Behind Enemy Lines
By Charles White, Prevention Specialist - Hepatitis C Awareness Project

When our organization's executive director, Phyllis Beck, invited me to attend and report on the Management of Hepatitis C in Prisons conference being held in San Antonio, Texas, January 25 and 26, 2003, I was not only excited, but honored to be a part of this informative event.  Because the conference was being organized by the Continuing Medical Education Department of the University of Minnesota, and sponsored by many respected agencies including the Centers for Disease Control and Prevention, the National Institutes of Health and the University of Texas Medical Branch, I knew this was going to be some powerful stuff.  But when Phyllis told me that we were to be two of the very few prisoner advocates in attendance, among a couple of hundred Department of Corrections Administrators and Medical Directors, I felt like I would be behind enemy lines. Nevertheless, I knew I must put my personal attitudes aside and reminded myself that the real enemy is Hepatitis C.

Recognizing that hepatitis C virus infection is disproportionately high among incarcerated populations, The Centers of Disease Control and Prevention (CDC) recently developed recommendations that provide a framework for identification of persons who would benefit from testing, counseling and medical management to prevent and control hepatitis C infection and its consequences.  Additionally, the National Institutes of Health (NIH) has
developed guidelines for the medical management of hepatitis C.  The primary objective of the conference was to help participants understand how these recommendations and guidelines pertain to prison populations.  The conference also gave participants an opportunity to describe and discuss controversies and the many challenges they face when implementing programs to manage hepatitis C inside correctional facilities.  By listening to presentations on the various ways US and State Prisons currently deal with hepatitis C and
those it affects, it didn't take long to realize that there are no clear and consistent standards.

Dr. Anne Spaulding opened with a welcome and conference overview followed by brief statements from the American Correctional Association and the National Commission on Correctional Health Care.  First day sessions were presented in panel format with Dr. Miriam Alter moderating the first session on the background of hepatitis C diagnosis, prevention and treatment.  Although opinions often differed, valuable information was presented on the clinical features of hepatitis C, vaccine development, diagnosis, therapy, and the burden of hepatitis C on US and State prison systems.

Dr. Rob Lyerla of the CDC moderated the next session that included the pros and cons of universal hepatitis C testing verses targeted testing.  One of the panelists, Dr. Anne Spaulding, discussed various implications the NIH guidelines held for prisons, but unfortunately, the entire session, which was titled, "Identification of Infected Prisoners and Treatment Outcomes," seemed overshadowed by lengthy conversations surrounding the legal landscape of hepatitis C and the financial impact expensive treatments have on already strained prison medical budgets.

I was encouraged to hear many doctors say that they had an ethical responsibility to treat all those who need treatment, but found an even greater number who felt management of financial resources to be their first and foremost priority.  Understandably, this is a complex problem with no singular or simple answer.  As an advocate for the incarcerated, my
obligation is to report the facts as accurately as possible to those for whom I work: the prisoners.

When considering how to identify, evaluate and treat persons infected with hepatitis C, it is obvious that there are those who will use the variables to treat as few prisoners as possible. For some, best practices are defined as the best way to accomplish this without the fear of being sued, and not the best standards of care.  When litigation does occur, hopefully the courts will continue to hold prisons accountable and require that incarcerated
persons receive a level of treatment equal to community standards.  As more is learned about treatment outcomes, opinions on who and when to treat will become less divided and the standard of care more well defined.

On day two of the conference, following a panel discussion on translating recommendations into practice, breakout sessions were offered on four different topics.  These included: Identifying Resources for Hepatitis C Management, Elements of Primary and Secondary Prevention, Evaluation of the HCV Positive Person for Possible Treatment, and Treatment Monitoring and Management of Complicated Patients.  This gave participants an opportunity to focus on discussions specific to their role in the management of the hepatitis C positive prisoner.

In the afternoon, breakout sessions were offered on: Inclusion Criteria, Case Identification, Prevention, and Program Needs.  I had the opportunity to participate in the session on Prevention facilitated by Drs. Lyerla and Kendig.  The discussion was interactive and showed willingness on the part of government agencies, prison administrators and community-based organizations to come together for the well-being of prisoners and the communities to which they will return.

It is difficult to summarize the entire conference in one short report.  The amount of information presented and discussed was immense.  I left feeling that important ground was covered and a door of opportunity to bring about necessary change was opened.  Much of what was presented dealt the mechanics of testing, diagnosis and subsequent therapy where appropriate.  These specifics, where accurate, will be used in articles, presentations and reports as part of our continued commitment to educate the HCV positive prisoner about his/her disease.

I wish I could tell you that everyone who attended this conference will implement the latest CDC recommendations and NIH guidelines as they are written. I cannot.  In fact, it was clear the intent of some would be to use these documents as a shield of protection to support decisions not to treat.  But for those who came to the conference with an open mind and an honest desire to learn, they take with them an understanding that can result in better and more efficient methods of addressing and managing hepatitis C infection.  If this aids in getting treatment to one more prisoner before they advance to cirrhosis, liver cancer or death, then the conference was most assuredly a gigantic success.