In March 2018, the All-Party Parliamentary Group published the report – Eliminating Hepatitis C in England. A report produced with the aim of moving towards achieving NHS England’s ambition to eliminate hepatitis C by 2025 at the latest. A target date some five years before the World Health Organization target of 2030.
One of the key risk factors was the acknowledgment that Hepatitis C disproportionately affects people who inject drugs (PWID) are the group most at risk of becoming infected with hepatitis C, with transmission occurring via shared syringes and other injecting equipment. Approximately 50% of PWID remain undiagnosed, and prevalence of hepatitis C among recent initiates in drug use was found to be 26%. PWID are a key target population for hepatitis C prevention, diagnosis, and treatment initiatives.
There is a high prevalence of hepatitis C among people in prison, due to a high population of PWID in prison, as well as unsafe injecting and tattooing taking place within prison.
Prisons, substance misuse services, and sexual health services have traditionally been the key settings to offer hepatitis C testing to high concentrations of at-risk populations. People in touch with these services are highly likely to have put themselves at risk for transmission, and the aim in these settings should be universal testing and regular re-testing of all service users. There are unique challenges and missed opportunities in each of these settings.
This report puts forward a series of desired outcomes and action-based recommendations to support objectives leading to elimination of hepatitis C, which are specific to prisons and prison healthcare providers:
- Increased awareness of hepatitis C among PWID and people in prison.
- Increased awareness of the ease and short duration of new direct acting antiviral (DAA) treatments among prisoners.
- Increased awareness of the ease and short duration of new DAA treatments among PWID.
- Prison staff are an effective source of information for prisoners on harm reduction and prevention.
- Fewer new infections as a result of improved knowledge of transmission risks.
- Increased coverage and uptake of testing in substance misuse services.
- Increased coverage and uptake of testing in prisons.
- Opt-out dry-blood spot testing for hepatitis C is fully implemented in substance misuse services and prisons.
- A target of 20,000 people per year treated is set, incentivised, and monitored.
Recommendations & Actions:
- Awareness-raising talks delivered by peers to be commissioned as an integral part of contracts for substance misuse services and in prisons.
- Nationally-approved NHS England Health and Justice publicity highlighting the ease of new treatments to be rolled out across HM prison estate.
- Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts in prisons.
- Nationally-approved publicity highlighting the ease of new treatments to be rolled out across substance misuse services.
- Hepatitis C peer programmes to be commissioned as an integral part of commissioning contracts for substance misuse services.
- BBV training to be made compulsory for prison staff.
- Peer programmes to be commissioned as an integral part of hepatitis C treatment services in commissioning contracts for substance misuse services and in prisons.
- Opt-out testing for hepatitis C to be commissioned by local authorities in substance misuse services.
- Re-offer of testing to all those engaged with substance misuse services every six months to be mandated and commissioned.
- Testing to be re-offered in prisons to those who did not receive a test at reception.
- Opportunities to be provided for those who previously tested to re-test in prison.
- Clear national protocol to be developed surrounding wording of opt-out test offer in prisons.
- Commissioners to support access for prisoners to second reception screening.
- Research to be conducted on transmission risk within prisons to determine impact of re-testing.
- Commissioning contracts for substance misuse services and prisons to have clear mechanisms to hold services to account for failures to meet testing targets.
- Unnecessary tests and appointments to be reduced, and the use of reflex tested dry blood spot samples, which necessitate only one sample and can be delivered in the community, to be mainstreamed.
- Proportional prison treatment targets to be set for prisons specifically in every ODN depending on prison population.
The findings of this inquiry give us much cause for optimism, and the firm belief that elimination of hepatitis C in the very near future is an achievable national ambition. Given the concentration of this at-risk population within the prison setting, these suggested actions offer real opportunities for prisons and prison healthcare providers to make a positive contribution to society for the elimination of Hepatitis C.