Unsafe injecting drug use is the main route of hepatitis C virus (HCV) transmission in developed countries, with an estimated 20 million people who inject drugs (PWID) infected worldwide.1 Over one-half of Irish prisoners report a history of opiate use, with 43% reporting a history of injecting.2 A 2000 study estimated the prevalence of HCV infection in the Irish prison population at 37%, increasing to 81% in those with a history of injecting drug use.3 With recent advances in treatment regimes, HCV is now a curable and preventable disease and prisons are a key location to access HCV-infected PWID. However, despite international guidelines recommending that prisons are a priority location for HCV screening and treatment, levels of prisoner engagement in HCV care remain low.
A recent Irish study aimed to explore prison governors’ and officers’ views on barriers and enablers to HCV screening and treatment.4 In this research, published in the BMC journal Health & Justice, five focus group sessions were conducted among two grades of security staff: the prison governor and the prison officer. The governor component of the study was national in coverage and included input from 13 of the 15 prisons in the Republic of Ireland. For convenience and due to restricted access to other prison locations, the prison officer focus groups were confined to two Dublin prisons: Mountjoy male prison and the Dóchas Centre female prison.
Results
The following themes relating to barriers and enablers to both HCV screening and treatment emerged from the focus groups.
Priority of safety and security
All focus groups included discussions about issues of security and safety in their prisons. While supportive and understanding of the benefits of prison healthcare, their primary focus was to ensure the safety of both staff and inmates. In particular, prison staff reported security concerns related to the protection of prisoners and how burgeoning gangland feuds and rival factions made their jobs very difficult. This created barriers to both HCV screening and treatment since it reduced face-to-face time with prisoners and medical staff because security staff are required to accompany prisoners to medical appointments.
Concerns about personal risk
A recurring theme throughout the focus groups was concern for personal safety. This concern covered the areas of personal safety and risk of exposure to, and acquisition of, blood-borne viruses, including HCV. Prison officers described a work environment of increasing inter-prisoner violence and severity of assault often leading to open wounds and blood loss.
Lack of knowledge
Lack of knowledge among staff was recognised as a major barrier to HCV screening and treatment. Participants identified the provision of education and training as a means of addressing this knowledge deficit. All grades of staff felt a lack of knowledge in relation to the newer HCV treatments and the risks of transmission impacted on their ability to engage with prisoners on this issue. Participants also identified the lack of knowledge among prisoners as a barrier to HCV treatment; in particular, the inaccurate information being circulated regarding the side-effects of treatment, which were historical and associated with interferon-based treatment.
Concerns regarding confidentiality
Prison officer participants reported that lack of confidentiality was a barrier to HCV screening and treatment. Often breaches in confidentiality were inadvertent and were related to prisoners being called to attend certain clinics that were connected with HCV, addiction treatment or HIV care. A number of officers felt that if issues regarding confidentiality were addressed that more prisoners would approach prison officers to discuss HCV-related concerns and that this might be a resource to educate prisoners on HCV-related issues.
Prisoners’ fear of treatment and stigma
A number of participants identified fear of treatment as a barrier to prisoners engaging with health services. Fear of treatment was linked to the side-effects of interferon treatment, liver biopsy, and the concerns about stigma. It was suggested that making screening routine or opt-out had the potential to reduce stigma.
Time of screening
Both prison officer and governor participants favoured a structured and systematic approach to HCV screening. The committal period was identified by all groups as an opportune time to engage prisoners with health services and provide HCV screening. Some prison officers identified other time periods that might be suited to HCV screening. They described ‘down times’ within the week where routine work was not scheduled and that health-related programmes provided during these times might have the added benefit of relieving boredom for prisoners.
Peer workers
Participants in all focus groups agreed that trained peer workers had the potential to facilitate prisoner engagement with health services, including HCV screening and treatment. The narrative around peer workers included prisoners having more trust in their peer networks than ‘The System’.
In-reach hepatology and fibroscanning services
The availability of in-reach hepatology and mobile elastography were seen as enablers to prisoner engagement in HCV care. In particular, the cost-effectiveness and staff-saving benefits of in-reach services were viewed by the governor focus groups as a major benefit. The reduction of risk associated with prisoners having to attend hospital services was also noted.
Conclusions
The authors noted that although Irish prisons are a key setting to identify and treat HCV-infected PWID, this can only be achieved by the elimination of identified barriers to HCV screening and treatment in Irish prisons. In particular, they suggest that upscaling HCV management in prisons requires an in-depth understanding of all barriers and facilitators to HCV screening and treatment. Engaging prison officers in the planning and delivery of healthcare initiatives may be a key strategy to optimising the public health opportunity that prison provides.
1 Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais DC, Horyniak D, et al. (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet, 378(9791): 571–83. https://www.drugsandalcohol.ie/15845/
2 Drummond A, Codd M, Donnelly N, McCausland D, Mehegan J, Daly L, et al. (2014) Study on the prevalence of drug use, including intravenous drug use, and blood-borne viruses among the Irish prisoner population. Dublin: National Advisory Committee on Drugs and Alcohol (NACDA). https://www.drugsandalcohol.ie/21750/
3 Allwright S, Bradley F, Long J, Barry J, Thornton L and Parry JV (2000) Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. Br Med J, 321(7253): 78–82. https://www.drugsandalcohol.ie/6741/
4 Crowley D, Van Hout MC, Murphy C, Kelly E, Lambert JS and Cullen W (2018) Hepatitis C virus screening and treatment in Irish prisons from a governor and prison officer perspective – a qualitative exploration. Health & Justice, 6(1): 23. https://www.drugsandalcohol.ie/30873/
