While most medical attention has been on COVID, work has been underway to eliminate another viral disease, hepatitis C.

In Australia, approximately 120,000 people have hepatitis C. It’s mostly spread through injecting drugs using unsterile equipment. Left untreated, hepatitis C can cause liver damage, leading to cancer, liver failure and even death.

In 2016, Australians with hepatitis C gained access to a highly effective treatment option: direct-acting antivirals. These can cure hepatitis C in eight to 12 weeks. Australia took on the World Health Organization’s goal of eliminating hepatitis C by 2030.

Thousands of Australians commenced treatment. But numbers have slowed recently, prompting concern the goal of eliminating hepatitis C by 2030 may be unreachable. However, one sector has been making great progress in eliminating hepatitis C: prisons.

High rates of drug use among those entering prison

In Australia and many other countries, the criminalisation of drug use results in the frequent incarceration of people who inject drugs. About half of people entering prison report a history of injecting drugs.

While drug courts and diversion programs help keep some people out of prison, more needs to be done to treat drug use as a health issue rather than a criminal one.

The over-incarceration of people who inject drugs results in high rates of hepatitis C among the prison population. In 2016, of people entering prison who reported injecting drugs, approximately 50% had been exposed to hepatitis C but not all may have had an active infection. This compares with less than 1% of those entering prison who did not report injecting.

Injecting drug use in prisons

Imprisonment enables some people to stop using drugs, but others continue to inject, and some start injecting.

No Australian jurisdiction provides sterile injecting equipment to people in prison, despite this being available in the community. The likelihood of syringe sharing in prisons is therefore high, and increases the risk of hepatitis C transmission.

One NSW study estimated 10% of people who injected drugs in prison were newly infected each year.

Another study found recent incarceration increases the risk of contracting hepatitis C by 62%.

Access to hepatitis C care in prisons

Direct-acting antivirals were listed on Australia’s Pharmaceutical Benefits Schedule (PBS) in 2016. These subsidised medicines were made available to all Australians, including people in prison. Prisoners are usually excluded from the federal government’s PBS subsidies, with medication costs falling to states and territories.

While overall hepatitis C treatment rates stagnated in Australia, the prison sector accounted for a rising percentage of all people treated. Between March 2016 and February 2017, around 6% (2,052) of all hepatitis C treatments occurred in Australian prisons. In 2020, this rose to 37% (3,005).

For some people, prison is one of few places they can receive hepatitis C treatment.

A pilot evaluation of a nurse outreach program in Victorian prisons found of the 416 people who started direct-acting antiviral treatment, most (86%) had never had hepatitis C care before.

An additional 75 people were released from prison before they could start treatment. After referral to their preferred physician, only 19 were prescribed direct-acting antivirals within six months of release. Seven of those people were treated only after they were re-incarcerated.

Many people leaving prison face multiple challenges, including housing instability, poverty, obtaining meaningful and reliable employment, and social connectedness. These are all potential barriers to accessing health care, including hepatitis C treatment.

Treatment in prison can also prevent new infections, as a recent study showed. This same study also saw a reduction in people being reinfected with hepatitis C.

One Queensland prison has even reported eliminating hepatitis C. However, new entrants and the lack of prison-based needle and syringe programs have made it difficult to maintain its hepatitis C-free status.

But prisons have more to do

While significant progress has occurred, there is more work to be done within the prison sector to accelerate hepatitis C elimination.

Rapid point-of-care hepatitis C tests could be used to diagnose people entering prison, enabling anyone who tests positive to be promptly referred for treatment.

Finger prick test — Point of care tests can promptly diagnose hepatitis C. Shutterstock

Harm reduction is critical. Strategies proven highly effective in the community should be widely accessible inside prisons, including opioid substitution treatment and needle and syringe programs. Despite widespread support for prison-based needle and syringe programs and international evidence showing that they can operate without compromising safety, no Australian jurisdiction has introduced one.

Many people serving supervised correctional orders in the community are likely to have undiagnosed or untreated hepatitis C. Greater coordination and provision of health services across the criminal justice system – including police detention, the courts and community-based corrective services – will enable more people to be diagnosed and treated.

These measures will reduce rates of hepatitis C in prisons and in the community.

Freya Saich is a member of the Public Health Association of Australia.

Alexander J. Thompson receives research funding from the National Health and Medical Research Council of Australia. He has received research funding for investigator-initiated projects focused on increasing testing and treatment for people living with hepatitis C, evaluation of novel treatments for people living with hepatitis C and evaluation and validation of novel diagnostics for hepatitis B from the following companies - Gilead Sciences, Abbvie, MSD Australia, Roche Molecular Systems, Inc (Gilead Sciences and Abbvie both produce DAAs that are used in Australia). In his clinical capacity, he has served on advisory boards to the following companies - Abbvie, Gilead Sciences, Roche Diagnostics, BMS, Merck, Immunocore, Janssen, Assembly Biosciences, Arbutus, Vir Biotechnology, Eisai, Ipsen, and Bayer. He has received speaker fees for presenting at educational conferences or seminars from the following companies - Abbvie, Gilead Sciences, Roche, BMS. He is a board member of the Gastroenterology Society of Australia.

Jacinta A. Holmes receives research funding from the Gastroenterological Society of Australia and has received unrestricted research funding for investigator-initiated projects from Gilead Sciences (who produces DAAs) focused on point of care testing for hepatitis C infection. She has received speaker fees from AbbVie and Gilead Sciences for presenting at conferences, education sessions, and post-conference webinars (which may include updates regarding hepatitis C infection and treatment of hepatitis C infection).

Rebecca Winter has previously received funding from the National Health and Medical Research Council. She holds an Honorary position at St Vincent's Hospital Melbourne and is an Adjunct Research Fellow at Monash University in the School of Population Health and Preventive Medicine. She is a member of the National Prisons Hepatitis Network.

Timothy Papaluca does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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