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)

Understanding Perceptions of Hepatitis C and Its Management Among People with Experience of Incarceration in Quebec, Canada: A Qualitative Study Guided by the Common Sense Self-Regulation Model

Hepatitis C virus (HCV) disproportionately affects certain sub-populations, including people with experience of incarceration (PWEI). Little is known about how perceptions of HCV and treatment have changed despite simplifications in testing and treatment in carceral settings. Nineteen semi-structured interviews were conducted with people living with or having a history of HCV infection released from Quebec provincial prison. Interviews were guided by the Common Sense Self-Regulation Model (CS-SRM) and aimed to explore cognitive and emotional representations of HCV and coping strategies. Among the 19 participants, seven (37%) were diagnosed with HCV in prison and 14 (74%) had previously received HCV treatment. Participants' HCV illness perceptions were influenced by fear (of HCV transmission, death, and the well-being of family) and stigma (related to HCV, injection drug use, and incarceration). While some sought education and social and professional support, others self-isolated or engaged in high-risk behaviors to cope. Despite advances in HCV treatment, PWEI continue to experience various forms of stigma and fear surrounding their HCV diagnosis, resulting in delayed HCV care. These findings provide insights into how prison-based healthcare providers can better utilize HCV illness perceptions to evaluate willingness to engage in HCV care among PWEI.

Hepatitis C treatment outcome among people in prison: The SToP-C study

BACKGROUND AND AIMS

Hepatitis C virus (HCV) burden is higher among people in prison given high prevalence of injecting drug use. This study evaluated direct-acting antiviral (DAA) treatment outcome in prisons.

METHODS

The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study enrolled individuals incarcerated in four Australian prisons (2017-2019). Participants with detectable HCV RNA were offered sofosbuvir-velpatasvir for 12 weeks. Sustained virological response (SVR) was assessed in intention-to-treat (ITT; participants commencing treatment and due for SVR assessment before study close) and per-protocol (PP; participants with documented treatment completion and SVR assessment) populations.

RESULTS

Among 799 participants with HCV, 324 (41%) commenced treatment (94% male; median age, 32 years; median duration of incarceration, 9 months). In ITT population (n = 310), 201 had documented treatment completion (65% [95% CI: 59-70]), and 137 achieved SVR (ITT-SVR: 44% [95% CI: 39-50]). In PP population (n = 143), 137 achieved SVR (PP-SVR: 96% [95% CI: 91-98]). Six participants had quantifiable HCV RNA at SVR assessment from treatment failure (n = 2) or reinfection (n = 4). Release or inter-prison transfer was common reasons for no documented treatment completion (n = 106/109 [97%]) and no SVR assessment (n = 57/58 [98%]). In ITT analysis, longer incarceration was associated with increased SVR (adjusted OR per month 1.03 [95% CI: 1.01-1.04]).

CONCLUSION

Among participants who completed DAA treatment and were assessed for SVR, treatment outcome was consistent with non-prison clinical studies. However, most individuals did not complete treatment or lacked study-documented treatment outcome due to release or transfer. Strategies to accommodate dynamic prisoner populations are required to ensure continuity of HCV care, including treatment completion and post-treatment care.

'I'm not hep C free': afterlives of hepatitis C in the era of cure

Since the advent of more effective, new-generation treatment for hepatitis C, immense resources have been devoted to delivering cure to as many people with the virus as possible. The scale-up of treatment aims to prevent liver disease, liver cancer and onward transmission of hepatitis C, but social research shows that people also approach treatment with its social promises in mind, including the hope that it might reduce or eradicate stigma from their lives. Such hopes reflect broader ideas about medical cure, which is seen as an end point to illness and its effects, and capable of restoring the self to a (previous) state of health and well-being. But what does cure mean among people for whom treatment does not produce an end to the social effects of a heavily stigmatised disease? While new treatments promise to eliminate hepatitis C, accounts of post-cure life suggest that hepatitis C can linger in various ways. This article draws on interviews with people who have undergone treatment with direct-acting antivirals (n=30) in Australia to explore the meanings they attach to cure and their experiences of post-cure life. We argue that dominant biomedical understandings of cure as an 'ending' and a 'restoration' can foreclose insight into the social and other effects of illness that linger after medical cure, and how individuals grapple with those afterlives. Drawing on recent conceptual re-framings of cure from medical anthropology and disability studies, we suggest that thinking at the limits of 'curative reason' helps to better address the afterlives of chronic illness. In the case of hepatitis C, reconceptualising cure could inform improved and less stigmatising ways of addressing people's post-cure needs. And in the era of hepatitis C elimination, such reconceptualisation is increasingly important as the cohort of people undergoing treatment and cure expands worldwide.