the effort to prioritize services. The model emphasizes two factors that have received little attention in many state prison systems: the system's overall capacity to offer HCV treatment, and the remaining duration of an inmate's sentence.

The prioritization of HCV treatment becomes a critical issue for the drug-using community because injection drug use is the most common cause of HCV transmission. And because of the link between drug use and criminality in the U.S., hepatitis C is 10 times more prevalent in state prisons than in the community at large.

“If the objective is to minimize the disease burden, prison systems should be the focus,” Turgay Ayer, the study's lead researcher and an associate professor at the Georgia Institute of Technology, tells Addiction Professional.

Ambiguous standards

The Federal Bureau of Prisons encourages the prioritization of inmates for HCV treatment, but the standards that are suggested for this have been inconsistently applied. It is suggested that disease state, remaining sentence length and injection drug use status be considered in the decision-making process, but no consensus has emerged over how these criteria should be applied. Ayer says he speculates that the criteria have been left ambiguous intentionally, because of this lack of agreement.

The absence of a consensus came clear to Ayer when he recently asked a group of doctors attending a conference to judge which of two hypothetical inmate profiles should receive priority for hep C treatment: someone who doesn't use intravenous drugs and has a longer sentence, or someone who uses intravenous drugs and has a shorter sentence. “It was an even split,” Ayer says of the responses.

The journal article lays out the specifics of a modeling framework to support decision-making on how to allocate limited resources for HCV treatment in state prisons. The authors state that some systems' tendency to consider only liver health status falls short compared with other potential approaches. The model that the study advances also considers factors such as sentence duration and the prison system's treatment capacity.

Ayer describes a key takeaway from the research by presenting two scenarios:

• In settings where treatment capacity is particularly limited, the priority should be on saving the sickest patients with the longest sentences. Where capacity to reach more people with effective drug treatments is highly restricted, “You care less about preventing future infections here,” Ayer says.

• In settings where treatment capacity is greater, the priority should be on treating inmates with shorter sentences, in order to help prevent future infections in the community as offenders leave custody. This strategy doesn't leave inmates with longer sentences behind in such systems, as some capacity exists to treat them later in their prison stay.

In essence, the issue becomes one of balancing the interests of saving individual lives and enhancing community health by preventing HCV transmission. The remaining length of sentence becomes an important factor in helping to strike the proper balance, study authors explain.

“When the treatment capacity is higher, you can achieve both goals,” Ayer says.

The study paper cites a survey published in 2016 that showed a considerable range in HCV treatment capacity among state prison systems, from less than 1% in Oklahoma to around 13% in Indiana.

The remaining length of sentence is described in the study as a more practically applied variable than injection drug use status. The researchers stated that injection drug users should be prioritized for treatment when they have less advanced disease states and where HCV reinfection can be well-controlled.