Treatment
For both chronic HBV and HCV infections, highly effective antiviral treatment exists that can reduce the progression to cirrhosis, the risk of hepatocellular carcinoma and liver-related deaths.
Although the incidence and prevalence of viral hepatitis in prisons is high and access to treatment generally limited, this is improving with several countries establishing dedicated test-and-treat programs.
Treatment for hepatitis C
Section titled “Treatment for hepatitis C”There have been many modelling studies exploring the impact of HCV treatment as prevention for people who inject drugs. These studies have found that even modest levels of antiviral treatment, especially with DAAs, could substantially reduce chronic HCV prevalence within the next 10 to 20 years (Vickerman P, 2010; Bennett H, 2015).
These modelling studies indicate potential prevention benefits in targeting treatment towards people who inject drugs in order to avert the greatest number of HCV infections (Trickey A, 2019). These studies show that the indirect impact of ‘treatment as prevention’ is greatest when risk of re-infection is low (i.e. when harm reduction coverage is good). The Surveillance and Treatment of Prisoners With Hepatitis C (SToP-C) study, conducted in four Australian prisons, demonstrated that scaling up HCV treatment was locally cost effective (Shih STF, 2024).
For HCV, the introduction of highly effective, short duration, direct acting antiviral (DAA) therapies has revolutionised the treatment of HCV, with cure rates of over 95%.
The short-course oral, curative DAA treatment regimen has few if any side-effects. DAAs can cure most persons with HCV infection, and treatment duration is short (usually eight to 12 weeks). These drugs can play an important role in disease control by reducing viral loads and onward transmission of infection.
However, despite the availability and high cure rates of DAA therapies, data in most countries in the EU on testing and treatment in prison remains scarce and of limited quality (EMCDDA, 2022).
EUDA and ECDC recommend offering antiviral treatment for people in prison who are diagnosed with chronic HCV infection in line with the guidelines applied in the community and meeting the same provision standards as in the community (ECDC/EMCDDA, 2018).
The European Association for the Study of the Liver (EASL) and WHO also recommend that HCV treatment should be offered to all incarcerated individuals with chronic HCV, with WHO highlighting the importance of continuity during inter- and intra-prison transfers and after release (EASL, 2020; WHO, 2022).
WHO recommend therapy with pan-genotypic DAAs for all adults, adolescents and children down to 3 years of age with new recommendations for pan-genotypic treatments issued in 2022 (WHO guidelines on the treatment of adolescents and children with chronic HCV).
The Global Guidelines for Viral Hepatitis Service Delivery in Prisons, support the prompt initiation of DAA therapy in prisons. Given short sentences and challenges associated with the movement of people in prison, the evaluation and initiation of DAAs should be done in the shortest time, within a single visit wherever this is possible (INHSU Prisons, 2024).
Recent guidance from ECDC and EMCDDA also recommended pan genotypic regimes that require no pre-treatment genotype testing in advance of starting therapy for populations such as people in prison where a streamlined care pathway is preferable (ECDC/EMCDDA, 2023).
Clinical pro-formas are available to support the implementation or scale up of treatment programmes in the prison setting.
The World Health Organization has developed a patient management card for chronic hepatitis B and C (see Annex 1). Others can be found in the resource list below and adapted for your setting.
It is important to note that the availability of different treatment regimens, and any restrictions or conditions related to their use, will differ between countries. Check your local, regional or national guidelines related to the treatment of hepatitis B and C in the planning stage of your implementation process (see Section 2: Strategy Development).
Simplified service delivery directly in prison is essential to improving access to testing and treatment, reducing delays, and enhancing cost-effectiveness. It also promotes treatment adherence, reduces stigma, and contributes to positive public health outcomes in the prison community and beyond.
Treatment for hepatitis B
Section titled “Treatment for hepatitis B”The guidance from EUDA and ECDC in relation to the prevention and control of hepatitis in prisons recommends offering antiviral treatment for those who are diagnosed with chronic HBV infection in line with the guidelines applied in the community and meeting the same provision standards as in the community (ECDC/EMCDDA, 2018).
The guidance recommends offering antiviral treatment for those who are diagnosed with chronic HBV infection and considered eligible for treatment as per local clinical recommendations.
WHO also recommends treatment for HBV, as part of their recommended package for people living in prisons and other closed settings, with continuity during inter- and intra-prison transfers and after release (WHO, 2022).
The main goal of antiviral treatment for chronic HBV infection is long-term suppression of the virus to minimise damage to the liver and the occurrence of liver failure, liver cirrhosis or liver cancer and to improve overall quality of life and survival.
Treatment is not indicated for all individuals with chronic HBV. People diagnosed with chronic HBV infection should be fully assessed for their risk of disease progression to determine whether or not antiviral treatment should be started.
This assessment consists of analysis of their liver function and viral load and the severity of their liver disease.
The long-term administration of a potent nucleos(t)ide analogue with high barrier to resistance, i.e., entecavir, tenofovir disoproxil or tenofovir alafenamide, represents the treatment of choice (EASL, 2017; EASL 2025).
Most people who start hepatitis B treatment must continue it for life and the medication should not be discontinued without medical assessment. EASL treatment guidelines indicate that the main goal of treatment of hepatitis B is to improve survival and quality of life by preventing disease progression, and consequently the development of hepatocellular carcinoma (EASL, 2017; EASL 2025).
All treated patients should be monitored for therapy response and adherence. Further guidance around treatment for hepatitis B can be found in the EASL guidelines (EASL, 2017; EASL 2025) and WHO guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection (WHO, 2024).
Challenges and solutions
Section titled “Challenges and solutions”| Challenge | Solution |
|---|---|
| Limited access to treatment: Availability and access to direct acting antiviral (DAA) medications for hepatitis C treatment or oral medications for hepatitis B, may be restricted in prison settings due to factors such as structural prison barriers. | Increase awareness on the importance of promoting prison health as public health intervention and implement common protocols for the provision of treatment in prison to facilitate access. |
| Specialised Healthcare Personnel Shortages: Prisons may face challenges in recruiting and retaining healthcare professionals with specialised training in hepatitis treatment, including hepatologists and infectious disease specialists. This shortage can hinder the delivery of high-quality care. | Training of other non-specialised healthcare staff including primary care physicians and nurses, or in-reach of specialist staff from the community should be considered to support treatment capacity. Task shifting between providers is also an option. Collaboration with government bodies is important to move towards the development of a stronger healthcare workforce in prisons. |
| Coordination with External Healthcare Providers: Coordinating treatment plans between prison healthcare providers and external specialists, such as those in community hospitals, can be intricate. | Establishing formal partnerships and communication protocols with external healthcare providers, including regular meetings, shared electronic health records, and collaborative care plans, can streamline coordination and ensure continuity of care for inmates transitioning between prison and community settings. |
| Harm Reduction Integration: Challenges may arise in implementing harm reduction initiatives, such as needle exchange programs and opioid agonist treatment, within the hepatitis treatment plans in the prison environment. | Integrating harm reduction strategies, particularly for individuals with substance use disorders, into hepatitis treatment plans is essential. Re-emphasize the importance of harm reduction to reduce re-infection and to increase treatment adherence. |
| Education and Training Needs: Providing ongoing education and training for both healthcare staff and people living in prison is crucial for successful treatment implementation. Overcoming challenges related to educational resources and strategies is essential for enhancing treatment adherence and outcomes. | Consider adapting the use of existing materials as well as the development of tailored educational materials and training programs specifically designed for prison healthcare providers, including online modules, workshops, and continuing education opportunities. |