8 The Catalan model of hepatitis care, a special approach in prisons Andres Marco Mouriño, Joan Colom Farran and Neus Solé i Zapata, Catalonia, Spain

Model of care

This meeting has been organised and funded by Gilead Sciences Europe Ltd Date of preparation: September 2019. HCV/IHQ/19-02//1239t © Gilead Sciences Europe Ltd

Why is a special approach in prisons needed?

Outcomes of prison elimination programme and nurse liaison4

1. Department of Justice, Catalonia. Available at: http://www.gencat.cat/justicia/estadistiques_serveis_penitenciaris/1_pob.html (accessed September 2019); 2. Lens S. Update of the prevalence and viremia of hepatitis C in Catalonia, 2018; 3. Information provided by Andres Marco. Infectious Diseases. Prison Health Programme. Catalan Institute of Health. Unpublished data; 4. Marco A, personal communication, unpublished data. APRI: aspartate aminotransferase-to-platelet ratio index; DAA: direct-acting antiviral; FIB-4: Fibrosis-4; HCC: hepatocellular carcinoma; NSP: needle and syringe programme; OST: opioid substitution therapy; SVR: sustained virological response

Aim: to eliminate HCV infection in Catalan prisons before 2021 through the systematic screening of HCV upon admission to prison, to decrease reinfection rates and to decrease loss to follow-up after release by linking to specialist care

Eliminating HCV infection in prison populations is possible through a concerted public health approach. However, intra-/extra-penitentiary coordination is needed for successful elimination strategies and infection control liaison nurses are key to providing a post-release continuum of care

Catalonia, Spain

Cumulativeprison population

in Catalonia in 20181

13,912

A special approach to

eliminate HCV infection in Catalan prisons by 2021, as part of the wider regional elimination plan

HCV

Strengths of the programme• Universal screening reduces the risk of undetected infection• Easier access to high-risk and/or difficult-to-reach groups who have little

contact with conventional care (PWID, psychiatric patients)• Opportunity to educate and offer harm reduction and vaccinations• Opportunity to act as epidemiological observatories of some populations

at risk of HCV infection/reinfection

Liaison nurses initiative: successes and challenges• Infection control nurse liaison initiative successfully implemented and recognised by the Departments of Health and Justice• Liaison nurses have improved intra-/extra-penitentiary coordination• Lack of continuity in information from the Department of Justice • Administrative bottlenecks with hospitals• Prison-related issues: transfers, permits, new criminal cases• Patient-related issues: some have little motivation for health engagement

83.7%of inmates screened4

HCV

860inmates treated with DAAs (2015–2018)3

2.2%decrease in HCV RNA+ among inmates from 2018 to 20193

HCV

4.6%of all inmates in Catalan prisons have

been exposed to HCV1

The prevalence of HIV in Catalan prisons is also 4.9%1

Prevalence of viraemic HCV in Catalan prisons is 1.9%1 which is

~4 times higherthan the general population HCV

viraemic prevalence of 0.47%2

~43% of inmates with chronic HCV do not complete

the ‘continuum of care’3Heterogeneity in operating procedures and categories

of prisoners across the 9 prisons in Catalonia

Key interventions used to enhance HCV testing, linkage to care (LTC) and treatment uptake • Prison-based onsite HCV testing (antibodies, RNA) with facilitated referral and treatment• Non-invasive liver disease assessment using transient elastography• Prison-based, harm reduction services (OST, NSP) and mental health services• Infection control liaison nurses provide intra-/extra-penitentiary coordination

What is the microelimination approach in prison and how does it work?4

Key features of Catalonia’s prison elimination plan• Universal, voluntary infection screening on admission • Periodic screening for those with high-risk behaviours• Harm reduction programmes (OST, NSP) & vaccinations

• Information and educational activities• Viral infection training (external consultants, prison doctors)• Intra/extra penitentiary co-ordination

Following release from prison

Infection control liaison nurses provide intra-/extra-penitentiary coordination for inmates

Inmates released with• Other chronic diseases and pharmacological treatment• Acute conditions/diseases that require follow-up• Incomplete vaccinations

• Inmates released with severe psychiatric disorders, ie patients with ≥3 central nervous system drugs

HCV-infected inmates• Released untreated• DAA treatment not completed• SVR but needs screening for HCC Hospital

• Inmates released with OST

Drug addiction centres Mental health centres

Primarycare centres

2 nurses per prison

Incarcerated Released

Prison doctor Infectious disease programme

Sharedmedical records

Sharedmedical records

HCV screening and assessment on admission

Single step diagnosis

Automatic

programming

HCV Ab+

HCV HCV Ab+

If drug use• Harm reduction (OST, NSP)• Drug addiction programmes• Mental health services

ALERT

Disease evaluation (FibroScan®, [APRI, FIB-4], ultrasound)

Prescription treatment

Custodial sentence given

Custodial sentence over

Intra-/extra-penitentiary coordination