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Table 1. Barriers to prison-based HCV treatment and potential solutions
Barriers Solutions
System/prison factors System/prison factors
Low HCV screening rates HCV testing for all detainees on incarceration
Short prison sentences Increase number of DAA prescribers to facilitate local
Low prioritisation of a chronic disease treatment
Frequent interprison transfers interrupting treatment Promote jurisdiction-wide care to manage frequent prisoner
Limited harm reduction strategies transfer
High rates of dropout in HCV care cascade relating to missed opportunity in: Increase access to harm reduction strategies
Confirming HCV diagnosis
Referring for assessment
Commencing therapy
Prisoner factors Prisoner factors
Prisoner attitudes and knowledge regarding: Promote prisoner group education to manage deficiencies in
HCV screening - including fear of diagnosis, difficulty with venepuncture HCV-related knowledge
HCV therapies - side effects, tolerability, efficacy
Perceived stigma of HCV treatment
Motivation
Economic factors Economic factors
High list price of HCV DAA therapies Validation of simplified methods of fibrosis determination (ie
Limited prison healthcare resources APRI) to minimize the need for FibroScan
Treatment factors Treatment factors
Toxicity of historical PEG RBV therapy Utilization of short duration, all oral DAA therapy for HCV
Duration of treatment Implementation of facilities including telehealth to address
Specialist access limited access to specialist care
Knowledge gap among prison medical, nursing and security staff regarding Education programs for prison healthcare staff regarding HCV
current HCV cascade of care diagnosis and treatment
DAA: direct acting antivirals; HCV: hepatitis C virus; PEG RBV: pegylated interferon & ribavirin; APRI: aspartate aminotransferase to platelet ratio
index

[20]
prisoners who were identified as a PWID . Significant heterogeneity between different regions was observed
[Australasia (35%), Central Asia (38%) and Latin America (4.7%)] [15,20] .

HISTORIC HCV TREATMENT AND BARRIERS
Less than one percent of eligible prisoners living with HCV are currently treated while incarcerated [21,22] . HCV
management within the prison relies on screening, clinical and laboratory assessment, specialist assessment,
treatment access and confirmation of cure. At each step, there are organisational and financial barriers which
have traditionally limited the number of prison based treatment [Table 1].

Screening and assessment
[23]
Despite WHO recommendations that all prisoners should be screened for HCV , practice varies greatly
worldwide. Only 34% (10/29) of European countries and 20% of the United States jurisdictions report
established HCV screening protocols [24,25] . Furthermore, where HCV screening is available, access to
screening may be restricted to prisoners with a risk factor for HCV, such as PWID status or deranged liver
[26]
[16]
biochemistry , despite the fact that incarceration itself is an independent risk factor for HCV infection .
Uptake of screening may be variable. A Canadian study identified that only 30% of prisoners were tested while
incarcerated although universal opt-in screening being policy, and HCV screening across 21 English prisons
reached less than 3% of prisoners [27,28] . The cause of this is likely multi-factorial, including the cost of HCV
diagnostics, the prioritisation of preventative health care within a prison budget, prisoner movement within
prison systems limiting health centre access, and the stigma that can be associated with HCV testing [29,30] .
Screening uptake may also be impeded by prisoner factors including lack of knowledge about HCV or fear of
[31]
diagnosis . PWIDs can have very difficult venous access resulting in fear of venepuncture - one prison based
[32]
study utilised dried blood spot testing for HCV screening and noted a 12.2% increase in uptake . Barriers to
HCV screening may be best addressed by implementing universal opt-out practices in all correction facilities
[29]
worldwide to increase diagnosis rates and treatment throughput .
Seropositive prisoners require further diagnostic testing to confirm chronic infection and stage liver fibrosis.