Abstract
Objectives:
Hepatitis C virus (HCV), the most common blood-borne infection in the United States and a leading cause of liver disease, disproportionately affects populations who are incarcerated. Despite the prevalence of HCV infection among people involved in the criminal legal system, HCV testing and treatment policies are not yet standardized. Our study sought to examine the differences in HCV testing and treatment protocols across Massachusetts county jails.
Methods:
In this cross-sectional study, we examined the HCV testing and treatment protocols of the 14 county jails in Massachusetts from November 2022 through February 2023.
Results:
Of the 12 jails that responded to requests for information, 10 jails used opt-in testing, 1 jail used opt-out testing, and 1 jail had no testing protocol. All 12 jails explicitly inquired about HCV history at intake, but only 3 jails inquired about current HCV treatment. For the 5 jails that had treatment initiation policies, all had barriers to treatment, including mandatory length-of-stay or sobriety requirements.
Conclusion:
Findings from this study underscore the need for policy changes that require adoption of universal opt-out HCV testing across county jails and standardized HCV treatment protocols, with a focus on linkage to outpatient care and treatment of substance use disorder. This approach can address HCV in populations who are incarcerated and can help mitigate health disparities between incarcerated people and the general public.
Hepatitis C virus (HCV) is the most common blood-borne infection in the United States. 1 Despite the availability of curative treatments, HCV is a leading cause of hepatocellular carcinoma, cirrhosis, and liver failure. 2 HCV disproportionately affects people who are incarcerated 3 ; an estimated 16% to 23% of people who are incarcerated have HCV antibody positivity, 4 a 10- to 20-fold higher prevalence than in the general US population. 3 The prevalence is higher among people who are incarcerated because the dominant risk factor for HCV in the United States is injection drug use and substance use disorder (SUD), the rate for which is estimated to be 12 times higher among populations in jails and prisons than among the general population.5,6 As many as 58% of people who inject drugs have a lifetime history of incarceration. 7 People with SUD are overrepresented in the incarcerated population largely because of criminalization of SUD 8 and intravenous drug use. In the United States, non-Hispanic Black and Hispanic people are overrepresented in the incarcerated population,9,10 and racial and ethnic minority groups constitute most HCV cases in incarcerated populations.9,11 Untreated, chronic HCV in incarcerated populations leads to increased morbidity and risk of premature death.12,13
The overall incarcerated population in the United States includes people housed in local jails and in prisons; however, most people who are incarcerated are housed in local jails. Jails have 19 times the number of admissions per year than federal and state prisons. 8 People who are incarcerated in jails comprise people detained pretrial or people serving short sentences, 14 with most people incarcerated in jails returning to their communities after release, where the spread of HCV can continue.
The high prevalence of HCV in incarcerated populations provides an occasion to identify and treat HCV. 15 Many people who are incarcerated in jails may lack access to regular, preventive care in their communities. The criminal legal system is therefore a location for HCV identification and initiation of treatment because of the disproportionately high rates of HCV and the large number of individuals involved in the system. 16 In addition, because of the high turnover of people who are incarcerated in jails, the identification and treatment of HCV among people in jails could help eliminate the prevalence of HCV in incarcerated populations and in the community. 17
Many health and medical societies, including the World Health Organization, recommend routine HCV screening among incarcerated populations. 18 The US Federal Bureau of Prisons recommends HCV screening in all state and federal prisons, 15 whereas the US Preventive Services Task Force and the Infectious Diseases Society of America recommend HCV screening for all people who were ever incarcerated. 19 Traditionally, the Centers for Disease Control and Prevention (CDC) has recommended HCV testing among people born from 1945 through 1965, also known as the “birth cohort,” but in 2023, CDC expanded its guidance to recommend screening for all adults.20,21
Although the American Association for the Study of Liver Diseases recommends opt-out HCV testing for jails, 22 the health care policies of local jails are determined by their own county, not by state or federal regulations. 14 With policies determined by local regulations, HCV testing and treatment often vary among counties in the same state. Therefore, we conducted a cross-sectional analysis to examine the HCV testing and treatment protocols for all county-operated jails in Massachusetts and to describe the differences among them.
Methods
Study Design and Data Collection
From November 2022 through February 2023, we submitted written requests to the sheriff’s office of each county in Massachusetts, requesting all current policies and protocols on HCV testing and treatment. When we did not receive a response after an initial request for information, we made 5 additional requests in writing and by telephone. The Boston Medical Center/Boston University Institutional Review Board (IRB) determined this study as exempt from IRB review with a Health Insurance Portability and Accountability waiver of authorization.
Measures
We used information acquired from county sheriff office websites and nationwide detention facility databases 23 to describe jail characteristics, including number of beds and annual bookings for each jail. We derived population counts and demographic information for each county from the 2020 American Community Survey (ACS) 5-year estimates. 24 We used these results to identify associations between jail HCV policies and county rurality, racial and ethnic minority populations, and percentage of residents living below the federal poverty level. The primary investigator (C.F.) coded and analyzed the forms received from each jail.
Testing measurements
We coded each jail as opt-in testing (testing that an individual elects to do), opt-out testing (testing that is completed unless the individual declines), or no testing. We further characterized the testing protocols as universal (testing was offered to all people in jails) or targeted (testing was offered based on self-reported risk factors such as anal receptive sex, intravenous drug use, history of blood transfusions or organ transplant, tattoos, and a history of HIV infection). We also gathered information on the inclusion of HCV history in jail intake forms on medical history and the frequency of recurrent testing.
Treatment measurements
We determined whether jails asked questions about current HCV treatment on admission. If jails had a policy on HCV treatment initiation, we further determined whether these policies had a length-of-stay requirement (any minimum amount of time to spend in jail) or sobriety requirement for treatment initiation.
Results
Massachusetts has 14 counties, with 1 jail in each county, except for Nantucket County, which has no jails and sends people who are detained to Dukes County, and Suffolk County, which has 2 jails (Nashua Street Jail and South Bay House of Correction). Other than for Nantucket County, individuals are detained in the county of their arrest. Jails ranged from 40- to 1892-bed individual capacity, with yearly bookings from 891 to 4988 individuals (Table 1). Counties ranged from rural, with Franklin County being the most rural and having an average of 101 people per square mile, to urban, with Suffolk County being the most urban and having an average of 13 758 people per square mile. The demographic makeup of counties ranged from 88% to 90% non-Hispanic White residents in Barnstable, Berkshire, and Franklin counties to 45% non-Hispanic White residents in Suffolk County. Suffolk (18.7%) and Hampden (17.3%) counties had the highest percentage of residents living below the federal poverty level, whereas Nantucket County had the lowest percentage (6.0%).
Characteristics of Massachusetts counties and county jails (N = 14), November 2022 through February 2023 a
Population counts and percentages are derived from 2020 American Community Survey 5-year estimates 24 ; jail characteristics are derived from individual county and sheriff websites and national databases. 23
People arrested in Nantucket County are detained in Dukes County Jail and House of Correction.
We received responses on HCV testing and treatment protocols from 12 of the 14 Massachusetts county jails. Of the 12 jails that responded, 11 had HCV testing protocols (Table 2); 10 jails had opt-in testing, 1 had opt-out testing, and 1 had no testing. Several of the opt-in protocols offered testing only to people with HCV risk factors, such as SUD, but did not universally offer HCV testing to all people who were detained. All 12 jails that responded explicitly inquired about HCV history on intake forms on medical history. However, only 3 jails explicitly inquired about current HCV medication treatment during the intake process. Five of 12 jails had written policies on initiating treatment during incarceration. Of the 5 jails that had treatment protocols, all had a length-of-stay requirement and 3 had a sobriety requirement.
Hepatitis C virus (HCV) testing and treatment protocols of Massachusetts county jails (N = 14), November 2022 through February 2023 a
Abbreviations: —, not specified; NA, not applicable.
Jail characteristics are derived from individual county and sheriff websites and national databases. 23
HCV testing and treatment protocols were not provided.
Discussion
In our evaluation of HCV testing and treatment protocols in Massachusetts jails, we found a lack of standardization across counties and variations in testing and treatment protocols. Testing for HCV in correctional settings can be categorized into 2 approaches: targeted screening, which is based either on risk factors or on being a member of a group with high HCV prevalence (eg, the birth cohort), and universal screening. 17 Universal screening is not limited to risk factors or cohorts but is offered either on an opt-in basis, in which individuals must request testing, or on an opt-out basis, in which testing is offered universally and individuals may choose to decline. In our evaluation of jails that offered testing, most (10 of 11) offered an opt-in test that relied on requests for testing from people who were detained. Only 1 jail offered universal opt-out testing (Berkshire County). Notably, Berkshire County is a rural county with mainly non-Hispanic White residents. Two jails with opt-in protocols did not offer universal screening but limited screening to people in the birth cohort or people with known risk factors, such as SUD and intravenous drug use.
Universal opt-out testing can be the most clinically effective and cost-effective strategy.17,25,26 Evidence has suggested that testing that depends on the reporting of risk factors by an individual is an inadequate strategy and will not decrease the rate of disease. 27 Many people who are incarcerated fear being stigmatized by correctional staff, health care workers, and peers and may forgo admission of risk factors and testing to avoid stigmatization.28 -30 A previous study of people incarcerated in Rhode Island found that relying on risk-based screening missed most HCV infections. 31 Previous studies also showed that relying on birth-cohort testing is inadequate for people who are incarcerated, 32 with approximately half of new HCV cases being found outside the birth cohort in a study of testing in the Dallas County Jail. 15
A commonly cited barrier to HCV testing in jails is the cost of antibody and RNA HCV testing. 27 County jails receive funding based on their county policies; therefore, access to health care, budget, testing, and treatments vary by county. As a result, some jails may not have the clinical capacity to conduct phlebotomy for every person who is incarcerated. The development of point-of-care testing is a promising method to reduce the need for phlebotomy and decrease the time to diagnosis; however, the cost of point-of-care testing remains a consideration. 33 Because people tend to be detained for shorter lengths of stay in jails than in prisons, local jails are unlikely to have cost savings through HCV testing and treatment. However, the cost of not testing or treating patients with HCV is ultimately experienced by society as a whole. Certainly, cost savings can be appreciated in the prison population: in a Massachusetts-based study, people incarcerated in prisons who had HCV (vs did not have HCV) required longer lengths of hospitalization, had higher 30-day readmission rates, and had overall increased costs of hospitalizations. 34 Other data have shown that opt-out testing would be cost-effective because it may lead to vaccination for hepatitis A and B, which is commonly performed when HCV is identified, as well as risk-reduction counseling, 27 although these savings may be more likely realized in prisons than in jails.
Once HCV is identified in a person incarcerated in jail, further barriers may occur related to HCV treatment initiation. One barrier is the relatively short length of stay, which limits the completion of treatment while incarcerated. However, if initiated, HCV treatment can be successful for people who are incarcerated in jails, even for those who are released mid-treatment.35,36 Although a person who is discharged mid-treatment would require linkage to outpatient care for completion of treatment, combined strategies of transitional care coordination and patient navigation have also been shown to be successful. 8 Previous qualitative analysis has suggested that people who are incarcerated have a favorable view of beginning HCV treatment while in jail, 37 and initiation of treatment could prevent complications of cirrhosis and advanced liver disease. 38 The treatment of incarcerated populations could also decrease the rate of community transmission of HCV, creating further cost savings to society by decreasing the incidence of infection. Additional barriers to HCV treatment include not having linkages to care or receiving medications at discharge. Variable lengths of stay in jails may lead to incomplete treatment during incarceration and interruptions in treatment, such as inability to access medications and changes in health insurance coverage, which may lead to multidrug-resistant HCV. Sustained viral response (SVR) is commonly measured 12 weeks after the initiation of treatment to measure viral response to treatment; however, the variable lengths of stay in jails and challenges to people after release can create barriers to SVR measurement. 35 Novel approaches to treatment, such as the minimal monitoring approach, which dispenses an entire treatment course at initiation and does not require prolonged laboratory monitoring, has shown promising results in SVR and may be applied to populations incarcerated in jails. 39
Differences in testing and treatment protocols expand health inequities among incarcerated populations in Massachusetts. Of the counties in Massachusetts with poverty rates >17% (Hampden and Suffolk), 24 treatment protocols are either prohibitive due to length-of-stay requirements (Hampden) or nonexistent (Suffolk). These counties also have the highest percentage of residents of racial and ethnic minority groups, with 55% in Suffolk County and 38% in Hampden County. 24 These counties account for almost 10 000 annual bookings in Massachusetts, which perpetuates health inequities among populations that have been economically marginalized.
Conclusion
Overall, our study found no standardization in HCV testing and treatment protocols across Massachusetts county jails. Despite recommendations from medical and public health societies on HCV testing and treatment, most Massachusetts county jails had multiple barriers to testing, including opt-in testing or self-reported admission of risk factors. For those jails that did have treatment protocols, many had barriers to treatment, including mandatory length-of-stay requirements or sobriety requirements, despite the assertion from the Infectious Diseases Society of America that active drug use is not a contraindication to treatment. 22 These limitations in HCV testing and treatment are obstacles to harnessing the potential that correctional settings offer for public health intervention and perpetuate health inequities among the poorest communities in Massachusetts.
Many policy opportunities exist that could address inequities in HCV testing and treatment across the state. We believe that policies should be focused on universal opt-out testing. Although many jails may have financial, staffing, or other barriers to providing universal opt-out testing, we believe further implementation science studies could address these barriers and help Massachusetts jails provide more equitable testing. Treatment protocols should exist for all jails and should not be limited by lengths of stay, sobriety, or other requirements. Efforts should instead focus on linkages to outpatient care and treatment of SUD, which have been shown to be effective in people who are incarcerated. Of note, the recent Massachusetts waiver to Section 1115, which expanded Medicaid to cover treatment for incarcerated populations 90 days before release, provides a promising opportunity to initiate HCV treatment and diminish length-of-stay cost barriers. 40 Overall, addressing the barriers to HCV testing and treatment has the potential to address health inequities across the state.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
