Harm reduction and hepatitis C in prison

New European survey shows insufficient testing, treatment and harm reduction despite policy commitments.

Survey of 25 European countries

Earlier this month (11 May 2018), a cross-sectional survey of harm reduction and viral hepatitis C in European prisons in 25 countries was published in the Harm Reduction Journal

The survey, undertaken by Rob Bielen and colleagues, found that, despite the existence of evidence-based recommendations, infectious disease prevention measures such as harm reduction programmes are mainly inadequate in European prison settings. 

Background

At any given moment, an estimated 1.6 million men, women, and children are in prison throughout the 53 Member States of the World Health Organization (WHO) European Region. Furthermore, due to high turnover in prison populations, an estimated 6 million people in total are incarcerated at some point during a given year in these 53 countries. The prevalence of hepatitis C virus (HCV) infection among prisoners is many times higher than in the general population. The HCV prevalence in the general population in Europe ranges from 0.5% in Western Europe to 2.5% in Southern Europe and reaches 6% in Eastern Europe. In prisons, the estimated prevalence is 15.4% in Western Europe and 20.7% in Eastern Europe

The study

The Hep-CORE study was commissioned by the European Liver Patients’ Association (ELPA) in 2015 to determine the extent to which European countries were adhering to international policy guidelines for viral hepatitis. The original cross-sectional study was conducted in 2016 with a follow-up in 2017 which was designed to provide a benchmark against which to measure future changes in each of the 25 European countries.

This paper involved analysis of Hep-CORE data from three questions that refer to harm reduction, testing/screening, and treatment in penitentiary settings.

Hepatitis C Testing/Screening

As you can see in figure 1 below, testing/screening for HCV is provided in at least one prison in 21 (84%) of the 25 countries. However, in 16 countries, patient groups reported that there was no specific HCV screening policy for prisoners as a high-risk population. Though testing might be available in prison settings, it was reported to be offered only if requested by the prisoner or if a medical doctor proposed it. Therefore, coverage of testing is considered low overall.

In nine countries (36%; Bulgaria, Croatia, Denmark, France, Hungary, the Netherlands, Slovenia, Spain, and the UK), prisoners were identified as a high-risk population target for HCV testing/screening. The UK is the only country to administer a universal screening on prison admission with individuals required to opt-out if they don’t want to be tested.

Treatment

Twenty-one countries provide HCV treatment in prisons, while four countries (Bosnia and Herzegovina, Croatia, Macedonia, Poland) do not. Only nine of the patient groups that reported the availability of HCV treatment in prisons could provide information on the proportion of prisons providing HCV treatment. Of these, five countries (Slovakia, Slovenia, Spain, Sweden, UK) provide HCV treatment in all prisons, and the remaining four countries (Austria, Hungary, Portugal, Ukraine) provide HCV treatment in less than half of the country’s prisons.

Needle and syringe programmes

NSPs are a rarety. Spain provides NSPs in all its prisons, Macedonia in some and Germany in one.

Opioid Substitution Therapy

Eleven countries have OST available in prisons in all parts of the country. In five countries (Denmark, Finland, the Netherlands, Poland, Serbia), there are additional requirements for OST enrolment: in Poland, abstinence is a requirement,
and therefore, coverage is low, and in Denmark, Finland, the Netherlands, and Serbia, OST is provided only if initiation began before incarceration. 

In the UK, England and Wales have limitations on OST accessibility due to time-limited prescribing, whereas Scotland does not. In five countries (Bulgaria, Germany, Greece, Hungary, Sweden), OST is available in prisons in some parts of the country. Four countries (Bosnia and Herzegovina, Slovakia, Turkey, Ukraine) do not have OST available in prisons in their country.

Conclusion

The primary conclusion of the report is that although most countries have policies which stipulate the provision of hepatitis C testing and treatment, this is rarely translated into effective practice in prisons, particularly in terms of harm reduction measures.

The authors conclude:

Given the high prevalence of hepatitis C virus among prisoners, disease prevention measures, such as opioid substitution therapy and needle and syringe programs, are currently insufficient in European prison settings. Only a minority of HCV-infected patients in prisons have access to direct-acting antiviral therapy, which can easily and effectively cure HCV. Scaled-up opt-out testing during or upon entry to prison settings, linked to prompt treatment, would be a major step towards the elimination of HCV and reduce the further spread of infection to people who inject drugs, other prisoners or to the general population upon release.

 

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