Comparison of hepatitis C virus treatment between incarcerated and community patients

Statewide Assessment of the Hepatitis C Virus Care Cascade for Incarcerated Persons in Vermont

OBJECTIVES

Incarcerated persons in the United States have a high burden of hepatitis C virus (HCV) infection. This study assessed the impact of a statewide effort in Vermont to treat HCV in this group.

METHODS

We performed a retrospective, observational cohort study of all HCV-infected persons who were imprisoned in Vermont during the 19-month study period (December 2018-June 2020). The cascade of care comprised opt-out HCV screening, full access to direct-acting antiviral treatment (without hepatic fibrosis-based treatment restrictions), HCV specialist involvement, and medication-assisted treatment for patients with opioid use disorder. The primary outcome was sustained virologic response at 12 weeks after treatment completion (SVR12).

RESULTS

The study included 217 HCV-infected patients; the median age was 35 years (range, 18-73 years), 89% were male, 76% had opioid use disorder, 67% had a psychiatric comorbidity, and 9% had cirrhosis. Of the 217 patients, 98% had a liver fibrosis assessment, 59% started direct-acting antiviral treatment, 55% completed direct-acting antiviral treatment, and 51% achieved documented SVR12. Of the 129 HCV-infected persons who started direct-acting antiviral treatment, 92% completed therapy and 86% achieved documented SVR12. Psychiatric comorbidity was not significantly associated with achieving SVR12 (odds ratio = 0.67; 95% CI, 0.27-1.65; P = .38), nor was receiving medication-assisted treatment for patients with opioid use disorder (odds ratio = 1.45; 95% CI, 0.62-2.56; P = .45).

CONCLUSIONS

This study reports the highest SVR12 rate achieved in a state incarcerated population to date. HCV treatment in incarcerated populations is a practical and efficacious strategy that should serve a foundational role in HCV elimination.

Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic

OBJECTIVES

Nearly 1 in 3 people with hepatitis C virus (HCV) infection pass through the criminal justice system annually; the system is a crucial location for HCV screening, education, and linkage to care. We aimed to (1) determine the prevalence and incidence of HCV antibody positivity and (2) evaluate the demographic characteristics of people with HCV in a large urban jail.

METHODS

We offered universal opt-out HCV testing to any person undergoing a routine blood test at the Dallas County Jail from June 2015 through December 2019 (N = 14 490). We extracted data on demographic characteristics from the electronic medical record and collected data on risk factors from people with HCV antibody positivity. We performed univariate and multivariate analyses.

RESULTS

The prevalence of HCV antibody positivity was 16.7%; the incidence was 13.5 cases per 1000 person-years. HCV antibody positivity was significantly associated with older age (P < .001), female sex (P = .004), non-Hispanic White race versus non-Hispanic Black race (P < .001), and being released to prison versus not (P < .001). Among people born after 1965, those who were HCV antibody-positive were more frequently non-Hispanic White and Hispanic women, whereas among those born in 1965 or before, those who were HCV antibody-positive were more frequently non-Hispanic Black men.

CONCLUSIONS

The high prevalence and incidence of HCV antibody positivity in a large county jail argue for routine, universal HCV testing and prevention counseling in criminal justice settings. Changing demographic characteristics mirror those of the national injection drug use epidemic and shed insight into designing interventions for risk reduction, education, linkage to care, and treatment.

The impact of unrestricted access to direct-acting antiviral among incarcerated hepatitis C virus-infected patients

Background/Aims

Despite the disproportionally high prevalence rates of hepatitis C virus (HCV) amongst the incarcerated population, eradication remains challenging due to logistic and financial barriers. Although treatment prioritization based on disease severity is commonly practiced, the efficacy of such approach remained uncertain. We aimed to compare the impact of unrestricted access to direct-acting antiviral (DAA) among incarcerated HCV-infected patients in Singapore.

Methods

In this retrospective study, we reviewed all incarcerated HCV-infected patients treated in our hospital during the restricted DAA era (2013–2018) and unrestricted DAA access era (2019). Study outcomes included the rate of sustained virological response (SVR), treatment completion and treatment default. Subgroup analysis was performed based on the presence of liver cirrhosis, HCV genotype and HCV treatment types.

Results

A total of 1,001 HCV patients was followed-up for 1,489 person-year. They were predominantly male (93%) with genotype-3 HCV infection (71%), and 38% were cirrhotic. The overall SVR during the restricted DAA access era and unrestricted DAA access era were 92.1% and 99.1%, respectively. Unrestricted access to DAA exponentially improved the treatment access among HCV-infected patients by 460%, resulting in a higher SVR rate (99% vs. 92%, P=0.003), higher treatment completion rate (99% vs. 93%, P<0.001) and lower treatment default rate (1% vs. 9%, P<0.001).Conclusion: In this large cohort of incarcerated HCV-infected patients, we demonstrated that unrestricted access to DAA is an impactful strategy to allow rapid treatment up-scale in HCV micro-elimination.

Microelimination of Chronic Hepatitis C by Universal Screening Plus Direct-Acting Antivirals for Incarcerated Persons in Taiwan

Background

Incarcerated persons are a special population with higher hepatitis C virus (HCV) prevalence and should be prioritized for microelimination. In this study, we investigate the seroprevalence and evaluate the effectiveness and safety of direct-acting antiviral (DAA) therapy in custodial settings.

Methods

Incarcerated persons in Yunlin Prison were recruited to receive anti-HCV antibody screening. Patients with positive HCV ribonucleic acid (RNA) were treated with glecaprevir/pibrentasvir (GLE/PIB) in our special chronic hepatitis C (CHC) clinic in prison. The primary endpoint was sustained virologic response at week 12 off therapy (SVR12).

Results

A total of 1402 incarcerated persons were invited to anti-HCV screening and 824 (58.7%) accepted. The prevalence of anti-HCV positivity was 33.5% (276 of 824), and the viremic rate (detectable HCV RNA) was 69.2% (191 of 276). According to fibrosis index based on 4 factors, patients with F3 stage were 6 (3.1%), but none met the criteria of F4 stage. However, 6 (3.1%) had liver cirrhosis with splenomegaly, confirmed by findings of ultrasonography. The median log₁₀ HCV RNA level at baseline was 6.235 (2.394–7.403). Genotype (GT) 6 was predominant (39.3%), followed by GT 1a (22.0%) and 1b (14.1%). Mixed GT HCV infection accounted for 3.6% of total infections. In total, 165 patients received GLE/PIB therapy. The overall SVR12 rates were 100%.

Conclusions

Direct-acting antiviral therapy is highly effective and safe for incarcerated patients in Taiwan. Our special prison-based CHC clinic, linking universal screening to medical care, can serve as a model for microelimination of HCV in custodial settings.

The seroprevalence of untreated chronic hepatitis C virus (HCV) infection and associated risk factors in male Irish prisoners: a cross-sectional study, 2017

IntroductionData on chronic hepatitis C (HCV) infection prevalence in European prisons are incomplete and impact the public health opportunity that incarceration provides.AimsWe aimed to estimate the seroprevalence of untreated chronic HCV infection and to identify associated risk factors in an Irish male prison.MethodsWe conducted a cross-sectional study involving a researcher-administered questionnaire, review of medical records and HCV serology.ResultsOf 422 prisoners (78.0% of the study population) who participated in the study, 298 (70.6%) completed the questionnaire and 403 (95.5%) were tested for HCV antibodies. Of those tested, 92 (22.8%) were HCV antibody-positive, and of those, 53 (57.6%) were HCV RNA-positive, 23 (25.0%) had spontaneous clearance, 16 (17.4%) had a sustained viral response, 10 (11.0%) were co-infected with HIV and six (6.0%) with HBV. The untreated chronic HCV seroprevalence estimate was 13.1% and the seroprevalence of HCV among prisoners with a history of injecting drug use (IDU) was 79.7%. Risk factors significantly associated with past HCV infection were IDU (p < 0.0001), having received a prison tattoo (p < 0.0001) or a non-sterile community tattoo (p < 0.0001), sharing needles and other drug-taking paraphernalia (p < 0.0001). Small numbers of prisoners had a history of sharing razors (n=10; 3.4%) and toothbrushes (n=3; 1.0%) while incarcerated. On multivariable analysis, history of receiving a non-sterile community tattoo was the only significant risk factor associated with HCV acquisition (after IDU was removed from the model) (p = 0.005, β = 0.468).ConclusionThe level of untreated chronic HCV infection in Irish prisons is high, with IDU the main associated risk.

Hepatitis C virus infection in Irish drug users and prisoners - a scoping review

BACKGROUND

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners.

METHODS

A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O'Malley).

RESULTS

A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients' and Health Providers' Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST.

CONCLUSION

Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

A systematic review on models of care effectiveness and barriers to Hepatitis C treatment in prison settings in the EU/EEA

Hepatitis C prevalence in prison populations is much higher than in the community. Effective hepatitis C treatment within this population does not only have a direct individual health benefit, but may lead to substantial community dividend. We reviewed available evidence on hepatitis C treatment in prison settings, with a focus on the European Union/European Economic Area. A systematic review of the literature (PubMed, EMBASE, Cochrane library) was performed and complemented with searches for conference abstracts and grey literature. Thirty-four publications were included reporting on the effectiveness, acceptability and economic aspects of hepatitis C virus treatment models of care to achieve treatment completion and sustained viral response in prison settings. Available evidence shows that hepatitis C treatment in prison settings is feasible and the introduction of direct-acting antivirals will most likely result in increased treatment completion and better clinical outcomes for the prison population, given the caveats of affordability and the need for increased funding for prison health, with the resulting benefits accruing mostly in the community.

Comparison of effectiveness and discontinuation of interferon-free therapy for hepatitis C in prison inmates and noninmates

Chronic hepatitis C treatment with direct acting antiviral (DAA) therapy during incarceration is an attractive option, due to its short duration and to the possibility of directly observed treatment or supervision. The aim of this study is to compare the effectiveness and rates of discontinuation of DAA treatment in prisoners and nonprisoners. We studied all patients treated in the 10 prisons of Catalonia and at 3 public hospitals in the Barcelona area between 1 January 2015 and 30 April 2016. We analysed sustained viral response (SVR) and rates of discontinuation through intention-to-treat and modified-intention-to-treat analyses, the latter excluding discontinuations due to release from prison. One hundred and eighty-eight inmates and 862 noninmates were included. Prisoners were significantly younger than nonprisoners, with higher proportions of men, drug users, HIV infection, genotypes 1a and 3 and more treatment with psychiatric drugs. Overall, 98.4% of patients completed treatment. The discontinuation rate was low, but higher in inmates (3.7% vs 1.2% noninmates; P = .003) and in community patients >65 years old (2.8% vs 1.2% in under 65 seconds; P = .008). Among the inmates, 7 (42.8%) discontinuations were due to release. SVR was 93.1% in inmates vs 96.5% in noninmates (P = .08) by intention-to-treat and 95.1% vs 96.5% (P = .37) by modified intention-to-treat. Virologic failure rates were similar (3.8% vs 3% in noninmates; P = .60). SVR, virologic failure and discontinuation rates were similar in inmates and noninmates. Currently, prisons are considered a priority for the implementation of DAA. Improved coordination between penitentiary and community health systems would help to ensure therapeutic continuity in released prisoners.

Evaluation of cost-effectiveness of peginterferon plus ribavirin for chronic hepatitis C treatment and direct-acting antiviral agents among HIV-infected patients in the prison and community settings

BACKGROUND

In Taiwan, the majority of chronic hepatitis C carriers with HIV co-infection are intravenous drug users and inmates in correctional facilities. Peginterferon and ribavirin (PegIFN/RBV) have been the standard-of-care for chronic hepatitis C virus (HCV) infection more than decades. We evaluated the estimated cost-effectiveness of PegIFN/RBV from the National Health Insurance Research Database, covering the population of Taiwan from 1998 to 2013.

MATERIALS AND METHODS

This is an observational study, and study during was 2010-2016 and a total of 239 patients were treated with PegIFN/RBV. Of them, 156 patients were treated in the correctional facilities of Taipei, Taoyuan, Taichung and Taitung prisons, and 83 patients were treated in communities. The cost-effectiveness was analyzed in regimens of PegIFN/RBV and direct-acting antiviral agents.

RESULTS

By multivariate analysis, the patients completed PegIFN/RBV in prison (adjusted odds ratio [aOR]: 4.56, 95% confidence interval [CI]: 1.58-13.12, p = 0.005), HCV RNA level <800,000 IU/mL (aOR: 4.0, 95% CI: 1.27-12.66, p = 0.02) at baseline, and the presence of early virologic response (EVR) (aOR: 7.67, 95% CI: 1.89-31.06, p = 0.004) were independent predictors for sustained virologic response (SVR). For the subgroups of prisoners, HIV-infected prisoners and HIV-infected patients in communities, the SVR rate was 73.8%, 72.0% and 36.8%, and the average medical-care cost was US$7,701, $7,893, and $15,443 per SVR achieved, respectively. Also, the estimated medical-care cost for genotype 6 was US$9211.

CONCLUSIONS

Chronic HCV/HIV co-infected patients with genotype 1 and 6 in the community setting could benefit from DAAs in Taiwan.

Genotype distribution and treatment response among incarcerated drug-dependent patients with chronic hepatitis C infection

The prevalence of hepatitis C virus (HCV) infection is disproportionately high among prisoners, especially among those who are drug-dependent. However, current screening and treatment recommendations are inconsistent for this population, and appropriate care is not reliably provided. To address these problems, the present study aimed to identify unique characteristics and clinical manifestations of incarcerated patients with HCV infection. We included incarcerated patients who received treatment with pegylated-interferon combined with ribavirin at Mackay Memorial Hospital in Taitung and were serving sentences at either the Taiyuan Skill Training Institute or the Yanwan Training Institute. HCV genotypes 1 (41.4%), 3 (25.9%), and 6 (24.1%) were the most prevalent in the incarcerated patients. During the study period, we analyzed treatment response among 58 incarcerated patients and compared obtained results with treatment response among 52 patients who were living in the community. Higher sustained virological response rate was observed among patients with incarceration and HCV genotype other than 1. The odds ratios (corresponding 95% confidence intervals) for incarceration and genotype 1 were 2.75 (1.06–7.11) and 0.37 (0.14–0.99), respectively. Better treatment compliance among incarcerated patients might partially explain these results. The results of this study suggest that treatment of prisoners with HCV infection is feasible and effective. More appropriate and timely methods are needed to prevent HCV transmission among injection drug users inside prisons.

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

BACKGROUND

Incarcerated populations are disproportionately burdened by hepatitis C virus (HCV) infection. The introduction of highly-effective, direct-acting antiviral (DAA) treatment has potential to substantially reduce the burden of liver disease in this population, but accurate information about access to and utilization of this treatment is currently limited. The goals of this study were to characterize receipt of HCV care and treatment services for a cohort of HCV-infected adults identified in a state prison system, and to describe the complex health needs of this population.

METHODS

To estimate the proportion of patients who were treated for HCV while incarcerated, and the proportion linked to HCV care after release from prison, we used a deterministic matching algorithm to link administrative prison data, health care records, and a state public health surveillance database, which captures all positive HCV-related diagnostic test results through automatic laboratory reporting. Individuals not evaluated or treated for HCV while in prison were considered likely to have been linked to care in the community if the HCV surveillance system contained a record of a quantitative HCV RNA or genotype test within 6 months of their release date. Demographic and comorbidity data were manually extracted from the electronic health records for all patients referred for consideration of HCV treatment.

RESULTS

Between 2011 and 2015, 3126 individuals were known to be living with chronic HCV infection while incarcerated in the state prison system. Of these, 570 (18%) individuals were evaluated for HCV treatment while incarcerated and 328 (10%) initiated treatment with DAAs. Of the 2556 individuals not evaluated for treatment, 1605 (63%) were released from prison during the 5 year study period. Of these, 138 (9%) individuals engaged in HCV care in the community within 6 months. Data describing medical and psychiatric co-morbidities were available for the prison-based treatment cohort, which showed a high prevalence of major depression (39%), anxiety disorder (24%), alcohol misuse (52%), cocaine use (52%) and prior injection drug use (62%).

CONCLUSION

Despite HCV treatment advances, linkage to care and treatment rates for criminal-justice involved adults remains low, particularly for those who must seek care in the community after release from prison. Treating criminal-justice involved individuals for HCV during incarceration provides an opportunity to improve linkage to care and treatment rates among this vulnerable population.

A matched comparison study of hepatitis C treatment outcomes in the prison and community setting, and an analysis of the impact of prison release or transfer during therapy

Prisoners are a priority group for hepatitis C (HCV) treatment. Although treatment durations will become shorter using directly acting antivirals (DAAs), nearly half of prison sentences in Scotland are too short to allow completion of DAA therapy prior to release. The purpose of this study was to compare treatment outcomes between prison- and community-based patients and to examine the impact of prison release or transfer during therapy. A national database was used to compare treatment outcomes between prison treatment initiates and a matched community sample. Additional data were collected to investigate the impact of release or transfer on treatment outcomes. Treatment-naïve patients infected with genotype 1/2/3/4 and treated between 2009 and 2012 were eligible for inclusion. 291 prison initiates were matched with 1137 community initiates: SVRs were 61% (95% CI 55%-66%) and 63% (95% CI 60%-66%), respectively. Odds of achieving a SVR were not significantly associated with prisoner status (P=.33). SVRs were 74% (95% CI 65%-81%), 59% (95% CI 42%-75%) and 45% (95% CI 29%-62%) among those not released or transferred, transferred during treatment, or released during treatment, respectively. Odds of achieving a SVR were significantly associated with release (P<.01), but not transfer (P=.18). Prison-based HCV treatment achieves similar outcomes to community-based treatment, with those not released or transferred during treatment doing particularly well. Transfer or release during therapy should be avoided whenever possible, using anticipatory planning and medical holds where appropriate.

The lived experience of interferon-free treatments for hepatitis C: A thematic analysis

BACKGROUND

International discourse concerning the evolution in hepatitis C virus (HCV) therapy has tended to focus on improving outcomes, shortened treatment length and reduced side-effects of interferon-free regimens. How these treatments are being understood and experienced by the people receiving them has so far been overlooked. This study therefore aimed to explore the lived experience of individuals taking interferon-free HCV therapies.

METHODS

Data were generated through 16 semi-structured interviews with a purposive sample of eight participants, recruited from a university hospital in Scotland. The interviews took place between June 2015 and March 2016, before and after a period of interferon-free HCV treatment. The data were interrogated using a thematic analysis, underpinned by social phenomenological theory.

RESULTS

Three overriding themes were identified. 'Expectations and realisations' characterised the influence that interferon continued to cast over interferon-free treatment, contrasting the practicalities of taking interferon-free therapy with preconceived notions. 'An honour and a pleasure' portrayed a positive experience of an undemanding therapy, yet among those with a history of drug use, was also positioned as a privilege, associated with feelings of luck and guilt. 'Treatment needs' illustrated the strategies participants used to search for treatment efficacy, and the value those with a significant history of drug use placed on support. One nonconforming case is then discussed to enhance rigour and trustworthiness.

CONCLUSION

This is the first qualitative exploration of the experience of interferon-free HCV treatment reported globally. The results from this study suggest a cultural lag exists between the pharmacological developments which have been witnessed, and societal understandings of them. This has implications for the way services meet the needs of, and offer therapy to, HCV positive individuals.

Alcoholic liver disease: Clinical and translational research

The present review spans a broad spectrum of topics dealing with alcoholic liver disease (ALD), including clinical research, translational research, pathogenesis and therapies. A special accent is placed on alcohol misuse, as alcohol is a legally commercialized and taxable product. Drinking alcohol, particularly from a young age, is a major health problem. Alcoholism is known to contribute to morbidity and mortality. A systematic literature search was performed in order to obtain updated data (2008-2015). The review is focused on genetic polymorphisms of alcohol metabolizing enzymes and the role of cytochrome p450 2E1 and iron in ALD. Alcohol-mediated hepatocarcinogenesis is also discussed in the presence or absence of co-morbidities such as viral hepatitis C as well as therapeutic the role of innate immunity in ALD-HCV. Moreover, emphasis was placed on alcohol and drug interactions, as well as liver transplantation for end-stage ALD. Finally, the time came to eradicate alcohol-induced liver and intestinal damage by using betaine.

"Seek, test, treat and retain" for hepatitis C in the United States criminal justice system

PURPOSE

The purpose of this paper is to consider the potential benefits and challenges of applying a strategy of "seek, test, treat and retain" (STTR) to hepatitis C virus (HCV) in the US criminal justice system.

DESIGN/METHODOLOGY/APPROACH

The authors draw on the published literature to illustrate how each component of STTR could be applied to HCV in the US criminal justice system, and describe challenges to the implementation of this strategy.

FINDINGS

The burden of morbidity and mortality associated with chronic HCV infection in the USA is increasing and without significantly increased treatment uptake, will likely continue to do so for several decades. The authors argue that the US criminal justice system is an ideal focus for HCV case finding and treatment due to a high prevalence of infection and large volume of individuals in contact with this system. STTR would identify large numbers of HCV infections, leading to opportunities for secondary prevention and primary care. Important challenges to the implementation of STTR include treatment costs and training of prison medical providers.

ORIGINALITY/VALUE

This paper highlights opportunities to address HCV in the US criminal justice system.

Hepatitis C virus infection and prisoners: Epidemiology, outcome and treatment

The studies on hepatitis C virus (HCV) infection in prison populations are few and mostly cross-sectional. We analyzed prevalently the articles appearing on PubMed in the last ten years. HCV infection is frequent in prisoners, prevalences ranging from 3.1% to 38% according to the HCV endemicity in the geographical location of the prison and in the countries of origin of the foreign prisoners and to the prevalence of intravenous drug use, which is the most important risk factor for HCV infection, followed by an older age of prisoners and previous prison terms. HCV replication in anti-HCV-positive cases varies from 45% to 90% in different studies, and the most common HCV genotypes are generally 1 and 3. The response to antiviral treatment is similar in prisoners to that of the general population. Unfortunately, treatment is administered less frequently to prisoners because of the difficulties in management and follow-up. The new directly acting antivirals offer a good therapy option for inmates because of their good efficacy, short duration of treatment and low incidence of side effects. The efforts of the prison authorities and medical staff should be focused on reducing the spread of HCV infection in prisons by extending the possibility of follow-up and treatment to more prisoners with chronic hepatitis C.

Personality disorders do not affect treatment outcomes for chronic HCV infection in Spanish prisoners: the Perseo study

Background

The link between infection with hepatitis C virus (HCV) and personality disorders (PD) has not been investigated in detail. The aim of this study was to compare the effectiveness of HCV treatment in prisoners with and without PD.

Methods

We performed a prospective multicentre study in inmates from 25 Spanish prisons who had been treated with pegylated interferon alfa-2a plus ribavirin in 2011. PD diagnosis was based on the Personality Diagnostic Questionnaire-4+. We calculated adjusted Odds Ratios (AOR) and 95 % confidence intervals (95 % CI) using logistic regression.

Results

The sample included 236 patients (mean age: 40.3 years, 92.8 % male, 79.2 % intravenous drug users, and 26.3 % HIV-coinfected). The prevalence of PD was 72.5 %. 32.2 % of patients discontinued treatment; this percentage was higher in patients with HCV genotypes 1/4 (AOR = 3.55; CI:1.76–7.18) and those without PD (AOR = 2.51; 1.23–5.11). Treatment discontinuation was mainly for penitentiary reasons (40.3 %): release or transfer between prisons.

The rate of sustained viral response (SVR) was 52.1 % by ITT and 76.9 % by observed treatment (OT). SVR was higher among patients with genotype 2 or 3, and those with low baseline HCV-RNA. We did not observe any differences between individuals with and without PD in term of SVR, HCV genotype or HIV infection.

Conclusions

Our results support the safety and clinical effectiveness of the treatment of chronic HCV infection in correctional facilities, both in prisoners with PD and those without. Our data support non-discrimination between patients with and without PD when offering treatment for HCV infection to prison inmates.

Trial registration

Trial registration number (TRN) NCT01900886. Date of registration: July 8, 2013

Sofosbuvir-based treatment regimens for chronic, genotype 1 hepatitis C virus infection in U.S. incarcerated populations: a cost-effectiveness analysis

BACKGROUND

Prevalence of chronic hepatitis C virus (HCV) infection is high among incarcerated persons in the United States. New, short-duration, high-efficacy therapies may expand treatment eligibility in this population.

OBJECTIVE

To assess the cost-effectiveness of sofosbuvir for HCV treatment in incarcerated populations.

DESIGN

Markov model.

DATA SOURCES

Published literature and expert opinion.

TARGET POPULATION

Treatment-naive men with chronic, genotype 1 HCV monoinfection.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

No treatment, 2-drug therapy (pegylated interferon and ribavirin), or 3-drug therapy with either boceprevir or sofosbuvir. For inmates with short remaining sentences (<1.5 years), only no treatment or sofosbuvir 3-drug therapy was feasible; for those with long sentences (≥1.5 years; mean, 10 years), all strategies were considered. After release, eligible persons could receive sofosbuvir 3-drug therapy.

OUTCOME MEASURES

Discounted costs (in 2013 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

The strategies yielded 13.12, 13.57, 14.43, and 15.18 QALYs, respectively, for persons with long sentences. Sofosbuvir produced the largest absolute reductions in decompensated cirrhosis (16%) and hepatocellular carcinoma (9%), resulting in 2.1 additional QALYs at an added cost exceeding $54,000 compared with no treatment. For persons with short sentences, sofosbuvir cost $25,700 per QALY gained compared with no treatment; for those with long sentences, it dominated other treatments, costing $28,800 per QALY gained compared with no treatment.

RESULTS OF SENSITIVITY ANALYSIS

High reinfection rates in prison attenuated cost-effectiveness for persons with long sentences.

LIMITATIONS

Data on sofosbuvir's long-term effectiveness and price are limited. The analysis did not consider women, Hispanic persons, or patients co-infected with HIV or hepatitis B virus.

CONCLUSION

Sofosbuvir-based treatment is cost-effective for incarcerated persons, but affordability is an important consideration.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Multicenter study on the discontinuation and efficacy of chronic hepatitis C treatment in the Spanish penitentiary population (EPIBAND study)

OBJECTIVE

Imprisonment entails a golden opportunity for chronic hepatitis C treatment, as treatment adherence can easily be achieved in this setting. The objective of this study was to determine the proportion and causes of discontinuation of chronic hepatitis C therapy among the Spanish penitentiary population.

METHODS

This is an observational, prospective multicenter study performed in 26 Spanish penitentiaries between October 2007 and December 2009. Patients with chronic hepatitis C who were undergoing treatment with pegylated interferon plus ribavirin in accordance with clinical practice were included. The primary variable in the study was the proportion of discontinuation of treatment for chronic hepatitis C.

RESULTS

A total of 431 patients were included in this analysis (92.3% male; mean age, 37.9±6.3 years; 66.4% with high viral load; genotype 1, 51.0%; genotype 3, 35.7%; genotype 4, 11.8%; genotype 2, 1.4%; coinfected with HIV, 24.4%). The proportion of treatment discontinuation for chronic hepatitis C was 22.5% (n=97; 95% confidence interval: 18.65-26.75). Therapy discontinuation was more frequent during the first trimester of treatment (n=45; 46.4%), and release from prison was the most frequent cause for treatment discontinuation (n=35; 36.1% of discontinuations). Among 407 patients included in the efficacy analysis, sustained viral response was achieved in 52.1% (95% confidence interval: 47.12-57.02).

CONCLUSION

Treatment discontinuation for chronic hepatitis C in the penitentiary setting is low. However, further efforts should be made to improve the coordination between penitentiary institutions and external centers to ensure treatment after the inmates are released or transferred to other prisons.

The "hidden" epidemic: a snapshot of Moroccan intravenous drug users

Background

Hepatitis C virus is a persistent epidemiological problem, with an estimated 170 million individuals infected worldwide, and the leading cause of asymptomatic chronic infection, liver cirrhosis and hepatocellular carcinoma. Injection drug users (IDUs) have the highest seroprevalence as compared to chronic hemodialysis and transfusion patients, and this cohort remains the most under-studied high-risk group in North Africa to date. This study first sought to characterize the demographic, epidemiological, and genotypic profile of a total sample size of 211 chronically-infected IDUs living in the Tangier region of Northern Morocco, and secondly to contrast this to other chronically-infected patients, in order to uncover possible discrepancies.

Results

The general ‘profile’ of local IDUs marks a stark contrast to chronically-infected HCV Moroccan patients, other African countries, and neighboring European countries. The majority of Moroccan drug users were found to be middle-aged and celibate. A relatively high seroprevalence was found among drug users (60%), and this increased with age. The majority of drug users shared their needles and this hold implications for transmission, as seropositive status was significantly different between those users that shared vs. those that did not share their needles. In addition, IDUs exhibited genotypes 1a and 3a predominantly, as compared to the predominant 1b and 2a/2c genotypes found in chronically HCV-infected patients. The IDU genotypic profile closely matches the one in other European countries (Portugal, Spain, France, and Italy), which are invariably speculated as the potential source of currently-circulating genotypes in Moroccan IDUs.

Conclusion

These findings have implications for disease prevention, transmission and treatment, as this distinct IDU subgroup cannot be collectively pooled along with other HCV-positive high-risk groups. Local government, practitioners, and health institutions should take this into account when treating, prescribing antiviral therapy, and designing preventative public health campaigns.

HCV infected prisoners: should they be still considered a difficult to treat population?

Background

The prevalence of chronic hepatitis C virus (HCV) infection in the Italian correctional population is estimated to be around 38%. In this setting HCV infection treatment is controversial because of several factors such as active drug substance abuse, psychiatric illness, length of treatment, risk of re-infection, poor adherence and low success rate.

Methods

A retrospective data review of 159 inmates, positive for anti-Hepatitis C virus (HCV) antibody, evaluated to National Institute for Infectious Diseases “L. Spallanzani” (INMI) from January 2006 to December 2009, was conducted to evaluate rate of completion (feasibility) and outcome efficacy of chronic Hepatitis C Virus (HCV) infection treatment with Pegylated Interferon and Ribavirin in five correctional facilities in Rome.

Results

Of the 159 inmates evaluated in the study period, 50, all male (median age 39 years) were treated. Twenty patients (40%) did not complete treatment: 15 showed no response and therapy was stopped, 5 patients (10%) interrupted treatment because of adverse reactions. The global feasibility was 60%. The overall sustained virologic response (SVR) was 50% (32% for genotype 1 and 68% for genotype other than 1). The main predictors of SVR at the Multivariable Logistic Regression Odds Ratio (MLR-OR) were a better pretreatment histological diagnosis (absence of bridging fibrosis or cirrhosis [MLR-OR 11.85; 95% CI 1.96-71.62) and a HCV genotype other than 1 (MLR-OR 5.87; 95% CI 1.49-23.17).

Conclusions

Chronic HCV infection treatment in correctional facilities is feasible and effective and should be strongly recommended, in combination with preventive measures, in appropriately screened patients because it represents an important opportunity to treat a population with a high prevalence of chronic HCV infection among whom treatment options post incarceration may be limited.