Changing Treatment Landscape of Hepatitis C Virus Infection Among Penitentiary Inmates
Because of the high cost of treating all inmates with chronic HCV infection, the large number of inmates who are asymptomatic, and the potential decrease in medication costs after the introduction of generic versions, inmates are being prioritized for treatment based primarily on staging (presence or absence of liver disease). The rationale for using staging for prioritization is that patients with chronic HCV infection and no or minimal fibrosis at presentation seem to progress slowly, and treatment possibly can be delayed or withheld; whereas patients with significant fibrosis (septal or bridging fibrosis) progress almost invariably to cirrhosis over a 10- to 20-year period, so antiviral treatment becomes urgent.33
APRI: Biomarker for Liver Fibrosis
A liver biopsy is the gold standard for the diagnosis of liver fibrosis. Although generally safe, it is costly. It is also subject to sampling error and examiner discrepancy, which lead to incorrect staging of fibrosis in 20% of patients.5,33 Alternatively, various biologic markers can be used to diagnose liver disease. The aspartate aminotransferase (AST) platelet ratio index (APRI) is a simple and useful index based on readily available laboratory results: AST level and platelet count. APRI correlated significantly with fibrosis stage in patients with chronic HCV infection.33
At USP Canaan, 16 (12%) of the 137 inmates with chronic HCV infection had an APRI higher than 1, and 5 of the 16 had an APRI higher than 2.
Conclusion
In coming years, treatment of chronic HCV infection will consume a more significant portion of the health care budget. As treatment becomes more efficacious and safer, the paradigm may shift from a stage-based strategy to a treat-all strategy. Possibly, more inmates will ask for treatment as the treatment burden lessens due to fewer treatment-associated AEs. However, despite the efficacy of HCV treatment, there is no reduction in the overall lifetime medical costs, because the offset in downstream direct medical costs (from successful treatment) is less than the cost of a cure.30
In the BOP, many challenges remain: HCV infection rates are expected to be high, treatment costs astronomical, resources limited, and treated patients may become reinfected if high-risk behavior continues. Patient education is, therefore, an important component of effective prevention and treatment strategies. The U.S. Preventive Services Task Force recommends HCV screening for all high-risk persons and a onetime screening for all baby boomers.34 Federal prisons offer HCV testing to all inmates with risk factors, when clinically indicated, or on
request.
All inmates with chronic HCV infection were being monitored for treatment prioritization, as some were at higher risk for complications or disease progression and required more urgent treatment.35 Ideally, all inmates should be treated, as incarcerated persons are at elevated risk for HCV transmission, and successful treatment would benefit public health by reducing infection rates in the community.16 However, resource constraints are a reality in health care, particularly among underserved populations, and this situation provides the rationale for screening, monitoring, and treatment prioritization. This step-by-step approach, which rests on sound clinical judgment, helps control the budget.
