Prisons face hep C–treatment funding crisis

Correctional Service of Canada (CSC) could face a funding shortfall of up to $100 million if it adheres to a new standard of care that would see federal inmates infected with hepatitis C prescribed a new and expensive drug.

Internal government reports, released to CMAJ under the federal access to information law and reviewed by four external experts, appear to indicate that CSC may be delaying treatment for as many as 1750 infected federal inmates. CSC recently released the heavily censored reports to CMAJ, almost ten months past the deadline stipulated under the federal information law.

The funding shortfall is under-pinned both by CSC’s standard-of-care requirement to use the costly new drugs and a dramatic expansion in the number of inmates potentially treatable with these new drugs, which are better tolerated and more efficacious than the drugs CSC previously used.

In 2014, CSC spent $4 million to treat about 240 patients with older and cheaper drugs. The new medication will more than triple treatment the cost for the same number of inmates, according to a forecast prepared by Henry deSouza, CSC’s director general of clinical services and public health, in September 2014.

That translates into a cost of as much as $15 million annually for those 240 patients, the CSC told CMAJ. “CSC is currently assessing options to address this financial pressure,” stated spokeswoman Lori Halfper in an email.

But this number may severely understate the actual cost that CSC faces, say experts who reviewed the data CSC released to CMAJ. That’s because new guidelines published last year by the Canadian Association for the Study of the Liver (CASL) recommend that “All patients with chronic [hepatitis C virus] infection should be considered candidates for antiviral therapy,” explains Dr. Peter Ford, a physician who treats patients with HIV and hepatitis C in federal prisons in Ontario.

The CASL guidelines were subsequently endorsed by the federal Canadian Agency for Drugs and Technologies in Health in December and by Quebec in July.

To adhere to those guidelines, CSC will have to vastly expand the number of inmates it considers for treatment, Ford says. CSC estimates that 2500 inmates are infected, he notes.

As of 2016, according to CSC, the 12-week treatment per patient using the combination therapy Harvoni will average $67 000. At that price, following CASL clinical guidelines will result in a CSC funding shortfall of well over $100 million.

CSC Health Services is planning a consultation meeting in early 2016 “with all medical specialists treating CSC offenders with hepatitis C,” says Jon Schofield, a communications advisor for CSC.

The CSC acknowledged in an analysis given to CMAJ that “The number eligible for treatment is larger than the old therapy.” In recent years about 70% of infected inmates have been advised by specialists to “wait for a new generation of treatment.” In Ontario, where about 30% of federal inmates are incarcerated, CSC estimates that as many as 884 patients await treatment.

Policy at Correctional Services Canada may be failing to limit the spread of hepatitis C in prisons.

Image courtesy of ejwhite/iStock

Dr. Fiona Kouyoumdjian of St. Michael’s Hospital, Centre for Research on Inner City Health in Toronto notes that the very small proportion of inmates currently being treated “raises the question of whether health care is meeting professionally accepted standards, as required by the Corrections and Conditional Release Act.”

Kouyoumdjian, and Glenn Betteridge and Adam Cook of the Toronto-based Canadian Treatment Action Council, concur with Ford’s view that the CASL guidelines compel the CSC to dramatically expand the number of inmates it considers for treatment.

CSC’s “Cost Containment Plan,” which appears to be based on a hard cap of 240 prisoners treated per year, “is much more restrictive than the approach taken by public drug programs in the community, under which everyone who meets the eligible criteria for hep C drugs can access them,” says Betteridge, a lawyer and CTAC policy researcher.

“Restrictions on treatment according to disease stage are no longer tenable for many people living with chronic hep C,” says Betteridge. “CSC should get moving and develop an implementation plan to provide the highest standard of care to all prisoners rather than engaging in cost-containment planning and arbitrary rationing of treatment driven by untenably small budgets.”

While noting that intravenous drug use is rampant in federal prisons, and needle exchanges forbidden for almost a decade, Ford warns that CSC is “doing little to prevent the spread of hepatitis C within the institutions. Hepatitis C in prisons is a major public health issue because people continue to get infected in prison — even CSC admits this — and they will go out and spread the disease.”

“Prison represents an important, and often the only, opportunity to treat a significant proportion of hep C positive individuals,” Ford says. “What is needed is for CSC to start behaving in a responsible manner, which includes openness rather than secrecy and a willingness to take outside advice about both treatment and prevention. Also there needs to be a significant input of government money not just for drugs, but also to increase the inadequate levels of staffing.”