Liver, Pancreas and Biliary Tract
Hepatitis C virus infection in jail: Difficult-to-reach, not to-treat. Results of a point-of-care screening and treatment program

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Abstract

Background

An unmet objective in the pursuit of HCV elimination is the creation of a simple and fast operating model to identify difficult-to-treat populations, like prisoners. Of many obstacles, the first is represented by the poor knowledge of inmates HCV-Ab prevalence. Moreover, due to the peculiar status of conviction, often their access to antiviral therapy is neglected.

Aims

To evaluate the prevalence of HCV infection in a penitentiary Institution of Southern Italy through a point-of-care screening and treatment program.

Methods

We conducted a prospective observational study in two phases: first, we reviewed all the prisoners’ clinical records, to verify HCV-Ab execution. Subsequently, we performed a universal point-of-care screening and treatment program.

Results

We enrolled 670 patients. Overall, 310(46.27%) were already HCV-Ab tested. At the screening initiation, 23.28% patients were discharged, whereas 8.35% refused. Of the remaining 458 subjects, 58(12.67%) were HCV-Ab positive and 46 HCVRNA positive. All these underwent DAA, obtaining 100% SVR. At the end of the program, a total of 491(73.28%) subjects had HCV-Ab available. Sixty-nine (14.05%) were positive. A total of 214(31.94%) subjects were lost to follow-up.

Conclusions

We revealed a prevalence of 14.05% of HCV-Ab in conviction. Antiviral treatment was safe and efficacious. More efforts are advisable to provide screening for HCV-Ab in conviction.

Introduction

Prison inmates represent a group at a high prevalence of HCV infection and at high risk of spreading [1,2]. This population, together with Persons who inject drugs (PWIDs) and Men who have Sex with Men (MSM), has been identified as one of the primary objectives of screening and treatment campaigns, with the goal of harm reduction [[3], [4], [5]]. Nevertheless, due to its peculiar characteristics (conviction, availability of healthcare facilities and medical devices etc.), this population represents a substantial challenge, as it can be seen in the reported insufficient access to the harm-reduction measures, even in the high income industrialized countries [6]. This aspect has become crucial nowadays, considering the recent availability of a safe and efficacious cure for HCV infection with the orally-administered direct antiviral agents (DAA), that eliminate HCV infection in almost all patients, regardless of the viral genotype or the disease stage [7]. This therapy has been proved to be so effective that the World Health Organization (WHO) has set up in 2016 an “elimination program” for HCV infection worldwide, with the objective of end the HCV epidemic by 2030 [8]. With this aim in mind, the European Association for the Study of Liver (EASL) International Liver Foundation proposed the “micro-elimination” of HCV infection. The proposed strategy is based on breaking down the major elimination goal into smaller ones. These smaller elimination goals are set to be more feasible and have as objective high risk populations, such as convicts, in which screening and treatment strategies must be prioritized in order to quickly reduce the burden of the infection in the major population [9]. This program is based on the deployment of “case-finding” and “linkage-to-care” projects that are particularly difficult in a setting such as the prison inmates [9,10].

A recent metanalysis published in 2013 reported a prevalence of HCV infection in prison of about 26%, with higher levels in those who were also person who inject drugs (PWIDs - up to 64%) [11]. Nevertheless, precise data on this point are not available, particularly in Italy. In fact, other reports describe prevalence rates that range from 3.1%–86%, with the presence of an active infection (HCV-RNA positive) ranging from 45%–90% [1,12]. Focusing on the Italian perspective, even if several papers investigated the prevalence of HCV infection among prisoners in Italy, data are often conflicting and incomplete, with estimated prevalence rates ranging from 22.4%–38% [[13], [14], [15]]. Nevertheless, if we consider that the number of prisoners in Italy was of almost 102,000 in 2016, it is estimable that 10,000–30,000 subjects may have an HCV infection in conviction. For this reason, it is advisable to perform case-finding and linkage-to-care programs in this population, to reach the 2030 elimination goal, set by WHO.

Section snippets

Patients and methods

A collaboration between the Administration of Criminal Justice of the Salerno Province, the Department of Territorial Activities, Special Operative Unit for health protection of minors and adults, Penal Area of Salerno and the Internal Medicine and Hepatology Division of the Department of Medicine and Surgery of the University of Salerno, was set up to perform a prospective observational study, with the aim of carrying out a point-of-care program for screening and treatment of the convicts of

Oral salivary test

The quick oral HCV Ab testing was performed by using an HCV rapid oral antibody test (OraQuick®, Orasure Technologies, Bethlehem, Pa, USA). OraQuick is a single-use disposable indirect immunoassay intended for use in symptomatic or asymptomatic patients at high risk of infection that has been FDA approved for the scope and demonstrated reliability of the results comparable with the standard HCV-Ab serum ELISA tests [17,18].

HCV-RNA and HCV genotyping

HCV-RNA sampling was performed on positivity for HCV-Ab (by OraQuick and/or serum ELISA test: enzyme-linked immunosorbent assay III, Abbot laboratories Chicago) by performing a Real Time PCR (Cobas TaqMan v2.0, Roche Diagnostic Systems).

Fibrosis assessment by transient elastography

Fibrosis assessment was performed with an Echosense Fibroscan® device model 430 (EchoSense, Paris, France) [19], in patients that didn’t show clear evidence of clinical cirrhosis (enlargement of the portal vein and of the spleen with coarse pattern and surface scarring at the ultrasonography, and/or low platelet count and/or low serum albumin, and/or esophageal varices etc.). TE was considered reliable when met the standard criteria: an interquartile range (IQR) less than 30% of the median

Statistical analysis

The statistical analysis of the collected data was performed with parametric and non-parametric tests when appropriate. In particular, student’s t-test and Mann–Whitney were performed for continuous variables, and chi-square test with Yates correction or Fisher-exact tests were used to compare frequencies and categorical variables. Before applying the correct analysis, a Kolgoromov–Smirnov K–S “Goodness of fit” test for normality was performed to assess if there was a normal or not-normal

Results

During the first phase of the study, the clinical records of 670 convicts were examined. Ninety-four percent of them were male, 82.54% were Italian (and therefore 17.46% were not), 125 subjects (18.65%) declared active/inactive use of injective drugs (see Table 1). Of these 670 patients, for more than half of them (360–53.73%) there was no information on the HCV-Ab status. The other 310 (46.26%) had available HCV-Ab testing. Of these, 54 (17.42%) were HCV-Ab positive. After this first phase,

Discussion

In the present study a “point-of-care” screening and treatment program demonstrated the prevalence of HCV infection in convicts in a detention facility in Southern Italy. Our results show an overall HCV-Ab prevalence of about 14%, which is slightly lower in respect of other studies from the same geographical area, that report a percentage of such infection ranging from 22.4%–38% [[13], [14], [15]]. This discrepancy may be due to the fact that the higher prevalence study was conducted almost 15

Conclusions

The present study reported a high prevalence of HCV-Ab positivity among prison inmates of a penal facility of Southern Italy, particularly among those subjects that declared drug use. We assessed an excellent outcome in patients treated with DAA. Moreover, evaluating the number of subjects that were not screened for HCV-Ab and of those who escaped the program, we demonstrated that, in prison, HCV infected patients are not difficult to treat, but to reach. All the efforts of the scientific

Conflict of interest

None declared.

Acknowledgment

The authors thank to Dr Berardo Guzzi (English Certificate of Proficiency released by University of Cambridge) for his English assistance.

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