Last month, Health Affairs published new research on hepatitis C treatment in American prisons. Hepatitis C is a liver disease and the most common bloodborne pathogen in the United States, infecting approximately 1 percent of the general population.(1) Within the prison population, however, the prevalence of hepatitis C is higher: 17 percent. Prisoners are a key demographic to decrease the spread of hepatitis C, which is spread through IV drug abuse because approximately 20-55 percent of inmates have used IV drugs in the past.
The article is the most recent investigation to identify the number of inmates with hepatitis C, and identify how these people are being treated. This is important now because today hepatitis C is treatable through direct-acting antivirals (DAAs). Treatment is important because hepatitis C can lead to cirrhosis, portal hypertension and chronic liver failure requiring liver transplant. The DAAs are very expensive with a 12-week course costing $43,418-$94,500. Yet 90% of the time, the treatment is curative, preventing the morbidity associated with chronic hepatitis.
The main finding of the article was that despite the drugs being available and effective, less than 1 percent of known infected inmates actual receive treatment. This is despite US Supreme Court rulings that prison officials must provide adequate medical care of inmates, and the Federal Bureau of Prisons’ Clinical Practice Guidelines recommend the use of DAAs. Currently, prisoners in Massachusetts are suing the state for withholding treatment.(2) On average, each state spent about 6 percent of their annual drug budget on hepatitis C medications: $39.8 million annually. This is despite the fact that many states actually negotiate lower prices.
Clearly, cost plays a major role in this failure to treat inmates with DAAs. However, other reasons cited by the authors include outdated treatment guidelines which do not take into account DAA availability. As of January, 1st, 2016, Tennessee’s treatment guidelines did not recommend DAA medications, and only recommended hepatitis C testing for inmates meeting certain indications, unless specifically requested by an inmate. In addition, state protocols only recommend treatment for those with more severe disease, including cirrhosis.
In the Health Affairs article, the authors describe several ways to increase treatment and decrease costs. First, the federal 340B Drug Discount Program allows health institutions to partner with prisons and provide healthcare services including hepatitis C treatment, a system being used by three of the four departments paying the least for DAAs. Pooled procurement of DAAs is also recommended, as currently many departments negotiate independently for drug prices. Finally, increased federal involvement and funding is needed help treat inmates. Once inmates are released, the federal government bears a significant proportion of the cost of hepatitis C, which is much higher if it’s untreated. Treatment in an institutional setting may provide greater savings and more effective treatment, while treating those at the highest risk of spreading the disease. This article is a first step towards understanding the burden and availability of effective treatment for one of the most high-risk populations in the United States.
1. Beckman AL, Bilinski A, Boyko R, et al. New Hepatitis C Drugs Are Very Costly And Unavailable To Many State Prisoners. Health Aff (Millwood) 2016;35:1893-901.
2. Loftus P. Prisoners Sue Massachusetts for Withholding Hepatitis C Drugs. The Wall Street Journal 2016 Jun 11, 2015.
Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital