As part of the Welsh Parliament’s 2019–2021 inquiry into the provision of health and social care in the adult prison estate, the Hepatitis C Trust submitted evidence on hepatitis C in prisons. This article considers the charity’s main recommendations around testing, training, and treatment, as well as what prisons are missing about preventing hepatitis C.
Wales is signed up to the World Health Organization’s target of eliminating hepatitis C by 2030, which represents a commitment to achieving a 90% reduction in new chronic hepatitis C infections and a 65% reduction in mortality. In few settings is this call to action more pertinent than in prisons, where undiagnosed and untreated hepatitis C is endemic, and illicit drug use occurs without the range of harm reduction resources that people can access in the community.
HMP Swansea was reported to be the first remand prison in the UK to have eliminated hepatitis C in 2019. As of 5 September that year, everyone in prison had either tested negative for the virus or were already in receipt of treatment. Much of this success was attributed to a rapid testing and treatment system pilot, which enabled people in prison to start treatment for their hepatitis C infection within a day of entering the prison system; prior to this, testing and treatment often took several weeks, and many were released before they had chance to start treatment.
The biggest barrier to eliminating hepatitis C in Wales in prisons, according to the Hepatitis C Trust, is identifying and treating those who have not yet been diagnosed. ‘Opt-out testing’ was introduced in Welsh prisons in 2016 – a policy which, if ideally implemented, would involve offering testing to everyone within 7 days of entering the prison, not just those who screen as high risk for blood-borne viruses, and continuously re-offering testing throughout their prison stay when appropriate. Increasing the uptake of testing via this method, combined with training staff to raise awareness of hepatitis C and creating structures to facilitate treatment for a mobile population, are said to be vital for identifying and treating those who have not yet been diagnosed.
Testing
Welsh prisons have been routinely testing for blood-borne viruses such as hepatitis C since 2010, and towards the end of 2016, introduced opt-out testing. This led to a considerable rise in people being tested on arrival at prison, from 8% in 2016 to 34% in 2020, but is still “a long way off what is needed to eliminate hepatitis C”. One of the issues is that while everyone in prison may have been offered testing, delivery has been inconsistent across the prison estate.
HMP Parc Bridgend has been using a new test which provides results on the same day, rather than sending samples off to be examined in a laboratory. This has been an important step towards using testing technology that is fit for purpose and appropriate for the setting. As the Hepatitis C Trust says, “what may work at a training prison where someone will spend an extended amount of time may not at a reception prison where someone may be in and out in five days”. If someone is offered testing but cannot be tested for several days or weeks, this may be too late to give them the opportunity to benefit.
Training
Anecdotal evidence suggests that many people who choose to opt out of testing do so on the grounds that they have been tested before and already know that they have hepatitis C. The Hepatitis C Trust recommends that, where this occurs, staff should explain that they may have only tested positive for hepatitis C antibodies, and they would need a further test to determine whether they naturally cleared the virus or still have an active infection.
Facts about hepatitis C
A positive test for hepatitis C antibodies indicates exposure to the hepatitis C virus at some point, but does not confirm a current infection.
A small proportion of those infected with hepatitis C will naturally clear the virus from their body in the first six months. Estimates from Public Health England, however, suggest that 3 in 4 people will develop a chronic infection.
Training for prison staff is important for them to be able to support people in prison to engage with screening for blood-borne viruses, and for staff themselves to know how to respond appropriately if people in prison decide to opt out of receiving a test.
One way to ensure all prison staff have sufficient training is to make it a compulsory part of their personal development plans. But, even with training, prison staff may see facilitating access to healthcare as just one of many competing priorities in their day-to-work (1 2 3), and something that ultimately comes second to ensuring the security of the prison.
For example, a study set in the Irish Prison Service found that staff responsible for delivering frontline services perceived their primary duty to be ensuring the safety of both staff and people in prison. Increased concerns about security, due to feuds between gangs and other rival factions, made prison officers’ jobs very difficult, and diverted them from other activities.
Treatment
Since 2015, direct-acting antivirals have been available for treating hepatitis C, which have a considerably shorter duration of treatment, markedly fewer side effects, and significantly higher success rates than previous treatments. However, people eligible for treatment would not necessarily know this, and may have reservations based on their knowledge or perceptions of older types of treatment. Involving peers in the delivery of healthcare may help to build trust in services, and dispel fear and stigma associated with hepatitis C treatment.
HMP Swansea achieved what many prison settings have struggled to do – they eliminated hepatitis C by detecting and treating current infections. Yet, as a remand prison, where the population tends to have a short stay before being moved to another custodial setting or being released back into the community, the story doesn’t end there. A challenge for many prisons is working with other agencies along the journeys of people in prison to provide continuity of care in the treatment of hepatitis C.
“This population present the particular challenge of being a mobile group, moving around within the prison estate and out of it, such as into homelessness services or substance misuse services. This can make it difficult to locate a prisoner to give them their test result or to continue treatment.” The Hepatitis C Trust
Medical teams at HMP Cardiff have been working closely with governors to ensure that those who test positive for hepatitis C are placed on ‘medical hold’, which should ensure that the person in prison is not moved to another prison during their treatment period, and if they are moved (even out of Wales), their medications should go with them.
The Hepatitis C Trust says that it is essential for a national structure to be put in place that would enable people to access treatment wherever they are, and make sure that on release from prison people are registered with a GP who can receive their medical records.
Prevention
Hepatitis C is spread through blood-to-blood contact, most commonly through people sharing injecting equipment. People who inject drugs in prison are particularly vulnerable because they do not have access to the same range of harm reduction advice and resources that are present in the community, and may be more likely to share injecting equipment.
Needle exchange programmes are a cornerstone of hepatitis C prevention, and exist in many countries where the underlying consumption of drugs is illegal. Yet few countries implement them in prisons. Across Europe, prison-based needle exchanges are only available in Spain, Germany and Luxembourg. In Luxembourg and Spain, the intervention is available in nearly all (95–100%) prisons. In Germany, there is a single programme in a women’s prison in Berlin, which makes this a very low-coverage intervention considering that there are 181 prisons in total.
In the short term, the gap in provision in Welsh prisons makes the other strands of hepatitis C elimination – testing and treatment – all the more important. But, in the long-term, the Hepatitis C Trust recommends that policymakers and prison authorities consider introducing needle exchange programmes in prisons.
CATIE, a source of information in Canada about HIV and hepatitis C, identified four models for implementing needle and syringe programmes in prison:
- Syringe dispensing machines (automated machines that dispense new syringes when a used syringe is inserted into the machine).
- Hand-to-hand distribution by prison healthcare staff.
- Hand-to-hand distribution by non-governmental organizations (NGOs) or other external personnel.
- Peer worker distribution (distribution by people in prison trained as peer outreach workers).
Reviews of harm reduction in Europe have time and again found that the provision of harm reduction in prisons is inadequate compared with outside prisons (1 2). In prisons, the barriers include a hard line prohibition on drugs, and “the peculiar prison context as place of punishment and the moral considerations around it”. In guidance published in 2016, the Hepatitis C Trust acknowledged that “harm reduction is key” to minimising the transmission of blood-borne viruses, yet said the “nature of the intra prison setting” has prevented the full range of harm reduction approaches from being implemented.
The 2019 Prison Drugs Strategy, published by the HM Prison and Probation Service – the national agency responsible for prison and probation services in England and Wales – stated unequivocally that the availability of illicit drugs in prisons is a threat to safety and security, obstructs recovery for people in prison with drug use problems, and leads to others to develop problems while in prison. It neglected to mention harm reduction in the context of preventing injecting-related infections and viruses such as hepatitis C and HIV, despite prisons being high-risk environments for the transmission of blood-borne diseases, for example due to overcrowding, poor sanitation, inadequate health care and a greater likelihood of sharing injecting equipment (with more people).
A 2018 study on what it would take for the UK to meet the World Health Organization’s elimination target found that, in three diverse areas of the UK, current levels of harm reduction services are averting a great deal of transmission. For policymakers, the findings suggested that opioid substitution therapy and high-coverage needle and syringe provision in particular are the cornerstones of hepatitis C control.
Treating chronic hepatitis C infections is also vital for protecting people from harm and helping to prevent the further spread of the virus. In prisons, however, the constraint on preventing new infections through harm reduction services that are commonplace in the community must certainly be impeding efforts to eliminate the virus.
The original article can be found here: The Health, Social Care and Sport Committee’s Inquiry into the Provision of Health and Social Care in the Adult Prison Estate: HSP 04: Response from the Hepatitis C Trust. Submitted to the Welsh Parliament Health, Social Care and Sport Committee by the Hepatitis C Trust (2019–2021).
The Hepatitis C Trust is a patient-led and patient-run national charity for people with hepatitis C. It was commissioned by NHS England to roll out a peer-to-peer programme across the prison estate, which involved delivering training to prison staff and offering peer-to-peer support to inmates on transmission routes and treatment.
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