INHSU Global Guidelines for Viral Hepatitis Service Delivery in Prisons

Introductionz

There are over 11.5 million individuals in prison (hereafter referred to as ‘people in prison’) at any one time [1], with a global incarceration rate of 140 per 100,000 population, and national rates ranging up to 629 per 100,000 in the USA [2]. Each year, an increasing number of men and women spend time in prisons, jails, and other closed settings - the vast majority of whom return to the community within a relatively short timeframe [1,3]. The population of people in prison is heavily over represented with the most marginalised groups from the community, including those from poorer socioeconomic strata, immigrants and other foreign nationals, those with poor mental health, and those with high rates of substance use and associated infectious diseases [4]. Chronic viral hepatitis caused by hepatitis B virus (HBV) and hepatitis C virus (HCV) constitutes the major health burden of infectious diseases among people in prison globally [5].

First Section

Rule 24 of the United Nations Standard Minimum Rules for the Treatment of Prisoners (codified as the Mandela Rules) defines the equivalence of care principle: that “prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health care services free of charge without discrimination on the grounds of their legal status” [6]. However, there are multiple challenges to health care implementation in the prison sector, including competing correctional and health priorities, logistical constraints such as frequent movements of people in prison and limited space for clinical service provision, as well as knowledge and attitudinal barriers among correctional and healthcare providers and those who are incarcerated [7]. In addition, prisons are unique in physical structure, and people in prison form a distinct micro-society with their own rules and regulations [8]. The environment features overcrowding, high exposure to violence and drugs, lack of purposeful activity, separation from family networks, and emotional deprivation [8].

As there are close associations between injection drug use, incarceration, and bloodborne virus (BBV) infections, the prevalence of chronic HBV and HCV in the prison sector is substantially higher than in the general population, estimated to be 4.8% for chronic HBV [5,9] and between 13-26% for HCV (prior exposure; anti HCV antibody positive) [5,10,11]. Although available data is more limited, the incidence of new HBV and HCV infections in prisons is also high, with ongoing injection drug use and the sharing of limited and unsterile injecting equipment being key risk factors [10,12–16].

In 2016, the World Health Organization (WHO) set global viral hepatitis elimination targets, including treating 80% of people infected with HCV or HBV, reducing HCV and HBV incidence and liver-related mortality by 90% and 65% respectively, and providing HBV vaccination to 80% of individuals [17]. The 2022-2030 Global Health Sector Strategy on Viral Hepatitis updated these targets to incidence rates of 5 per 100,000 for HCV and 2 per 100,000 for HBV, and disease specific mortality of 2 per 100,000 for HCV and 4 per 100,000 for HBV. Most countries are not on track to meet HBV and HCV elimination targets by 2030 [18]. This is in large part due to the omission of people in prison in global viral hepatitis elimination efforts [19–21]. For example, only 23 countries globally prioritize people in prison in their national hepatitis plans [22].

It is clear that well-resourced and prison adapted health care for HCV and HBV is efficacious in carceral settings [23,24]. While many people in prison remain susceptible to hepatitis A virus (HAV) and HBV, availability of HAV and HBV vaccination is highly variable globally high rates of immunisation coverage have been reported in this setting in some countries [25–27]. Furthermore, the implementation of evidence-based harm reduction services, which are commonplace in the community, including opioid agonist therapy (OAT) and needle and syringe programs (NSP), has stalled in prisons [28–30] despite being endorsed by the United Nations [31–33]. As these interventions are not consistently available or reliably implemented across the prison sector, there is an urgent need to build the evidence base for OAT and NSP in reducing HCV and HBV incidence in prisons. 

In the context of WHO global elimination goals for viral hepatitis [17], prisons and people in prison have been identified as key priorities for national and global elimination efforts [20,34]. To deliver on the elimination goals for HCV and HBV, national commitments for the prison sector in the domains of policy, testing, treatment, continuity of care, prevention and harm reduction, education, monitoring and evaluation, and consideration of minority populations, are needed. 

The objectives of these guidelines are:

1. To present a critical analysis of the evidence supporting viral hepatitis service delivery for people in prison - both for the individual, as well as for global elimination efforts.
2. To make recommendations for best practice standards in viral hepatitis service delivery in the prison sector.

To view the entire guideline, please visit The International Network on Health and Hepatitis in Substance Users – Prisons Network (INHSU Prisons) website online.