Progress and challenges in hepatitis C elimination from Australian correctional centres. Professor Andrew Lloyd AM
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1 Progress and challenges in hepatitis C elimination from Australian correctional centres Professor Andrew Lloyd AM
2 Disclosures Investigator-initiated research project funding from: Gilead Sciences Merck Sharpe & Dohme (MSD) Bristol-Myers Squibb No personal remuneration from pharma
3 Overview Background Prisons, prisoners and hepatitis C Hepatitis C in Australia Studies to inform policies and practice Challenges and solutions towards elimination Organisations Providers Individuals
4 Prisons Unique physical structure, commonly overcrowded Predominantly short stay Frequent movements Uncontrolled exposure to violence Lack of purposeful activity Separation from family networks Significant risk of physical & psychological harm A distinct micro-society with their own rules & regulations de Viggiani N. Unhealthy prisons: exploring structural determinants of prison health. Sociology of Health & Illness 2007;29:115-35
5 Prisoners million individuals in prison at any one time (2015) 144 per 100,000 worldwide 196 per 100,000 in Australia 698 per 100,000 in USA Increasing rates of imprisonment of women (+50% since 2000) Increasing rates in Oceania (driven by Australia) (+59% since 2000) Predominantly male Over-representation of ethnic minorities Low socioeconomic status Low literacy Walmsley R. World prison population list. 11 th edition 2015 Institute for Criminal Policy Research (
6 Hepatitis C and prisoners 1.5M prisoners (15.1%) infected globally Dolan K et al. Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees. Lancet 2016 (epub online July )
7 The Australian hepatitis C epidemic largely PWID 230,000 chronically infected Lifetime PWID (184,000) PWID in prison 20,000 (10%) Current PWID 15,000 (8%) 30,000 (16%) 15,000 (8%) 9,000 (5%) PWID in OST
8 Prison studies to inform hepatitis C elimination Hepatitis C Incidence & Transmission Study in prisons (HITS-p) Prospective cohort HCV-uninfected PWID prison inmates Outcomes (n=590): n=196 incident cases over 1452 person-years of follow-up n=37 reinfection / superinfection cases over 286 person-years Luciani F et al. Addiction 2014, 109 (10), ; Pham S et al. Hepatology 2012, 55: Nurse-led model of hepatitis care (NLMC) Task transfer from specialist physicians to nurses Protocol-driven nurse assessment and triage Specialist support via telemedicine Outcomes - Safe, well accepted by inmates and staff - Reasonably efficient - 1 in 4 screened were treated Lloyd A et al, Clin Infect Dis 2013, 56: Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) Treatment as prevention in Australian prisons
9 Challenges in hepatitis care in the prison sector Organisations Separation of the powers custodial versus health care Health care payers Government versus private insurers Local health authorities versus corrections health Health workforce Capacity specialist physicians, GPs, nurses Hepatitis skills Arain A, Post JJ, Lloyd AR. Enhancing assessment and treatment of hepatitis C in the custodial setting. Clin Infect Dis. 2013, 57:S70-4.
10 Challenges in hepatitis care in the prison sector Providers Health service models hospital outpatients vs. in reach specialist-driven service vs primary care (nurses and GPs) Movements Between prisons Prison-community Length of stay Co-morbidities and health care priorities Mental health Injecting drug use Arain A, Post JJ, Lloyd AR. Enhancing assessment and treatment of hepatitis C in the custodial setting. Clin Infect Dis. 2013, 57:S70-4.
11 Challenges in hepatitis care in the prison sector Individuals Inmates Knowledge Stigma Cultural sensitivities Health care providers Knowledge Stigma Competing priorities Custodial staff Stigma Arain A, Post JJ, Lloyd AR. Enhancing assessment and treatment of hepatitis C in the custodial setting. Clin Infect Dis. 2013, 57:S70-4.
12 Solutions in hepatitis care in the prison sector Organisations Separation of the powers Justice health, in-reach Health care payers universal access to testing & Rx Health workforce skills based training Module 1 Hepatitis C nursing workshop Module 2 Written assessment Module 3 Clinical skills training workshop Module 4 Clinical skills on-the-job training Module 5 Clinical skills assessment Possible exit point Certificate of Attendance Certificate of Attainment Annual performance review
13 Solutions in hepatitis care in the prison sector Organisations National Hepatitis C Strategies since PWID and prisoners prioritised Partnership approach, with involvement of government, community, clinical/peak bodies, and academic representatives $AUD1 billion for HCV treatment over 5 years ( ) Access for all to highly effective hepatitis C treatment a priority
14 Solutions in hepatitis care in the prison sector Providers Health service models Movements Length of stay Co-morbidities & health care priorities Efficiencies DAA vs IFN era Nurse time per patient: 75 mins. (vs. 180 mins.) Specialist time per patient: 5 mins. (vs. 35 mins.) Assessment to treatment initiation: 12 wks (vs. 22 wks) % treated / assessed 95% (vs. 29%) currently 60 treated per month (vs. 15 per month)
15 Solutions in hepatitis care in the prison sector Individuals Inmates Health care providers Custodial staff
16 Acknowledgements Key staff NLMC Jac Clegg Fran Pekin Jeffrey Post Population Health nurses Key staff HITS-p Suzy Teutsch Luke McCredie Key staff SToP-C Marianne Byrne SToP-C nurses Partners Justice Health & Forensic Mental Health Network Corrective Services, NSW NSW Health Hepatitis NSW NUAA Community Restorative Centre Funding NSW Health NHMRC Partnership Grants Gilead Sciences Bristol-Myers Squibb
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