New data released by Correctional Services Canada (CSC) reveal a dramatic decline in the number of inmates in treatment for hepatitis C as the service struggles with budget cuts, increasing inmate populations and exploding hepatitis treatment costs.
According to the data obtained by CMAJ following an Access to Information request, the number of inmates treated for hepatitis C dropped in all but one year between 2007 and 2013. There were 328 patients treated in 2007, dropping to 229 by 2013 — a 29% reduction during a time when the federal prison population increased about 25%, to more than 15 000.
Two physicians and two nurses working in federal prisons say access to hepatitis treatment has been sharply reduced in all prisons and is unavailable in some prisons. One of the two physicians and both nurses who spoke with CMAJ about lack of access to hepatitis C treatment requested they not be named for fear of professional reprisal. They warned that in restricting access to hepatitis C treatment, CSC risks inflaming the spread of the disease — which is considered a major public health threat affecting at least 250 000 Canadians — inside prisons and, if prisoners are released, among the public at large.
The other physician, Vancouver-based Dr. John Farley, who treats inmates in eight federal prisons in British Columbia, went on the record, saying that “there should be a full and independent review of this situation. Decisions about hepatitis C treatment have been taken out of the hands of clinicians at the point of care. Numerous barriers to treatment have been created to reduce the number of inmates who get treatment.”
The numbers confirm a long-held suspicion that CSC may be curbing access to care, said Adam Cook, hepatitis C policy researcher for the Canadian Treatment Access Council. “Given that the prison population has grown significantly through this period, and hepatitis rates have also been growing, the reduction in treatment numbers is extremely worrying.”
![Figure](https://www.cmaj.ca/content/cmaj/187/18/1345/F1.medium.gif)
A prison physician is calling for a full and independent review into the drop in treatment rates.
Image courtesy of Aguru/iStock
CSC data obtained by CMAJ show that the number of inmates diagnosed with hepatitis C also declined between 2007 and 2013, by nearly half, with a corresponding reduction in the CSC’s estimate of hepatitis C prevalence from 32% in 2007 to 17% in 2013.
The CSC declined to provide an interview to explain the decline in the number of diagnosed cases or its prevalence estimates.
However, in a written statement, Lori Halfper, a senior communications advisor for CSC, said the reduction in prevalence results from better data quality. “In the last five to six years, laboratory testing algorithms for HCV [hepatitis C virus] have increasingly made available confirmatory testing for active viral infection,” stated Halfper. “Therefore the prevalence estimate has become increasingly accurate with respect to inmates with active infection [presence of the virus].”
According to Halfper, 83% of newly admitted inmates accepted blood tests for HCV in 2013, and among inmates incarcerated in 2013, 72% had a blood test for HCV at least once. “There are no requirements for routine, annual HCV blood tests for all inmates,” she added.
Two nurses charged with HCV testing at CSC facilities confirm that inmates are offered tests upon entry. But they say the rigour of CSC’s hepatitis C surveillance, reporting and case follow-up has diminished dramatically in recent years. And the nurses confirm the view of the two physicians that access to treatment has been restricted.
“I would be extremely wary of CSC’s surveillance data,” Farley warns. “The quality of data collection has become atrocious. I see no evidence that, while access to treatment has been cut, prevalence has declined.”
Dr. Jordan Feld, a clinician–scientist at the Toronto Western Hospital Francis Family Liver Clinic, said the decline in hepatitis C prevalence claimed by CSC is surprising. “If there is a real decrease of this size in the prevalence, it’s good news. The overall prevalence in the population is actually going down because there are fewer new infections and people are dying, and a small number are being cured. But that should not explain such a massive decline in prevalence in federal prisons. And CSC’s explanation that the laboratory testing algorithms have changed is not satisfactory in explaining their figures because only HCV antibody testing results were provided. The antibody test is very reliable and has not changed appreciably over this interval.”
Howard Sapers, the Correctional Investigator of Canada, says that although the number of diagnosed hepatitis C cases is down, the prevalence remains very high, and “that doesn’t strike me as a success story.” Information about CSC’s hepatitis testing methods is too patchy, he warned. “We don’t know if the number of undiagnosed cases is up.”
The apparent decline in cases may be related to a 10% budget cut at CSC in 2012, according to a written statement from the physician who declined to be named: “The prison health care system is under stress with increasing prisoner numbers and decreased funding.”
The fixed sum allocated for hepatitis C therapy is insufficient, he writes. “Patients are prioritized according to severity of disease. Sometimes further money becomes available later in the financial year. But there is no guarantee. Each penitentiary is told how many patients they can treat and are provided with drugs accordingly. The system appears to run out of money for hepatitis drugs early in the financial year — usually after three to four months.”
According to figures obtained by CMAJ in 2012, CSC’s bill for hepatitis drug treatment increased almost sevenfold between 2005 and 2010. Then, in 2011, CSC achieved a 40% reduction in hepatitis C treatment costs, although it stated that the number of diagnosed cases decreased only 8% and the prevalence dropped only 3%. The cost savings was achieved through “a bulk purchase of hepatitis C medication,” CSC explained.
In 2012, when the CSC’s overall budget was cut, the service began preparing for a new generation of hepatitis C drugs that cost an estimated $60 000 per treatment, or almost twice as much as the old ones.
Under the Access to Information law, Glenn Betteridge, a Canadian Treatment Access Council policy researcher and former prisoner health lawyer, obtained the August 2015 CSC formulary of medications for federal inmates. It indicated that the CSC is restricting access to the latest drugs and controlling treatment costs, he says.
“The formulary tells us that CSC is treating the new drugs as ‘exceptional medications’ for which prescribing is taken out of the hands of the doctor and is in the hands of an administrative decision-maker who may not have resources to review cases in a timely manner,” Betteridge says.
In response, CSC’s Halfper stated that “treatment initiations are based on recommendations from a medical specialist. CSC balances the demand for treatment with patient safety within defined resources and in the context of patients with complex health care needs.”
The service relies on “one national and five regional pharmacists who have the authority to make final case management decisions,” CSC added.