On October 10, history was made with the announcement of the newest hepatitis C medication, Harvoni. Gilead Sciences’ pill contains two drugs, sofosbuvir (Sovaldi) and ledipasvir. Harvoni is approved for the treatment of genotype 1, hepatitis C virus (HCV) infection. Cure rates range from 94 to 99%. Treatment is typically 12 weeks, although 40% of patients may need only 8 weeks of treatment; patients with cirrhosis who failed prior treatment will need 24 weeks. Harvoni has a few mild side effects; fatigue and headache are the most common.

However, a war is raging, ignited when Gilead slapped a $1000 per pill price tag on to its first HCV drug, Sovaldi. Twelve weeks of Sovaldi costs $84,000, but since Sovaldi is given with at least one other drug, the costs are much higher. Gilead’s new drug, Harvoni costs more at $94,000, $63,000 for 8 weeks, and $188,000 for 24 weeks of treatment with this $1,125 daily pill. These prices are driving state Medicaid programs and some insurance companies to push back by instituting stringent pre-authorization regulations. For example, some states force patients to qualify for HCV treatment by proving they have cirrhosis.

HCV patients are the victims in this war. I believe that this victimization is partly caused by stigma. HCV’s association with drug use doesn’t win us any sympathy. Although it appears that healthcare is abandoning HCV patients, few are more ignored than people with HCV who are in jails and prisons. However, the incarcerated were not ignored by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, who assigned a high treatment priority to the incarcerated. (For more information, see Recommendations for Testing, Managing, and Treating Hepatitis C provided under Resources.)

This month’s article addresses the issue of HCV in prisons, and discusses the pros and cons of treating the incarcerated, especially in  the light of the cost of treatment. With little data about HCV in jails, the discussion is limited to HCV in U.S. prisons.

The Reality of Incarcerated Persons with HCV

HCV prevalence in the U.S. is determined by data collected from the National Health and Nutrition Examination Survey. Since this household survey only sampled non-institutionalized people, we don’t know how many incarcerated people have HCV. The Centers for Disease Control and Prevention (CDC) estimates that of the 2.2 million people in U.S. jails and prisons, 30% have hepatitis C. Other estimates are between 17% and 60%. Compared to the prevalence of HCV in the general population (1.6%), HCV rates in prisons and jails are high.

Arguments in Favor of Offering HCV Treatment to the Incarcerated
Since more than 90% of those in prison will be released, treating the incarcerated is good for all of us. The HCV Guidelines state, “Persons who have successfully achieved an SVR (virologic cure) no longer transmit the virus to others?successful treatment benefits public health.” With such a high density of HCV+ people, prisons seem like an excellent place to offer treatment.

Furthermore, with a 1% acute HCV infection rate in prisons, it is also good for others in prison. With high-risk behaviors such as injection drug use, tattooing, men having sex with men, violence, and sharing of personal care items, it is surprising that the acute HCV rate isn’t higher. However, it may be higher, since HCV is not well-tracked in prison.

Various state prison systems see the logic in treating HCV in this at-risk population. Illinois and Iowa made national news when they approved Sovaldi to treat HCV patients. Other states are considering this, while some have clearly rejected the idea.

From a medical standpoint, it makes sense to treat HCV in prisons. Healthcare delivery is always the right thing to do. It is never OK to turn our backs on anyone who needs medical care.

Arguments Opposing HCV Treatment for the Incarcerated
Medically, there are no reasons to withhold HCV treatment in prisons. The new drugs are easier to tolerate, lifting the decades-old concern about the neuropsychiatric side effects that accompanied ribavirin and interferon. 

One could argue that the cost of Harvoni makes treatment prohibitive. The problem with this argument is that if we don’t treat HCV early, we may face more serious and expensive problems. Cirrhosis, liver cancer, and transplantation cost far more than treating HCV in its early stages. This just pushes the problem down the line, leaving someone to have to pay for the patient’s medical care, whether that patient is incarcerated or released. Moreover, even if you are able to cure HCV in a cirrhotic patient, you still have a patient with a serious liver disease, so the system gains little by only treating cirrhotics. 

There is also the argument that patients who are cured may become re-infected with HCV, and you have wasted money treating them. That is like saying that someone in a knife fight might get stabbed again, so we shouldn’t stitch the wound. It sounds crazy, but isn’t that what we are saying?

Caring for the sick is always the right thing to do. Withholding healthcare is inhumane and immoral. No one is excluded from the Hippocratic Oath. “With regard to healing the sick?I will take care that they suffer no hurt or damage.”

Centerforce – Hepatitis Education Tools 
Centers for Disease Control and Prevention – Hepatitis C and Incarceration
Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C, edited by Heather Colvin and Abigail Mitchell  
National Hepatitis Corrections Network  
Recommendations for Testing, Managing, and Treating Hepatitis C

This article is reprinted from the HCV Advocate, November 2014. Copyright 2014 with permission from the HCV Advocate and Lucinda Porter.