Treatment Behind Bars
Part I: Who pays for direct-acting antiretrovirals in prisons?
by Larry Buhl
The new class of direct-acting antiretrovirals (DAAs) that have revolutionized treatment of hep C have greatly boosted the chances of recovery. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America now recommends Sovaldi for treating hepatitis C in most circumstances.
But treating everyone with hepatitis C in correctional facilities with Sovaldi would put a serious strain on all departments of corrections. For perspective, the average annual cost for states to house an inmate is just under $30,000, according to the National Association of State Budget Officers. A standard twelve-week treatment regimen of Sovaldi can cost nearly three times that much.
Paying for HIV meds doesn’t typically break corrections budgets these days. That’s because budgets expanded to cover those meds in the 1990s, when the first cocktails effectively made HIV a manageable disease. But the same budget expansion has not happened with the hepatitis C meds. And the rate of hepatitis C is estimated to be ten times higher than HIV.
The rate of infection with the hepatitis C virus (HCV) in the general public in the U.S. is two percent, according to the CDC, but in correctional facilities across the nation, the infection rate is estimated at seventeen percent. A new study from the National Center for Biotechnology Information estimates that nearly two million people with antibodies to the virus are incarcerated. The study did not state when they became infected—needle sharing during IV drug use and tattooing can happen inside and outside prison walls.
Who gets treated?
The availability of the new drugs, which promise a cure in nine out of ten cases, presents a dilemma for correctional systems.
States, municipalities, and correctional facilities are now deciding which of their incarcerated populations with HCV will get the new meds, and it’s a complicated method for analyzing the need versus cost. Right now it’s a patchwork quilt of guidelines. In general, the policy is triage: treat the inmate with the combination of most severe liver damage who’s serving the longest sentence.
“With the new DAAs the number of people considered good treatment candidates is much higher than a few years ago, but the slow adoption of the new meds is due mainly to the cost,” Gabriel Elber, staff counsel of the ACLU’s National Prison Project, tells A&U.
Elber notes that prioritization of treatment, while not ideal, does not necessarily lead to poorer health outcomes in every case. “With HIV there is a point you must intervene. With HCV it’s not so clear. Treating HCV is as much an art as a science.”
Some correctional systems do have more options than others for affording treatment. Prisoners in the federal system are in luck. The federal government’s 340B program allows federal correctional facilities to negotiate much lower prices for meds. And 340B also allows facilities affiliated with academic centers or the Veterans Administration take advantage of those institutions’ discounted pricing. These correctional systems simply inherit the prices negotiated by the academic center.
But not every correctional facility has that pre-existing relationship in place, and the 340B program mandates that whoever provides the medication must provide overall care for the infected person, something few academic centers can do effectively.
As for state facilities, budget increases to pay for new meds would have to come from state legislatures, and that’s a tricky proposition. “There’s a huge deficit of political will in the matter,” says Michael Nimberg, executive director of the National Hepatitis Education Project.
Nimberg and other HCV care advocates say competition in the marketplace is the greatest hope for those infected with hepatitis behind bars. The price of the “older” DAAs is expected to drop with approval of newer meds over the next two years.
Still, Nimberg says that even if all states DOCs were to acquire the new meds at the wholesale price they still wouldn’t be able to treat everyone with the virus.
Some experts have floated the possibility that the inability of corrections to treat all infected with HCV might lead to cuts in the prison population across the country. California is already reducing its prison population because of a 2011 U.S. Supreme Court decision that said inadequate healthcare in the state’s prison system violated inmates’ Eighth Amendment rights.
HCV advocates agree that hep C will not be eliminated in the general population until it’s better addressed in correctional settings. “When prisoners with hepatitis C are released back into the general community, there’s a risk of spreading the disease,” Nimberg says. “Correctional health equals public health.”
Larry Buhl is a radio news reporter, screen- writer, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at www.laborpainspodcast.com.