Hepatitis C (HCV) in detainees who inject drugs is rife across Australia and could be prevented, contributing significantly to reducing HCV prevalence in the general population. People in custodial settings are one of the largest cohorts living with HCV; in 2015, there was a 31% antibody prevalence amongst detainees around Australia.
Australia has committed to eliminating HCV by 2030. To achieve this, an expansion of harm reduction in prisons is essential. A combination of three strategies is needed to achieve this, all of which are supported by evidence.
- Treating all detainees with HCV antibodies with direct-acting antivirals
- Introducing needle and syringe programs to prisons
- Expanding access for detainees to pharmacotherapy
Treating all detainees with HCV antibodies with direct-acting antivirals
In recent years a new interferon-free direct-acting antiviral (DAAs) has been made available through the PBS to everyone living with HCV. This represents a huge achievement for Australia with no restrictions to access as there are in other countries. DAAs are 90% successful at clearing the virus (sustained virologic response) and have little to no side effects. Over the last years there has been an increase in awareness campaigns and medical practitioner training and general practitioners received prescription rights. The number of people reached (19% of people living with chronic HCV) and the increase in general practitioners prescribing (22%) as of 2017 is very encouraging. DAAs do not however provide protective immunity and reinfection can occur.
DAAs in prisons could have a big impact on the overall prevalence of HCV in Australia. Detainees represent one of the largest cohorts of people with HCV; if every detainee with HCV was treated and left custody free of the virus, this could significantly reduce transmission rates in the general population.
A Queensland prison has successfully trialled DAAs, nearly eliminating the virus from within its walls. The Lotus Glen Correctional Centre has achieved a success rate of 97% of detainees with a sustained virologic response less than two years after DAAs were introduced onto the PBS. They estimated that prevalence declined from 12.6% prior to the program to 4.3% one year after implementation and down to 1.1% ten months later with only two noted reinfections. The success of this program was the wide distribution of DAAs to 95% of the population who tested positive (119/125 detainees) significantly reducing the pool of HCV.
However, to successfully expand DAA coverage, we will need to address misconceptions about the treatment among detainees and provide harm reduction services. The NSW Surveillance and Treatment of Prisoners with Hepatitis C study interviewed detainees about the distribution of DAAs and received a negative response. Here's what some of the detainees had to say:
"There's no point getting on [treatment] if you're still going to use drugs, because eventually you're going to contract it back again, so it's just pointless doing it really"
"Like once everybody's had the [treatment] you know what I mean, say there's 10 people and there's only 1 person that's got [HCV], well eventually he's going to re-infect everybody else again)"
"A lot of people come through the remand centre, so if someone gets out, gets hep C again and then comes back, it sort of defeats the purpose, you are just going to be chasing your tail…too many people in and out, in and out"
Introducing needle and syringe programs to prisons
Sharing injecting equipment, a practice necessitated by the illegality of contraband and drugs, means that every injection made in prison holds with it the risky chance of acquiring HCV. Needle and Syringe Programs (NSPs) provide clean equipment, collect used injecting equipment and are the source of education, counselling services and referrals to other services. These programs have existed in the Australian community since the 1980s'. As of 2016, there were 3,509 NSPs nationally, 300 of which are inconspicuous vending machines that dispense clean injecting equipment. The Australian Government widely appraises NSPs and their success is evident in the numbers – between 1991 and 2000 roughly 21,000 cases of HCV had been prevented because of NSPs.
However, there are currently no NSPs in any prison in Australia despite a continual push from the Australian Capital Territory. Data from the Global State of Harm Reduction Report 2016 shows "that only eight countries provide NSP in at least one prison... despite the fact that up to 90% of people who inject drugs will be incarcerated at some point". The safety of staff, a vital component of any prison, is often cited as a main reason for not introducing prison NSPs. However, there is over 20 years of international prison data showing that, where prison NSPs exist, there have been no attacks, no unintended negative consequences or reported injecting initiation, and reports of syringe sharing are rare.
There are a small number of NSPs in prisons around the world to copy however based on Australia's needs, the following would be advisable in our context. Sterile equipment to be made available via vending machines. Vending machines reach hard-to-reach, high risk people who inject drugs and, for example, are successfully used in Moldova's prisons and in the Australian community. Vending machines are to be in secure locations to keep the transaction confidential, build a prisoner's trust and remove concerns of retribution. Working on a one-for-one basis the vending machines will reduce circulation of unsafe equipment.
Sterile equipment, education, counselling and referral services will be available through staffed NSPs in all prisons. Staff can offer health information, make referrals to other services and provide access when a vending machine is out of use. The use of external staff is recommended; the use of external staff will prevent conflicts arising between correctional officers and internal health staff.
Expanding access for detainees to pharmacotherapy
Pharmacotherapy programs, e.g. opioid substitution therapy (OST) are an essential component of harm reduction. OST is the replacement of problematic opiate use with legally prescribed medications, usually methadone or buprenorphine. It is an effective intervention that, by reducing the need for illegal opiates, reduces injecting prevalence and consequently availability of unsafe syringes. Access to pharmacotherapy in prisons is possible however there are numerous restrictions to access and few detainees are on these programs. With the increase in OST places, Australia will also need to further accredit at least one more opiate pharmacotherapy prescribers for each prison and register more prison physicians to administer OST.
The following recommendations are based on the Author's study of domestic and international harm reduction programs and recommendations and were originally developed for a Masters in Health Policy thesis (available on request).
- Substantially increase voluntary HCV screening of detainees on entry, throughout the duration of their stay and on exit
- Increase distribution of DAAs to all detainees testing positive to HCV antibodies as soon as practicable
- Introduce NSPs to all prisons and remand centres across Australia
- Increase the number of prison opioid substitution therapy places to equal those available in the community
- Provide compulsory harm reduction education to all prison staff
- Distribute blood-borne virus safety kits to all new detainees including educational materials, information on services available in the prison, a vending machine dummy syringe and a safe storage box.
Australia used to be at the forefront of global harm reduction. But since the 1990s, when the country successfully stopped HIV from rapidly spreading across the nation, Australia has moved forward slowly. In 1993 the World Health Organization recommended that all harm reduction services available to the community be made available to detainees. It is time for Australia to meet this recommendation as other countries have. The world has changed, our needs have changed and now a new epidemic is upon us with the solution there for the taking.
Written by Sally Cruse, Management Consultant – Nous Group
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