Persons in custody in Canadian prisons have a 25-fold higher rate of hepatitis C (HCV) infection than the general population. However, access to HCV treatment in prisons depends on whether the institution is federal or provincial. Recently, Correctional Service Canada increased its budget in order to provide HCV treatment for all 2,700 infected persons in federal prisons. However, this budget increase has no effect on the approximately 20,788 inmates living with HCV in provincial and territorial institutions.
There are a number of reasons that may explain why provincial and territorial prisons have not taken the same approach towards HCV care. This includes high turnover rates due to shorter incarceration times, frequent transfers, and the high cost of new curative treatments that must be paid by provincial and territorial health budgets.
However, prisons provide unique opportunities to engage high-risk individuals into HCV care. Research has shown that inmates are motivated to receive HCV treatment, but have encountered barriers to care such as reliable transportation and lack of care continuity following release from prison. The ongoing presence of risky behaviours in prison settings, including a lack of sterile syringes and tattooing equipment, means that there is a high risk of transmission during incarceration or upon release. Therefore, engaging inmates in HCV care during incarceration may be the most opportune time.
The care of inmates in federal versus provincial and territorial prisons may require different strategies and care models. Because of the challenges that exist at the provincial level, specifically the shorter incarceration times and frequent transfers, a focus on HCV treatment may be misguided. Rather, robust systems that ensure timely diagnosis and effective referral to treatment and continuity of care services at the time of release — systems that are not currently in place — could substantially improve the effectiveness and cost-effectiveness of prison-based treatment as prevention strategies and should be prioritized.
With this in mind, I was awarded a $994,103 research grant through Gilead’s HCV SCALE (Screening Access and Linkage to CarE) competition. Given the challenges that are unique to provincial prisons, my goal is to improve HCV care in Quebec’s provincial prisons by focusing primarily on screening and linkage to care. Using a prison-based multi-disciplinary team model approach, I hope to ensure that all inmates with chronic HCV receive HCV screening, liver disease assessments, pre-discharge planning, and post-release transportation.
This study is unique for several reasons. First, there are very few care models focused entirely on HCV care in prison settings; current models are largely based on HIV. Second, the program will be delivered by a team of allied health care professionals whose roles are well defined and task specific. Finally, the intervention targets every component of the cascade of HCV care, from screening to linkage to care, in an attempt to minimize attrition along the cascade.
My research will focus on ensuring the sustainability of this care model in hope that it can be replicated across provincial and territorial prisons throughout the country. Our outcome measures will focus on effectiveness, acceptability, and cost-effectiveness. While we know that drug addiction counselling and access to needle exchange programs will be of equal importance in an attempt to reduce the risk of transmission and reinfection in this high-risk population, my team hopes that this research will influence policymakers to change the way HCV care is delivered in prisons in Canada.