Introduction
Hepatitis C, a blood-borne virus, is a significant public health concern in Australia. Although preventable and treatable, it is associated with substantial morbidity, mortality and social problems (Australian Institute of Health and Welfare, 2013). In custodial settings, as with other health and social disadvantage, the prevalence and impacts of hepatitis C are compounded (Department of Health, 2014). 90% of cases of new hepatitis C infections in Australia are a result of unsafe injecting practices. This, accompanied by high rates of imprisonment for drug related offences, means that the prevalence of hepatitis C is disproportionately high in custodial settings (Snow, Young, Preen, Lennox & Kinner, 2014).
Understanding the complex nature of hepatitis C, and it’s social and structural determinants is key to designing and implementing more effective prevention and treatment responses (Dean & Fenton, 2010). This paper will describe and analyse the individual, social and environmental contexts, impacts and public health responses to hepatitis C among prisoners in Australia, with a focus on hepatitis C acquired through unsafe injecting practices.
Insights into research and information gaps, as well as a description of a more comprehensive public health response will be provided. It will be concluded that there are evidence based public health responses to hepatitis C among prisoners that should be implemented as a priority to address the compounding ill health and social position of some of the most vulnerable and excluded Australians (Treloar, McCredie & Lloyd, 2015).
Social Distribution and Production
The prevalence of hepatitis C among prisoners is 40 times that of the general Australian population (Snow, Young, Preen, Lennox & Kinner, 2014). Inequalities in the distribution of hepatitis C and associated morbidity and mortality relating to class, gender, culture and ethnicity are well documented. Individual-level determinants such as high risk injecting practices are clearly a major driver of hepatitis C acquisition among prisoners and between 56% and 90% of injecting drug users have been imprisoned at least once (Fetherston, Carruthers, Butler, Wilson & Sandicich, 2013). However, the patterns and distribution of hepatitis C are further influenced by a range of social and structural factors and consideration must be given to the physical, social, economic, legal, cultural and policy aspects of the context (Dean & Fenton, 2010). Lower educational attainment (bellow year 10) and living in poverty are factors found to be significantly associated with injecting drug use and hepatitis C transmission risk in prison (Fetherston, Carruthers, Butler, Wilson & Sandicich, 2013).
The ‘built environment’ also provides interesting insights into the social production of health disparities in prisons. This is because individuals are physically confined and deprived of a range of personal freedoms, compounding the structural factors that influence health outcomes independently of individual-level attributes (Awofeso, 2010). In the case of hepatitis C, prisoners are shown to have increased opportunities for onward transmission because of the high rates of interpersonal contact with other prisoners (Dean & Fenton, 2010). The scarcity of sterile injecting equipment in prison environments also amplifies the likelihood of transmission of hepatitis C due to the sharing of unsterile equipment. Research has show that up to 72% of prisoners have shared injecting and that some syringes may have been circulating for up to 5 years. Cleaning agents like bleach can also be unavailable or difficult to obtain (Fetherston, Carruthers, Butler, Wilson & Sandicich, 2013).
Gender disparities in hepatitis C status among prisoners have been found across Australia. Up to two-thirds of female prisoners have hepatitis C, compared to one-third of their male counterparts despite women constituting only 7.5% of the prison population (Armstrong & Steele, 2011). Some evidence suggests that this has origins in the complex interrelationship between gender, injecting drug use, domestic and family violence, victimisation and the fact that prevention and treatment programs remain largely male centered (Armstrong & Steele, 2011).
The prevalence of hepatitis C among Aboriginal and Torres Strait Islander prisoners is also disproportionately high, with 43% of Aboriginal and Torres Strait Islander prisoners having hepatitis C, compared with 33% of other detainees (Department of Health, 2014). This again, is attributable to the increased social disadvantage and poorer general health experienced by Aboriginal and Torres Strait islanders when compared to other Australians. Research has also shown that Aboriginal and Torres Strait Islander prisoners are less likely to access services due to a ‘cultural divide’ in the provision of health services (Rodas, Bode & Dolan, 2011).
Social Construction & Perspectives of the Affected Community
The way that hepatitis C is socially constructed is a significant contributor to the high rates of transmission and lack of treatment among prisoners. This is difficult to untangle from the construct of illicit injecting drug use itself, which is largely considered morally reprehensible, and leads to stigmatisation and discrimination within the community and services (Australian Illicit and Injecting Drug Users League, 2010). Awareness of hepatitis C across the general population is low and there can be a lack of public interest tainting the socio-political perspective of the disease as a whole. This enables policy makers to limit funding for prevention, treatment and education (Suarez & Shindo, 2008). Social theory suggests this stigma, discrimination and criminalisation of injecting drug use can be understood as ‘structural violence’. That is, a form of violence whereby systems, social structures and institutions harm people by preventing them from meeting their basic needs and creating unequal life chances (cited in Australian Illicit and Injecting Drug Users League, 2010).
The social construction of hepatitis C among prisoners themselves is in contrast to the perceptions of the general population. Injecting drug use has been described as normative within prison, and there is an increased acceptance among prisoners of hepatitis C as common (Treloar, McCredie & Lloyd, 2015). Research that sought the personal perspectives of prisoners found that decisions to share injecting equipment were influenced by the social organisation of injecting in trusted networks (Treloar, McCredie & Lloyd, 2015). Most participants could identify that sharing injecting equipment could lead to hepatitis C infection; however, they believed that the lack of programs for distributing sterile injecting equipment and the difficulties in cleaning equipment were also important considerations. Some suggested that there is also an acceptance among some prisoners regarding the perceived inevitability of being in poor health (Treloar, McCredie & Lloyd, 2015).
Individual, Social and Economic Impacts
Hepatitis C is a slowly progressive disease that accounts for substantial morbidity and mortality including liver fibrosis or cirhossis which increases the risk of cancer, liver failure and mortality (Warhaft, 2013). There is also significant emotional, mental health and quality of life impacts on individuals, families and society (Dean & Fenton, 2010).
Neglecting prisoners health care needs has a substantial impact on the health of the general community, particularly as 95% of prisoners will be released back into the community following their sentence. This extends the risk of hepatitis C transmission to their families and communities (Hepatitis Australia, 2011). The financial burden of hepatitis C to the Australian community is substantial, particularly as it relates to ambulatory care, hospital services and medications. This constitutes about $850 per diagnosed patient in the early stages of disease, increasing to $120,000 for patients requiring a liver transplant (Hepatitis Australia, 2011). At a personal level, the lifetime productivity costs are estimated to be approximately $19,624 (Hepatitis Australia, 2011). In the long term, a person may be unable to work, have relationships breakdown, by exposed to mores stigma and discrimination and experience isolation which is further compounded by the fact that they were also imprisoned (Awofeso, 2010).
Describing and Analysing Australia’s Public Health Response
The policy response to hepatitis C prevention and interventions within correctional settings in Australia is complex and vast. Previously, there have been national policy documents that have specifically addressed hepatitis C in correctional settings, though these have lapsed. Currently, the Fourth National Hepatitis C Strategy identifies people in custodial settings as a priority population, but does little to detail the specific interventions, funding approaches and mechanisms to address the issue (Department of Health, 2014). The lack of national policy leadership is partially attributable to the fact that the administration of correctional settings is the responsibility of the states and territories (Wallace, 2011). Also, as noted previously, the implementation of hepatitis C interventions are influenced by a broader social, political, legal and philosophical environment. As such, there is a tendency for injecting drug use and associated hepatitis C to be considered as security concerns rather than health issues within prisons (Wallace, 2011). At a state and territory level, there is a diverse mix of legislation, internal policies, procedures and rules that regulate the provision of hepatitis C prevention and interventions. This is further complicated by the influence of prison officer unions, the media, health care reforms and employment agreements (Wallace, 2011).
International frameworks from the United Nations and World Health Organization state that prisoners should receive health care equivalent to that available in the community (Australian Institute of Health and Welfare, 2014). While this principle is adopted in Australian policy documents, it is far from enacted in practice. For example, all jurisdictions provide testing for hepatitis C; however, people may be tested at the point of incarceration but not at discharge so its not know if they have contracted the disease while in prison (Rodas, Bode & Dolan, 2011). Treating hepatitis C is even more complex in prison settings as pharmaceutical treatment duration may exceed many prisoners’ sentences. To date, only three jurisdictions have provided data on the numbers of prisoners being given hepatitis C treatment. In these jurisdictions, 231 prisoners were receiving medication for Hepatitis C during a single year, which is less than 2% of the prisoners in those jurisdictions (Australian Institute of Health and Welfare, 2013). While the difficulties in continuing a treatment regime past a prisoners discharge should not be underestimated, there is a lack of appropriate throughcare or transitional programs that would allow this to occur.
It is equally important to consider the illicit drug policies that have been shown to reduce the transmission of hepatitis C in custodial settings. This includes the provision of measures that seek to pragmatically reduce the harms from drug use such as peer education and needle and syringe programs, as well as interventions that reduce the demand for drugs including drug treatment and opioid substitution treatments. While it is beyond the scope of this paper to discuss these interventions in detail, it is important to note that their access, quality or capacity differs across custodial settings. The provision of readily accessible disinfectant to sterile syringes remains patchy and its effectiveness is still questionable. No jurisdictions currently provide needle and syringe programs despite the evidence of their efficacy and effectiveness in prison settings. Most jurisdictions provide some harm reduction education, and some do so through peer based models (Rodas, Bode & Dolan, 2011). Many jurisdictions also provide access to opioid substitution in prison, though numbers may be capped well below demand, and in Queensland, for example, there is no such treatment available to men (Snow, Young, Preen, Lennox & Kinner, 2014). In regards to broader drug treatment and rehabilitation activities, in many cases they are delivered by custodial authorities rather than health services and their philosophical approach and quality have been called into question (Warhaft, 2013).
Response of the affected community
There has been some research into the way that prisoners avoid transmission of hepatitis C, manage risk or seek to protect their own health despite the limitations in the existing public health response. For example, due to the lack of sterile injecting equipment in prisons, prisoners have stated that they attempt other ways of cleaning equipment or only inject in smaller networks to reduce opportunities for contamination. Prisoners, however, note that factors outside of their control influence their behavior including a lack of access to disinfectant and fear of coming to the attention of correctional staff (Treloar, McCredie & Lloyd, 2015). Prisoners have also expressed support for initiatives that would seek to protect or improve their health. For example, research in the Australian Capital Territory found that prisoners overwhelmingly support the introduction of a needle and syringe program (Stoove & Kirwan, 2010).
Further Research and Information Required
Access to high quality evidence is seminal to inform appropriate prevention and treatment services for hepatitis C in prison, although a number of gaps exist. This includes a disparity in the collection, analysis and publication of data by correctional facilities across Australia. The other paucity of research relates to injecting in prison, the factors for cessation and the specific contexts around sharing of injecting equipment (Fetherston, Carruthers, Butler, Wilson & Sandicich, 2013). Some of the social determinants as they relate to hepatitis C and injecting are also not sufficiently understood and available research may be only based on clinical indicators. This is particularly true for understanding the issue from a gendered perspective (Armstrong & Steele, 2011). Increasing the input of prisoners themselves within research and policy processes would also likely improve the relevance and quality of the information produced.
Proposed Public Health Response
There are clear systemic problems in providing a comprehensive and coordinated public health response to hepatitis C among prisoners that adequately addresses the social determinants of health. However, there is a significant body of literature and experience that can help inform where efforts should be directed. While a comprehensive description of a full public health response is beyond the scope of this paper (particularly in terms of addressing all of the factors that contribute to the identified inequities), some targeted priorities have been identified below that would have the potential to make a significant difference. The approaches are themed utilising a public health framework developed by Turrell and colleagues that identifies the need to provide upstream, midstream and downstream interventions (Turrell, Oldenburg, McGuffog & Dent, 1999). It must be acknowledged that these priorities reflect what the evidence states about best practice in hepatitis C prevention and treatment in prison, but do not comment on the broader fiscal realities or complexities of implementing such policies.
Upstream (Macro-level) interventions
Federal leadership and effective regulatory regimes must be addressed through the development of national policy related to hepatitis C in custodial settings that ensure Australia meets its international human rights and health care equivalency obligations. This policy needs the buy in of States and Territories, including mechanisms for accountabilities. This could help direct a paradigm shift in relation to the prioritisation of prisoner and public health alongside security considerations, as well as an adoption of a more comprehensive understanding of health that extends beyond the biomedical approach. Comprehensive policy reviews and updates must occur within the broader health and social welfare systems to provide equal access for prisoners, including for example, removing the exclusion of inmates from direct access to Medicare (Hepatitis Australia, 2011).
Midstream (Intermediate-level) interventions
Appropriate harm and demand reduction interventions related to injecting drug use must be available to empower prisoners to improve their own health. It must be acknowledged that it is unrealistic and not feasible for prison environments to be kept completely drug free, and therefore the association between the behavior of injecting drug use and hepatitis C transmission in prisons must be fairly addressed. This should include universally accessible needle and syringe programs, opioid substititution treatment and drug treatment delivered by appropriately trained health services.
Downstream (Micro-level) interventions
The opportunity that prison environments create for intervention with those who already have hepatitis C should be capitalised upon. This includes providing screening at regular intervals to all prisoners and providing hepatitis C treatment programs. These should be widely available and have transitional support to allow for community based continuation of treatment for people leaving the prison system. The system must be sufficiently flexible to allow for the adoption of new generation therapies that are becoming available internationally that reduce treatment duration (Snow, Young, Preen, Lennox & Kinner, 2014).
Conclusion
While the challenge should not be underestimated, the prison environment creates a unique opportunity to intervene on hepatitis C prevention and transmission with a highly marginalised population group. Through documenting and analysing Australia’s public health response to hepatitis C in prisons it has become apparent that the understanding and response comes from a largely biomedical approach. This approach largely fails to acknowledge the World Health Organization’s description of health as ‘a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity,’ (cited in Wallace, 2011). This reflects the adoption of a largely punitive approach, and implementing a more comprehensive approach to hepatitis C among prisoners has the strong potential to benefit the prisoners themselves as well as the broader community to which most prisoners will return (Awofeso, 2010).
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