Why is viral hepatitis elimination important in prison?

Prisons provide an important setting for the prevention of hepatitis B and C and for the opportunity to test and treat a large number of individuals at high risk of being infected, who may not access mainstream health services in the community.

Effective evidence-based measures are available including therapies for lifelong management of hepatitis B, hepatitis C treatment and measures for the prevention of blood-borne infections including harm reduction interventions and vaccination against HBV (ECDC/EMCDDA, 2023).

While this setting provides an important opportunity for service provision for many people who otherwise won’t access treatment or seek help from healthcare services, multiple challenges to healthcare implementation in the prison sector present barriers to people living in prison reliably accessing hepatitis testing, treatment, and prevention measures.

There is evidence to support the effective implementation of viral hepatitis interventions in prison settings (Vroling H, 2018; ECDC, 2018). Such programmes typically involve opt-out testing programmes, early access to effective antiviral treatments, harm reduction strategies, HBV vaccination programmes and linkage to care post release.

Studies and pilot programs from various countries in Europe have demonstrated the feasibility and effectiveness of such initiatives (Cuadrado A, 2021; Jones AM, 2022). Indeed, evidence related to prevention measures shows that in prison settings, condoms may promote safer sex, OAT reduces illicit opioid use and risks related to equipment sharing, and the provision of sterile drug injection equipment is possible and in combination with other measures can help reduce blood-borne virus transmission (ECDC/EMCDDA, 2018).

Evidence around vaccination in prisons is limited but suggests that the provision of HBV vaccination using accelerated schedules may result in higher vaccination completion rates in prison settings (Stasi C, 2019).

Further information around the different vaccine schedules and the protection provided can be found in the factsheet: HBV vaccination. In relation to testing and treatment, evidence shows that pro-active provision of blood-borne viruses testing leads to high uptake and that treatment is feasible and effective in prison (ECDC/EMCDDA, 2018).

Most importantly, the scaling up of prevention and control programmes has shown substantial reductions in the incidence of viral hepatitis within prison populations, in certain cases achieving micro-elimination goals in prisons, as well as having a broader impact on the community burden of disease.

Indeed, the STOP-C study conducted in four prisons in New South Wales, Australia, is one example where a major scale up of hepatitis C testing and treatment was associated with reduced HCV incidence among people in prison (Hajarizadeh B, 2021).

In 2017, the European Association for the Study of the Liver’s International Liver Foundation advocated for a micro-elimination approach to help overcome the often-overwhelming challenges of achieving HCV elimination at the national level, by breaking down national elimination goals into smaller goals for specific population groups to enable interventions to be delivered more efficiently using targeted measures (Lazarus J, 2018).

Micro-elimination is focused around scaling up interventions to help eliminate hepatitis in defined segments of the population or in specific settings, which when brought together can comprise an effective strategy to incrementally achieve national elimination (CATIE, 2019).

Given the disproportionate prevalence of viral hepatitis in prisons, and that prisons can provide controlled environments able to facilitate the effective provision of prevention and control services, including harm reduction, testing and antiviral treatment, prisons are a promising setting for micro-elimination.

Several observational studies have demonstrated successful micro-elimination programs, including the El Dueso prison in Cantabria, Spain. El Dueso virtually eliminated hepatitis C through a comprehensive ‘test and treat’ program and through the provision of harm reduction services including NSP and OAT.

Those with stays for more than 30 days were offered treatment for hepatitis C through directly observed therapy (DOT). In the space of 14 months between 2016 and 2017, 99.5% of people in the prison agreed to be screened.

As a result of this program, the incidence of new hepatitis C infections decreased from 1.7 per 100 person-years to 0 per 100 person-years (Cuadrado A, 2018). There were no cases of HCV reinfection during follow-up, demonstrating the potential for micro-elimination in prison settings across Europe.