Survey of US Correctional Institutions for Routine HCV Testing

Abstract

To ascertain HCV testing practices among US prisons and jails, we conducted a survey study in 2012, consisting of medical directors of all US state prisons and 40 of the largest US jails, that demonstrated a minority of US prisons and jails conduct routine HCV testing. Routine voluntary HCV testing in correctional facilities is urgently needed to increase diagnosis, enable risk-reduction counseling and preventive health care, and facilitate evaluation for antiviral treatment.

There are an estimated 4 to 7 million persons in the United States infected with HCV.^1,2 Morbidity and mortality from HCV are increasing and in 2007, death from HCV exceeded that from HIV infection for the first time.^3,4 Persons who inject drugs are at increased risk for HCV infection and for being incarcerated. Multiple studies have demonstrated high HCV prevalence rates among persons behind bars.^5–7 In 2010, the Institute of Medicine (IOM) called for the development of comprehensive viral hepatitis services for incarcerated populations including offering testing, hepatitis B virus vaccination, education, and medical management in partnership with community providers.⁸

Despite the Centers for Disease Control and Prevention (CDC) releasing HCV testing recommendations in 1998 and subsequent recommendations for prevention and control of viral hepatitis within correctional facilities in 2003,^9-10 recent studies estimate that 50% of persons infected with HCV are unaware of their infection,^11–14 thus reducing opportunities for risk-reduction counseling and treatment. In response to this, the CDC updated HCV testing recommendations for the US general population in 2012, which added at least 1-time testing among persons born between 1945 and 1965, now commonly referred to as the “birth cohort” screening recommendations.¹⁵ However, the 2012 recommendations did not provide a specific testing recommendation for incarcerated individuals. Given the increased prevalence of HCV among criminal justice populations, we conducted a survey among US prisons and jails to gain a better understanding of current HCV testing practices within correctional facilities.

METHODS

In 2012, we surveyed Medical Directors of all state prison systems and 40 of the largest US jails. The survey included 5 items regarding HCV testing to determine if facilities provided any HCV testing, and if so, what approaches were used (routine including opt-in, opt-out, and mandatory; inmate request; physician order; and court or facility order). Routine testing was defined as providing a screening test to all persons in custody who are not known to be HCV-infected; definitions for opt-in, opt-out, and mandatory testing were provided. In the survey instructions, we acknowledged that within a correctional system, there may be different testing policies between facilities. Therefore, we requested that survey responses should describe the most common practice within the system. An introductory e-mail describing the project included a unique link to the survey. Nonresponders were asked to complete the interview by telephone.

RESULTS

Forty-three of the 50 state prisons (86%) and 23 of the 40 jails (58%) responded (Table 1). The majority of prisons and jails provided HCV testing when requested by an inmate or ordered by a physician and among the systems reporting HCV testing, 60% and 35% of prisons and jails, respectively, provided HCV testing when court or facility-ordered. Only 11 prisons and 1 jail facility provided routine HCV testing to inmates. The jail facility provided HCV testing on an opt-in basis, and among the prison systems, routine testing was conducted using opt-in (n = 3), opt-out (n = 3), and mandatory (n = 5) approaches.

TABLE 1—

Survey Results Regarding HCV Testing in US Prisons and Jails: 2012

Survey Question	Prisons (n = 43), No. (%)	Jails (n = 23), No.(%)
Do the facilities under your jurisdiction provide any HCV testing to persons in custody?
All facilities	40 (93.0)	18 (78.3)
Some facilities	2 (4.7)	2 (8.7)
No	0 (0.0)	3 (13.0)
Don’t know	1 (2.3)	0 (0.0)
What approaches are used to determine when HCV testing is provided to persons in custody? (approaches not mutually exclusive)
Routine testing	11 (25.6)	1 (4.3)
Inmate request	32 (74.4)	13 (56.5)
Physician order	41 (95.3)	19 (82.6)
Court or facility order	25 (58.1)	7 (30.4)
Other	2 (4.7)	0 (0.0)
Not applicable	1 (2.3)	3 (13.0)
Is the routine HCV program in effect in all facilities or some facilities?
All facilities	9 (20.9)	1 (4.3)
Some facilities	2 (4.7)	0 (0.0)
Not applicable	32 (74.4)	22 (95.7)
On what basis is the routine HCV testing offered in facilities under your jurisdiction?
Opt-in	3 (7.0)	1 (4.3)
Opt-out	3 (7.0)	0 (0.0)
Mandatory	5 (11.6)	0 (0.0)
Not applicable	32 (74.4)	22 (95.7)
When is routine HCV testing provided to inmates? (approaches not mutually exclusive)
Upon entrance	11 (25.6)	1 (4.3)
Upon exit	2 (4.7)	0 (0.0)
Not applicable	32 (74.4)	22 (95.7)

DISCUSSION

Despite the high prevalence of HCV among incarcerated populations and the fact that expanded HCV testing would yield significant numbers of new diagnoses,¹⁶ few facilities in this study conducted routine HCV testing. HCV testing among high prevalence populations improves cost-effectiveness.¹⁷ HCV testing that depends on recognition of risk by health care providers and reporting of risk by inmates is inadequate and will not decrease the burden of undiagnosed infection.¹⁸ A more comprehensive approach to HCV, as recommended by the IOM, is urgently needed that includes routine voluntary HCV testing for all inmates. The success of routine HCV testing in the Pennsylvania state prison system was recently reported.¹⁹

We acknowledge that there are barriers to HCV testing in this population, including the cost of antibody screening, confirmatory testing, and the need to provide medical care and treatment to persons identified as having chronic infection. Furthermore, routine HCV testing in jails presents additional challenges because of the transient nature of the jailed population,²⁰ which may limit the delivery of test results and referral for treatment evaluation. However, treatment options for HCV infection are increasing with the development of new direct-acting antivirals.^21,22 We need to incentivize correctional systems to screen for, treat, and cure this disease, and sufficient resources and training must be made available. Treatment has been successfully delivered within prisons,^23–26 and incarceration may be the ideal time to treat some individuals who lack stable and adequate health care in the community. There are multiple benefits to HCV diagnosis even if treatment is not feasible, including risk-reduction counseling, vaccination for hepatitis A virus and hepatitis B virus when appropriate, and evaluation for antiviral treatment either within the correctional setting or in the community following release in partnership with community health care providers.

We urge the CDC to develop policy guidance for correctional facilities that calls for routine voluntary HCV screening for all persons with undiagnosed HCV status. Testing must be linked to counseling, primary health care including vaccination for hepatitis A and B, and evaluation for HCV treatment. Investment in HCV treatment networks that include correctional providers and community partners must be developed in conjunction with expanded testing. To remove the financial disincentives to HCV testing within correctional facilities, this investment needs to be coupled with a reallocation of health care resources that removes the financial burden of HCV treatment from the public safety domain and incorporates the cost into a broader public health strategy.