Then and now: Making advancements in hepatitis care within BC correctional settings

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The transfer of responsibility for Correctional Health Services to PHSA in October 2017 has led to a marked increase in screening and diagnoses for hepatitis C virus (HCV), according to new research by BC Mental Health and Substance Use Services and BC Centre for Disease Control (BCCDC). The study is part of a larger joint effort to improve care for clients living with hepatitis C and other sexually transmitted and blood-borne infections (STBBI), and could have profound implications in future redesigns of models of health care delivery.

Across Canada, it is estimated that 3.5 to nearly 40 per cent of people who are incarcerated in provincial and federal correctional centres have a past or current hepatitis C infection. Early testing and diagnosis is the first step to engaging people living with HCV infection into care and treatment. If left untreated, it can lead to liver damage (cirrhosis), cancer and death. The sheer number of people who pass through the criminal justice system, combined with the higher rates of HCV infection, make correctional facilities an ideal venue for preventing, testing and treating HCV.

A team led by Sofia Bartlett, a senior scientist at BCCDC, examined the number of HCV tests that were ordered from all 10 provincial correctional centres from April 1, 2011 to March 31, 2021 as well as new, first time positive HCV diagnoses based on data from the BCCDC Public Health Laboratory, the primary diagnostic testing facility here in BC.

Among the findings, an estimated 4 percent of people entering correctional centres received an HCV test in 2017, which increased to 23 percent in 2020. As a result, the province has been able to catch more cases of HCV since Correctional Health Services transition to BC Mental Health and Substance Use Services. In 2020, 101 clients who were incarcerated received a new positive HCV diagnosis, representing a 77 per cent increase compared to 2017.

“Initially, we were only looking at the number of tests that were being ordered beginning in 2019. Then when we started to look backwards, we realized that the huge increase in the number of hepatitis tests in the years leading up to then coincided perfectly with the transition of correctional health services," said Bartlett, who presented on the study’s findings at the 2021 International Conference on Hepatitis Care in Substances Users on October 12.

“There’s been a real improvement in hepatitis testing and care, and others who conduct HCV research across the globe have been really interested in hearing more.” - Sofia Bartlett

When COVID-19 was declared a pandemic, the number of HCV tests that were ordered had dropped to pre-2017 levels, but likely because fewer people were admitted into correctional centres, Bartlett explained.

“Though the health care system has been under enormous strain during the pandemic and Correctional Health Services have had so much additional work to do, the team still kept up with hepatitis screening, which is so important,” she added.

Screening, treatment and linkage to care

As the first steps in the treatment approach, screening and confirmation of hepatitis C infection are important to ensure people are aware of their HCV status, and linked to appropriate care.

“While people are in corrections, it’s the perfect opportunity to test people and get them started on treatment,” said Pam Young, a co-author of the study and program manager at Unlocking the Gates Services Society, a peer-led mentoring program that offers support for clients who are being released from custody.

“Often while in the community, life gets in the way of people seeking treatment and they face multiple barriers such as substance use, mental health or stigma, which makes it even harder for them to follow through with medical appointments.” - Pam Young

To help reduce some of these barriers and improve access to HCV treatment, the two organizations in partnership with Unlocking the Gates have been collaborating on another initiative named Test, Link, Call, a project that provides free cell phones, complete with a calling/texting plan, to people living with HCV who have experienced incarceration. Right now, only clients who self-refer to Unlocking the Gates are able to participate in Test Link Call, however Correctional Health Services staff will soon be able to refer clients directly to the program.

The team recently celebrated a milestone. Through the help of this hardware and connections to peer support, the first participant enrolled in the program successfully made it to an appointment with a hepatitis C specialist—a “major win” in Bartlett’s eyes, who created a personalized certificate to help honour the client’s achievement, a ritual she is planning to continue.

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Roy Ang, regional director for Correctional Health Services interior and island sites, says peer-led projects like these are crucial to supporting reintegration efforts for many other clients as well.

“Returning home can be exciting for some, but it can also be an overwhelmingly stressful experience of adjusting to life on the outside. Having someone who brings that lived experience and who can help usher clients through that process is so invaluable,” says Ang.

Prison health is public health

Bartlett and Young are conducting engagement sessions with participants, health care staff and correctional officers to gather feedback on how STBBI testing and care is currently provided in provincial correctional centres. This feedback will culminate in a new policy and guideline to support STBBI testing and linkage to care, including hepatitis C, in correctional settings—a resource that could later be used by other jurisdictions. The team hope to have this finalized by spring 2022.

“People were really open and wanted to have their voices heard. We were pleasantly surprised by the candor of participants willing to share their thoughts and experiences with us. Having peers participating in research with peers is very powerful, as people tend to feel more comfortable and open up more,” said Young.

Some experts have called for a greater focus on health and health promotion in the corrections setting—to view prison health as an essential part of public health.

Bartlett explains, “Addressing hepatitis C and other STBBIs in correctional settings is really important for the health of people who are incarcerated but it’s also important for the health of our communities. People who are incarcerated in the provincial system don't stay in there forever, which is why this isn’t a correctional health kind of issue, it’s actually a public health issue."

"The more people that we're able to test and link to care in corrections in a safe and acceptable way, the better that is for all of us.” - Sofia Bartlett