Access to Hepatitis C Drugs in Prison Still Lagging

Though under lock and key, state prisoners are considered "hard to reach" when it comes to getting them into treatment for hepatitis C virus (HCV) infection.

That matters because although 1% of the US population is known to be HCV-infected, the estimated rate in the US prison population is 17%. Getting these inmates access to direct-acting antivirals (DAAs) for HCV could put a big dent in the US epidemic of HCV.

In a recent study in Health Affairs by Adam Beckman, then a research assistant at the Yale Global Health Justice Partnership, and colleagues at Yale University and other institutions, report on their survey of state prison authorities. The team's primary goal was to learn what the obstacles might be to making HCV treatment and testing routine in state prisons. They also surveyed the treatment landscape.

Their main findings: the vast majority of state prisoners are not getting treated; states vary widely in their approaches to HCV treatment; and the biggest barrier is the high price of direct-acting antivirals (DAAs).

Federal prison policy endorses treatment with DAAs. In state prisons, the scope of health services is determined by state budgets and priorities.

Though DAAs have a better than 90% cure rate and minimal side effects, they are not available to the majority of state prisoners. Less than 1% of infected inmates in known HCV cases at prisons included in the study are getting these effective drugs, the team found.

“Prison officials understand the desirability of using these treatments,” Beckman wrote, “However the high price of direct acting antivirals such as sofosbuvir and ledipasvir/sofosbuvir (Harvoni/Gilead) is a major barrier to implementation of HCV treatment within state prison systems.”

The researchers surveyed state prisons in all the states and asked for estimates of HCV infected inmates, but since not all prisons screen for HCV, it was impossible to get comprehensive figures. Of those states that did offer numbers, the proportion of infected inmates ranged from 1% in North Carolina to 41% in New Mexico.

Based on data they did receive the authors estimate that 10% of the 106, 266 in reporting states have HCV and that only 949 or 0.89% are receiving treatment.

Representatives from 49 state prison systems responded to the January, 2015 survey, and of those 41 states offered HCV infection and treatment data. States varied widely in the scope of their treatment programs.

Oklahoma, for instance, at the time of the survey was not giving DAAs to state prisoners, while New York was treating 5.9%.

Other variations included the fact that some states used primary care physicians for treatment, while most used specialists.

Most states prioritized inmates’ eligibility for treatment solely using clinical criteria, such as cirrhosis, while others judged whether a prisoner’s past behavior should make him or her ineligible. Whites appeared to be over-represented in the treatment group, or 37% compared to the 24% who were African-Americans.

The prices states paid for DAAs also varied, with Nevada getting ledipasvir/sofosbuvir at a bargain cost of $44,421 per full course of the drug while Michigan paid $94,500. Those figures were collected in September, 2015.

The researchers note that other government purchasing entities have gotten DAAs at discounts (at least 24% for the Federal Bureau of Prisons, Department of Defense and Department of Veterans Affairs, for instance). Medicaid discounts can be even larger.

In a measure of the impact of the price, eight states reported they were spending 20% or more of their pharmacy budgets on HCV treatments.

In conclusion, the authors note that while state prison systems generally want to treat prisoners for HCV, they often cannot afford to do so.

They suggest that since an untreated prison population remains a barrier to ending HCV in the US, government should get further involved either by increasing funding for HCV treatment, pursuing larger discounts, or both.

Taking such measures “could make hepatitis C treatment more readily available for those who require it in state correctional facilities.”