Management of Hepatitis C in the Prison Setting

1
Management of Hepatitis C in the Prison Setting

• Nat Wright Clinical Director HMP Leeds, GP
  advisor UK Department of Health Offender Health
  Unit
• Journal of Prisoner Health Conference Varna,
  Bulgaria, 2007

2
Hepatitis C

• Global health problem mean over 50 (range
  30-98) prevalence amongst IDUs infected despite
  low HIV prevalence.
• 3 (170 million) of worlds population infected
  (cf 40 million infected with HIV)
• Incidence 11-29 per 100 person years
• Up to 20 can clear the virus
• Chronic infection significant morbidity and
  mortality
• 6 genotypes 1,2,3 more common in Western Europe
• Nationally rates higher in inner city areas
  (partic London and the North West).
• UK 0.5 population infected (cf 1.8 USA and 1
  France)

3
Morbidity

• Certified cause of death in 100 people each year
• Contributes to 5000 deaths each year from
  complications of chronic liver disease (including
  cirrhosis and primary liver cancer)
• Substantial burden on the NHS in UK cause of
  15 of chronic liver transplants
• Antiretroviral treatments drug costs of 12,000
  per year per patient
• In community benefit of methadone maintenance for
  primary prevention marginal, though added health
  gain when consider HIV risk reduction

4

• Should everyone in the prison with a history of
  injecting drug use be offered screening, and
  treatment if diagnosed positive or should
  healthcare be more targeted?

5
Prison Issues

• Large throughput on short sentences presents
  problems with screening all IDUs in remand
  prisons
• Antiviral treatment typically 6 months (range
  3-12)
• For those on longer sentences prison ideal place
  for screening and treatment
• Case less convincing for those on shorter
  sentences unless patient specifically requests
  and is highly motivated

6
Stages of Grief associated with a positive
diagnosis

• Shock
• I was just stunned, I thought, you are telling
  me Ive got hepatitis C and you just say it like
  you were saying hello to me and he just walked
  away.
• (John, 48)
• Denial
• Well I was devastated to be honest with you and
  I didnt believe it. I wanted them to check it
  and they did and it came back the same.
• (Steve, 31)

7

• Anger
• When he actually told me I just said, No.
  Finished. And I turned round to (accompanying
  person) and I said, Deal with this, Im out, I
  have to get out of here. And I just walked out.
  I was so angry.
• (Harry, 49)
• Depression
• Its not every day you wake up feeling like
  that, Its just every so often. Its just when
  your body feels like doing it. You just cant get
  nowhere, you cant motivate yourself or nothing.
  Everything you do is really hard to do.
• (Jimmy, 33)

8

• Resignation and Readjustment
• Im used to it now. Ive got used to it and it
  still doesnt bother me really. I just tend not
  to speak about it.
• Stigma and a diagnosis of exclusion
• They (hospital staff) said use the commode, they
  didnt say why and then I said, is it cos Ive
  got hep C? and they said yeah.
• (Sally, 24)
• He (dentist) claimed to not have the sterilising
  equipment that would be required in order to
  treat me and that hed have to refer me to a
  specialist.
• (Mike, 46)

9
Secondary Prevention

• PEG interferon-ribavirin dual antiviral therapy
  currently the most effective treatment at
  achieving a sustained virological response in
  those HCV-RNA positive.
• Such a response reduces the risk of developing
  chronic hepatic cirrhosis, or hepatocellular
  carcinoma.
• Dual therapy is also indicated in cases of
  co-infection providing HIV status (as indicated
  by CD4 count) is stable.
• In cases of low CD4 count treatment of HIV with
  highly active antiretroviral treatment is
  indicated before treatment of HCV with dual
  antiviral therapy.

10
Treatment Outcomes
11
In Conclusion

• Much can be done in the prison to address
  co-morbidity directly related to injecting drug
  use. Clear protocols can help target health care
  to maximise clinical and cost effectiveness