6.1 Clinical assessment and referral for ongoing care and treatmentAll 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.
Inmates with symptoms of hepatitis C and inmates who are known to be hepatitis C antibody positive should be offered assessment by appropriately trained medical, nursing or allied health staff to determine whether they have chronic hepatitis C infection. This assessment should be consistent with the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003).
Inmates with chronic hepatitis C must be referred for health status assessment, health monitoring and ongoing care, including treatment (Lloyd 2006, Read V 2006, Boonwaat 2006). The decision to undertake treatment is made by the inmate on the advice of the health service provider (Dore 2005). Studies have shown the time taken to consider and then decide on whether to start treatment is quite protracted. As well as considering the details of therapy (including different drugs, side effects, success rates etc) inmates and their health providers will be faced with decisions about post-release management – another complex situation. The actual clinical decisions for inmates are identical to those in the community and are outlined in the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003). However, the process may be a little different. Ongoing clinical assessment and care is provided to all inmates with hepatitis C regardless of whether they decide to have antiviral treatment.
It is important that those inmates at increased risk of disease progression have priority access to treatment. The demonstrated benefits of treatment include an improvement of symptoms and quality of life (mental and physical), a decrease or elimination of progression of liver disease, viral eradication and reduction in the risk of virus transmission (Seivert in Crofts 2001).
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6.2 Counselling about treatment optionsInmates who are recommended for treatment require full discussion and counselling about all aspects of therapy.
Treatment options will have been raised with the inmate in the process from the test discussions through to diagnosis and assessment. Counselling about treatment options and treatment is in line with those standards outlined in the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003).
Prognosis is determined by a number of factors including the clinical assessment. Counselling is the process by which the inmate can explore his or her preparedness to commence treatment. This is a complex decision making process in the community which can be even more complicated in the custodial setting. Studies have demonstrated that decision making about undertaking hepatitis C treatment is a lengthy process (Temple-Smith 2006). Adherence to treatment regimens is improved when patients are provided with information, resources and support to anticipate interruptions or changes to their lives and to minimise or prevent adverse effects (Kolor 2005).
Counselling about treatment should at a minimum address:
- the preparedness and enthusiasm of the inmate;
- the desirability to commence treatment while in prison and if relevant the capacity of the inmate to continue treatment post release;
- pre-existing psychiatric illness which may recur or amplify as a result of treatment;
- commitment to not becoming reinfected; and
- the impact of treatment failure, at present, once treated, a person can not access subsidised treatment for a second time.
Counselling about treatment options should be made available to all inmates in custodial settings.
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6.3 Treatment planningPre-treatment planning and preparation for inmates who decide to access hepatitis C treatments will result in better outcomes.
The success of any medical management is highly dependent on adequate planning and preparation. This is even more important in settings that do not routinely provide specialist and specialised clinical services. Inmates require the same, if not higher levels of treatment planning and preparation as individuals who are treated in the community.
Treatment regimens for hepatitis C are prescribed in the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003). This model applies equally to all Australians and no distinction is made in the Model for people in custodial settings.
Currently, treatment plans are initiated for either 24 weeks or 48 weeks, depending on the specific genetic structure (genotype) of the virus. Patients are required to have a virological response to treatment in order to remain on treatment after the first 12 weeks. A person is said to have a “sustained response” if the hepatitis C virus cannot be detected in their blood six months after completing the treatment. A sustained response is thought to mean that the illness is cured.
The complexity of treatment planning in the custodial setting arises from factors specific to that setting. This includes, but may not be limited to:
- access to liver biopsy, where clinically indicated;
- access to serological and clinical monitoring while on therapy;
- the duration of stay in the custodial setting;
- the capacity to provide appropriate support to the inmate while on treatment;
- stable accommodation in the custodial facility, or if relocation occurs capacity of the receiving facility to provide continuity of care; and
- post release care for the patient who is released during treatment or soon after treatment ceases.
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6.4 Ongoing care and symptom managementInmates on treatment for hepatitis C require regular medical attention to monitor their progress and to manage any adverse effects.
Ongoing care during treatment is essential. This allows for the monitoring of clinical markers and the patient’s capacity to cope with the side effects of treatment. In the community setting, side effects are managed by regular monitoring and dose reduction or cessation of treatment, and the provision of prophylactic or therapeutic drugs and strategies to manage side effects.
A number of factors may prevent access to this same range of strategies in the custodial setting. Consequently, possible side effects need to be carefully addressed in treatment planning and in the management of the patient, once treatment has commenced. Access by the inmate to: serological and clinical monitoring; drugs or other supports to reduce side effects; and psychological or psychiatric support are critical.
Currently, Australians who have accessed treatment once through the Pharmaceutical Benefits Scheme are unable to access subsidised treatment at a later time. The decision to commence an inmate on treatment must therefore be made with a commitment to provide the necessary support to maintain that inmate on treatment to complete their treatment course and to facilitate care in the community should an inmate be released whilst on treatment (Watson 2006).
6.5 Access to drug substitution and pharmacotherapyTreatment of drug use is an integral part of the care of many individuals with hepatitis C within and outside custodial facilities.
Methadone maintenance and other pharmacotherapy (eg buprenorphine, naltrexone) have demonstrable benefits in the community and custodial setting. These need to be encouraged and expanded as part of a balanced prevention and treatment program (Dolan 2001, Dolan 2006).
There are no exclusion criteria for access to specialised hepatitis C treatment relating to either current or previous injecting drug use or maintenance on drug substitution treatment. In the community people who inject drugs and people on drug substitution programs, primarily methadone, have been successfully treated for hepatitis C (Hallinan R 2006, Sasadeusz J 2006). Consideration should be given to stabilising the drug use of inmates who inject drugs via pharmacotherapy, prior to commencing hepatitis C treatment. Providing the same range of addiction treatment that is available in the community to inmates maximises the success of management of drug use in custodial facilities.
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6.6 Monitoring of hepatitis C for inmates who are not receiving treatmentAccess to regular health status assessment and monitoring by inmates with hepatitis C infection who are not in therapy is necessary to determine progression of their disease.
All people infected with hepatitis C benefit from regular monitoring of their general health and liver function status. Hepatitis C is a dynamic condition; similarly, treatment recommendations and decisions made by clinicians and patients can be reviewed and changed on the basis of changed circumstances. All jurisdictions should ensure that inmates infected with hepatitis C have access to health services for monitoring of their health status consistent with the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003), regardless of whether they are on treatment or not.
6.7 Post release planning and careCareful 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.
There is a high turnover of inmates through Australian custodial facilities with many inmates detained for relatively short periods. This situation means that although voluntary testing programs are often in place, many inmates have not been assessed or offered treatment for hepatitis C. There is the risk that an inmate may be infected prior to release given that incarceration is an independent risk factor for hepatitis C infection. Inmates are a Public Health opportunity to reinforce prevention and health promotion messages. Further, inmates who are assessed as having hepatitis C require effective discharge planning and referral by custodial health services.
Inmates who are preparing for or have started treatment require support on release to provide them with a continuity of care. This has been reported as a problematic area for the management of hepatitis C and drug and alcohol issues. Community agencies and professional medical organisations provide a useful referral service in relation to these individuals, particularly drug and alcohol services because of the critical role they play post release.
As part of the continuum of care, custodial health services should establish linkages with community agencies and professional organisations to plan for and maximise access to post release care.