Figure

Figure. Timeline of hepatitis C virus screening recommendations and treatments that advance hepatitis C elimination in carceral settings, United States. Colored circles on the timeline indicate the year certain recommendations were...

Guidelines for testing and screening for HCV in the United States have evolved since the original recommendations were first published by the Centers for Disease Control and Prevention (CDC) in 1991 (Figure). Although risk-based HCV testing was recommended in 2003, it missed a substantial proportion of persons with HCV (19). During 2019–2020, the American Association for the Study of Liver Diseases (AASLD), Infectious Diseases Society of America (IDSA), US Preventive Services Task Force, and CDC recommended universal HCV screening for all adults at least once during a lifetime (15,20,21). CDC (2022) and AASLD/IDSA (2023) recommended universal opt-out HCV intake screening of incarcerated and detained persons (22,23).

Models estimate that universal opt-out screening in US prisons would diagnose >122,000 HCV infections and prevent ≈13,000 new prison-associated infections, ≈2–3 times more than would be possible with risk-factor based assessments (24). Implementing universal opt-out HCV screening and associated treatment costs would increase state prison healthcare budgets by an estimated 12.4% (24). Thus, budgetary constraints might limit the broader adoption of universal opt-out HCV screening and treatment.

During 2004–2012, the Pennsylvania Department of Corrections (DOC) successfully began a universal opt-out screening program resulting in 93% of incarcerated persons screened for HCV at intake (19). Similarly, the Washington DOC successfully screened 83% of its incarcerated population during 2012–2016 (25). The Pennsylvania and Washington screening programs identified 18%–20% HCV seropositivity rates (Table 1) (19,25).

Partnerships between carceral facilities and departments of health are promising strategies to enact universal opt-out HCV testing. The Indiana Department of Health embedded an epidemiologist in the Indiana DOC and began universal HCV screening at intake, which ultimately identified a 12% intake viremia prevalence (26). The collaboration between Indiana’s Department of Health and DOC resulted in a transition to universal treatment, the creation of a peer education program, a community care transition program, and development of data tracking capabilities to generate HCV care cascades (26).

During 1998–2014, interferon-based therapies were the gold standard for hepatitis C treatment but were ineffective, poorly tolerated, and unsafe for many persons (27). The approval of sofosbuvir in 2013 shifted the treatment paradigm toward safe, highly efficacious, oral DAA therapies that had >95% sustained virologic response (SVR) rates and few contraindications (15,28). SVR is defined as no detectable HCV RNA in blood after completing treatment. Attaining SVR after treatment with DAAs reduced all-cause mortality, end-stage liver disease, and hepatocellular carcinoma among Medicare beneficiaries during 2014–2016 (14). In 2019, the AASLD/IDSA recommended treating all patients with current HCV infection except those who had a short life expectancy and cannot be remediated by HCV therapy (15). Although treatment remains expensive, manufacturer competition and negotiated pricing have substantially driven down DAA costs.

Considerable costs associated with chronic liver disease can be prevented by treating HCV infection. In 2019, the estimated annual cost of sequelae from chronic HCV infections ranged from $17,500 per year for nonadvanced fibrosis to $262,000 within the year after a liver transplant (29). Cost-benefit analyses show that universal opt-out screening in prisons is cost-effective, reducing ongoing HCV transmission, the incidence of advanced liver diseases, and death from liver disease (24). A 2020 study found that a test all, treat all, and linkage to care at release model would cost prisons $1,440 per person and result in a 23% increase in lifetime SVR and 54% reduction of cirrhosis cases (30).

Financial and other barriers continue to limit access to HCV treatment in US carceral settings (Table 2). However, some initiatives have demonstrated promising outcomes.

Proponents of expanded DAA treatment to prevent chronic HCV infection in incarcerated persons must also contend with substance use disorder and the overdose crisis among persons who inject drugs (PWID). Although robust evidence exists indicating that providing sterile injecting equipment reduces HCV transmission, no carceral facility currently provides sterile injection equipment. Persons released from prisons or jails are 10–40 times more likely to die from an overdose than are persons in the general population; the greatest risk for death is 3–4 weeks after release (44,45). Medications for opioid use disorder (MOUD), such as methadone, naltrexone, and buprenorphine, are highly safe and efficacious. Exposure to MOUD during incarceration is associated with 85% reduction in all-cause mortality and 75% reduction in overdose-related deaths in persons after reentry into the community (45).

MOUD is a critical component of HCV prevention because it decreases unsafe injecting practices in PWID; MOUD alone can reduce the risk for HCV infection by 50% and reinfection by 73% among PWID (46). Initiating HCV treatment also increases the uptake of MOUD (47). As of 2022, a total of 15 laws across 12 US states had expanded access to MOUD in prisons and jails for substance use treatment (45).

Lack of insurance coverage and lack of coordinated handoff between carceral and community healthcare systems complicate healthcare transitions for incarcerated persons after release (48). California was the first state to apply for Section 1115 waivers of the Medicaid Inmate Exclusion Policy to secure payment coverage for substance use treatment for persons who would otherwise lose coverage during incarceration under that Medicaid policy (49). Although DAAs are included, waivers are unlikely to directly increase DAA treatment because many persons are treated during incarceration. However, the waivers can substantially improve linkage to care for MOUD and mental health treatment to prevent new or recurrent HCV infection after release.

National data on the incidence and prevalence of HCV in carceral settings is required to improve HCV surveillance efforts and monitor progress across the country. Collaboration between US public health organizations and DOCs is essential both for data collection and improved control of HCV transmission in the carceral setting. Identifying facility-specific barriers and allocating data-driven resources are critical to improve HCV surveillance and treatment.

The US Congress is currently considering funding for a National Hepatitis C Elimination Initiative. This $11.3 billion initiative would enhance screening, testing, treatment, prevention, and monitoring of hepatitis C for all Americans; the goal is to reach elimination targets within a 5-year period (50). Of note for incarcerated persons, the plan includes point-of-care HCV RNA testing, provider training and technical assistance for implementation, and a national drug procurement plan that would cover incarcerated or detained persons. Carceral facilities can make considerable steps toward elimination now by using universal opt-out screening and providing DAA and MOUD treatment, improving linkages to community care, and building data infrastructure to track progress toward HCV elimination.

Broadly implementing hepatitis C testing and treatment programs in US prisons and jails advances public health and health equity. HCV elimination in carceral settings not only profoundly affects a person’s health but also improves community health. Only through screening and treating hepatitis C in carceral health settings can we achieve national HCV elimination goals.