Around the country, prisoners are clamoring to be cured of a potentially deadly disease, while prison administrators are reeling from the treatment’s price tag. Hepatitis C, a virus that can eventually cause cirrhosis, liver cancer, and other serious outcomes, affects some three million Americans, one-third of whom pass through U.S. prisons and jails each year.
One 12-week treatment course can cost upwards of $90,000. With a constitutional obligation to provide medical care to inmates, prison officials—whose health-care budgets are a zero-sum proposition—are struggling to treat even a fraction of those with the disease.
But a new study suggests that despite its cost, testing all prison inmates for hepatitis C—and treating them when appropriate—is extremely cost-effective. Using an “opt-out” system—testing each prisoner as a matter of course unless he specifically declines—could prevent between 10,900 and 12,700 new hepatitis C infections, most of which would occur in the community after infected prisoners returned home. The study also found the testing and treatment would lead to a significant decrease in the number of liver transplants, cases of liver cancer, and other liver-related deaths in the community.
“Hepatitis C is a progressive disease—it could take 30 years to progress to advanced liver cancer,” says Dr. Jagpreet Chhatwal, a radiologist at Harvard Medical School and the study’s senior author. “If you compare that to the average time spent inside prison, which is three to five years, it would make sense these people would be part of the community when this started happening.”
Transmitted primarily by injection drug use, hepatitis C afflicts 17% of prisoners, compared to 1% of the general population. Public health advocates have for years described testing and treatment of hepatitis C in prison as a “public health opportunity.” Given high rates of the disease, “testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States,” argued three correctional and public health physicians in a medical journal 10 years ago (and again last year).
That’s not how things panned out. Because the most serious complications of hepatitis C can take decades to emerge, cash-strapped correctional officials have been reluctant to treat seemingly healthy inmates whose medical problems won’t show themselves until long after they are released. What’s more, first-generation treatments took up to a year, caused serious side-effects, and were only effective about half the time for most patients. Even prisons with dedicated treatment programs were treating a few dozen people out of the hundreds of thousands of prisoners with hepatitis C.
Now, new hepatitis C medications can cure 90% of patients in as few as 12 weeks; guidelines from the major medical societies recommend treating all patients with hepatitis C—and single out incarcerated people as a group for whom treatment could have the secondary benefit of preventing transmission to others. But still prison administrators in most states have been slow to offer testing or treatment in any substantial numbers. (In Massachusetts and Minnesota, prisoners have filed class-action lawsuits to gain access to the drugs.)
“There is an incentive for prisons to put their head in the sand,” says Emory Medical School’s Anne Spaulding, one of the co-authors of the paper. “The more cases you find with aggressive screening, the more cases you might need to treat.”
This new paper, which appears in the medical journal Annals of Internal Medicine, found that universal screening—and treatment of any prisoner whose liver disease is found to be moderate or severe—could avert $760 million in spending on liver transplants and other medical care over thirty years. At least 80% of that spending would have been in the general population. “That’s the whole motivation of this paper, showing if we start treating people in prison, the whole society benefits,” says Chhatwal. Because the benefits would accrue to society at large, and not to the prison, Chhatwal suggests that state and federal governments should step up and provide supplemental funding to manage hepatitis C in prisons. The paper put the first-year cost of implementing the screening and treatment programs at $1.1 billion across the state and federal systems—about 12 percent above what they’re spending on health care now. “Cost effective” is not the same as cost saving: “It means something will cost additional money, but it’s worth spending,” Chhatwal said.
