Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review

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.

Prevalence of blood-borne virus infections and uptake of hepatitis C testing and treatment in Australian prisons: the AusHep study

Background

Incarcerated people are at high risk of blood-borne virus infections, particularly HCV, and a priority population for elimination efforts. This national bio-behavioural survey evaluated blood-borne virus prevalence and HCV testing-and-treatment uptake amongst people in Australian prisons.

Methods

Randomly-selected participants from 23 representative prisons nationally were offered point-of-care testing for HIV and HCV (anti-HCV) antibodies, hepatitis B surface antigen (HBsAg), and HCV RNA (if anti-HCV positive). Demographic data and previous HCV testing and treatment were collected by structured interview.

Findings

1599 individuals participated (98% participation; 89%male; median age 35 years; 49% ever injected drugs). Prevalence estimates were: 31.7% (95% CI:28.8-34.8) for anti-HCV; 8.0%for HCV RNA (95% CI:6.4-9.9); 0.5% (95% CI:0.2-1.1) for HBsAg, and 0.8% (95% CI: 0.4-1.7) for HIV antibody. Among participants who had ever injected drugs (n = 787), HCV RNA prevalence was highest among those injecting and sharing needles/syringes within the past month [27.9%; adjusted odds ratio (aOR):4.54 (95% CI:2.65-7.77). Among participants (n = 1599), 70.4% (95% CI: 67.4-73.2) had ever been tested for HCV (62.6% in prison). The highest likelihood of having had HCV testing was observed among participants who injected drugs in the past month (aOR = 10.37, 95% CI:5.72-0.18.78). Among those eligible (n = 318), 84.6% (95% CI:79.2-88.7) had ever received HCV treatment (75.0% in prison), and 67.8% (95% CI:61.7-73.4) were cured. The likelihood of HCV treatment was higher among those previously imprisoned, (aOR = 2.67, 95% CI:1.20-5.93).

Interpretation

Despite high overall HCV testing and treatment uptake, the lower uptake and substantial ongoing HCV disease burden in some sub-populations highlights the need for continued prison-based elimination efforts with population-specific interventions.

Funding

The AusHep study was funded by the Australian GovernmentDepartment of Health and Aged Care.

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France

BACKGROUND

Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria.

METHODS

A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021.

RESULTS

Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR.

CONCLUSION

Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term.

PRACTICAL IMPLICATIONS

Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

HIV testing in jails: Comparing strategies to maximize engagement in HIV treatment and prevention

Despite 15,000 people enter US jails yearly with undiagnosed HIV infection, routine HIV testing is not standard. Maximizing the yield and speed of HIV testing in short-term detention facilities could promote rapid entry or re-entry of people living with HIV (PLWH) into care. The goal of this study was to evaluate the impact of third generation, rapid point-of-care (rPOC) vs. fourth generation, laboratory-based antigen/antibody (LBAg/Ab) testing on the HIV care cascade in a large urban jail during a planned transition. We used aggregate historical data to compare rPOC testing and LBAg/Ab testing in the D.C. Department of Corrections. We examined two time periods, January to August 2019 when rPOC testing was performed, and October 2019 to January 2020 after LBAg/Ab testing began. We calculated monthly rates of HIV tests performed, HIV test results received, HIV test results received among those tested, antiretroviral therapy (ART) initiation, and proportion of PLWH receiving discharge planning prior to release. We then conducted an interrupted time series analysis to assess the differences between testing periods. There were 14,237 entrants during the first time period and 7,569 entrants during the second. Transitioning from rPOC to LBAg/Ab testing increased the rate of test uptake by 38.5% (95% CI: 14.0, 68.3), decreased the rate of test results received among those tested by 13.1% (95% CI: -14.0, -12.1), and increased the combined rate of HIV tests performed and results received by 20.4% (95% CI: 1.5, 42.8). Although the rate of HIV testing was greater under LBAg/Ab, PLWH received results immediately through rPOC testing, which is critically important in short-stay enviroments. Increasing rPOC uptake would increase its value and combined testing may maximize the detection of HIV and receipt of results among persons passing through jails.

Reducing barriers to the hepatitis C care cascade in prison via point-of-care RNA testing: a qualitative exploration of men in prison using an integrated framework

BACKGROUND AND AIMS

Hepatitis C virus (HCV) is highly prevalent within the prison setting. Although HCV testing and treatment are available within prisons, system barriers can impede progress along the HCV care cascade for those who are incarcerated. The PIVOT intervention used a 'one-stop-shop' model (i.e. point-of-care HCV RNA testing, Fibroscan-based liver disease assessment and treatment) at a reception prison in New South Wales, Australia. This analysis sought to understand the role of point-of-care HCV RNA testing at intake in reducing barriers to the HCV care cascade within the male prison setting.

DESIGN AND SETTING

Qualitative analysis using semi-structured interviews in a reception prison in Australia.

PARTICIPANTS

Twenty-four men enrolled in the PIVOT study; all participants had undergone HCV point-of-care testing in the intervention arm.

MEASUREMENTS

Høj's Integrated Framework informed this analysis.

FINDINGS

Participants widely expressed the view that point-of-care HCV RNA testing on entry was beneficial for care engagement. Point-of-care testing was perceived as timely (compared with standard pathology) and reduced opportunities for adjudication by correctional officers due to fewer clinic visits for testing and results. Adoption of routine opt-out testing at prison intake was regarded as an important strategy for normalising HCV testing (and likely to increase pathways to treatment uptake) and fostered patient candidacy (i.e. self-perceived eligibility to access care).

CONCLUSION

Twenty-four men in prison in New South Wales, Australia, who underwent opt-out point-of-care HCV RNA testing on entry into prison, widely supported the programme as a means of overcoming barriers to HCV testing and treatment in the prison setting, as well as providing public health benefits through early detection of HCV infection among people entering into custody.

"To Be Honest, You Probably Would Have to Read It 50 Times": Stakeholders Views on Using the Opt-Out Approach for Vaccination in Jails

Background

Despite national guidelines on infectious disease testing and vaccination in prisons, there is heterogeneity on the implementation of these practices in jails. We sought to better understand perspectives on the implementation of opt-out vaccination for infectious diseases in jails by interviewing a broad group of stakeholders involved in infectious diseases vaccination, testing, and treatment in Massachusetts jails.

Methods

The research team conducted semistructured interviews with people incarcerated in Hampden County Jail (Ludlow, Massachusetts), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between July 2021 and March 2022.

Results

Forty-eight people were interviewed, including 13 people incarcerated at the time of interview. Themes that emerged included the following: misunderstandings of what opt-out means, indifference to the way vaccines are offered, belief that using the opt-out approach will increase the number of individuals who receive vaccination, and that opt-out provides an easy way for vaccine rejection and reluctance to accept vaccination.

Conclusions

There was a clear divide in stakeholders' support of the opt-out approach, which was more universally supported by those who work outside of jails compared to those who work within or are incarcerated in jails. Compiling the perspectives of stakeholders inside and outside of jail settings on the opt-out approach to vaccination is the first step to develop feasible and effective strategies for implementing new health policies in jail settings.

A Cross-Sectional, Retrospective Evaluation of Opt-Out Sexually Transmitted Infection Screening at Admission in a Short-Term Correctional Facility in Alberta, Canada

Incarcerated populations experience higher rates of sexually transmitted infections (STIs) than the general population, alongside inconsistent testing strategies. In response, universal opt-out STIs (chlamydia, gonorrhea, syphilis, and HIV) screening was implemented at admission in a short-term correctional facility in Alberta, Canada, for individuals ≤35 years. A cross-sectional, retrospective evaluation of testing outcomes between March 2018 and February 2020 was completed. Descriptive statistics were used to stratify STIs by gender, age group, and date for univariate analysis. Despite low uptake (31.2%), opt-out screening resulted in high positivity rates (14.9%, 10.8%, 29.5%, and 0.3%, respectively) and treatment completion (93.7%) while capturing a high proportion (52.6%) of asymptomatic cases. Opt-out screening at admission is feasible and can improve STI testing in high-risk individuals experiencing incarceration in Canada.

Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis

BACKGROUND

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).

METHODS

We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.

RESULTS

Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).

CONCLUSION

Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

Factors influencing decisions about whether to participate in health research by people of diverse ethnic and cultural backgrounds: a realist review

OBJECTIVE

To develop and refine a programme theory that explains factors that influence decisions to take part in health research by people of diverse ethnic and cultural backgrounds.

DESIGN

Realist review following a sequence of five steps: (a) scoping search and identification of programme theory; (b) evidence searching; (c) critical appraisal and data extraction; (d) organisation of evidence and (e) refinement of programme theory.

ELIGIBILITY CRITERIA

Documents (including peer-reviewed articles, grey literature, websites, reports and conference papers) either full text, or a section of relevance to the overarching research question were included.

DATA SOURCES

EMBASE, Medline, Web of Science, Psych Info, Google and Google Scholar were searched iteratively between May and August 2020. Search strategy was refined for each database providing a broad enough review for building of programme theory.

ANALYSIS

Data from eligible documents was extracted to build understanding of the factors that influence decision-making. Data were mapped to create a data matrix according to context (C), mechanism (M), outcome (O), configurations (C) (CMOCs) for the process of informed consent, to aid interpretation and produce final programme theory.

RESULTS

566 documents were screened and 71 included. Final programme theory was underpinned by CMOCs on processes influencing decisions to take part in research. Key findings indicate the type of infrastructure required, for example, resources, services and policies, to support inclusion in health research, with a greater need to increase the social presence of researchers within communities, improve cultural competency of individuals and organisations, reduce the complexity of participant information, and provide additional resources to support adaptive processes and shared decision making.

CONCLUSION

The review indicates the need for a more inclusive research infrastructure that facilitates diverse participation in health research through incorporating adaptive processes that support shared decision making within the informed consent process and in the conduct of research projects.

Prevalence and Management of Sexually Transmitted Infections in Correctional Settings: A Systematic Review

Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions-managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)-can counteract structural racism in healthcare.

An opt-out approach to hepatitis C virus testing in English prisons: the literature underpinning the policy

BACKGROUND

The World Health Organization's aim to eliminate hepatitis C virus (HCV) infection as a public health threat by 2030 is dependent on testing people. HCV prevalence is higher in prisons, so to increase test uptake an 'opt-out' approach to blood-borne virus testing in English and Welsh prisons was introduced.

AIMS

This literature review examines the evidence behind the introduction of this public health policy.

METHODS

Four healthcare databases were searched for publications between January 2000 and February 2020 on the opt-out approach to blood-borne virus testing in prisons.

FINDINGS

Sixteen studies published between 2009 and 2019 were included. Analysis of their findings showed that an increase in HCV test uptake in prisons occurs when an opt-out approach is used in combination with additional interventions. Contextual differences between UK and US prisons may affect HCV test uptake.

CONCLUSION

An opt-out approach to HCV testing in prisons can increase test uptake as part of a complex of interventions.

Becoming posthuman: hepatitis C, the race to elimination and the politics of remaking the subject

Hepatitis C has long been a public health problem in Australia. 'Revolutionary' new drugs with the potential to cure hepatitis C have now emerged. The Australian government has invested heavily in them, and has an ambitious goal to eliminate hepatitis C by 2030. Numerous shifts in policy and practice are required if the elimination agenda is to be realised. This paper explores the significance of these shifts. We ask: what is the race to elimination doing with the subject? We argue that the race to elimination can be understood, simultaneously, as a product of posthuman forces, capable of being analysed using the theoretical tools made available via the posthuman turn; producing an intervention in what it means to be human; and generating a dilemma for people who use (or used) drugs, people with hepatitis C, and posthuman scholarship. In drawing out these issues, we aim to: trace the significant developments underway in hepatitis C medicine and raise awareness of them; encourage reflection on the consequences of these developments; and invite reflections on what might be lost when the human is remade by hepatitis C medicine.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BACKGROUND

Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.

AIM

To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.

DESIGN & SETTING

Realist review in general practice settings.

METHOD

A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.

RESULTS

Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.

CONCLUSIONS

The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

Hepatitis B virus infection in EU/EEA and United Kingdom prisons: a descriptive analysis

People in prison are disproportionately affected by viral hepatitis. To examine the current epidemiology of and responses targeting hepatitis B virus (HBV) in prisons across the European Union, European Economic Area and United Kingdom, we analysed HBV-specific data from the World Health Organization's Health in Prisons European Database and the European Centre for Disease Prevention and Control's hepatitis B prevalence database. Hepatitis B surface antigen seroprevalence ranged from 0% in a maximum-security prison in United Kingdom to 25.2% in two Bulgarian juvenile detention centres. Universal HBV screening on opt-out basis and vaccination were reported available in 31% and 85% of 25 countries, respectively. Disinfectants, condoms and lubricants were offered free of charge in all prisons in the country by 26%, 46% and 15% of 26 countries, respectively. In 38% of reporting countries, unsupervised partner visits with the possibility for sexual intercourse was available in all prisons. The findings are suggestive of high HBV prevalence amidst suboptimal coverage of interventions in prisons. A harmonised monitoring system and robust data at national and regional levels are needed to better understand the HBV situation in prisons within the framework of the European action plan and Global Health Sector Strategy on viral hepatitis.

Using dried blood spot testing for diagnosing viral hepatitis

The target set by the World Health Organization to eliminate viral hepatitis as a public health problem by 2030 first requires methods of testing for hepatitis B and C virus that are acceptable to diverse populations. One such test is the dried blood spot sample method. This article explains what a dried blood spot sample is, how it is collected, and how it can help increase the viral hepatitis test uptake in prisons, drug and alcohol services, and other populations at risk of hepatitis B or C infection.

Detection, stratification and treatment of hepatitis C-positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

The United Kingdom is committed to eliminating hepatitis C virus (HCV) infection by 2025. The prison estate provides an opportunity to identify and treat HCV-positive individuals in a high-prevalence environment. We designed and implemented a pathway of care within a London prison to diagnose, stratify and link HCV-positive prisoners into care. This study was a two-phase case study of a HCV care pathway. New arrivals to the prison were offered blood-borne virus screening with dried blood spot testing at their secondary health check. Those with active infection completed disease stratification tests and were reviewed at a weekly hospital-based multidisciplinary team meeting to determine management. In Phase-2, the pathway was redesigned to improve testing and the referral of HCV-positive prisoners into treatment. Over the 30-month evaluation period, 12,946 people were received in the prison. During Phase-1, 19.6% of new arrivals completed blood-borne virus testing, with 7.3% identified as HCV-positive. Just 8.3% of HCV-positive individuals were treated or referred for treatment in Phase-1. During Phase-2, 30% of new receptions completed BBV testing and 3.9% were identified as HCV-positive. Linkage into care was improved, with 38.9% treated or referred during the second phase. Poor access to testing and referral to treatment limit the effectiveness of care provision for prisoners with HCV. Elimination of HCV in prisons requires local service configuration to ensure high uptake of testing, with all HCV-positive cases then offered treatment during custody or referral on to treatment after release.

Opt-out Testing Pilot for Sexually Transmitted Infections Among Immigrant Detainees at 2 Immigration and Customs Enforcement Health Service Corps-Staffed Detention Facilities, 2018

OBJECTIVES

Correctional settings (prisons, jails, detention facilities) provide a unique opportunity to screen for sexually transmitted infections (STIs) among correctional populations with a high prevalence of infection. Immigrant detainees are a distinct and poorly described correctional population. The main objective of this study was to determine the feasibility of a national STI screening program for immigrant detainees.

METHODS AND MATERIALS

We developed an opt-out STI testing program that included electronic health record integration, patient education, and staff member training. We piloted this program from June 22 through August 19, 2018, at 2 detention facilities with different operational requirements and detainee demographic characteristics. We assessed STI test positivity rates, treatment outcomes, estimated cost to conduct testing and counseling, and staff member perceptions of program value and challenges to implementation.

RESULTS

Of 1041 immigrant detainees approached for testing, 526 (50.5%) declined. Of 494 detainees who were tested, 42 (8.5%) tested positive for at least 1 STI; the percentage positivity rates were 6.7% (n = 33) for chlamydia, 0.8% (n = 4) for syphilis, 0.8% (n = 4) for gonorrhea, 0.6% (n = 3) for hepatitis B, and 0.2% (n = 1) for HIV. The estimated cost to detect any STI ranged from $500 to $961; the estimated cost to identify 1 person infected with HIV ranged from $22 497 to $43 244. Forty of 42 persons who tested positive began treatment before release from custody. Medical staff members had positive views of the program but had concerns about workload.

PRACTICE IMPLICATIONS

STIs are prevalent among immigrant detainees. A routine screening program is feasible if operational aspects are carefully considered and would provide counseling, education, and treatment for this vulnerable population.