This document presents evidence-based guidelines for the prevention, treatment and care of hepatitis C in custodial settings. It has been developed by the Prisons Working Group of the Hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH). The guiding principles for this document have been adopted from the National Hepatitis C Strategy 2005-2008.
The need for Guidelines
Some 200,000 Australians are infected with hepatitis C, which can be a debilitating and potentially life threatening disease. For the past 10 years it has been one of the most commonly reported notifiable infectious conditions. Those most at risk from the disease are the inmates of Australian prisons, where hepatitis C is six times more prevalent than in the general community. Recent studies indicate that one in three male inmates are hepatitis C antibody positive and that two thirds of all female inmates are, or have been infected with hepatitis C. These figures equate to up to half of the total fulltime prison population (estimated to be around 25,000 persons) being infected. Each year between 5,000 and 10,000 inmates are released from prison into the community, highlighting that hepatitis C prevention and control requires an urgent concerted response from both corrections and public health sectors.
There is no vaccine to protect against hepatitis C virus infection, therefore prevention efforts are directed at behavioural change supported by services such as needle and syringe and drug treatment programs. Treatment for chronic hepatitis C infection is now available in Australia and offers people with hepatitis C a strong chance of cure in 50% to 85% of cases. Projections indicate that without a substantial increase in the number of people accessing treatment, the number of people with hepatitis C related liver cirrhosis will continue to increase to between 7,000 and 10,000 by 2025.
A number of national and international policies refer to human rights within a custodial context, in particular the principle of equivalence in health care provision. Governments, through their health, justice and human services departments have a duty to safeguard the welfare and protect the health of all inmates and detainees under their control. The health of inmates, and the means to ensure their optimum health, is not only of concern to themselves and their families but is also important for the improved occupational health and safety of the staff of custodial facilities. Additionally, since the majority of inmates are eventually released back to their communities, interventions to address their health problems present opportunities to improve the public's health and safety.
The prevalence of hepatitis C is disproportionely higher among inmates compared to custodial the general community. Imprisonment is an independent risk factor for hepatitis C infection. There is a unique relationship between the prison environment and the spread of hepatitis C. Transmission of
hepatitis C in custodial settings combined with high levels of inmate movement to and from the community present significant challenges to our ability to control hepatitis C infection both within prisons and in the broader community.
Unless intensive efforts are directed towards preventing the spread of hepatitis C in custodial settings, transmission of hepatitis C will continue and the epidemic will grow. Periods of incarceration can provide an opportunity for the inmate population to have health assessments, diagnosis, education and treatment in relation to blood borne viruses. Health services in custodial settings have the potential to break the hepatitis C cycle. Inmates must have the means to protect their health, and to minimise the risk of transmission of hepatitis C to others.
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Implementing these Guidelines
The Australian Government is not responsible for administering prisons nor for arrangements for the health of inmates and staff in custodial facilities. However, the National Hepatitis C Strategy 2005-2008 recognises people in custodial settings as priority populations at risk of hepatitis C infections and as such, the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH) has a role in identifying sound, evidence based approaches to the prevention, treatment and care of hepatitis C in custodial settings across Australia. MACASHH has produced this document to provide guidance to those responsible for custodial facilities. Ultimately, the extent to which these Guidelines can be implemented in each state and territory is a matter for custodial services agencies and facilities in each jurisdiction.
Each state and territory has its own separate, independent systems of police, courts, prisons and juvenile institutions. Health services are provided variously by health or justice jurisdictions and supplied directly, or contracted, by public and private custodial facilities. Australia’s prison systems are relatively small and isolated from each other. This presents challenges for the coordination of policy development, implementation and evaluation, research and education.
These Guidelines are based on sound evidence, as described in the supplementary document, and have been developed following considerable consultation with key stakeholders.
Key Guidance points
1. Prevention of hepatitis C in Custodial Settings:
Education about Hepatitis C and the Routes of Transmission for Inmates
- Education of inmates about the prevention and management of hepatitis C, including treatment, is a fundamental, necessary and effective preventive intervention.
Infection Control in Custodial Settings
- Each institution needs to have in place appropriate infection control procedures. Staff education and training about infection control measures in relation to blood borne viruses is an integral part of the proper application of these procedures.
Recreational Sport and Exercise
- Compliance with the Guidelines on HIV/Hepatitis and Other Blood Borne Viruses in Sport (ANCAHRD 2001) reduces the risk of exposure to blood during sport and recreational activities within custodial settings.
Provision of Bleach and Disinfectant and Education about their Use
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- Provision of, and access to bleach and disinfectants is supported in custodial settings where no other safer alternatives are provided for decontaminating spills, surfaces or equipment. Education about the proper use of bleach is an essential component of its provision.
Access to Razors, Toothbrushes and Safe Barbering
- The risk of transmission from sharing personal items is reduced if each inmate receives free razors and toothbrushes that can be readily replaced and any razors and toothbrushes left in ablutions areas are removed.
- Adoption and application of infection control procedures for barbering equipment in custodial settings significantly reduces the risk of transmission.
Education and Counselling Related to Injecting Drug Use
- Easily accessible education and counselling about hepatitis C and injection drug use is a fundamental health promotion technique to support behaviour change. Tailoring the information to different groups’ needs is an important component of accessibility.
Drug Treatment Programs
- Access to Drug treatment programs including detoxification, drug free rehabilitation and drug substitution programs reduces hepatitis C transmission in custodial settings.
Tattooing and Body Art under Appropriate Infection Control Procedures
- Compliance with Australian infection control standards for tattooing and body art reduces the risk of transmission of hepatitis C in custodial settings.
Body Piercing and Appropriate Infection Control Procedures
- Compliance with Australian infection control standards for body piercing and other skin penetration practices reduces the risk of transmission of hepatitis C in custodial settings.
Prison-based Needle Syringe Exchange
- The provision of sterile injecting equipment in prisons is a controversial and complex issue. Any needle and syringe exchange trial which is being considered in the future by the Australian States and Territories would need to be supported by custodial staff and fully evaluated to assess occupational health and safety, impact on hepatitis C transmission and any other indirect effects.
2. Hepatitis C Testing in Custodial Settings:
The National Hepatitis C Testing Policy
- Voluntary testing for hepatitis C is available for all inmates in accordance with the National Hepatitis C Testing Policy which provides the framework for testing for hepatitis C in Australia, including within custodial services.
Risk assessment and Testing for Hepatitis C
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- Recommendations to inmates for hepatitis C testing are appropriate and based on thorough risk assessments.
Pre and Post-test discussion
- All information about hepatitis C, the test, prevention and management is provided appropriately, using understandable language and resources that are suitable to the inmates’ socio-cultural background. Privacy and confidentiality are essential to this process.
- Training, including regular updates, is essential for health staff who provide testing and follow-up.
- Pre-test discussion is provided and prepares individuals for hepatitis C testing and the results of testing. When offering a test, the practitioner provides appropriate information, in an understandable way, about risk, points of referral if necessary, assurances about confidentiality and privacy and assessment of the person’s preparedness to be tested.
- As part of the post-test discussion, test results are given in a clear and understandable way that is appropriate to the inmate’s cultural, educational and social background. Delivering negative results provides an opportunity to reinforce safe behaviours within custodial settings. Positive results are conveyed personally and privately. Components of this consultation include discussions of relevant health issues, the opportunities for referral and treatment, and prevention issues.
Hepatitis A and B Vaccination
- Co-infection with hepatitis C and hepatitis A and/or B can lead to worse health outcomes. Longer term imprisonment is an opportunity to protect inmates against vaccine preventable conditions such as hepatitis A and B.
- Participation by custodial services in sentinel site surveillance programs for hepatitis C provides useful data to understand patterns of infection and to develop and evaluate prevention programs at an institutional and jurisdictional level.
3. Hepatitis C Education and Counselling
- Hepatitis C educational programs provide access to the means to protect the individual and minimise the risk of hepatitis C transmission and are necessary and effective interventions for inmates and staff in custodial settings.
Access to Educational Materials
- The ready availability of current, easy to understand information about hepatitis C in prison including its prevention and medical management supports inmates to prevent hepatitis C transmission and to seek testing and clinical assessment if they are at risk.
Purpose Developed Materials
- Resources that are designed to meet the educational needs of groups of inmates are more effective communication tools.
- The provision of peer education within the custodial setting is another effective and proven method to decrease the transmission of blood borne viruses.
- Cooperative development of these programs between custodial staff and peer educators maximises their success.
Access to Counselling and Support Services
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- Improved access to support and counselling by a range of service providers will benefit individual inmates and the broader custodial community.
4. Treatment and Care of Inmates Living with Hepatitis C
Clinical Assessment and Referral for Ongoing Care and Treatment
- All inmates with clinical or laboratory evidence of hepatitis C infection require specialist medical assessment and are provided with the ongoing clinical care and treatment that is equitable with that offered to people with hepatitis C outside prison.
Counselling about Treatment Options
- Inmates who are recommended for treatment require full discussion and counselling about all aspects of therapy.
- Pre-treatment planning and preparation for inmates who decide to access hepatitis C treatments will result in better outcomes.
Ongoing Care and Symptom Treatment
- Inmates on treatment for hepatitis C require regular medical attention to monitor their progress and to manage any adverse effects.
Access to Drug Substitution and Pharmacotherapy
- Treatment of drug use is an integral part of the care of many individuals with hepatitis C within and outside custodial facilities.
Monitoring of Hepatitis C for inmates who are not on Treatment
- Access to regular health status assessment and monitoring by inmates with hepatitis C infection who are not undergoing hepatitis C treatment is necessary to determine progression of their disease.
Post Release Planning and Care
- Careful planning to maximise access to health care after release is critical to the inmate’s well being. The establishment of sustainable links between custodial health services and community health and support agencies is an integral to successful post release care.
5. Workforce development
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- All staff are given education, information and training about hepatitis C at orientation and with updates and refreshers provided through the course of their work within custodial services.
- Training should address matters relating to attitudes and values.
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