Diagnosis and Management of Hepatitis C (2024) | National Commission on Correctional Health Care

Diagnosis and Management of Hepatitis C (2024)

Diagnosis and Management of Hepatitis C (2024)

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Position Statement

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Jails and prisons in the United States should adopt opt-out education, testing, and treatment programs for hepatitis C virus infection (HCV) for all people newly admitted into the correctional facility in accordance with the following recommendations:

  1. Patient education: Hepatitis C education should include information on modes of transmission, prevention strategies, screening recommendations, and curative treatment options.
  2. Testing: Testing should include HCV antibody testing followed by reflex HCV RNA testing, if antibody positive, to confirm chronic HCV infection.
  3. Treatment: Treatment should include timely access to curative direct-acting antiviral (DAA) medications in accordance with current evidence-based treatment guidelines. Patients taking DAAs before admission should be continued on treatment at the time of incarceration.

Correctional systems should adopt HCV treatment strategies that are optimal for their settings. These may include training of on-site primary care providers, referral to on-site or off-site specialist care, or providing care through telehealth modalities.

Patients with HCV should receive evidence-based treatments for co-occurring substance use disorders, including medications for opioid use disorder (OUD).

Correctional systems should include adequate funding for HCV treatment programs in their health care budgets and pursue procurement strategies that maximize drug access and cost-effectiveness, including assessing eligibility for federal Medicaid waiver and Ryan White HIV/AIDS Program funding. Federal and state legislation, funding opportunities, and Centers for Medicare and Medicaid Services actions relevant to incarceration are changing rapidly, and facilities should stay current with the latest updates.

Correctional systems should evaluate their HCV programs by assessing relevant outcomes that will drive continuous quality improvement of patient care.

Discharge planning for residents with HCV should incorporate strategies that support continuity of care. These include providing antiviral medications at the time of release to bridge care, assisting with benefit applications such as Medicaid enrollment, coordinating with community partners to support psychosocial needs, linking to treatment for OUD, providing education on harm reduction strategies, and adopting patient navigator models.

Residents with untreated HCV who are discharging from jails or prisons should be provided linkages to community-based HCV treatment services.

Discussion

Many residents of U.S. correctional facilities have histories of exposure to HCV infection before incarceration. Exposures to HCV can also occur during incarceration, potentially through nonsterile injection drug use and unregulated tattoo practices. An analysis of state prison populations estimated that 8.7% of residents have chronic HCV infection, a nearly ninefold higher prevalence than in the U.S. general population.1 Many residents with HCV infection are unaware of their infection, their risk of developing serious liver disease, and the potential for transmission of HCV to others.

The U.S. Preventive Services Task Force recommends universal HCV screening for all adults at least once during a lifetime as well as screening for people with risk factors for HCV infection, including incarceration. HCV screening includes initial testing for anti-HCV antibodies; if positive, this is followed by confirmatory polymerase chain reaction testing to identify chronic HCV viremia.2 The Centers for Disease Control and Prevention (CDC) and the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommend universal opt-out HCV screening for people entering U.S. jails and prisons.3-5 Opt-out HCV screening programs have been effectively implemented in both jail and prison settings.6 HCV screening programs should include counseling to residents on HCV modes of transmission, prevention strategies, and curative treatment options. HCV educational efforts can be augmented by peer-to-peer education that has proven effective in the carceral setting.7

Incarcerated residents diagnosed with HCV infection should have timely access to curative treatments with DAAs in accordance with the most current evidence-based treatment recommendations.4 Newly admitted residents who are receiving DAA treatment for HCV should be continued on their medications. HCV treatment programs that adopt a range of strategies have been effectively implemented in U.S. jails and prisons.8-10 Treatment models include training of on-site primary care providers, referring patients to on-site or off-site specialists, and providing care through telehealth modalities. Clinical competencies of correctional health care professionals can be enhanced through investments in continuing medical education and innovative telementoring programs such as the Extension for Community Healthcare Outcomes program.11 HCV patients with co-occurring substance use disorders should have access to recommended treatments for OUD. Treating OUD is associated with lower rates of HCV reinfection in people who have been successfully treated for HCV with DAAs.12

The availability of curative treatments for HCV is a historic advancement in modern medicine: HCV elimination is now an achievable goal. A proposed national plan to eliminate HCV highlights the strategic priority of diagnosing and treating underserved patient populations, including those who are justice-involved.13 The collective commitment of correctional health care professionals will be vital to the success of this national initiative. The broad implementation of curative treatments for HCV in U.S. jails and prisons will advance the well-being of incarcerated residents, help address health inequities, and promote the public health of our communities.

August 2024 – Adopted by the National Commission on Correctional Health Care Governance Board

References

  1. Spaulding, A. C., Kennedy, S. S., Osei, J., Sidibeh, E., Batina, I. V., Chhatwal, J., Akiyama, M. J., & Strick, L. B. (2023). Estimates of hepatitis C seroprevalence and viremia in state prison populations in the United States. Journal of Infectious Diseases, 228(S3), S160–S167. https://doi.org/10.1093/infdis/jiad227
  2. Moyer, V. A., & U.S. Preventive Services Task Force. (2013). Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 159(5), 349–357. https://doi.org/10.7326/0003-4819-159-5-201309030-00672
  3. Centers for Disease Control and Prevention. (2022). At-a-glance: CDC recommendations for correctional and detention settings testing, vaccination, and treatment for HIV, viral hepatitis, TB, and STIs. https://stacks.cdc.gov/view/cdc/120256
  4. American Association for the Study of Liver Diseases/Infectious Diseases Society of America. (n.d.). HCV guidance: Recommendations for testing, managing, and treating hepatitis C.hcvguidelines.org
  5. Bhattacharya, D., Aronsohn, A., Price, J., Lo Re, V., & AASLD-IDSA HCV Guidance Panel. (2023). Hepatitis C guidance 2023 update: AASLD–IDSA recommendations for testing, managing, and treating hepatitis C virus infection. Clinical Infectious Diseases, https://doi.org/10.1093/cid/ciad319
  6. McNamara, M., Furukawa, N., & Cartwright E. J. (2024). Advancing hepatitis C elimination through opt-out universal screening and treatment in carceral settings, United States. Emerging Infectious Diseases, 30(13), S80–S87. https://doi.org/3201/eid3013.230859
  7. Thornton, K., Sedillo, M. L., Kalishman, S., Page, K., & Arora, S. (2018). The New Mexico peer education project: Filling a critical gap in HCV prison education. Journal of Health Care for the Poor and Underserved, 29(4), 1544–1557. https://doi.org/10.1353/hpu.2018.0111
  8. Syed, T. A., Cherian, R., Lewis, S., & Sterling, R. K. (2021). Telemedicine HCV treatment in department of corrections results in high SVR in era of direct-acting antivirals. Journal of Viral Hepatitis, 28(1), 209–212. https://doi.org/10.1111/jvh.13392
  9. Chan, J., Kaba, F., Schwartz, J., Bocour, A., Akiyama, M. J., Rosner, Z., Winters, A., Yang, P., & MacDonald, R. (2020). The hepatitis C virus care cascade in the New York City jail system during the direct acting antiviral treatment era, 2014–2017. EClinicalMedicine, 27, https://doi.org/10.1016/j.eclinm.2020.100567
  10. Hale, A. J., Mathur, S., Dejace, J., & Lidofsky, S. D. (2023). Statewide assessment of the hepatitis C virus care cascade for incarcerated persons in Vermont. Public Health Reports, 138(2), 265–272. https://doi.org/1177/00333549221077070
  11. Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., Parish, B., Burke, T., Pak, W., Dunkelberg, J., Kistin, M., Brown, J., Jenkusky, S., Komaromy, M., & Qualls, C. (2011). Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine, 364(23), 2199–2207. https://doi.org/1056/NEJMoa1009370
  12. Hajarizadeh, B., Cunningham, E. B., Valerio, H., Martinello, M., Law, M., Janjua, N. Z., Midgard, H., Dalgard, O., Dillon, J., Hickman, M., Bruneau, J., Dore, G. J., & Grebely, J. (2020). Hepatitis C reinfection after successful antiviral treatment among people who inject drugs: A meta-analysis. Journal of Hepatology, 72(4), 643–657. https://doi.org/10.1016/j.jhep.2019.11.012
  13. Fleurence, R. L., & Collins, F. S. (2023). A national hepatitis C elimination program in the United States: A historic opportunity. JAMA, 329(15), 1251–1252. https://doi.org/1001/jama.2023.3692

Definitions

Adolescents: people under the age of 18

Young adults: people ages 18-25

Discussion

A focus on rehabilitation of adolescents remains at the core of all health care and correctional programming in the juvenile legal system. Adequate sleep is critical to adolescent health and rehabilitation. Moreover, reports of sleep disturbance and requests for “sleep meds” are recurrent among many detained youth. The American Academy of Sleep Medicine recommends 8 to 10 hours of sleep per night for teenagers and 7 to 9 hours for young adults.3,4 However, as many as 73% of adolescents in the community get fewer hours of sleep,5 and approximately 24% suffer from insomnia.6

Adolescent insomnia may be related to medical comorbidities (including sleep apnea, particularly among youth with obesity and those who snore loudly) as well as the following risk factors often found in youth who are detained:

  • Psychological conditions (e.g., ADHD with medication treatment [stimulants], PTSD, anxiety disorders, depressive and other mood disorders)
  • Poor sleep hygiene (e.g., inconsistent sleep schedules; afternoon caffeine consumption; use of blue light electronic devices such as tablets, television, computers; and high-impact activities before “lights out”)
  • Acute stress/family disorganization7
  • Substance use, especially marijuana, alcohol, and psychostimulants

In addition, many youth enter the juvenile legal system already taking psychotropic or over-the-counter medication that either specifically targets insomnia or somehow impacts sleep architecture.

Additional risk factors for poor sleep specifically associated with the detention environment may impact sleep even in youth without premorbid medical or psychiatric conditions or prior history of sleep disturbance, including the following:

  • Adjustment issues (e.g., sights, sounds, smells, fears of being physically or sexually assaulted, fear of being bullied or extorted)
  • Environmental factors (e.g., doors slamming, yelling, loudspeaker announcements, staff talking by handheld devices/intercoms, comfort of bed and bedding, room temperature, room lights)
  • Sleep–wake cycle and forced phase shift at time of detention

Numerous sequelae of impaired sleep have been identified, including the following:

  • Psychological: Patients with impaired sleep have been found to be 4 times more likely to develop new major depression over the next 3 to 5 years, 2 times more likely to develop anxiety, and 7 times more likely to develop substance use disorders.8 Insomnia is also associated with suicide risk.9
  • Medical: Patients with impaired sleep have higher rates of hypertension, heart disease, and diabetes mellitus, 10 and obesity.11
  • Social: Incarcerated adults with impaired sleep have demonstrated lesser ability to partake in or benefit from prison-based programs compared to incarcerated adults without sleep impairment.12
  • Academic: Poor sleep interferes with executive functioning tasks including attention, information processing, and self-regulatory processes such as impulse control. School performance appears worse in those with impaired sleep.13

Overall, although sleep management has not been well-studied in the youth detention setting, the available evidence indicates that a multifaceted approach that incorporates psychoeducation, cognitive behavioral therapy, and, when indicated, medication has been shown most effective both for adolescents both in the community and in detention.

References

1     Levenson, J., London, S., Ekas, D., Woods, M., Vojtash, M., Mulvey, E., & Miller, E. (2022). Sleep among adolescents in juvenile detention. Sleep, 45(1), A218. https://doi.org/10.1093/sleep/zsac079.488

2     Sheppard, N., & Hogan, L. (2022). Prevalence of insomnia and poor sleep quality in the prison population: A systematic review. Journal of Sleep Research, 31(6), e13677. https://doi.org/10.1111/jsr.13677

3     Paruthi, S., Brooks, L. J., D’Ambrosio, C., Hall, W. A., Kotagal, S., Lloyd, R. M., Malow, B. A., Maski, K., Nichols, C., Quan, S. F., Rosen, C. L., Troester, M. M., & Wise M. S. (2016). Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 12(6), 785–786. https://doi.org/10.5664/jcsm.5866

4     Watson, N. F., Badr, M. S., Belenky, G., Bliwise, D. L., Buxton, O. M., Buysse, D., Dinges, D. F., Gangwisch, J., Grandner, M. A., Kushida, C., Malhotra, R. K., Martin, J. L., Patel, S. R., Quan, S. F., & Tasali, E. (2015). Recommended amount of sleep for a healthy adult: A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Journal of Clinical Sleep Medicine, 11(6), 591–592. https://doi.org/10.5664/jcsm.4758

5     Wheaton, A. G., Jones, S. E., Cooper, A. C., & Croft, J. B. (2018). Short sleep duration among middle school and high school students — United States, 2015. Morbidity and Mortality Weekly Report, 67(3), 85–90. http://dx.doi.org/10.15585/mmwr.mm6703a1

6       Hysing, M., Pallesen, S., Stormark, K., Lundervold, A., & Sivertsen B. (2013). Sleep patterns and insomnia among adolescents: A population-based study. Journal of Sleep Research, 22(5), 549–556. https://doi.org/10.1111/jsr.12055

7       Fellman, V., Heppell, P. J., & Rao, S. (2024). Afraid and awake: The interaction between trauma and sleep in children and adolescents. Psychiatric Clinics of North America, 47(1), 229–253. https://doi.org/10.1016/j.psc.2023.06.015

8     Morin, C. M., & Benca, R. (2012). Chronic insomnia. Lancet, 379(9821), 1129–1141. https://doi.org/10.1016/S0140-6736(11)60750-2

9     Wang, Z., Tang, Y., Wang, G., Deng, Y., Jiang, Y., Sun, W., Sun, X., Ip, P., Owens, J., Zhao, M., Xiao, Y., Jiang, F., & Wang, G. (2024). Insufficient sleep is associated with increasing trends in adolescent suicidal behaviors. Journal of Adolescent Health, 74(6), 1198–1207. https://doi.org/10.1016/j.jadohealth.2024.01.030

10   National Heart, Lung, and Blood Institute. (2022). What is insomnia? https://www.nhlbi.nih.gov/health/insomnia

11    Schneider, A.C., Zhang, D. & Xiao, Q. (2020). Adolescent sleep characteristics and body-mass index in the Family Life, Activity, Sun, Health, and Eating (FLASHE) Study. Scientific Reports, 10, 13277. https://doi.org/10.1038/s41598-020-70193-w

12   Harner, H. M., & Budescu, M. (2014). Sleep quality and risk for sleep apnea in incarcerated women. Nursing Research, 63(3), 158–169. https://doi.org/10.1097/NNR.0000000000000031

13    Perkinson-Gloor, N., Lemola, S., & Grob, A. (2013). Sleep duration, positive attitude toward life, and academic achievement: The role of daytime tiredness, behavioral persistence, and school start times. Journal of Adolescence, 36(2), 311–318. https://doi.org/10.1016/j.adolescence.2012.11.008

Resources

Adornetti, J. P., Woodard, K. N., Nogales, J. M., Carlucci, M., Crowley, S. J., & Wolfson, A. R., (2023). Sleep and circadian health in juvenile justice systems: A descriptive analysis. Sleep Health, 9(6), 876–881. https://doi.org/10.1016/j.sleh.2023.08.009

Asarnow, L. D., & Mirchandaney, R. (2024). Sleep and mood disorders among youth. Psychiatric Clinics of North America, 47(1), 255–272. https://doi.org/10.1016/j.psc.2023.06.016

Morris, N. P., Holliday, J. R., & Binder, R. L. (2021). Litigation over sleep deprivation in U.S. jails and prisons. Psychiatric Services, 72(10), 1237–1239. https://doi.org/10.1176/appi.ps.202100438

Penn, J. V., & Thomas, C. (2022). Practice parameter for the assessment and treatment of youth in juvenile detention and correctional facilities. Journal of the American Academy of Child & Adolescent Psychiatry, 44(10), 1085–1098. https://doi.org/10.1097/01.chi.0000175325.14481.21

Tamburello, A., Penn, J., Ford, E., Champion, M. K,, Glancy, G., Metzner, J., Ferguson, E., Tomita, T., & Ourada, J. (2022). Practice resource for prescribing in corrections. Journal of the American Academy of Psychiatry and the Law, 50(4). S1-S62.