Q&A: Expert discusses prevalence of hepatitis C in US state prisons

The World Health Organization has a goal to eliminate hepatitis C as a public health threat by 2030. The blood-borne virus affects more than 2 million people in the United States and killed more than 15,700 people nationwide in 2018, even though more than 95% of people infected with hepatitis C can be cured if they get the pills to treat the disease.

But a significant number of U.S. state prisons are failing to adequately address this curable disease, as approximately 55% of people in U.S. state prisons who had been infected are still not cured, according to a new Emory-led study—published in The Journal of Infectious Diseases.

We asked Anne Spaulding, MD, the study's lead author and an associate professor of epidemiology and global health at Emory University's Rollins School of Public Health, to answer five questions about why these findings are significant for both prison populations and society at large.

Why is this research important to the general public?

We wont achieve the goal of eliminating hepatitis C by 2030 without treating hepatitis C in the incarcerated population. The U.S. has the highest incarceration rates in the world and the prevalence of hepatitis C in prisons is about 10 times higher than it is in the general population.

The driver of the hepatitis C epidemic is injection drug use, especially when people share needles. Its how the virus spreads from one person to another. To eliminate a curable infectious disease, you need to know where the hot spots are. Prisons are the hot spots for hepatitis C. Our article revealed the hottest of the hot spots.

The opioid epidemic has not hit all states equally, and the legal systems response to drug use differs by state. Some states send many people who inject drugs like heroin to prison, others funnel them to rehab.

Why were incarcerated populations a meaningful group to study?

The incarcerated population has the highest rate of hepatitis C infection and is lagging the most in accessing care. In this study, we demonstrated that the virus was active in 55% of people in state prisons who had been infected. Everyone should have access to medical care while in prison—deliberate indifference to health needs of people in prison is a violation of the Eighth Amendment to the U.S. Constitution.

Did anything about the study's findings surprise you?

This paper examined both exposure to the virus and persistence of infection and showed that the heterogeneity of the epidemic persists. Our previous hepatitis C studies showed that the portion of prison populations that have antibodies differed by states.

This new study added details on the measurement of virus levels in the blood. We are now reporting by state, the rates of active infection by these blood measurements (viremia). This greater detail amplifies the differences state by state, as opposed to just antibody prevalence (marker of past/present infection combined).

Where is access to treatment most lacking?

In which sector of the criminal legal population is there inadequate treatment—thats easy. Jails, short stay facilities for people awaiting trial. Most persons in prison today were previously in jail; most persons in jail dont go to prison. Nearly 10 million Americans go to jail each year, and many have untreated hepatitis C.

In what prison system are there the most people who cant get treatment, and in what prison system is it hardest for an infected person to get treatment? These are difficult to answer without better data, and our study showed that how well state prisons know their epidemic varies markedly.

Some states, like Mississippi, cannot tell you how many people have ever been exposed. Others, like California, can tell you how many have been exposed, how many were infected when they came in, and how many still need treatment.

What did you learn from this study that can help address the problem?

Measurement of the prevalence of a disease, a dashboard so to speak, provides direction for where health care planners need to expend their efforts. This was helpful with COVID-19; we need something similar for hepatitis C in incarcerated populations. Hepatitis C can be treated systematically, on a population level, by prison health services. The treatment is costly but coming down in price—so the cure of hepatitis C in prisons is feasible.