Direct-acting Antiviral Therapy and Reinfection Among People With Chronic Hepatitis C Virus Infection and Recent Injecting Drug Use in the Prison Setting (The SHARP-P Study)

In Australia, hepatitis C virus (HCV)-related morbidity and mortality have doubled in the past decade, with health care costs of $220 million per annum associated with approximately 200,000 chronically infected cases. The majority of new (90%) and existing (80%) cases of HCV infection occur among people who inject drugs (PWID).

As there is a close relationship between imprisonment, injecting drug use, and HCV, in any given year, almost 20,000 of those with chronic HCV in Australia spend time in prison, including approximately 8,000 in New South Wales (NSW). These individuals are likely to represent the most marginalised and 'hard-to-access' subgroup of the affected population. In addition, the prison environment is a key venue for ongoing transmission. Amongst PWID in the prison setting the report of any injecting drug use decreased from 71% prior to prison entry to 27% following imprisonment. However, among people who reported injecting drug use, the proportion reporting sharing a needle/syringe increased from 29% prior to prison entry to 73%. In the community, 15-20% of current PWID report recent (last month) receptive needle/syringe sharing.

In prison, where there is no access to formal needle and syringe programs, sharing injecting equipment can be normative with inmates' accounts of injecting practice revealing few ways that they can minimise HCV risk. Establishing effective disease prevention in the prison context is challenging, as prisons are unique in physical structure, and prisoners form a distinct micro-society with their own rules and regulations. Many health problems amongst prisoners arise directly from conditions of imprisonment such as overcrowding, uncontrolled exposure to violence and illicit drugs, lack of purposeful activity, separation from family networks and emotional deprivation.

The existing strategies for HCV prevention in NSW prisons are delivered by Justice Health & Forensic Mental Health and Corrective Services. Justice Health & Forensic Mental Health provides a targeted screening program for blood-borne virus infection with pre- and post-test counselling, and opioid substitution treatment (OST) for those who are opioid dependent. Corrective Services provides bleach (or the quaternary amine disinfectant, Fincol) to clean used syringes. NSP is not available.

Despite these efforts, in the Hepatitis C Incidence and Transmission Study in prisons (HITS-p; n=590) led by CI-Lloyd, half of the cohort (49%) of PWID reported injecting drug use during follow-up in prison and 31% reported sharing injecting equipment. HCV incidence was 14.1/100 p-yrs (95% CI: 9.96, 19.3). There was no apparent protective effect of bleach cleansing or OST, highlighting the additional challenges of HCV prevention in the custodial setting.