About 3.2 million people in the U.S. have hepatitis C, a highly contagious virus that can lead to cirrhosis and liver cancer.
Dr. Jody Rich, a professor of medicine and epidemiology at The Warren Alpert Medical School at Brown University in Rhode Island, said prisons carry a heavy load of the disease, but they also have built in health care.
That may make prison a good place to start in exploring the public health potential of new hepatitis C drugs.
“Theoretically we [prisons] have everything we need. We have health care personnel, we have health care infrastructure, we have potential linkage to care in the community,” Rich said. “What we need to do is appropriate incentives and funding to make that happen.”
One inmate at the Washington State Department of Corrections is receiving new breakthrough drugs that can cure the hepatitis C virus in most people. The new drugs are revolutionary, but the costs are straining the DOC’s budget.
Decisions Of Care, Problems Of Price
Four years ago annual drug costs to treat hepatitis C in Washington State Prisons were around $843,000 dollars.
By March of this year, the department had already spent $1,290,853 to treat about 70 inmates. Of that, $143,000 went towards the purchase of new hepatitis drugs for one inmate.
Sold under the brand names Sovaldi and Olysio, the drugs the inmate received are much more effective than previous drug combinations.
Studies show patients who take these new drugs have a 90 percent chance of getting rid of the virus. Dr. Lara Strick, the DOC’s infectious disease coordinator, said the older drugs – Peginterferon and Ribavirin – have a lower effectiveness at clearing the virus: about 50 percent, depending on the patient.
The Sovaldi-Olysio protocol is also easier to take. The drugs can be taken orally while the interferon regimen needs to be injected weekly; sometimes for nearly a year.
The older drugs also cause intense side effects like depression. “Up until recently this has been a really rigorous difficult regimen with a lot of side effects that required a lot of monitoring and a very large workload for the nurses and the practitioners. I think that’s changing now,” Strick said.
Some patient advocates say in the long run the new drugs will be cheaper because for some patients, hepatitis C can lead to cirrhosis or liver cancer, both of which are expensive to treat.
The hope is that in the future more new hepatitis C drugs will enter the market, and that may lower the price of treatment. The DOC is also looking into the possibility of getting a drug discount from the manufacturer.
But for now the cost of the cure is problematic, according to Kevin Bovencamp, DOC assistant secretary of health services
At about $1,000, just deciding who will receive the new drug combination is complicated. Bovencamp said that determination is made by a committee of health care providers who meet twice a month.
“They’re taking a very conservative approach as far as I can tell,” Bovencamp said.
Bovencamp said that in a recent session, about 10 cases were reviewed, and none were approved. However, the DOC is ready to purchase the new drugs for a second inmate, and a third inmate is nearly approved.
“We will probably be asking for some financial increases around hepatitis C – that budget has been overspent the last year or two even with the older version of the drugs,” Boevencamp said.
Any increase to the DOC’s budget would have to be approved by the Legislature. The DOC has a constitutional mandate to provide medically necessary care to inmates, but Bovencamp said making the decision to provide care is a lot easier than figuring out how to pay for it.
“I think it’s too early to predict what the financial ramifications could be and what other programs it might impact if money has to be drawn over to pay for these drugs,” Bovencamp said. But, Bovencamp added, the financial ramifications of not providing care can be just as costly.
A sex offender being house at the Special Commitment Center on McNeil Island is currently suing the Department of Social and Health Services, which runs the facility. He’s alleging he’s been denied access to the new hepatitis C drugs.
Heavy Load Of Hepatitis
More than 2,600 inmates housed at the DOC are living with the hepatitis C. People can have it for decades and not know because they may not show symptoms.
Inmates can request to be tested and in Washington they are offered testing on the way into prison. But once inside, transmission can occur in the shadows.
“The problem in prison is that most of the behavior that can lead to potential exposure like drug use, tattooing and sex are not allowed in prison,” Strick said. Medical staff can only intervene if they know about an incident, she said.
The DOC doesn’t track how many inmates contract hepatitis C while in prison. Educating inmates is vital to helping prevent the virus’ spread.
On a recent foggy morning at the Washington Corrections Center in Shelton, about 50 inmates shuffled into the dining hall and sat down quietly.
In the front of the room Rich Feffer of the Hepatitis Education Project is getting a slide show ready. The Seattle nonprofit has been doing hepatitis education, prevention work and testing since the mid 1990s. They’ve been presenting in prisons for about 10 years.
After a short introduction Feffer cut right to the chase: “So do you guys know how many people out of a hundred total have hepatitis C?”
Guesses trickled in. “It’s actually about two out of 100,” Feffer answered. That’s the general population. In prison, Feffer said, the number is about 17 percent. And by some estimates, it’s much higher.
Feffer’s presentation is straightforward. “If you’re in here, you want to know how to protect yourself if you don’t have it. You’ll want to know how to take care of yourself if you do have it,” he told the inmates.
If you think you’ve been exposed to the virus ask to get tested, he said. If you have hepatitis C, be proactive about seeking treatment.
Correction 5/16/14: An earlier version of this story misspelled Dr. Jody Rich's name.