Clinical Assistant Professor
Department of Medicine
University of Washington
Infectious Disease Physician
Washington State Department of Corrections
Lara Strick, MD, MS, has no real or apparent conflicts of interest to report.
The high burden of HCV infection in correctional facilities makes incarcerated individuals an important population to reach and treat as we strive for HCV elimination. However, we are met with the reality of limited financial and personnel resources as well as the substantial time to treat all who are living with HCV infection in this setting. Often, patients with more advanced disease are treated first, but even if a mandate to treat all inmates with HCV infection arose, it would take years to realize this goal, as no system could immediately implement universal treatment.
Reducing Risk Through Prevention Services
In the meantime, what can be accomplished to bring us closer to our end goal of viral eradication, including among incarcerated populations? While newer paradigms and service provision infrastructure are being built for expanding HCV treatment in correctional settings, there are steps that can be taken now to reduce patient risk and to prevent more HCV infections. Perhaps the most persuasive argument for investment in prevention is the substantial cost savings compared with the capital necessary for treatment.
Effective risk reduction programs should be general enough to engage populations beyond just those who already have HCV infection or who are actively receiving treatment, and inclusive measures should teach jail and prison inmates how to inject, tattoo, and have sex safely. Implementation of such programs is not typically the role of the treating specialist but, instead, is often incumbent upon correctional nurses. However, hepatologists and infectious disease specialists involved in providing care to incarcerated populations can provide critical expertise and support regarding the benefit and value of such programs to both the facility administration and the public at large, as discussed below.
Gaining Buy-in From Custody, Partnering With Community-Based Organizations
Mounting effective prevention programming begins by gaining buy-in from the correctional administration. Implementation studies show that successful creation and execution of such programming requires an “HCV champion” working within the correctional facility. Thus, a physician, nurse, or other provider with a known and respected voice must jumpstart this process, which may require difficult conversations. This includes having the honesty to suggest that current measures to tackle drug use in our society are not working and to discuss the reality of ongoing transmission risk (both within the facility and upon release) and how it must be addressed rather than ignored. Discussions of how ongoing transmission risk affect the safety of the correctional work environment can sometimes help garner further support for HCV prevention programs.
In addition to identifying a champion on the inside to get things started, contracting with community-based organizations to create risk reduction education can provide the needed expertise and resources as well as the ongoing momentum required to keep classes up and running. Furthermore, bringing in an outsider typically engenders increased trust because these individuals are not “part of the system,” and the information they provide is more readily believed.
Disseminating Prevention Education via a Peer Model
One successful example of community partnering to reduce HCV risk among prisoners is the recruitment of the Seattle-based nonprofit Hepatitis Education Project to work alongside staff nurses inside the Washington State Department of Corrections. There, facilitators taught motivated volunteers fundamental HIV and HCV risk reduction, tailored to the incarcerated setting, along with effective communication skills.
This model is powerful because when newly educated inmates return to their varied housing units, gangs, or social networks—inside or outside of prison—they can spread accurate knowledge to hard-to-reach populations less willing or interested in attending formal classroom training. Additional utility may be gained by transitioning this educational concept to a peer-based model wherein the primary facilitator is an inmate or former inmate. It is important to approach such projects with a flexible attitude and creative mind as developing these programs for the correctional setting often requires adaptations or compromises with custody staff to make them successful.
Although the United States lags far behind in public acceptance and implementation of harm reduction services like condoms, needle exchanges, and regulated tattooing in the correctional setting, it is important to note that other countries have successfully launched such programming. For now, we need to rely on risk reduction counseling to augment prevention ahead of full maturation of our harm reduction initiatives. For instance, medication assistance for drug addiction is steadily garnering more attention across the United States as the public profile of the opioid epidemic expands, increasing the political will to broaden efforts to correctional facilities.
But perhaps the most important thing to remember is this: Implementation of prevention services targeting incarcerated patients is possible. Do not let the fact that you are serving a correctional population prevent you from practicing good medicine because, ultimately, prevention is good medicine.
What have been your greatest challenges in counseling and treating incarcerated individuals living with HCV infection? I invite you to share your experiences in the comments box below.