Summary Report: Management of Hepatitis C in Prisons Anne Spaulding MD CDC/ Division of Viral Hepatitis January 2003

Of All U.S. Patients with Hepatitis C, 39% Were Released From Prison and Jail (1997) Prevalence of hepatitis C in jails and prisons: 16 - 41%. Estelle v. Gamble: “deliberate indifference to serious medical needs.” Source: MMWR 2003 RR-1

Issues for Hepatitis C Management in Prisons Responsibility: most deaths after release. Cost-Effectiveness: How can we identify the patient who benefits from treatment? Capacity: would facilities be overwhelmed? Consistency: between different providers: protocol . driven care

Purpose of the Weekend Conference Translate 2002 NIH Consensus Panel Statement on Hepatitis C and the new MMWR on Corrections and Hepatitis into Practice. Review controversies and challenges: testing, counseling, and management. Describe ways to access community resources to improve continuity of care for hepatitis C patients.

Treatment Candidates, NIH Consensus Statements Condition 1997 2002 Normal ALT No No consensus Injection Drugs Alcohol Use 6 month sobriety before treatment Mild Disease Histologically Observe, biopsy every 3-5 years Individualize decision: Or treat if patient requests Compensated Cirrhosis Unclear if IFN prolongs life, delays HCC Can be treated, individualize decision HIV If stable Individualize decision IDU not absolute contraindication Abstinence before and during treatment

Hepatitis C and Injection Drug Use HCV therapy has been successful even when the patients are on daily methadone or have continued drug use. Prison is an environment of enforced sobriety, regimented lifestyle--an ideal time to treat? If you do not treat and complete on inside, will it be available on the outside?

Zero Sum for All Resources “A closed panel HMO with a fixed or declining budget.” --J. Curran, Dean, Emory School of Public Health

Prevention Recommendations Vaccinate all patients with chronic hepatitis C against hepatitis A. Vaccinate seronegative persons with risk factors for HBV against hepatitis B. Make drug and alcohol abuse treatment available to all patients who want and need it. Teach IDUs harm reduction. Incorporate both preventive measures and treatment in management of hepatitis C .

Prevention Strategies in Prisons Knowledge of inmate-patient’s status will enable incorporation of preventive measures. Supports proactive screening in high risk inmates? Not a legal requirement. “Good public health.” Likely to increase demand for treatment.

What Do You Need Now? “I did not even know our state had a hepatitis coordinator until I saw that map of coordinators and my state was highlighted. What we’re doing in prisons for hepatitis doesn’t make sense if we don’t carry it into the community.” State Department of Corrections Medical Director

Thank you

Easing the Exclusion Factors: Expands Potential Treatment Pool All Labs Nml Alcohol Drugs Abnormal ALT Rehabilitated

Easing the Exclusion Factors: Expands Potential Treatment Pool. Standardized definition of normal ALT: increase number of candidates. History of alcohol—57%1 History of injection drugs—76%1 Mild disease and compensated cirrhosis HIV co-infection: 80% HIV infected inmates HCV+2 References: 1. Allen, Spaulding et al. Annals of Int. Med. 2003 2. Rich, Chin-Hong. Lancet. 1997

Overview of Talk Background Purpose of the weekend conference For commissioners, medical directors, health administrators. What were priorities for prisons? What do attendees now need?

Will Liver Damage Progress in Inmates? Progression worse: Male Inmate population 93% male.1 Alcoholic State inmates: 40% history of binge drinking.2 Compromised immune system. Prison AIDS prevalence 4x higher than in community.3 References: 1. Sourcebook of Criminal Justice Statistics, Accessed 1/03 2. Bureau of Justice Statistics January 1999, NCJ 172871 3. Bureau of Justice Statistics October 2002, NCJ 196023