Understanding the policy framework
The capacity for implementation and scale up of viral hepatitis services, both in the community and in the prison setting, will be influenced by the political, economic and social context of the country and region.
This context may influence a variety of factors, such as local availability of antivirals for hepatitis B and hepatitis C, organisation of community and prison health services, local policies around harm reduction and other prevention measures (such as the vaccination of key populations), prescriber restrictions for antiviral medications and restrictions around who is eligible for hepatitis treatment, as well as the funding available for vaccines, testing or treatment.
A critical point in relation to the development of viral hepatitis services, is that whilst the financial costs of antiviral treatment still remain high in some countries, there is evidence from mathematical modelling that the prevention and treatment of viral hepatitis is cost-effective in Australian prisons (Kwon JA, 2021).
Prisons are unique settings for addressing the often fairly complex and multiple health needs of particularly key populations who often have poor access to health services in the community.
As these individuals move between the community and prison, efforts within the prison setting to address these health needs can result in a major benefit to the health of the wider community – this indirect benefit has been termed the ‘community dividend’ (UKHSA, 2015).
There is evidence that hepatitis B and C prevention and control interventions in prisons among countries in Europe are not fully implemented. Indeed, two studies from across EU/EEA countries reported a high burden of hepatitis B and C infections amidst suboptimal coverage of services including screening and harm reduction (Nakitanda AO, 2020; Nakitanda AO, 2021).
In 2023, a monitoring questionnaire disseminated by ECDC collected data related to the prevention and control of hepatitis B and C across EU/EEA countries including services in prisons and also collected data on the hepatitis C care cascade for people living in prison (see Section 4: Monitoring and Evaluation).
Data on access to treatment and prevention services for viral hepatitis in prison on the EU level are limited, but available policy data from the 30 responding countries indicated that only 19 countries reported the existence of an HBV testing policy or programme for people living in prison, and 21 for HCV (ECDC, 2024) (Figure 1).
Source: European Centre for Disease Prevention and Control. Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2022 data. Stockholm: ECDC; 2024.
Data collected by the EUDA indicate that, of the 27 EU Member States plus Norway and Türkiye, all countries reported that they offered testing for HCV or HBV in prison. However, the survey did not specify the modality of the offer (free, opt-out, etc.), and accessibility still varies across countries.
This highlights the importance of strengthening monitoring systems to validate the total number of people tested for viral hepatitis in prisons in order to better understand testing coverage among incarcerated persons across EU.
Of the 29 countries reporting to EUDA, 28 OAT continuation from community services to prison (only Slovakia does not have OAT continuity), 24 can initiate OAT in prison and 23 can continue OAT from prison to the community, only 14 have prison/community guidelines for OAT, seven offered take-home naloxone, and only three had established NSP service programmes (EMCDDA, 2022) (Figure 2).
In relation to other interventions targeted at the prevention of viral hepatitis in prisons, 20 countries reported HBV vaccination was available and 19 countries indicated that condoms were available.
These data refer to the official availability of those interventions, but no sufficient information is available on their coverage and their actual implementation, although efforts are on going in that direction.
Source: EMCDDA, 2022 (OAT: Opioid agonist treatment)