Health Services - implementation
The prison-based health services are pivotal to successful implementation as scale-up of testing and treatment is primarily a health intervention.
As a health assessment of all newly incarcerated prisoners is typically undertaken in correctional systems, universal opt out screening at this time is recommended (Kronfli 2018). A model of care which maximises opportunities for testing and treatment of all prisoners, with simplified pre-treatment work-up and on-treatment monitoring, will assist in optimising scale-up (Mohamed 2020). Models which transfer tasks away from specialist physicians to primary care practitioners or nurses, who are skilled in hepatitis, offer improved efficiency (Overton, 2019, Papaluca 2019). A triage process can ensure the small minority of complex patients are referred for specialist review. In addition, use of telemedicine for these specialist interactions can further resolve delays associated with transfer to specialist clinics in hospital settings (Neuhaus 2018).
Maintaining skilled health care staff to run the model of care is also an important consideration. Staff availability may be constrained due to part time work arrangements, and a lack of suitably qualified staff in rural correctional centres. This may be overcome by development of standardised operating procedures for the care cascade and training multiple health care staff to manage hepatitis C testing and treatment activities.
In the initial phase of the SToP-C implementation, the corrections administrators stipulated daily supervised dispensing of the DAA medications. However, the large number of prisoners being treated and the relatively limited number of hours available for escort of individual prisoners to the health clinic for dispensing restricted the number of prisoners being seen, and therefore reduced treatment scale-up.
Prisoner self-administration was then implemented following a triage assessment to select suitable prisoners. More than 80% of all prisoners were considered suitable for self-administration (please refer to the Resources page for the patient risk assessment tool used in SToP-C). Nursing staff were thereby freed up to perform other tasks.
Maintaining qualified staff
A key issue observed during the SToP-C program was maintaining qualified and trained staff at the selected correctional centres, resulting in reduced productivity.
Various staffing models were attempted, including nursing teams working together where administrative and clinical care tasks were shared to better manage the workload for greater coverage. This was negotiated with each individual centre, to address whether the clinic space could accommodate the team, as well as the provision of alternate space within the prison as a workaround, reiterating the importance of partnerships between corrections and health services. In addition, job advertisements in local media, and via local hospitals and health districts assisted in recruiting suitably qualified staff for the roles.
Mobilising the resources required for effective testing and treatment scale-up is vital for successful implementation. Ensuring adequate clinic space is allocated to the scale-up project will assist in optimal prisoner throughput, and thence treatment numbers. Non-traditional locations (i.e. outside the health clinic) can be utilised for patient review sessions which do not involve venepuncture, or portable kits for safe and secure handling of venepuncture equipment including sharps disposal may be explored with correctional authorities, ideally with storage nearby to the space where clinical interactions take place.
Permission to use clinical equipment and supplies in alternate locations
As health clinic space was limiting scale-up, options for alternative locations were explored with the correctional authority. This included use of such space for clinical interactions including venepuncture, and secure storage of clinical supplies. No guideline for such approvals was in place across the correctional authority.
Agreement with the manager of each prison was reached. There were inconsistencies in the approvals provided on the rules for storage and use of venepuncture equipment across different correctional centres. Some centres required a dedicated safe for medication and restricted use of equipment to health care clinics, and others allowed venepuncture in non-traditional areas within the prison (e.g. in work locations).
As the prisoner population includes many people who inject drugs (PWID), poor venous access is a common problem. The time taken for the health care consultation may be greater in this circumstance, thereby reducing the prisoner throughput. Access to ultrasound-guided phlebotomy, as well as specialist phlebotomists may assist in these circumstances. Alternative strategies may include salivary testing for hepatitis C antibodies and fingerstick blood sampling to test for viraemia (Mohamed 2020).
Self-administration of DAA medications offers an important means to support scale-up. However, if self-administration is associated with poor treatment adherence the individual and population-level benefits may be lost. Such non-adherence may result from the prevalent co-morbidities amongst prisoners including mental health conditions, limited cognitive capacity, as well as diversion as a result of stand-over by other prisoners. Accordingly, triage for self-administration is recommended, taking these factors into account (please refer to Resources page for self-medication suitability assessment tool). Optimal adherence may also be supported by provision of targeted education to those on treatment.
Self administration of medication
A requirement for daily supervised dosing is resource intensive impedes the efficient scale-up of treatment. A process was needed to ensure appropriate assessment of prisoners for self-administration of DAAs, so that large numbers of prisoners could be treated but those needing supervision were identified.
During the SToP-C program, patient risk assessments were completed prior to allowing self-administration of medication. Education resources provided to the prisoners also included messaging regarding the importance of treatment adherence, as well as tolerability and the low side effect profile of DAA therapy. Dosing instructions were tailored to individuals who were receiving concomitant medications, and viral load was tested at 4 weeks following therapy initiation to evaluate adherence and determine whether supportive counselling was required.
“There was a few boys here that were forgetting. I would just have to remind them. I was that one saying “you take your pill today?”
Frequent movements for transfers between correctional centres or for release to freedom, provide a significant challenge to the continuity of care for those on DAA treatment. For correctional system-wide scale-up efforts all health care staff should be educated about hepatitis C testing and treatment to support continuity of care. For those released to freedom, all of the remaining DAA medication to complete the course should be provided to the prisoner on release, along with arrangements for suitable medical follow-up (e.g. for SVR testing) in the community.
Additional harm minimisation interventions should be encouraged during and after DAA treatment to support scale-up and TasP. In the community, the combination of OAT and NSP at high coverage has been shown to reduce HCV transmissions. In the prisons, the measures include regular use of bleach or disinfectants to cleanse injecting devices, provision of OAT, and NSPs where available.
Data collection and information systems
In addition to the regularly updated correctional data regarding the prisoner population, tracking the scale-up of testing and treatment in the health service is critical. This is best completed with individual level data collected in coded format to allow linkage to the correctional dataset. These data should monitor each milestone in the hepatitis care cascade, including those who have participated in each step and the outcome of that step.
- Education of the at-risk population to get tested
- Screening for hepatitis C antibodies and virus (by PCR)
- Clinical and laboratory assessments of those with chronic hepatitis C
- Prescription and provision of DAA medication
- Monitoring after treatment completion for cure (or sustained virological response, SVR) by PCR
- Monitoring after cure for reinfection in those with ongoing risk behaviour
- Retreatment of those who become reinfected
In addition, access to records of those who discontinue the care cascade due to being released to freedom or transferred (and lost to follow-up) should be obtained if possible.
The use of standard proformas is an essential element of hepatitis testing and treatment scale-up, to ensure uniformity across centres (please refer to Resources page for examples of SToP-C clinical proformas).
Specimen transport systems for timely shipment of blood samples to external laboratories for diagnostic pathology testing should be put into place, or existing systems enhanced to manage the increased throughput during scale-up. Laboratory capacity should also be assessed, to ensure capacity to receive and test samples, and provide laboratory reports in a timely manner.
Information systems to support continuity of care for those who are transferred or released to freedom are important, notably via timely data collection with shared access to systems recording key information regarding all prisoners commenced on treatment.
Forming and maintaining collaborative relationships with all stakeholders is critical for successful implementation of hepatitis C testing and treatment scale-up. Once the project team has been developed, all relevant internal and external stakeholders should be identified, to ensure support and avoid impediments to the project. The stakeholders should include individuals or groups who are interested in, or may be affected by, the implementation of the testing and treatment scale-up. These would typically include funding bodies, correctional authorities, health authorities, prisoner representatives, as well as key consumer group and ethnic minority group representatives.
A communication strategy should be developed, to address the needs of all stakeholders. This should include regular updates regarding the status of implementation of the testing and treatment scale-up, tailored to suit the various stakeholder groups. Information sheets and other promotional materials, as well as opportunities for face-to-face information provision may assist with maintaining engagement of the stakeholder groups throughout the testing and treatment scale-up. This may include provision of quarterly updates, articles in newsletters, and annual meetings with progress reports (please refer to Resources page for examples of SToP-C newsletters and stakeholder communications).
Regular combined meetings with health and correctional staff directly involved in the scale-up and prison management are important to ensure harmonised implementation. These communications with health service leaders by the scale-up team should be followed by endorsement and dissemination of progress toward targets to all staff in internal communications such as via newsletters, email, or conveyed during staff meetings, including publicising staff champions.
Establishing open communication
There was a high turnover of prison-based managerial staff in all four SToP-C centres.
Regular site visits and phone calls with the managers of security and nurse unit managers at all four sites were arranged during SToP-C. This was undertaken by the project team and the local staff, to ensure continuity of the project. Moreover, these regular methods of communication acted as a forum of discussion to overcome any operational barriers that arose during the study, which assisted in strengthening the relations between corrective services and health care management teams.
Management of prisoners with chronic hepatitis C and with other health conditions mandates open lines of communication between hepatitis service staff and other health care providers, such as mental health and drug and alcohol services, to harmonise health care priorities and interventions and to prevent miscommunication of roles and responsibilities.
A handover mechanism for communication between health care staff on transfer of those on DAA treatment between prisons, to ensure continuity of care, should follow existing health service processes. The impact of frequent prisoner movements such as transfers between centres, and release to freedom should be considered. These instances necessitate protocols and procedures for redirection of medication supplies, as well as arrangements for clinical follow-up. All health care staff should be educated about hepatitis C testing and treatment to ensure continuity of care.
Continuity of care for prisoners transferred to a new prison or released
Frequent prisoner movements between prisons require systems for the redirection of medication and clinical follow up in real time. Also, a challenge for prisoners commenced on DAA treatment is ensuring continuity of care when released to freedom, particularly when this release occurred ‘unexpectedly’ immediately following a bail or parole hearing.
Close cooperation with correctional authorities was necessary to ensure timely provision of information regarding prisoner transfers. Health staff followed up with hepatitis nurses at new prisons to ensure arrival of remaining medication at the new prison, and made appointments for the transferred prisoner at the receiving prison via the electronic patient administration system. Correctional staff were regularly reminded of the importance of allowing for opened bottles held in the prisoner’s cells to be transported with his/her other possessions.
Health staff monitored anticipated court dates indicating possible release, and also asked the prisoner at regular intervals of the anticipated remaining time in custody. If health staff anticipated release, they ensured all residual medication for the treatment course was available to the prisoner and a follow-up referral for health care in the community was provided. A card containing contact information of the project team was also provided, to allow the prisoner or their health care providers in the community to make contact to access the medication and clinical information.
Communication and Education
Education of all members of the health care staff, especially those not usually engaged in hepatitis care (such as psychiatrists, psychologists, drug and alcohol clinicians) will improve knowledge, and attitudes towards scale-up of hepatitis C testing and treatment in the prisons. Such education may include information provided as part of orientation, as well as ongoing training days, potentially with video, online and print resources. This will assist in development of a positive environment regarding hepatitis C testing and treatment in which prisoners can easily approach any member of the workforce to access hepatitis services (Please refer to Resources page for examples of staff education and training materials).
For prisoners, the starting point for engagement with prisoners is education to improve knowledge and to modify attitudes and trust. Education programs should aim to raise awareness of the simplicity, effectiveness, and benefits of prison-based testing and DAA treatment. The education program should be prison-focused and include multiple modalities including print, video, as well as face-to-face campaigns in health promotion days. (Please refer to Resources page for examples of SToP-C prisoner education materials).
Those who are unaware of hepatitis C, or who place other personal priorities above hepatitis C infection, or are distrustful of health services may remain unlikely to participate in testing or treatment programs. Hence, the education program should include a peer-to-peer approach, recognising that literacy levels are generally low, and that messaging needs to be engaging for prisoners. Peer educators may be selected from amongst the prisoner population on the basis of: correctional authority support for the individual, established peer prisoner recognition, and a suitable anticipated length of stay in the centre.
Both a training and support program for these peer educators, as well as simple graphic-rich resources to support the peer-to-peer interactions in the wings, are key.
Content should include information about:
- Ways to access hepatitis services
- The notion that it is okay to be retreated for those who become re-infected
- Available prevention measures
“There are still barriers. There’s definitely a group of individuals who presumably have chronic hepatitis C who are pretty stand-offish about the health sector, pretty distrustful of whoever it is in that health hierarchy. And that’s a big enough disincentive that they won’t come forward. Hard for us to know how big that group is but, but I’m pretty sure they’re there.”
Education resources for prisoner engagement
Low levels of prisoner knowledge about new hepatitis C treatments was identified as a potential barrier to treatment uptake when DAA therapy was first available. Experience or perception of unpleasant side effects, related to the old interferon-based therapy, was a fear held by many prisoners. There was a need for a comprehensive education campaign to inform prisoners about the new, oral, safe, curative, DAA medications.
During the SToP-C program, prisoner education resources including posters, booklets and videos were developed and approved by the correctional authority. Negotiations with the various prisons was necessary to agree on methods and locations of distribution of these materials, such as in the clinics, wings and educational centres. The video was displayed on loop via the prison-wide audio-visual system so that it could be viewed by prisoners on their cell televisions, or in other common areas. The messaging and graphics in these resources had input from prisoners to ensure suitable language and engaging content. The resources were tailored for low literacy levels and adapted for men and women. Simple messaging and calls to action were used. The need for testing, regardless of risk behaviours, was promoted to encourage all prisoners to get tested and mitigate stigma attached to doing so.
”Well the new ones [the DAAs], it’s just you don’t even know that they’re doing the treatment, because there’s no side effects. It doesn’t make you crook or anything.”
“The wing I was in had a few boys on it [treatment] at the time and I know a few other boys that had got hep C that I was trying to suggest we get in and they get the blood tests. So, yeah, we all talk to each other, see how we’re going on the treatment, you know.”
Furthermore, all staff in contact with prisoners should be capable of providing advice and facilitating referral for testing and treatment. Models of care which integrate hepatitis C testing and treatment into the clinic are recommended to reduce stigma.
Health service staff should recognise the importance of ensuring that confidentiality is maintained and be aware of the potentially negative connotations of a hepatitis C diagnosis, and the misperception that it implies current injecting drug use. Prisoners visiting the clinic for testing and treatment are often concerned they may be ‘outing’ themselves as potential injecting drug users. In prisons where stigma surrounds potential implications around injecting drugs, prisoners may be reluctant to get tested and therefore treated.
For treatment as prevention to be effective, large numbers of prisoners must be tested and treated to reduce transmission. Confidentiality assurances through education materials are useful in developing a trusting environment for prisoners to present to the clinic. Moreover, prisoners should be discouraged from disclosing specific injecting events which may trigger legislated reporting by health staff to correctional authorities.
“I didn’t want to share it [that I had hep C] too much because everyone’s got their own opinion and they like to judge people, so I kept it quiet first. You know, there’s a bit of a stigma that goes along with it.”
Testing and treatment protocols may need to be adapted around cultural sensitivities or norms. Staff should be trained in cultural sensitivity towards special populations, and additional time allocated to prisoner interactions. Education should be tailored to meet the concerns of specific groups, and translated into languages prevalent amongst the prisoner population. Peer education delivered by influential prisoners, or a respected cultural or religious leader is recommended. With such support, targeted testing and treatment plans may be aimed at groups known to have a high prevalence of hepatitis C infection or with high rates of risk behaviours.
They could be feeling like they are in trouble if they were to come up to the clinic and try and do something about [hep C] anyhow, because they’ll be thinking everyone else will find out they’ve got hep C if they are doing the hep C program and that’ll put … they might not be part of that crowd anymore.