‘Behind closed doors, no one sees, no one knows’: hepatitis C, stigma and treatment-as-prevention in prison

Stigmatising space-times: Addressing healthcare stigma beyond interpersonal interactions

Stigma related to blood-borne viruses (BBVs) and sexually transmitted infections (STIs) has been shown to undermine the quality of healthcare. Given the pervasiveness and multiple manifestations of stigma within healthcare settings, recent research has argued that stigma should be addressed 'universally' i.e. for all stigmatising attributes and conditions, across all healthcare services. As part of the development of a universal approach to stigma, we analyse 20 interviews conducted with key stakeholders with expertise in BBVs, STIs and stigma in Australian healthcare settings. Inspired by research that addresses stigma as a biopolitical and spatial-temporal phenomenon, we examine how stigma weaves through relationships between people, time, space and technologies of healthcare provision. We begin with a discussion of funding structures and time constraints, followed by an examination of matters relating to the geographical location of the clinic and, finally, an analysis of smaller scale service environment space-times. In doing so, we bring attention to significant spatial-temporal matters that shape the production of stigma and address the need to balance universal concerns about healthcare quality with the specific forms of stigma that can emerge in relation to particular health issues and populations, such as BBVs and STIs. Overall, we examine how ambitious responses to stigma such as that proposed by the 'universal precautions' approach broaden our focus beyond interpersonal interactions and help draw attention to a wider range of objects, spaces and temporal dynamics that must be addressed in any effort to address stigma.

A Qualitative Systematic Review of Barriers and Facilitators to Hepatitis B and C Programmes in Prisons

The prevalence of viral hepatitis among people in prisons is higher than in the general population. Screening, treatment and vaccination programmes exist within prisons to reduce the incidence of hepatitis, although lower uptake has often been reported compared to similar programmes outside of prisons. We conducted a systematic review of qualitative evidence to explore the barriers and facilitators to hepatitis B and C reduction programmes in prisons from the perspectives of people in prison, custodial staff and prison healthcare staff. Comprehensive searches of five databases (to November 2023) yielded 28 studies for review inclusion. Four synthesised findings were identified: (i) accurate, up-to-date knowledge of viral hepatitis disease and treatment among people in prison and staff is a facilitator to programme uptake, particularly when imparted by a trusted source; (ii) personal subjective and relative views have a bearing on participation with the programme; (iii) social interactions and relationships both within the community of people in prison and between them and staff groups influence participation in the programmes; and (iv) the organisational structure of the prison and healthcare services within it affect programme participation. Based on these findings, we make recommendations for the adaptation of viral hepatitis programmes to individual custodial settings thereby improving equitable programme access and hepatitis B and C reduction in this complex environment.

COVID-19 and the biopolitics of stigma in public housing: dividing practices and community boundaries in pandemic times

The COVID-19 'hard lockdowns' in Melbourne, Australia in 2020 targeted public housing estates thus trading on perceptions of risk associated with public housing as some of the most stigmatised sites in post-industrial cities. This article draws on interviews with Melbourne public housing tenants on their experience of COVID-19 lockdowns to analyse the place of stigma in residents' accounts. Pairing Wacquant et al's (2014) concept of 'territorial stigma' with sociological work on the biopolitics of stigma we consider the dynamics of stigma, tracing how it functions to delimit community boundaries and justify pandemic containment measures. Residents navigate multiple layers of stigma, including stereotypes of public housing, normative judgements of neighbouring residents, and a broader public housing system riven with structural issues. Members of these communities are both the targets of stigma and seek to distance themselves from those seen as vectors of stigma. Our participants report mobilising social distancing strategies couched in normative assessments of perceived risk based on physical appearance, presumed drug use and past conduct. We explore the implications of these enactments of territorial stigma and trace the logics of abjection that construct public housing as deprived urban zones, home to abject 'Others' perceived as threatening the health of the community.

Development of an evidence-based hepatitis C education program to enhance public health literacy in the Australian prison sector: The Hepatitis in Prisons Education program (HepPEd)

BACKGROUND

Australia's prisons have a high chronic hepatitis C (HCV) prevalence (8 %). Antiviral therapies and prison-based hepatitis services are available, but only a minority of those eligible are being treated. Improving the HCV public health literacy of the prison sector via targeted education may overcome key barriers to scale-up treatment. This paper describes the: i) HCV public health literacy of the prison setting; ii) barriers and solutions for HCV education and service engagement; iii) HCV education program co-design and development processes; and iv) HepPEd resources.

METHODS

A national needs assessment was conducted to analyse the HCV public health literacy of the target audience groups in the prisons (healthcare providers; custodial officers; people in prison) to inform development of a prison-specific HCV education program (HepPEd). Structured interviews were conducted with key informants (n = 40). Three National Steering Committees, one for each target group, were convened to co-design and develop HepPEd.

RESULTS

Only healthcare providers involved with hepatitis care were considered to have 'good' to 'very good' HCV health literacy (including knowledge, attitudes, and capabilities), with all other groups considered less favourably. Key barriers identified included being time poor (healthcare providers), poor motivation (custodial officers) and stigma (people in prison). Peer education delivery was considered a key facilitator for custodial officers and people in prison. A suite of multi-modal resources addressing the perceived gaps in HCV health literacy was developed, with a broad theme of 'Let's talk about hep C'. Delivery of HepPEd was designed to overcome key barriers and utilise facilitators for each group.

CONCLUSIONS

Significant gaps in HCV health literacy were perceived amongst the target audience groups. The comprehensive co-design and development processes utilised in HepPEd suggest the program will be well-placed to improve the HCV public health literacy of the prison sector and thereby enhance HCV testing and treatment rates amongst people in prison.

A complex increase in hepatitis C virus in a correctional facility: bumps in the road

OBJECTIVE

The prevalence of hepatitis C virus (HCV) in correctional facilities in Australia among people who inject drugs is 60%, with disproportionate effects observed in Aboriginal and Torres Strait Islander people. Following the micro-elimination of HCV in a Queensland correctional facility (QCF), newly acquired cases began to increase in mid-2019. Here we discuss the public health response to increasing HCV in a QCF.

METHODS

Enhanced surveillance was performed to obtain contextual outbreak data on risk factors including injecting drug use, sharing of personal hygiene equipment and do-it-yourself-tattooing.

RESULTS

In the sixteen months, there were 250 notifications of new and re-infected HCV infections in prisoners in the QCF. Qualitative data revealed the leading factor in transmission to be injecting drug use.

CONCLUSIONS

Drivers for increased HCV transmission in correctional facilities include boredom, waiting lists for opioid substitution programs, changes in injecting behaviours and sharing of injecting paraphernalia. Point-of-care testing combined with education and the development of a needle and syringe program may be promising ways forward for managing HCV in correctional facilities.

IMPLICATIONS FOR PUBLIC HEALTH

Correctional facilities are key locations to target sexually transmitted infection (STI) and blood-borne virus (BBV) testing and treatment as well as health promotion to improve the health of inmates and the communities they return to.

Evaluating the Prevention Benefit of HCV Treatment: Modeling the SToP-C Treatment as Prevention Study in Prisons

BACKGROUND AND AIMS

Between 2014 and 2019, the SToP-C trial observed a halving in HCV incidence in four Australian prisons following scale-up of direct-acting antiviral (DAA) therapy. However, the contribution of HCV treatment to this decline is unclear because the study did not have a control group. We used modeling to consider this question.

APPROACH AND RESULTS

We parameterized and calibrated a dynamic model of HCV transmission in prisons to data from each SToP-C prison on incarceration dynamics, injecting drug use, HCV prevalence trends among prison entrants, baseline HCV incidence before treatment scale-up, and subsequent HCV treatment scale-up. The model projected the decrease in HCV incidence resulting from increases in HCV treatment and other effects. We assessed whether the model agreed better with observed reductions in HCV incidence overall and by prison if we included HCV treatment scale-up, and its prevention benefits, or did not. The model estimated how much of the observed decrease in HCV incidence was attributable to HCV treatment in prison. The model projected a decrease in HCV incidence of 48.5% (95% uncertainty interval [UI], 41.9-54.1) following treatment scale-up across the four prisons, agreeing with the observed HCV incidence decrease (47.6%; 95% CI, 23.4-64.2) from the SToP-C trial. Without any in-prison HCV treatment, the model indicated that incidence would have decreased by 7.2% (95% UI, -0.3 to 13.6). This suggests that 85.1% (95% UI, 72.6-100.6) of the observed halving in incidence was from HCV treatment scale-up, with the remainder from observed decreases in HCV prevalence among prison entrants (14.9%; 95% UI, -0.6 to 27.4).

CONCLUSIONS

Our results demonstrate the prevention benefits of scaling up HCV treatment in prison settings. Prison-based DAA scale-up should be an important component of HCV elimination strategies.

It is time for us all to embrace person-centred language for people in prison and people who were formerly in prison

The use of person-centred language is well accepted regarding substance use and infectious disease healthcare and research, and appropriate acronyms have become commonplace, e.g., "people who inject drugs (PWID)" has mostly replaced phrases like "injecting drugs users". However, the use of the term's 'prisoner' or 'prisoners' remains common. Although less common, terms such as 'offenders' and 'inmates' are also still used on occasion. This persists despite calls from people with lived experience of incarceration, and fellow academics, to stop using these terms. Given the considerable overlap between substance use, infectious diseases, and incarceration, in this commentary we discuss how they interact, including the stigma that is common to each. We propose that using person-centred language (i.e., people in prison or people formerly in prison) needs to become the default language used when presenting research related to people in prison or people formerly in prison. This is a much-needed step in efforts to overcome the continued stigma that people in prison face while incarcerated from prison officers and other employees, including healthcare providers. Likewise, overcoming stigma, including legalised discrimination, that follows people who were formerly in prison upon gaining their freedom is critical, as this impacts their health and related social determinants, including employment and housing.

Considering treatment-as-prevention scale-up for Australian prisons: a qualitative sub-study of expert stakeholders from the Australian 'surveillance and treatment of prisoners with hepatitis C' project (SToP-C)

Background

With direct-acting antivirals dramatically reshaping the public health response to the hepatitis C virus (HCV), prisons are set to play a critical role in elimination efforts. Despite the theoretical demonstration of HCV treatment-as-prevention in prison in mathematical modeling, limited empirical data exist. The Australian ‘Surveillance and Treatment of Prisoners with Hepatitis C’ project (SToP-C) is the world’s first trial of HCV treatment-as-prevention in prison. Drawing on interviews with HCV expert stakeholders, this paper explores the factors respondents identified as crucial to the success of future scale-up. Accounting for such perspectives matters because of the influence expert discourse has in shaping implementation.

Methods

Semi-structured interviews were conducted with nineteen HCV experts working across key policy, advocacy, research and clinical dimensions of the Australian HCV response. Data were coded using qualitative data management software (NVivo 11). Analysis proceeded via a hybrid deductive and inductive approach.

Results

Notwithstanding concerns regarding the lack of primary prevention in Australian prisons, stakeholders reported broad levels of support for the intervention and for the future scale-up of HCV treatment. A number of considerations, both external and internal to the prison system, were identified as key. The principal external factor was an enabling political-cum-policy environment; internal factors included: obtaining support from prisons’ executive and custodial staff; promoting health within a security-first institutional culture; allocating time for treatment within prisoners’ tightly regulated schedules; ensuring institutional stability during treatment given the routine movement of prisoners between prisons; prioritizing the availability of retreatment given the paucity of primary prevention; and securing sufficient clinical space for treatment.

Conclusion

The challenges to implementation are considerable, ranging from macrolevel concerns to in-prison logistical matters. Nonetheless, we argue that prisons remain an obvious setting for treatment scale-up, not only for prevention and potential elimination benefit, but for the treatment opportunities they afford a socially disadvantaged and underserved population. While noting widespread concerns among respondents regarding the paucity of primary prevention in Australian prisons, results indicate broad levels of support among expert stakeholders for HCV treatment scale-up in prison.