Martha Paynter supports better Hepatitis C treatment coverage in prisons
Over a year ago, a CBC story exposed that prisoners in Nova Scotia are denied access to curative Hepatitis C treatment. This discriminatory policy puts other prisoners and the public at risk. In the year since, prisoner and health advocates, physicians, and patient groups have led calls for change. The responsibility for health services for provincial prisoners is at the nexus of Department of Health and Wellness, the Nova Scotia Health Authority, and Department of Justice (Corrections). Prisoners fall through the gap where these authorities fail to converge.
Hep C is an infectious liver disease transmitted through contact with blood. A portion of people infected will clear the infection on their own. Between 60-80% will develop chronic Hep C and be at risk of cirrhosis or liver cancer, if not treated. Although there is no vaccine to prevent Hep C, anti-viral medication can cure 95% of cases. An estimated 461,000 people in Canada have a history of Hep C infection, and 44% of people who are chronically infected are unaware of their infection.
Due to the high rates of asymptomatic chronic infection, and the availability of curative treatment, the Canadian Association for Study of the Liver has called for universal Hep C screening of Canadians born between 1945-1975. The Canadian Agency for Drugs and Technology in Health recommends all patients be considered for treatment. Significant increases in testing and treatment will be necessary to move towards the World Health Organization’s goal for worldwide elimination of Hepatitis C by 2030.
Approximately 0.6-0.7% of the population in Canada is infected with Hep C. A Correctional Service of Canada study from 2016 found 25.4% of federally-incarcerated people are infected with Hep C, a rate 36 times higher than the general population. Infection rates differ by sex and race: 25% of incarcerated men in the study reported Hep C infection compared with 33% of women; among Indigenous women, the rate was 45%. Prisoners have complex social and health histories which put them at greater risk of infection.
Incarceration is itself a risk factor. The most common cause of Hep C transmission is sharing drug injection equipment. Other common modes of infection include tattooing, sharing personal hygiene equipment such as razors or nail clippers, and unprotected sex in which contact with blood may occur, such as in the presence of a sore from a sexually-transmitted infection. The risks are gendered. A 2004 study of federally-incarcerated women found 27% engaged in tattooing; 24% in unprotected sex; 19% in injection drug use; and 9% in slashing and self-injury. Although not without gaps, the Correctional Service of Canada offers prisoners Hep C testing, treatment and harm reduction measures such as condoms, bleach (for cleaning equipment), and in at least two facilities, a safe needle exchange program. NS Provincial corrections does not have a comprehensive approach for harm reduction.
Treating Hep C has increased Correctional Service of Canada’s drug expenditure budget. The cost of treatment, such as sofosbuvir, is reported as $1000/pill, daily, for 8-12 weeks. However, the pan-Canadian Pharmaceutical Alliance negotiated vastly lower (and undisclosed) prices for the Canadian market in 2017. The argument that Hep C treatment is too expensive rings false. Ontario recognizes that the short-term expense of treatment prevents extensive long term costs, such as for liver transplant, and the province claims to offer treatment to everyone.
However, British Columbia is the only province offering testing and treatment to provincial prisoners. In 2017, the BC Provincial Health Services Authority took over provision of prison health services from a private for-profit contractor, Chiron. Last September, Jennifer Metcalfe, Executive Director of West Coast Prison Justice Society, reported that the change in service provider resulted in fewer prisoner complaints about health, and new provision of Hep C treatment.
In Nova Scotia, where the rate of Hep C is reportedly higher than the national average, Nova Scotia Health Authority is the prison service provider. A recent Freedom of Information and Protection of Privacy request revealed misunderstanding between Department of Health and Wellness, Nova Scotia Health Authority, and Corrections as to where responsibility for prisoner health lies. At least six months went by in 2018 without key actors meeting to address Hep C.
While Department of Health and Wellness delegates prisoner health responsibility to Nova Scotia Health Authority, Hep C is a public health and infection prevention concern, both of which are Department of Health and Wellness responsibilities. The Department must step up and respond to the confusion resulting in inadequate prevention, testing and treatment of Hep C for provincial prisoners.
Payment is not the only issue. As most provincial prisoners are remanded (unconvicted and unsentenced), their average length of incarceration is less than one week. Proactive efforts are required for coordination of testing and treatment in the prisons to continue with community-based service providers. We never deny a hospital patient a medication because we expect them to be discharged. Likewise, we should not withhold treatment for incarcerated persons.