HCV Behind Bars: Part 2

[Hep Talk]

HCV Behind Bars: Part II
How one state grapples with hepatitis c in the correctional system
by Larry Buhl

Lara Strick, MD
Lara Strick, MD

In the August issue’s Hep Talk I covered the issues facing state correctional facilities who face the dilemma of who gets treatment for HCV. With the population of incarcerated individuals with HCV estimated at seventeen percent, it is impossible for state departments of correction to treat everyone in their care that carries the virus, even if they can negotiate a lower price, as some educational institutions can. And there are no national protocols for whom to treat, when to treat, and how.

Only three states have full-time infectious disease experts who oversee patient care: Oregon, Washington, and New Mexico. Dr. Lara Strick is a University of Washington clinical assistant professor of infectious diseases and an infectious disease consultant to the Washington State Department of Corrections. I spoke with her about the challenges of treating and managing care for HCV-infected inmates on a limited DOC budget.

Larry Buhl: With a limited Department of Corrections budget, only a few inmates with HCV are able to be treated with DAAs, in any state. Can you describe the protocol that sets up criteria for who is eligible for treatment in Washington?
Lara Strick:
We are in the midst of changing our protocol, but basically we have a hep C care review committee that discusses each case to determine eligibility for treatment. All of these cases tend to be fairly complicated. If the committee votes to treat the patient based on criteria mainly on medical necessity then the patient is treated. There are some higher levels of approval, particularly for some of the more controversial regimens. But the system is somewhat flexible.

The issue of prioritization isn’t limited to corrections. We know cost is a driving factor. As we get better and better regimens with fewer side effects, the other barriers to treatment disappear. At that point the biggest barrier is cost. You have to figure how to prioritize treatment.

Without going into individual cases, can you explain how some decisions might be made in who is treated with Sofosbuvir?
Whether you’re in prison or in the community, prioritization is based on medical necessity, whether that has to do with the degree of fibrosis of the liver, other clinical consequences of the disease, or other factors. It gets complicated fast. For some patients, even though they may have advanced disease, there are several newer regimens around the corner that may be better for them. If they can wait, based on certain criteria, they may be better off waiting. It’s hard to put a blanket statement on who must be treated now, who doesn’t need to be treated now or who would be better waiting until better therapies are available. Cost is not the only factor.

Not only are they more effective, but they will be interferon-free. Most of the regimens now still include interferon. But by the end of the year there will be additional interferon-free regimens available that might be a better option to wait for.

Until prices on the new meds come down, is it possible that lawmakers at the state level will make hepatitis treatment a bigger budget priority?
State Medicaids foot the bill for a large percentage of the hep C-positive population in the community as well. So in the end it winds up being state dollars whether behind bars or in the free world. Specifically trying to get funding for the incarcerated, if you look at the cost of hepatocellular carcinoma and the clinical consequences of end-stage liver disease for correctional systems, and the fact that they are growing, you may be able to convince legislators that it is to everyone’s advantage to fund treatment now rather than waiting for the long term consequences of the disease.
Both education and risk reduction programs are important. The cost is not cheap but when you compare it to a treatment course being $100,000, risk reduction and education are a bargain. Promoting both is the most effective thing long term, but it doesn’t deal with the people who are already infected.

What else would you like readers to know about how hepatitis C is treated in correctional systems?
With the newer medications becoming approved in the next three years, the end of the epidemic is within sight. But to impact the epidemic, corrections needs to be included. The hope is that as the cost goes down this is a disease we treat more like HIV. With HIV, we treat everyone, not just those with a higher degree of damage or a greater progression of the disease.

Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at www.laborpainspodcast.com.