Universal opt-out screening for hepatitis C virus (HCV) within correctional facilities is an effective intervention to improve public health.

Purpose Worldwide efforts to identify individuals infected with the hepatitis C virus (HCV) focus almost exclusively on community healthcare systems, thereby failing to reach high-risk populations and those with poor access to primary care. In the USA, community-based HCV testing policies and guidelines overlook correctional facilities, where HCV rates are believed to be as high as 40 percent. This is a missed opportunity: more than ten million Americans move through correctional facilities each year. Herein, the purpose of this paper is to examine HCV testing practices in the US correctional system, California and describe how universal opt-out HCV testing could expand early HCV detection, improve public health in correctional facilities and communities, and prove cost-effective over time. Design/methodology/approach A commentary on the value of standardizing screening programs across facilities by mandating all facilities (universal) to implement opt-out testing policies for all prisoners upon entry to the correctional facilities. Findings Current variability in facility-level testing programs results in inconsistent testing levels across correctional facilities, and therefore makes estimating the actual number of HCV-infected adults in the USA difficult. The authors argue that universal opt-out testing policies ensure earlier diagnosis of HCV among a population most affected by the disease and is more cost-effective than selective testing policies. Originality/value The commentary explores the current limitations of selective testing policies in correctional systems and provides recommendations and implications for public health and correctional organizations.

When security and medicine missions conflict: confidentiality in prison settings.

Purpose - It is a simple fact that prisons cannot exist - practically, legally, ethically or morally - without the support of physicians and other health professionals. Access to adequate healthcare is one of the fundamental measures of the legitimacy of a jail or prison. At the same time, there is a fundamental tension in the missions of the prison and doctor. The primary mission of the prison is security and often punishment. Reform and rehabilitation have intermittently been stated goals of prisons in the last century, but in practice those humane goals have rarely governed prison administrative culture. The primary mission of the physician is to promote the health and welfare of his or her patient. The paper aims to discuss these issues. Design/methodology/approach - At times, what is required to serve the patient's best interest is at odds with the interests of security. Much of the work of the prison physician does not conflict with the operation of security. Indeed, much of the work of the prison physician is allowed to proceed without much interference from the security regime. But given the fundamental discord in the legitimate missions of security vs medicine, conflict between the doctor and the warden is inevitable. Findings - In this paper, the authors consider the example of patient confidentiality to illustrate this conflict, using case examples inspired by real cases from the experience of the authors. Originality/value - The authors provide an ethical and practical framework for health professionals to employ when confronting these inevitable conflicts in correctional settings.

How health care reform can transform the health of criminal justice-involved individuals.

Provisions of the Affordable Care Act offer new opportunities to apply a public health and medical perspective to the complex relationship between involvement in the criminal justice system and the existence of fundamental health disparities. Incarceration can cause harm to individual and community health, but prisons and jails also hold enormous potential to play an active and beneficial role in the health care system and, ultimately, to improving health. Traditionally, incarcerated populations have been incorrectly viewed as isolated and self-contained communities with only peripheral importance to the public health at large. This misconception has resulted in missed opportunities to positively affect the health of both the individuals and the imprisoned community as a whole and potentially to mitigate risk behaviors that may contribute to incarceration. Both community and correctional health care professionals can capitalize on these opportunities by working together to advocate for the health of the criminal justice-involved population and their communities. We present a set of recommendations for the improvement of both correctional health care, such as improving systems of external oversight and quality management, and access to community-based care, including establishing strategies for postrelease care and medical record transfers.

Incarceration, community health, and racial disparities.

Several recent studies have shown that the racial disparities in U.S. mortality nearly disappear in prisons. We review the social determinants of the recent epidemic of incarceration, especially the war on drugs, and describe inmate morbidity and mortality within the context of U.S. health disparities. Incarceration provides an important public health opportunity to address health disparities by accessing a high-need, medically-underserved, largely non-White population, but it has also been associated with poor long-term health outcomes. Viewing incarceration within the context of community health and community life shows that the more equitable mortality rates among inmates are not evidence of the beneficial effects of incarceration so much as an indictment of disparities in the community at large. Because people of color are incarcerated far more frequently than Whites, the experience may ultimately exacerbate rather than mitigate health disparities.

Physicians in US Prisons in the Era of Mass Incarceration.

The United States leads the world in creating prisoners, incarcerating one in 100 adults and housing 25% of the world's prisoners. Since the 1976, the US Supreme Court ruling that mandated health care for inmates, doctors have been an integral part of the correctional system. Yet conditions within corrections are not infrequently in direct conflict with optimal patient care, particularly for those suffering from mental illness and addiction. In addition to providing and working to improve clinical care for prisoners, physicians have an opportunity and an obligation to advocate for reform in the system of corrections when it conflicts with patient well-being.

Treatment outcomes with pegylated interferon and ribavirin for male prisoners with chronic hepatitis C.

GOALS: To report our experience with pegylated interferon and ribavirin treatment of hepatitis C virus (HCV) RNA-positive inmates at the Rhode Island Department of Corrections. BACKGROUND: An estimated 1 out of 3 HCV-infected individuals will spend time in a jail or prison within a 1-year period, making prisons a unique setting for management of chronic HCV. STUDY: Chart review of all inmates identified as having initiated HCV treatment between October 2000 and April 2004. HCV-infected individuals were identified by HCV antibody screening at intake for known risk factors, elevated aminotransferase levels, or per individual request. Treatment followed standard guidelines with weight-based dosing of pegylated interferon-alpha2b and ribavirin. End points were completion of therapy plus 6 months for sustained virologic response (SVR), therapy discontinuation, and loss to follow-up. RESULTS: The cohort included 71 male patients, was mostly white (80%), and genotype 1 (65%). All 9 African Americans (AA) had genotype 1. Of 59 patients having liver biopsy, 41 had early stage disease. Overall SVR was 28%. Response rate was lower for genotype 1 compared with genotypes 2 and 3 (SVR 18% vs. 60% and 50%). Of inmates with genotype 1, no difference existed in treatment response by race (SVR 22% AA vs. 18% white). Thirty-three patients completed treatment, 26 stopped for side effects, and 5 for initial nonresponse. Eleven were lost to follow-up. CONCLUSIONS: Acceptable HCV treatment outcomes can be achieved in prisons. Our small study indicates no difference in treatment response by AA versus white race for genotype 1.

Deaths of detainees in the custody of US forces in Iraq and Afghanistan from 2002 to 2005.

In light of the large number of detainees who continue to be taken and held in US custody in settings with limited judicial or public oversight, deaths of detainees warrant scrutiny. We have undertaken the task of reviewing all known detainee deaths between 2002 and early 2005 based on reports available in the public domain. Using documents obtained from the Department of Defense through a Freedom of Information Act request, combined with a review of anecdotal published press accounts, 112 cases of death of detainees in United States custody (105 in Iraq, 7 in Afghanistan) during the period from 2002 to early 2005 were identified. Homicide accounted for the largest number of deaths (43) followed by enemy mortar attacks against the detention facility (36). Deaths attributed to natural causes numbered 20. Nine were listed as unknown cause of death, and 4 were reported as accidental or natural. A clustering of 8 deaths ascribed to natural causes in Iraq in August 2003 raises questions about the adequacy and availability of medical care, as well as other conditions of confinement that may have had an impact on the mortality rate.

Opportunities to address the hepatitis C epidemic in the correctional setting.

An estimated 15%-40% of incarcerated persons in the United States are infected with hepatitis C virus (HCV). Approximately 1.4 million HCV-infected persons pass through the corrections system annually, accounting for one-third of the total number of HCV-infected persons in the United States. This high prevalence of HCV infection is due to the substantial increase in drug-related arrests over the past 2 decades. Although the hepatitis C epidemic in the corrections system may be viewed as a burden on correctional health systems, it is an important public health opportunity and an obligation. Research on the implementation of cost-effective HCV screening, prevention, and treatment programs among incarcerated persons is essential. Testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States.