Summary
The project aimed to assess the feasibility of blood spot testing for HBV and HCV in a category B and C prison and to evaluate the number of prisoners seen and treated in the liver clinic.
A walk-in service was provided in HM Prison Elmley to test for hepatitis B and C, followed by clinic appointments at Maidstone Hospital in all positive cases: 160 prisoners were tested for HCV antibodies of which 33.75% were positive, and those that were positive for Hepatitis C virus then went on to be tested for HCV RNA where 23.75% were RNA positive. The results highlight that HCV testing in prisons has the potential to vastly increase the number of people who are identified as HCV positive.
Challenge
There is a high incidence of chronic hepatitis B and C in the UK prison population and this is predominantly related to the prevalence of previous IV drug usage in prisoners. Prisoners have restricted opportunities for access to counselling and testing for viral hepatitis and the delays in obtaining formal blood test results often interfere with disease assessment, as does the prison service’s policy of regularly moving prisoners from prison to prison.
HM Prison Elmley – the largest of a local cluster of prisons - has approximately 1,000 male inmates, in whom the total prevalence of chronic viral hepatitis is estimated to be 20-25%. The liver clinic at Maidstone Hospital wanted to optimise case finding in viral hepatitis C (and B) in the largest local prisons with a blood spot test carried out in the prison itself with the results notified directly to the team’s hepatitis clinic to expedite the referral process.
Objectives
To assess the feasibility of blood spot testing for HCV (and HBV) in category B and C prisons. A secondary objective was to evaluate the number of these prisoners subsequently seen and treated in the liver clinic.
Solution
A walk-in service, advertised to all prisoners, was provided in Elmley prison to provide testing for hepatitis B and C. Follow-up clinic appointments at Maidstone Hospital for further assessment in all positive cases was arranged. During the course of the study, testing was extended to HMP Rochester, which held approximately 700 inmates, where a total of 39 prisoners were tested. The walk-in service was advertised throughout both prisons.
Prisoners tested using blood spot testing kits were notified of their results. Those with negative results or were antibody positive but PCR negative were informed by letter. Those with positive results were either given an appointment to attend healthcare or the results were directly communicated by our research nurse.
PCR positive patients were subsequently seen with a view to antiviral therapy in the formal hepatitis clinic, unless declined by the patient or a prison move of other healthcare issue supervened.
Results
The programme ran from June 2013 to July 2014 and 160 male prisoners were tested using the blood spot testing kit (121 from HM Prison Elmley and 39 from HM Prison Rochester). Of these, 1.25% tested positive Hepatitis B core antibody, whilst no prisoners tested positive to Hepatitis B surface antigen. All 160 were tested for HCV of which 33.75% were positive. Those that tested positive for Hepatitis C virus then went on to be tested for RNA. From the total number of prisoners 23.75% were RNA positive. Those that tested positive for both HCV antibodies and HCV RNA underwent genotyping. Of the 38 prisoners that were PCR positive, 30 (78.9%) were informed of their results directly by the research nurse. Five of these (13.2%) have commenced treatment as a result of this study and continue to be followed up in the liver clinic in Maidstone.
Learnings
HCV testing in prisons has the potential to vastly increase the number of individuals who are identified. Discussion and education allows those who are PCR positive to take ownership of the disease and take personal measures to reduce harm e.g. reduce alcohol, safe IVDU technique, practise safe sex and address vertical transmission risks. There is a strong argument for integration of HCV testing with other routine prison healthcare service provision. Appropriate pre-test counselling and post-test counselling needs to be implemented along with identification of risk behaviour and education about the value of treatment.
Evaluation
The study highlights that this high risk population does have a high prevalence of Hepatitis C - prior to it, the vast majority of the prisoners were unaware of their Hepatitis C status. As a consequence this can increase transmission amongst the prison population and the general public. The drop-in sessions were successful as they provoked curiosity among the other prisoners and as a consequence more were tested as part of a large group – but it was difficult arranging sessions that did not clash with the prison routine and prison movements.
The number of patients ultimately starting treatment was a relatively small proportion of those eligible, but these individuals would have not have otherwise been able to start antiviral therapy.
