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Page 2 of 10 Papaluca et al. Hepatoma Res 2018;4:64 I http://dx.doi.org/10.20517/2394-5079.2018.53

[1]
70 million people chronically infected with HCV, with a global prevalence of 1.0% . Over time, HCV mediated
inflammation leads to the development of liver fibrosis, and can subsequently cause decompensated cirrhosis
[2,3]
and hepatocellular carcinoma (HCC) . HCV accounts for approximately 500,000 deaths per year globally
[4,5]
and remains the leading indication for orthotropic liver transplantation in the western world . Viral hepatitis,
[6,7]
including HCV, is responsible for > 60% of incident HCCs and was the 7th leading cause of death globally .
The advent of direct acting antiviral (DAA) therapy has revolutionised HCV treatment. HCV DAA therapy
is highly efficacious, yet simple, safe and short in duration in relation to pegylated interferon-α and ribavirin
[8]
(PEG RBV) which had significant toxicity and poor efficacy . The introduction of DAA therapy led the World
Health Organisation (WHO) to propose targets for the reduction of HCV incidence and mortality of 80% and
[9]
65% respectively by 2030 . In developed countries, injecting drug use continues to be the primary risk factor
for acquiring HCV, accounting for the majority of incident cases [10,11] . As such, treatments scale up amongst
people who inject drugs (PWID) are key to achieving these elimination targets, which are supported by
[12]
multiple HCV modelling studies . PWIDs however are often marginalised and historically it’s been difficult
for them to be engaged in care.

There are an estimated 10 million prisoners worldwide, with over 2 million incarcerated in the USA alone [13,14] .
This population has an extremely high prevalence of chronic HCV infection. Conservative estimates
[15]
suggest there are approximately 1.5 million prisoners living with HCV at any given time . This reflects the
close association between PWID, incarceration and HCV due to the criminalisation of injecting drug use.
[16]
Incarceration itself is an independent risk factor for HCV infection and over 50% of PWIDs will spend
[17]
some time in prison . Recent modelling has demonstrated that to achieve the proposed WHO elimination
targets, HCV treatments must be significantly scaled up amongst PWIDs to influence reductions in HCV
[12]
incidence and prevalence . The prison system is an ideal setting for such public health initiatives given these
characteristics and can play a key role in elimination efforts. However, to date there has been limited prison
based HCV treatment in the setting of prisoner, organisational and funding/policy barriers. In 2015, a survey
conducted in 49 of the 50 State Department of Corrections in the US, responsible for the care of 1,348,716
[18]
prisoners, estimated that < 1% of prisoners with chronic HCV infection were receiving treatment .

This article explores the prevalence of HCV within correctional facilities, presents the existing literature
describing the efficacy of HCV treatment, and discusses the barriers to implementation and upscaling of HCV
treatment in prisons. Finally, the opportunity for correctional HCV treatment programs to support HCV
eliminations goals in the era of DAA therapy is discussed.

HCV PREVALENCE GLOBALLY, IN PWIDS AND CORRECTIONAL FACILITIES WORLDWIDE
Recent systematic reviews have estimated that HCV prevalence is approximately 1.0% worldwide, with 71 million
[1]
people affected . Countries with high HCV viraemia prevalence include those found in Northern Africa,
the Middle East and Central Asia, where prevalence may exceed 3%. A systematic review investigating HCV
prevalence amongst PWIDs estimated that worldwide, 67% are affected by chronic HCV. Thirty eight of 79
countries, where data regarding HCV prevalence are available, have a HCV prevalence amongst their PWIDs
of greater than 60% - these included China (67%), Russia (72.5%) and the USA (73.4%).

Due to the close association between injecting drug use and incarceration, the high prevalence of HCV within
the PWID community has created the epidemic in correctional facilities worldwide. Studies demonstrate that
56%-90% of PWID will spend time in prison during their lifetime and HCV prevalence is up to 40 times higher
[19]
amongst incarcerated populations when compared with the community . A recent systemic review assessed
[15]
HCV prevalence amongst incarcerated populations . The midpoint HCV prevalence was 15.1%, equating to
[13]
1,546,500 of prisoners globally being affected by HCV , and prevalence exceeded 10% in six of nine regions
worldwide. A second review estimated anti-HCV prevalence at 26% amongst prisoners, and 64% amongst those