Testing and treating the oversized prison population in the United States for hepatitis C could make it easier to stave off a national epidemic, but how to pay for it remains elusive.
Nearly 4 million Americans may be infected with the hepatitis C virus (HCV) and not know they are carriers. The virus can take decades to make people ill with cirrhosis, cancer, or liver failure. About a million people could die because of HCV by 2060, researchers say, and those who survive will have required critical and costly treatments, including liver transplants.
“We know this is going to come crashing down on us,” says lead author Josiah D. Rich, professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital. “It’s already starting to come crashing down. The next 10 to 20 years are going to be ugly.”
The single best setting for fighting the epidemic is U.S. prisons and jails, where more than 10 million people cycle through each year. In part because a major means of HCV transmission is through injection drug use, a large portion of the nation’s infected population passes through the criminal justice system.
A new study published in the New England Journal of Medicine estimates that one in six inmates is infected and one in three infected Americans ends up locked up for some time in their lives. “We can head off a lot of disease and expense if we invest now,” Rich says. “How do we do that most efficiently and effectively? What we’re arguing in the paper is that we do it using the criminal justice system infrastructure.”
High Costs, But Are They Worth It?
The key barrier, Rich says, is the very high cost of hepatitis C drugs. A 12-week course of Sovaldi, made by Gilead Sciences, costs $84,000 a person. Treating all current inmates with HCV would therefore cost $33 billion, the authors estimate. Treating just half the people who cycle through prisons and jails in a given year would cost $77 billion.
But drug costs don’t have to be nearly so high if state prison systems can negotiate reasonable discounts with drug makers, as the federal government does for its prisoners.
And while prisons have a clear disincentive to spend money to treat people who may well be released before they become sick, the money cannot and need not come solely from their budgets.
“The criminal justice system cannot be expected to shoulder the prohibitive costs of hepatitis C treatments alone,” says coauthor Brie A. Williams, associate professor of medicine at University of California, San Francisco. “Recognizing that infectious disease epidemics cannot be contained behind prison walls, we must develop a national strategy for responding to them that includes financial support and an infrastructure to test and treat prisoners, both within prisons and jails and after they return to our communities.”
'Part of Fabric of Health Care'
U.S. society as a whole will pay the costs of an inadequately addressed HCV epidemic, the authors write. Helping prisons to provide this treatment will also curb the need for litigation by prisoner advocates to a community standard of HCV care for prisoners, says coauthor Scott A. Allen, professor of medicine at the University of California, Riverside.
“Even with the high cost, the drugs appear to be cost-effective,” Allen says. “Private insurers in the community appear to be covering it. That establishes a clear community standard, and prisons will be held to that standard by the courts. The public policy question isn’t whether or not we pay for hepatitis C care but how we pay for it.”
A potential model already exists in the Ryan White Care Act, the three authors note. Congress could consider replicating that achievement of funding widespread HIV services and treatment for people who couldn’t obtain them otherwise them. An HCV version could include programs and grants for prisons and jails, as well as programs to prevent reinfection of inmates after they are released.
“Seizing this opportunity for timely care will require leaders to consider the criminal justice system as part of the fabric of U.S. health care,” the authors write. “This step will help to change the perception of the HCV epidemic in the criminal justice system, transforming it from a legal liability to a critical opportunity to change the course of HCV in the United States.”
The research for the article required no direct funding, but Rich disclosed an honorarium he received from Gilead for speaking at a meeting in 2012.