[Ip-health] New Hepatitis C Drugs Are Very Costly And Unavailable To Many State Prisoners

Gregg Gonsalves gregg.gonsalves at gmail.com
Wed Oct 5 08:24:34 PDT 2016


New Hepatitis C Drugs Are Very Costly And Unavailable To Many State Prisoners

Adam L. Beckman1,
Alyssa Bilinski2,
Ryan Boyko3,
George M. Camp4,
A. T. Wall5,
Joseph K. Lim6,
Emily A. Wang7,
R. Douglas Bruce8 and
Gregg S. Gonsalves9,*

+Author Affiliations

1Adam L. Beckman was an undergraduate at Yale College and research
assistant at the Yale Global Health Justice Partnership, both in New
Haven, Connecticut, when completing this work.
2Alyssa Bilinski is a PhD candidate in health policy in the Harvard
Graduate School of Arts and Sciences, in Cambridge, Massachusetts.
3Ryan Boyko is a PhD candidate in the Department of Epidemiology of
Microbial Diseases at the Yale School of Public Health, in New Haven,
and a fellow at the Yale Global Health Justice Partnership.
4George M. Camp is co–executive director of the Association of State
Correctional Administrators, in Hagerstown, Maryland.
5A. T. Wall is director of the Rhode Island Department of Corrections,
in Cranston.
6Joseph K. Lim is an associate professor of digestive diseases and
director of the Yale Viral Hepatitis Program, Yale University School
of Medicine, in New Haven.
7Emily A. Wang is an associate professor of general medicine at Yale
University School of Medicine.
8R. Douglas Bruce is an associate clinical professor of medicine at
Yale University School of Medicine and chief of medicine of the
Cornell Scott-Hill Health Center, in New Haven.
9Gregg S. Gonsalves (gregg.gonsalves at yale.edu) is codirector of the
Yale Global Health Justice Partnership, a research scholar in law and
lecturer in law at Yale Law School, and a PhD candidate in the
Department of Epidemiology of Microbial Diseases at Yale School of
Public Health.

↵*Corresponding author


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Abstract

Prisoners bear much of the burden of the hepatitis C epidemic in the
United States. Yet little is known about the scope and cost of
treating hepatitis C in state prisons—particularly since the release
of direct-acting antiviral medications. In the forty-one states whose
departments of corrections reported data, 106,266 inmates (10 percent
of their prisoners) were known to have hepatitis C on or about January
1, 2015. Only 949 (0.89 percent) of those inmates were being treated.
Prices for a twelve-week course of direct-acting antivirals such as
sofosbuvir and the combination drug ledipasvir/sofosbuvir varied
widely as of September 30, 2015 ($43,418–$84,000 and $44,421–$94,500,
respectively). Numerous corrections departments received smaller
discounts than other government agencies did. To reduce the hepatitis
C epidemic, state governments should increase funding for treating
infected inmates. State departments of corrections should consider
collaborating with other government agencies to negotiate discounts
with pharmaceutical companies and with qualified health care
facilities to provide medications through the federal 340B Drug
Discount Program. Helping inmates transition to providers in the
community upon release can enhance the gains achieved by treating
hepatitis C in prison.

Access To Care

Public Health

Disparities

Cost of Health Care
Special Populations

Hepatitis C is the most common bloodborne viral infection in the
United States.1⇓–3 It was a cause of more deaths in 2013 than sixty
other infectious diseases combined, including HIV, pneumococcal
disease, and tuberculosis.4While the prevalence of hepatitis C in the
noninstitutionalized US population is approximately 1 percent, the
prevalence among prison inmates is about 17 percent.1,5,6 Nearly
one-third of all Americans with hepatitis C spend at least part of the
year in a correctional facility.5

Since hepatitis C is primarily spread through drug injection and
infrequently through sexual intercourse, and since 20–55 percent of
inmates have injected drugs, treating prisoners infected with
hepatitis C can prevent transmission of the virus.6⇓⇓–9 Consequently,
providing hepatitis C treatment for inmates presents a unique public
health opportunity to reduce the nationwide epidemic.6,10,11 Moreover,
the US Supreme Court ruled in Estelle v. Gamble12that prison officials
cannot be deliberately indifferent to the known medical needs of
inmates and must provide adequate medical care.13 Historically, many
prisoners with hepatitis C have not received treatment, despite a high
rate of infection in the inmate population.14⇓–16 However, no studies
in the past fifteen years have shown the number and distribution of
inmates in each state prison system who receive treatment.

New direct-acting antiviral oral treatments for hepatitis C, including
sofosbuvir (Sovaldi) and the combination drugs ledipasvir/sofosbuvir
(Harvoni) and sofosbuvir/velbatasvir (Epslusa), recently entered the
market.17⇓⇓–20 Compared with the former standard of care—pegylated
interferon alpha and ribavirin administered for six to twelve
months—direct-acting antivirals are much more effective. They have a
cure rate of more than 90 percent, have almost no side effects, are
oral regimens instead of injections, and shorten treatment duration to
two to six months.21 The increased simplicity, efficacy, and
tolerability of direct-acting antivirals improves the feasibility of
implementing hepatitis C treatment in the prison setting.

Prison officials understand the desirability of using these
treatments. The Federal Bureau of Prisons’ Clinical Practice
Guidelines, which were adopted in April 2016 by the federal prison
system, recommend the use of direct-acting antivirals for treating
hepatitis C in many instances.22 However, the high price of
direct-acting antivirals such as sofosbuvir and ledipasvir/sofosbuvir
(US retail prices in 2015 for a twelve-week course were $84,000 and
$94,500, respectively) is a major barrier to implementation of
hepatitis C treatment within state prison systems.23,24

Recent studies have demonstrated that treating hepatitis C in state
prisons is both feasible and cost-effective.6,21,25 However, data on
contemporary hepatitis C treatment rates and the purchasing of
direct-acting antiviral regimens in state prison systems are lacking.

We administered a survey to the directors of the departments of
corrections in all fifty states, inquiring about current hepatitis C
care practices in state correctional facilities. Findings from this
study can inform efforts to increase treatment opportunities for
incarcerated patients with hepatitis C and prevent further
transmission of the infection within prisons and upon individuals’
release.

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Study Data And Methods

Design And Sample

In February 2015 we sent an introductory e-mail message to the
commissioners of the fifty state departments of corrections describing
the study and including a link to module 1 of the online survey
questionnaire. In October 2015 participants were given an opportunity
to review their responses to ensure accuracy and were invited to
participate in module 2. At this stage, nonrespondents to the
introductory message were invited again to participate in module 1 and
asked to participate in module 2 as well.

Both modules of the questionnaire can be found in the online
Appendix.26 No incentives were offered for participation in the
survey.

Data Collection And Measurements

Module 1 was the primary survey module. It included questions about
the number of inmates in a state’s prisons known to be infected with
hepatitis C (including both acute and chronic hepatitis C) on or about
January 1, 2015,27 the number of prisoners receiving any form of
hepatitis C treatment (including both new direct-acting antiviral
regimens and older interferon-based regimens) at that time, the
availability of relevant resources for inmates with known hepatitis C,
the annual amount of prison spending on hepatitis C treatment, and
efforts being undertaken by the prisons to acquire sofosbuvir and
ledipasvir/sofosbuvir regimens.

Module 2 focused on the price of direct-acting antivirals. It asked
how much money the state’s prisons were paying as of September 30,
2015, for a twelve-week course of sofosbuvir and for a twelve-week
course of ledipasvir/sofosbuvir. Respondents were also asked what
arrangement was being used to acquire the medicines at the price they
paid.

In addition, we used publicly available data from the Bureau of
Justice Statistics on inmates in state prisons on December 31, 2014,
to describe the approximate population of inmates in each state
facility.28

Data Analysis

We summarized responses to the survey items using frequencies, means,
and medians. All analyses were conducted using the statistical
software R, version 3.1.2, or Microsoft Excel, version 14.4.9.

Ethics Approval

The Human Investigation Committee at Yale University determined that
the study did not meet criteria for approval as human subjects
research and was therefore exempted from review.

Limitations

This study had several limitations. First, the design was
cross-sectional and did not capture how treatment access, drug prices,
and available medical resources might have changed over time.
Nonetheless, we provide important information about hepatitis
C–related medical care for a vulnerable population that is challenging
to study.

Second, estimates of inmates known to be infected with hepatitis C
were provided by state departments of corrections and were therefore
limited by the departments’ access to information about hepatitis C in
the states’ prison systems, different hepatitis C screening practices
across states, and the frequency with which hepatitis C registries
were updated. For example, we report that overall 10 percent of
prisoners were known to be infected with hepatitis C on or about
January 1, 2015. However, a recent study estimated the 2006 prevalence
of hepatitis C in US prisons at 17.4 percent, by extrapolating from
seroprevalence data provided by state correctional systems with
routine hepatitis C testing.5

Our data do not represent an estimate of hepatitis C prevalence in
state prisons, since states that do not routinely test inmates for
hepatitis C may be unaware of hepatitis C infections. Instead, we
captured the number of inmates known by state departments of
corrections to be infected, and we thereby provide a perspective on
the surveillance data used by those departments to guide hepatitis C
practices.

Third, our estimate of the proportion of inmates with known hepatitis
C who were receiving treatment had limitations. Since the prevalence
of hepatitis C is likely greater than the prevalence of prisoners
known to be infected, the proportion of inmates with hepatitis C
(diagnosed and undiagnosed) receiving treatment is probably even lower
than what we report. Also, the proportion of inmates with hepatitis C
being treated did not include inmates who might have received
treatment previously, were clinically ineligible for treatment, or
might have spontaneously cleared the infection (which occurs in 15–25
percent of hepatitis C cases).29

Future research is needed to characterize the proportion of inmates
with hepatitis C involved in the entire treatment cascade.
Nonetheless, our study provides previously unavailable information at
the state level about access to hepatitis C therapies among patients
in the prison setting.

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Study Results

Respondents And Resources Related To Hepatitis C

Representatives from forty-nine of the fifty state departments of
corrections completed module 1 of our Hepatitis C and State Prisons
Survey. Collectively, these departments reported having 1,348,716
inmates incarcerated as of December 31, 2014 (99.8 percent of the
total US state prison population) (data not shown).

Departments of corrections in forty-one states (84 percent) reported
data on hepatitis C infections and treatment (Exhibit 1). Seventeen
states reported offering routine opt-out hepatitis C testing (in this
testing, inmates receive the test as a matter of routine unless they
opt to be excluded). Medication-assisted treatment programs for
substance use disorders were available through fourteen state
departments of corrections.

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Exhibit 1

Characteristics of state prison systems and hepatitis C–related
medical care for inmates

Ten states used only internal medicine or family practice physicians
to provide treatment to prisoners with hepatitis C (Exhibit 1), but
the other thirty-nine states reported that physicians with specialty
training (for example, in gastroenterology, liver disease, infectious
disease, or addiction medicine) were treating patients known to have
hepatitis C.

Eighteen of the states participating in the Medicaid eligibility
expansion under the Affordable Care Act (ACA) were enrolling prisoners
in Medicaid before their release, the point at which their eligibility
would begin (data not shown). That practice could help inmates
transition to using health care resources in the community.

Prisoners Infected With Hepatitis C

Reported Cases Of Hepatitis C:

In the forty-one states with corrections departments that reported
data on hepatitis C infection and treatment, the proportion of inmates
who were reported to be infected with the virus on or about January 1,
2015, ranged from 1 percent in North Carolina to 41 percent in New
Mexico, with a median of 10 percent (interquartile range [IQR]: 8–13)
(for a map of the United States that shows the reported proportion of
hepatitis C–positive prisoners in state prisons, see the Appendix).26
This overall proportion corresponded to a total of 106,266 prisoners
(10 percent) in the forty-one states that reported data on hepatitis C
infection and treatment.

Prisoners Receiving Treatment:

Among the forty-one states that reported data on inmates known to have
hepatitis C and their treatment, 949 inmates (0.89 percent of the
106,266 inmates with known hepatitis C) were receiving any form of
treatment for the virus on or about January 1, 2015 (data not shown).
Demographic data were reported for 800 of these 949 inmates. Of the
800 inmates, 658 (82 percent) were male, 455 (57 percent) were ages
41–60, 297 (37 percent) were white, and 192 (24 percent) were African
American.

At the state level, the median proportion of prisoners with known
hepatitis C being treated at this time was 0.45 percent (IQR:
0.12–1.48). This proportion varied across the forty-one states,
ranging from 0.0 percent in Oklahoma, Pennsylvania, South Carolina,
and Wyoming to 5.9 percent in New York (Exhibit 2) (for a list of
proportions by states, see the Appendix).26 Twenty-seven of the states
(66 percent) were treating fewer than 1 percent of prisoners known to
have hepatitis C.

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Exhibit 2

US state prisoners receiving any treatment for hepatitis C as a
proportion of inmates with known hepatitis C infections, January 1,
2015

SOURCE Authors’ analysis of data for 2015 from the Hepatitis C and
State Prisons Survey, module 1. NOTES “Treated” means receiving any
hepatitis C treatment on or about January 1, 2015. “No data” means
that the state did not participate in the survey or had missing data.

States with a relatively high proportion of inmates reported to have
hepatitis C did not necessarily treat a greater number of patients
than states with a relatively low proportion of inmates with known
infections (for a side-by-side comparison of the proportions of
inmates with hepatitis C and inmates with hepatitis C who were
receiving treatment, see the Appendix).26 None of these figures
accounted for inmates with known hepatitis C who might have completed
treatment before January 1, 2015, or been otherwise ineligible for
treatment.

Reported Spending On Treatment:

At least $39.8 million was spent yearly on hepatitis C treatment by
the forty-one departments of corrections that reported data on
spending (for an explanation of how this amount was calculated, see
the Appendix).26 Departments reported spending a median of 6 percent
(IQR: 3.0–16.5) of their annual drug spending on hepatitis C drugs.
Sixteen states devoted 10 percent or more of their drug spending to
hepatitis C drugs, and eight states devoted 20 percent or more
(Exhibit 1).

Protocols For Triaging Testing And Treatment:

States varied in their reported hepatitis C testing protocols. For the
thirty-two states without routine opt-out hepatitis C testing (Exhibit
1), the main indications for being tested included having abnormal
results from other tests (twenty-nine states; data not shown), HIV
(twenty-seven states), or a substance use disorder (sixteen states).

States used a variety of factors to prioritize hepatitis C treatment
for inmates who tested positive for the virus. In terms of clinical
criteria, forty-one states reported that patients with cirrhosis were
prioritized for receiving hepatitis C treatment (for a bar graph of
criteria used to triage which inmates received hepatitis C treatment,
see the Appendix).26 Twenty-three states reported prioritizing
treatment for patients with chronic hepatitis C. In terms of
nonclinical criteria, forty-four states considered the length of a
patient’s remaining prison sentence in triaging patients for hepatitis
C treatment. Five states reported taking into account a patient’s
likelihood of recidivism, and twelve states said they considered a
patient’s chance of reinfection (for example, by engaging in risky
behaviors). (The survey did not ask whether longer sentences, a higher
likelihood of recidivism, or a greater chance of reinfection led to a
higher or lower priority for treatment.)

States could also indicate that they used “other” criteria to
prioritize treatment for prisoners; those states were asked to explain
what the criteria were. Five states noted weighing a prisoner’s
compliance with treatment for drug use, alcohol abuse, or both. Three
states considered prisoners’ mental health conditions. In addition,
ten states noted triaging based on the aspartate aminotransferase to
platelet ratio index (APRI), a tool for assessing the severity of
liver scarring, and four states reported that they followed all of the
Federal Bureau of Prisons guidelines.22

Reduced Prices For Medications

At the time that the departments of corrections were completing module
1 of the survey, forty-four (90 percent) states were taking steps to
acquire the direct-acting antivirals sofosbuvir and
ledipasvir/sofosbuvir at a price lower than the US list price (data
not shown). The strategy most frequently used (by twenty-nine states;
66 percent) in an attempt to acquire sofosbuvir at a lower price was
direct negotiations with pharmaceutical companies. California,
Maryland, Texas, and Wisconsin were the only four states to report
having already signed a contract with Gilead Sciences Inc. to obtain
sofosbuvir, but eight states (18 percent) were seeking such a
contract.

Sixteen states pursuing a reduced price for sofosbuvir (36 percent)
were pursuing discounts through the federal 340B Drug Discount
Program, a program created under the Veterans Health Care Act of 1992
that offers discounted drug prices to eligible health care
organizations with sizable low-income, vulnerable patient populations.
Thirteen states (30 percent) indicated that they were addressing the
prices of sofosbuvir through pooled procurement (for example,
collaborating with other state correctional systems or organizations
to purchase the medication in a greater quantity than a single
organization would purchase alone and thus to get a reduced price).

States could also indicate that they were trying “other” approaches;
those states were asked to explain what approach they were using. Five
states (9 percent) reported that they were addressing the price of
sofosbuvir through discounts from the Minnesota Multistate Contracting
Alliance for Pharmacy, a purchasing organization for government
agencies that provide health care services.

Price Of Purchasing Medications

Thirty-one (63 percent) of the forty-nine states that responded to
module 1 of the survey also responded to module 2. As of September 30,
2015, all thirty-one states were either seeking to acquire or had
purchased sofosbuvir, ledipasvir/sofosbuvir, or both. The states that
provided financial data were paying a median of $76,084.50 for a
twelve-week course of sofosbuvir and $63,509.00 for a twelve-week
course of ledipasvir/sofosbuvir (Exhibit 3).

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Exhibit 3

State prison systems’ cost of purchasing a twelve-week course of
sofosbuvir and a twelve-week course of the combination drug
ledipasvir/sofosbuvir, September 30, 2015

SOURCE Authors’ analysis of data for 2015 from the Hepatitis C and
State Prisons Survey, module 2. NOTES The median prices were those
paid by the state prison systems that provided data (eighteen for
sofosbuvir and nineteen for ledipasvir/sofosbuvir). In the United
States in 2015, the retail cost of a twelve-week course of sofosbuvir
(Sovaldi) was $84,000 (median price: $76,085) while the cost of a
twelve-week course of ledipasvir/sofosbuvir (Harvoni) was $94,500
(median price: $63,509).

For sofosbuvir, the lowest price was $43,418, in Connecticut, and the
highest was $84,000, in Michigan. As of September 30, 2015, two of the
three states paying the lowest price (Connecticut and Nevada) were
pursuing discounts through the 340B Drug Discount Program, and the
third (Alabama) was using direct negotiations with Gilead. The three
states paying the highest price were using direct negotiations
(Oklahoma) or no strategy (Idaho and Michigan).

For ledipasvir/sofosbuvir, the lowest price was $44,421, in Nevada,
and the highest was $94,500, in Michigan (Exhibit 3). The three states
paying the lowest price (Nevada, Connecticut, and Virginia) were
pursuing discounts through the 340B Drug Discount Program. The three
states paying the highest price (South Dakota, Idaho, and Michigan)
were not using any strategy.

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Discussion

We found that only 0.89 percent of the 106,266 inmates known to have
hepatitis C in states with departments of corrections that provided
the relevant data in our survey were receiving any form of treatment
on or about January 1, 2015. This finding comes despite evidence that
treating hepatitis C in the prison setting is cost-effective and may
be critical for ameliorating the national hepatitis C
epidemic.10,21,25 Increasing the financial resources for prison health
care and reducing the prices for direct-acting antivirals may be
necessary to make it feasible to expand hepatitis C treatment in state
correctional systems.

To our knowledge, this study is the first in fifteen years in the
peer-reviewed literature to document the number of prison inmates
receiving hepatitis C treatment, and the only one to do so since the
release of direct-acting antivirals. Though limited, previous reports
about hepatitis C treatment in state prisons suggest that treatment
has not been provided to many inmates with the virus.14⇓–16 Most
recently, a monograph from the Coalition of Correctional Health
Authorities and the American Correctional Association reported that 56
percent of surveyed correctional systems treat fewer than twenty
inmates with known hepatitis C on average per year,16 which is
consistent with our observation that few inmates with known hepatitis
C receive treatment. Our study expands on previous work by making
recent treatment data available at the state level. That information
is critical for meeting best-practice standards and guiding policies
set by state departments of corrections.14

The Price Of Direct-Acting Antivirals

We also found that numerous state departments of corrections were
receiving smaller discounts on the prices for sofosbuvir and
ledipasvir/sofosbuvir than other state and national agencies. Though
information about pricing discounts is often confidential, the US
Senate Committee on Finance’s 2015 report on the pricing of sofosbuvir
and ledipasvir/sofosbuvir noted that the Federal Bureau of Prisons,
Department of Defense, and Department of Veterans Affairs receive at
least a 24 percent discount on these drugs and that Medicaid receives
at least a 23 percent discount.30 Moreover, recent reports indicate
that the Department of Veterans Affairs and Medicaid programs that
accepted the conditions of offered rebates may receive more than a 50
percent discount.31 In contrast, ten of eighteen state departments of
corrections received less than a 10 percent discount on sofosbuvir as
of September 30, 2015, with Michigan paying the full $84,000 list
price, and five of nineteen states received less than a 10 percent
discount on ledipasvir/sofosbuvir.

While other researchers have pointed to a lack of transparency related
to the pricing of direct-acting antivirals as a major problem,32 we
are the first to report the prices paid by some state departments of
corrections and to highlight the gaps in knowledge or capacity among
states on how to obtain lower prices. Moreover, we found that eight of
the departments of corrections in this study were spending 20 percent
or more of their pharmacy budget on hepatitis C treatments. Therefore,
without increased discounts or funding, price may remain a barrier to
expanding the use of direct-acting antivirals in state correctional
facilities.

Our findings also reveal that at the time of our study, only a few
states were using some price reduction strategies. Other state
departments of corrections might secure lower prices by adopting some
of these strategies. For instance, pooled procurement by state
correctional systems could lead to greater purchasing power, which
could drive down the price of direct-acting antiviral medications.
State departments of corrections might benefit from working with
county or other state agencies, such as the Medicaid program, to
receive lower prices. Thirteen of the forty-nine states that responded
to our survey reported being involved in pooled procurement.

The federal 340B Drug Discount Program may offer another vehicle for
securing discounts (usually 20–50 percent) on drugs.33 Although state
prisons do not qualify for the program, institutions that are eligible
for it, such as federally qualified health centers, can partner with
prisons and provide health care services to incarcerated people—and in
such cases, the incarcerated people can be considered patients of the
entity eligible for the program. Sixteen of the departments of
corrections in our sample reported pursuing discounts through the 340B
program, and this mechanism was used by three of the four departments
paying the lowest prices for sofosbuvir and all four of the
departments paying the lowest prices for ledipasvir/sofosbuvir.

Finally, since many inmates will eventually be released into society,
after which the federal government may bear a substantial proportion
of the costs of untreated hepatitis C, a coordinated federal
initiative to treat people with hepatitis C—including in the
correctional setting—might be appropriate. Future research should
investigate which strategies are most effective for achieving the
largest discounts for and the greatest access to expensive hepatitis C
medications.

Trends In Hepatitis C Care In State Prisons

Our results also document several important trends in hepatitis C care
that are occurring in some state prison systems. First, forty-one
state departments of corrections (84 percent) reported data on
hepatitis C cases and the number of inmates receiving treatment for
hepatitis C. Collecting and reporting such up-to-date data are
critical to monitoring the epidemic and designing appropriate
responses.

Second, seventeen departments (35 percent) reported offering routine
opt-out hepatitis C testing, which is more than the eleven state
prison systems that reported using any form of routine testing in a
2012 survey.34 The difference may mean that this practice has become
increasingly widespread in recent years. However, further expansion of
hepatitis C testing, particularly for inmates with HIV or substance
use disorders, is necessary.

Third, fourteen state departments of corrections have
medication-assisted treatment programs for substance use disorders.
These programs may help reduce the chance that inmates who receive
treatment for hepatitis C will become reinfected through future drug
injection while incarcerated or after release.

Fourth, the vast majority of states reported that physicians with
specialty training (for example, in gastroenterology, liver disease,
infectious disease, or addiction medicine) were treating patients
known to have hepatitis C; only 20 percent of the states did not
report that hepatitis C treatment was provided by specialist
physicians. Training both specialist and nonspecialist physicians in
hepatitis C treatment within prison systems is essential to ensuring
that appropriate care is provided to inmates.

Fifth, among states participating in the ACA’s expansion of
eligibility for Medicaid, eighteen were enrolling prisoners in
Medicaid before their release—when their eligibility would begin.
Correctional systems that clinically evaluate inmates for hepatitis C
treatment before discharge and help them enroll in Medicaid may
effectively connect them to treatment after their release. State
Medicaid programs have been restricting access to direct-acting
antivirals, but some programs have recently announced that
beneficiaries with hepatitis C will be eligible for the
medications.35,36

For inmates receiving hepatitis C treatment in prison, transitioning
care from prison to the community upon release is critical to ensuring
that health gains achieved in treatment are not lost. To accomplish
this goal, the statute forbidding Medicaid involvement in the care of
inmates may need to be reconsidered. A reasonable alternative would be
to allow Medicaid to pay for high-priority public health treatments
such as hepatitis C medications.

Finally, most state corrections departments in our survey reported
prioritizing hepatitis C treatment for patients with cirrhosis and
certain comorbid conditions, as recommended by the Federal Bureau of
Prisons’ Clinical Practice Guidelines.22Future research into the
concordance between state prison practices and such guidelines is
essential, as guidelines are regularly updated with changes in
treatments for hepatitis C.

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Conclusion

Given the high burden of hepatitis C within correctional environments,
greater access to hepatitis C treatments would cure many of the
individuals at the highest risk of spreading hepatitis C infection.9
However, the substantial price of treatment prevents many state
corrections departments from purchasing the quantities of medications
necessary to treat all of those in need. As a result, many departments
are forced to make difficult decisions about triaging patients,
leaving many inmates without any treatment. Efforts at the state and
federal levels, such as increasing targeted funding and pursuing
greater drug discounts, could make hepatitis C treatment more readily
available for those who require it in state correctional facilities.

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Acknowledgments

The authors appreciate feedback from Elizabeth Bradley, Yale School of
Public Health; Alice Miller, Yale Law School and Yale School of Public
Health; Judith Resnik, Yale Law School; and Christine Ricardo, Yale
Law School. The authors thank the commissioners of state departments
of corrections for their time and efforts; Brittany Brothers, of the
Association of State Correctional Administrators, for her assistance
in administering the survey; and the Arthur Liman Public Interest
Program at Yale Law School and the Association of State Correctional
Administrators.



-- 
Gregg Gonsalves
Global Health Justice Partnership
Yale Law School-Yale School of Public Health
P.O. Box 208215
New Haven, CT 06520-8215
Email: gregg.gonsalves at yale.edu
Skype: gregggonsalves




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