142nd APHA Annual Meeting and Exposition

Annual Meeting Recordings are now available for purchase

Economics of treating HCV in prisons

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Wednesday, November 19, 2014 : 1:20 PM - 1:45 PM

Benjamin Linas, MD, MPH , HIV Epidemiology and Outcomes Research Unit, Boston Medical Center, Boston, WA
Approximately 1% of individuals in the United States have hepatitis C virus (HCV)[i]. The true prevalence may be higher, as estimates exclude prisoners and the homeless. Correctional institutions house a disproportionate number of high-risk individuals, with national prevalence in prisons estimated at 17.4%[ii]. Correctional populations represent approximately 1/3 of total US HCV cases[iii].

HCV can lead to cirrhosis and liver cancer and is the leading cause of liver transplants in the US[iv].  As the cohort of HCV-infected prisoners ages, the burden of liver-related morbidity and mortality on correctional healthcare budgets will increase.

Historically, HCV therapy was only modestly effective, and it required 12 months of treatment with toxic medications. As a result, very few HCV-infected individuals were treated for their infection.

HCV treatment is rapidly improving. By the end of 2014, it may be possible to treat all HCV genotypes using 8-12 weeks of oral therapy with little toxicity and efficacy approaching 100%.  These advances in HCV therapy eliminate barriers to treatment, but they are also very expensive, with drug costs greater than $1,000/day.

It is difficult to find a medical rationale for not treating HCV in correctional settings.  Because prisons and jails provide an opportunity for controlled, directly observed therapy, one could argue that prison may become the best location to treat some difficult to reach populations.

Cost is now the primary obstacle for correctional systems to provide HCV therapy. Correctional institutions face an unsolvable paradox, whereby they are constitutionally mandated to provide the community standard of care to inmates[v], but legally prohibited from leveraging Medicaid and Medicare resources. Treating every infected prisoner with new regimens would exhaust correctional healthcare resources.

Many prisons and jails attempt to minimize the potential cost of HCV by not offering HCV screening. While this approach may be rational from the perspective of the prison healthcare budget, it is in opposition to a sensible public health strategy.

This presentation reviews cost considerations for provision of HCV treatment in corrections.

[i] National Center for Health Statistics, Centers for Disease Control. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/about/major/nhanes/currentnhanes.htm. Retrieved 4.2.2014.

[ii] Varan et al.Hepatitis C Seroprevalence Among Prison Inmates Since 2001: Still High but Declining. Public Health Reports, 2014; 129: 187-195.

[iii] Varan et al.Hepatitis C Seroprevalence Among Prison Inmates Since 2001: Still High but Declining. Public Health Reports, 2014; 129: 187-195.

[iv] http://www.cdc.gov/Hepatitis/

[v] Estelle v Gamble, 429 US 97 (1976)

Learning Areas:

Advocacy for health and health education
Biostatistics, economics
Chronic disease management and prevention
Clinical medicine applied in public health
Provision of health care to the public

Learning Objectives:
Describe the high cost of HCV treatment. Compare cost effectiveness considerations of treating hepatitis C prisons and/or jails. Evaluate the implications of expensive new hepatitis C medications for correctional health care budgets.

Keyword(s): Hepatitis C, Prisoners Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a physician scientist dedicated to improving the health of vulnerable persons living with HIV and HCV infections. My research investigates the comparative- and cost-effectiveness of interventions to identify and treat HIV and HCV, employing methods of computational biology and clinical epidemiology. My aim is to maximize the benefits of evolving therapies for HIV and HCV in the “real-world”, where resources are constrained and the best methods for managing infected individuals are not certain.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.