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Hepatitis C screening of prison inmates would benefit wider community and be cost-effective

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The benefits of screening prison inmates for infection with the hepatitis C virus (HCV) and treating those who test positive for the infection would extend far beyond the prison population, according to projections made by investigators from Massachusetts General Hospital (MGH),the University of Pittsburgh Graduate School of Public Health, Georgia Institute of Technology and Emory University.

In a report published in the Nov. 23, 2015 edition of Annals of Internal Medicine, the research team describes how their simulation found that a prison-based screening and treatment program could reduce HCV transmission in the general community and would be highly cost effective over the long run.

"In addition to reducing the transmission of HCV after prisoners are released, universal HCV testing and treatment in prisons would reduce outcomes of advanced HCV – such as liver cancer, end-stage liver disease and death – among prisoners," says Jagpreet Chhatwal, PhD, of the MGH Institute for Technology Assessment, senior author of the report. "We now have highly effective treatments for HCV, so we wanted to know the impact of providing routine testing and treatment to inmates, a group in which the infection is highly prevalent."

Among individuals with a history of incarceration, HCV infection is primarily transmitted by the use of injected drugs. It is the leading cause of liver cancer, and HCV-associated liver failure is the most common situation requiring a liver transplant. While about one percent of the general U.S. population is infected with HCV, more than 17 percent of prisoners are infected. HCV-associated liver disease is a frequent cause of death among prisoners, recently surpassing HIV infection.

In recent years several drugs capable of eradicating HCV infection in more than 90 percent of patients have become available, but they are quite costly, which could discourage their use in state and federal prisons that have limited budgets for inmate health care.

"Prisons are an ideal setting for routine infectious disease screening, and with new treatments that are curing a substantially greater number of people infected with HCV, there is real potential to reduce the number of cases across the U.S.," says study co-author Anne Spaulding, MD, MPH, assistant professor of epidemiology at Emory’s Rollins School of Public Health.  

To evaluate the health and economic benefits of instituting HCV screening and treatment in U.S. prisons, the team -- including lead author Tianhua He, MD, formerly at the University of Pittsburgh Public Health Dynamics Laboratory and now at Tsinghua University Medical School in Beijing -- developed a computer simulation model to project outcomes of several screening strategies. The four scenarios were one-time screening of current and newly incarcerated individuals with a history of injected drug use or universal opt-out screening of all current inmates as well as new inmates for one, five or ten years.

Their model simulated the dynamics of HCV disease among inmates and the general population and incorporated factors such as the progression of HCV disease, transmission of HCV to uninfected individuals, and the movement of inmates into and out of prisons. The model projected both the costs involved with screening and treatment and the resulting benefits – cost savings from the reduction of future treatment needs and the prevention of both serious HCV-related outcomes among infected inmates and of further transmission in the community. For example, universal opt-out screening followed by treatment would cost 12.4 percent over the amount legislators currently allocate to prison budgets, but that amount would decline precipitously over time. 

"Our model is the first of its kind to capture the indirect, society-wide benefits of HCV control interventions in prisons," according to lead author He. "We expect this new approach to measuring the impact of medical interventions on HCV in the wider community may also be applied to future studies of other infectious diseases."

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