Testing rates for HCV in prisons in the United Kingdom remain far below the national minimum target of 50% and without radical change, prison testing rates will pose a major barrier to the elimination of hepatitis C in the UK, researchers from the University of Nottingham warn in a study published in the Journal of Viral Hepatitis.
The prevalence of hepatitis C is high among prisoners in the United Kingdom; a 2014 study found that 8% of people in prisons in England and Wales had hepatitis C antibodies. Incidence of hepatitis C is also high in prisoners. A Scottish study found that between a quarter and a third of people who injected drugs during their prison stay acquired HCV, demonstrating the high risk of HCV transmission in the prison setting and the need for effective testing, treatment and harm reduction interventions in prisons.
To improve testing rates in prisons in England, opt-out testing as soon as possible after reception into prison was introduced in April 2014, with the aim of testing at least 50%-70% of people entering prisons.
Researchers from the University of Nottingham evaluated rates of testing in 14 prisons in the East Midlands between January 2015 and July 2017. They also visited prisons to clarify how testing took place and what difficulties staff had faced in implementing opt-out testing. The prisons varied from prisons with a low turnover of inmates to prisons admitting large numbers of people for short periods, either on remand or prior to transfer to other prisons in the region.
Between July 2016 and June 2017, 20,075 people were admitted to prisons in the region. In some cases, people were admitted to prison twice (or more), due to transfer or reoffending. Testing rates varied from 7.6% to 40.7% and prevalence varied from 0.9% to 80%.
The researchers analysed factors potentially associated with a higher likelihood of testing, based on their investigations in prisons.
Five factors were associated with a higher likelihood of testing.
People were more likely to undergo testing if the majority of the prison intake came from other prisons rather than the community (OR 2.2, 95% CI 1.9-2.3). Prisons in which the majority of people were admitted from the community are likely to be short-term remand prisons in which the average stay is around ten weeks. On admission to prison, people should have an immediate health check to identify urgent health problems and a comprehensive check-up a week later. How and when opt-out testing is offered varies from prison to prison. The lack of resources to deal with opt-out testing of a high volume of new inmates in prisons may explain the lower testing rate in these prisons.
People were more likely to test if they were in a prison where they were permitted to walk to the healthcare facility without a prison officer (OR 1.7, 95% CI 1.5-1.8) or if they were in a prison where at least 50% of inmates reported that it was easy to see a nurse (OR 2, 95% CI 1.8-2.2).
Testing was more likely in prisons where antiviral treatment for hepatitis C was not available on the premises than in prisons where it was provided through an outreach service to the prison from a local hospital (OR 1.3, 95% CI 1.2 – 1.5). The researchers say that providing an identifiable hepatitis C service in the prison may lead to stigmatisation of people known to attend it, and may contribute to reluctance to test.
Testing was also more likely in prisons where health care was provided by a private sector provider than in prisons where the NHIS provided health care (OR 1.3, 95% CI 1.2-1.5).
The researchers say they found wide variations in how opt-out testing was presented to people in prison and substantial variation in understandings among prison staff of what an opt-out testing policy meant.
But the research group concludes that the biggest barrier to improved uptake of testing is prison infrastructure. “Most prisons are not equipped in terms of staff or space to deal with the increased workload that a 50% testing target would engender.” They say that remand prisons should be a focus for quality improvement.
By Keith Alcorn
Jack K, Thomson BJ, Irving WL. Testing for hepatitis C virus infection in UK prisons: what actually happens? J Viral Hepat, 2019, 1-11.