Abstract and Introduction
Abstract
It is well-established that prevalence of Hepatitis C (HCV) infection in prisoners is disproportionately higher than in the general population. While developments in screening and treatment for HCV have enabled greater detection and treatment in prison, release is a high-risk time for HCV infected prisoners returning to the challenges of community living. A scoping review was conducted to examine the evidence on individual, provider and system level factors that influence compliance with HCV treatment in patients transitioning from prison to community. Retrieved articles were screened and those eligible were selected for data extraction. Quantitative and qualitative studies were included. Electronic peer-reviewed databases were searched in February 2022: 140 articles were initially identified of which seven were included in the final review. Six key themes characterized the literature: education, case management and discharge planning, hepatology in-reach nurses, transition clinics, primary care providers and system wide approach. This summary scoping review highlights the paucity of research in this area. There is a need for experimental research to investigate specific interventions, and to understand HCV care-specific barriers and facilitators. A multi-pronged approach is needed to address barriers to healthcare services in general but also specific barriers relating to HCV. Factors that facilitate compliance should also be recognized and amplified across regional HCV elimination strategies.
Introduction
It is well-established that prevalence of Hepatitis C (HCV) infection in prisoners is disproportionately higher than in the general population. While developments in screening and treatment for HCV have enabled greater detection and treatment in prison, release is a high-risk time for HCV infected prisoners returning to the challenges of community living.
A scoping review was conducted to examine the evidence on individual, provider and system level factors that influence compliance with HCV treatment in patients transitioning from prison to community.
Electronic peer-reviewed databases were searched: 140 articles were initially identified of which seven were included in the final review. Five key themes were identified, described below and in Table 1:
Education
Education was a key theme that appeared in four studies included in this review.[1–5] Authors noted the importance of a multi-layered education provision:
Patient Education. There was an overall lack of patient knowledge of the disease process and associated health implications. Fear of HCV treatment was a common among prisoners, with concerns that it was invasive with an unfavourable side effect profile. On-site provision of disease-specific education by healthcare providers to prison staff and prisoners was identified as an important facilitator to improving compliance with HCV treatment upon release.
Peer Dissemination/Navigators. A recurrent theme about the way in which HCV-related knowledge was acquired in prison was communication with other incarcerated individuals. Peer dissemination of HCV knowledge resulted in increased trust and engagement with treatment, in part attributed to shared life experiences and the social exclusion.[4] Peer navigation holds particular promise in facilitating transition to medical and social services on release—highlighting the importance of fostering positive bonds whilst in prison to allow for meaningful engagement and integration into society.
Studies indicated that prisoners who have successfully completed HCV treatment express hope for social reinclusion and a desire to remain drug free. Part of this psychosocial shift included a commitment to engage with peers to educate and support them through treatment.[2]
Stakeholder Education. Stakeholder education was highlighted as a key facilitator to enhanced compliance with HCV treatment. Successful examples of micro-elimination of HCV in prison settings has largely been attributed to the delivery of 'prison- focused' education for prisoners, prison officers and clinicians. Providing education to all relevant stakeholders, particularly community providers, could improve therapeutic relationships. Poor provider attitudes such as disrespect, inadequate communication and negative perceptions of prisoners' sexuality have created stigma and barriers to accessing HCV treatment upon release.[2,5]
Case Management and Discharge Planning
The role of comprehensive case management and discharge planning was a recurring theme.[1–3,5,6] Development of structured transition plans should incorporate several key elements to provide the greatest chance for linkage to care:
Discharge Planning. A comprehensive multi-disciplinary discharge plan could mitigate competing priorities at the time of release that impact not only an individual's ability to access HCV treatment but also their ability to reorientate themselves back into society in a meaningful way. High prison turnover and unplanned or unforeseen prison transfers make it difficult to effectively plan a comprehensive discharge. Developing inter-establishment protocols for care continuity would allow receiving facilities to quickly identify the medicinal needs of new prisoners and more time to focus on case management.[1]
Case Management. The presence of social support post incarceration has been demonstrated to facilitate linkage to HCV care. Many individuals in contact with the criminal justice system experience fractious interpersonal relationships. Thus, the role of case managers and support from peer navigators should not be overlooked. This can facilitate ongoing HCV care by fostering social supports for an otherwise marginalized individual.
Transportation. A recent qualitative study indicated that transportation to healthcare facilities was a major barrier to HCV treatment continuation in the community.[7] A lack of transportation on release from prison, untimely prison transfers and difficulties establishing a secure base upon release make it difficult for prisoners to avail of HCV treatment even if they were initially motivated to complete treatment. Community hubs, specialist in-reach services or transitional care facilities have all been suggested as a means of navigating these logistical barriers.
Hepatology In-reach Nurses
Prisoners and ex-prisoners describe relationships with in-reach nurses as one based on trust, familiarity and support. They are an important factor in a prisoner's transition and are often the only constant presence over many episodes of reincarcerations and reintegration from prison to community.[2]
Developments in pharmacological HCV treatment and the introduction of direct acting antivirals (DAAs) means that reduced clinical supervision is required during the HCV treatment regimen. Reduced nurse–patient contact may reduce the time available to address psychosocial issues that often impacts prisoners' compliance. The therapeutic alliance between patient and nurse may not be as well-established due to less regular contact. Treatment may result in HCV elimination but fail to address other complex issues that may influence a return to drug use or other risk-taking behaviours. Overall, the role of the in-reach nurse was viewed as positive by prisoners, but consideration needs to be given to the role of specialist in-reach nurses both in terms of their provision of medication and more in-depth psychosocial support.
Transition Clinics and Primary Care Providers
Transitional clinics are defined as 'primary care–complex care management programmes tailored to engage recently released prisoners in care'. Findings suggest that a hybrid model of healthcare provision is most effective in optimizing transition care. The combination of support options may involve linking primary care providers with specialist in-reach nurses, substance abuse or mental health services.[3,4,6] Primary care providers have successfully taken the lead in the management of several chronic diseases such as asthma, chronic obstructive pulmonary disease and diabetes.[6]
Ultimately, many individuals recently released from prison will need a range of support services. Transitional clinics are one potential vehicle from which to deliver this support. The transition clinic model does not necessarily require new infrastructure as clinics are often embedded within pre-existing community health centres with training for primary care providers.
However, it is important to note that primary care providers in the UK are already experiencing significant strain, with declining GP numbers, rising demand and struggles to recruit and retain staff. Any initiative to extend the remit of primary care to provision of transitional care for released prisoners must be part of a system wide discussion about responsibility and shared care arrangements.
A System Wide Approach
For many prisoners, release from prison is as an extremely chaotic period following the relative stability of prison life. Lack of housing, difficulty sourcing stable or meaningful employment, co-existing substance or mental health issues all have implications for an individual's ability to engage with ongoing treatment.
Several studies recognized the need for a multi-pronged, system wide approach to HCV treatment in prisoners transitioning to community.[2,4–6] This includes the need for enhanced collaboration between the criminal justice and public health systems. There was widespread recognition that any strategy intended to enhance HCV compliance in prisoners transitioning to community needs to be contextualized to address competing priorities. This means a sustained, collective effort across multiple agencies and departments (e.g. criminal justice department, medical and mental health services, social services and public health departments).
Two studies[4,8] in the review suggested 'decriminalization' policies as a step towards reducing the overall HCV burden in prisons. 'Decriminalization' describes the removal of criminal sanctions against an act or behaviour. Instead of prosecution and potential incarceration, individuals may face sanctions such as fines, revoked licences or diversion to treatment programmes. If successfully implemented, decriminalization policies could potentially help tackle wider prison issues such as overcrowding, unsafe drug injection and high-risk sexual behaviour that facilitates onward transmission of HCV within prisons and to the community on release.
Jail diversion programmes are an alternative to incarceration. Such programmes divert individuals with serious mental illness and substance use disorders from jail to community-based care. The global aim of such an approach is to reduce the number of people incarcerated for nonviolent crimes without increasing public safety risk.
J Viral Hepat. 2023;30(4):278-282. © 2023 Blackwell Publishing
