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- Understanding the legislative and policy framework
- Understanding the prison environment
- The prisoner population
- Understanding the existing hepatitis C testing and treatment services
- Engaging stakeholders and formulating the plan
- Correctional authority – planning
- Health services – planning
Health services - planning
Prison health services should work collaboratively with the correctional authority throughout the planning phase to ensure the proposed model is feasible and is supported by the prison management.
Workforce and other resource requirements
It is challenging and potentially unreliable for the health system to assess risk behaviours, and then ensure this is followed by timely testing and treatment of all positive prisoners.
Efficiencies can be gained by testing all newly incarcerated prisoners via universal opt out testing and initiating DAA treatment as soon as possible, so that transmission risk is reduced. Point-of-care testing, including via finger stick blood sampling, may be a very efficient means of achieving universal testing.
A combination strategy to screen both the existing population and newly incarcerated prisoners is recommended for scale-up.
“The project has actually made our job a lot easier because we’ve been so short-staffed for years and we haven’t had a population health nurse here, so it has taken all of those people who want to be tested for hep C off our list.”
There is strong evidence for simplified models of care, with task transfer away from specialist physicians. The hepatitis C care cascade is very standardised, the assessment is no longer complex, and DAA treatment is both safe and highly effective (Overton, 2019, Papaluca 2019).
Such models typically involve hepatitis-skilled nurses or primary care practitioners managing the majority of prisoners. A small minority of prisoners, notably those with advanced liver disease or complex co-morbidities, may need to be trained for specialist review.
An estimation of the necessary workforce allocation of these providers for treatment scale-up should include:
- The estimated burden of chronic hepatitis C infection in the prison
- The desired rate of scale-up
- The expected patient throughput, including consideration of potential logistical barriers
It is important to note that the need for ancillary staff may increase, for example those responsible for managing drug receipt and storage in the pharmacy, and those providing supervised dispensing to prisoners.
High level organisational support is needed to secure an adequate allocation of the health services budget to hepatitis testing and treatment scale-up activities. In addition, consideration of simplified pathways for testing and treatment should be made – such as use of point-of-care tests for diagnosis, fibro-elastography or laboratory-based fibrosis assessment algorithms, and removal of on-treatment monitoring.
The following costs should be considered:
- Time commitments of primary care practitioners, nurses, and specialist physicians
- Pathology tests including specimen shipment costs
- Pharmacy services
- DAA medication purchase
- Fibro-elastography machines (if planned)
- Staff education and training
- Patient education
The planned mode of medication administration will have a significant impact on resourcing. Self-medication by prisoners is recommended, with weekly or monthly dispensing. This may require advocacy and negotiation with both the health service and correctional authorities.
Preparation of the health data needed for monitoring and evaluation of the scale-up plan may exceed routine data reporting and should be costed. The costs associated with the participation of health personnel in the scale-up planning and management committees should also be considered.
Prisoner self-administered medication
In SToP-C, the correctional authorities harboured concerns regarding diversion of DAA medications to an illicit market (given their high purchase cost, and misinformation of the DAAs as being psycho-active). This concern was underpinned by a policy which mandated supervised daily administration of all medications. The time and personnel resources involved in such a dispensing approach significantly limited scale-up.
Promoting the need for large scale-up and the lack of psycho-active effects of DAAs to correctional authorities was successful in gaining agreement to allow almost all prisoners to self-medicate. Both rapid rate of scale-up and communication to prisoners that access to DAAs was unrestricted helped to diminish their notional value in covert prison currency. Integration of a nurse-led risk assessment of each prisoner prescribed DAAs ensured that only a small minority of prisoners with significant psychological illness or cognitive impairment, or those vulnerable to standover, continued to have supervised medication.
The large majority of people are now taking their pills on a daily basis in their cells, and not being required to come to the clinic. So that is a huge change and really opens up the overall capacity in terms of treatment.“
Data collection and information systems
Understanding the extent and quality of the health information already being collected regarding the hepatitis C care cascade is important to enable monitoring and evaluation of scale-up. Information gaps or issues with access to data should be identified during the planning phase so that the potential to upgrade IT systems, supports and processes can be considered and costed.
IT support for data extraction and preparation of reports is also recommended. An electronic health record which allows identification of each of the events in the care cascade and the outcomes, as well as extraction of such results, is recommended.
Considerations for communication and education
The scale-up plan should include a strategy for communicating with health care staff regularly. Regular communications with health service leaders by the project team should be followed by endorsement and dissemination of progress toward targets to all staff by senior personnel. Methods of dissemination may include newsletters, emails, or announcements during staff meetings, including publicising staff champions (please refer to Resources page for examples of SToP-C newsletters).
Robust procedures for communication between health staff members are required for continuity of care, both across different prisons when prisoners are transferred, or upon release to freedom for those on DAA treatment.
All health staff should be engaged in diminishing the stigma and discrimination associated with hepatitis C infection.
Planning for inclusion of content addressing this in health staff orientation and education programs is recommended.
“Having hep C is bad… straight away people link it to injecting drug use… The stigma of hepatitis, I just want to get rid of it and be done with it… You’re like a pariah.”
Knowledge, attitudes and stigma
Although healthcare staff in the prison sector are generally aware of hepatitis C, amongst those not routinely participating in hepatitis care, there are widely varied levels of awareness of hepatitis C and the highly effective DAA treatments, as well as the important role of the prison sector in regional and national elimination. In addition, not all health care staff have positive attitudes towards the merits of hepatitis C testing and treatment of prisoners.
These knowledge gaps and attitudinal barriers may be overcome by provision of hepatitis C education. Stigma should be considered in planning communications with targeted messaging to correct misinformation, emphasising the right of prisoners to healthcare equivalent to the community, and endorsing the community-wide public health benefits and the prison-specific reduction in risks from needle-stick injuries associated with scale-up. In addition, it remains important to maintain a system to ensure confidentiality of the hepatitis C status of individual prisoners, from correctional officers as well as other prisoners, when planning scale-up. Please refer to Resources page for examples of staff education and training materials, as well as SToP-C educational materials for prisoners.
“My thoughts are that it sounds to be the right thing to do to offer these people [in prison] the ability to have treatments for the condition they have because it is treatable. And, and, if you treat them, the lower the likelihood that they’ll give it to somebody else.”
To encourage testing and treatment for hepatitis C, prison-focused hepatitis education for all prisoners is warranted. Targeted campaigns to coincide with the initiation of scale-up, as well as ongoing education for new prisoners should be planned. Information on ways to access the hepatitis services should also be covered. Peer education programs may complement and enhance scale-up efforts by reaching disengaged prisoners. Approval of the correctional authority will be needed for such education programs and should be sought in the planning phase.
The characteristics of particular prisoner sub-populations may impact on the several aspects of planning the logistics of scale-up of hepatitis C testing and treatment, including higher prevalence of risk behaviours such as injecting drug use, cultural sensitivities or stigma within ethnic minorities about hepatitis C infection, and restricted movement of prisoners in protection programs.
These issues should be considered in planning education programs, and the logistics of testing and treatment scale-up. Targeting groups (as opposed to individuals) for education, testing, and treatment may assist in reducing the stigma associated with hepatitis C infection.
“I’ve been chatting with my sistas (the Aboriginal women I hang out with) about getting tested, because I knew I was positive… We found out three of us were infected and so now we are all getting treated.”