Hepatitis C infection (HCV) is a major global epidemic with an estimated 399,000 people dying annually from HCV-related liver failure and cancer.1 Unsafe injecting drug use is the main route of HCV transmission in developed countries, with an estimated 20 million people who inject drugs (PWID) infected worldwide.2 Over one-half of Irish prisoners report a history of opiate use, with 43% reporting a history of injecting.3 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.4 With recent advances in treatment regimes, HCV is now a curable and preventable disease and prisons provide an ideal opportunity to engage this hard-to-reach population. However, despite increased access to primary healthcare while in prison, many HCV-infected prisoners do not engage with screening or treatment.
A recent Irish study aimed to identify barriers and enablers to HCV screening and treatment in Irish prisons.5 In this research, published in the BMC Harm Reduction Journal, four focus groups took place in Mountjoy Prison for males and in the Dóchas Centre medium-security prison for adult females at the Mountjoy Campus in Dublin. Participants were recruited at both sites by open invitation through posters and directly by custodial and healthcare staff. Focus groups were facilitated by an experienced team of facilitators and included a series of open-ended questions covering the following areas: experience of community-based and prison-based HCV screening and treatment; barriers and enablers to uptake; challenges related to incarceration and release; inter-prison variations in healthcare delivery; and the role of security staff and peers in prison HCV management.
Results
The following themes related to barriers and enablers to both HCV screening and treatment emerged.
Barriers
Lack of knowledge
All focus groups identified lack of knowledge as a major block to engagement with HCV treatment services. Prisoners were aware of their own lack of knowledge and were often confused about the different types of hepatitis. In addition, many prisoners were confused about the mode of transmission.
Fear of liver biopsy and treatment and concerns regarding confidentiality
Many prisoners spoke about their fear of treatment and the negative stories they had heard from other inmates. In addition, prisoners expressed concerns regarding confidentiality, with some believing that non-medical staff had access to their medical records. Many explained how prisoners were often called on the prison landing for certain blood tests and hospital appointments and that this revealed their medical status to the other prisoners and security staff.
Fear of being stigmatised and systematic barriers
In addition to concerns about confidentiality, prisoners indicated that there was a fear of being stigmatised by other prisoners and staff if they became aware of their HCV status. Several participants described a double stigma: the first associated with HCV status, and the second being a prisoner in a hospital setting. In particular, the practice of handcuffing male prisoners for security reasons while attending outpatient appointments was identified as increasing the chances of experiencing stigma and shame. Many prisoners also expressed frustration at the many systemic blocks to screening and treatment. These included delays in having bloods taken in addition to further long delays in receiving results.
Enablers
Opt-out screening at committal and in-reach hepatology and fibroscanning
Screening on committal was seen by most inmates as an enabler to treatment, describing it as ‘more private’ and ‘more suitable’. However, some participants were concerned that adapting to new surroundings on committal was already a stressful time – with some inmates also having to manage withdrawals. Participants identified the presence of in-reach hepatology services at both locations as a facilitator to engagement with treatment, given that the availability of on-site specialist hepatology reduced the need for prisoners to attend hospital outpatients. In addition, the majority of prisoners expressed satisfaction with access to, and the experience of, fibroscanning – with many highlighting that they had better access to fibroscanning within prison than in the community.
Stability of prison life and peer support
All focus group participants agreed that prison eliminated many of the blocks experienced by this cohort in the community, in particular with regard to homelessness, personal motivation, competing priorities, and access to healthcare and drug treatment. Moreover, participants identified peer educators as a potential facilitator to HCV screening and treatment, as a number of prisoners had experienced mass HIV and TB screening programmes involving Red Cross peer workers while serving previous sentences and described it as facilitating their engagement.
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. It is hoped that the barriers and enablers to HCV screening and treatment reported by Irish prisoners in this research will inform both national and international public health HCV elimination strategies.
2 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/
3 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/
4 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/
5 Crowley D, Van Hout MC, Lambert JS, Kelly E, Murphy C and Cullen W (2018) Barriers and facilitators to hepatitis C (HCV) screening and treatment – a description of prisoners’ perspective. Harm Reduct J, 15: 62. https://www.drugsandalcohol.ie/30075/
