Treating Infectious Diseases In Prisons: Controlling Epidemics and Reducing Costs

During a session at AMCP Nexus 2017, Steven Miller MD, chief medical officer of Express Scripts summarized the threat posed by untreated infectious diseases in prisons.

“We have a million people that are incarcerated who have hepatitis that are not being managed, so we as a society are not smart enough to realize, they are the reservoir that is going to reinfect the population,” he said.

Treatment of infectious diseases in people who are incarcerated is an important issue given the high prevalence of infectious diseases, particularly hepatitis C viral (HCV) infection and human immunodeficiency viral (HIV) infection, in this population. It is estimated that more than 10 million people are incarcerated in the United States, and of these 17% have HCV and about 1.3% HIV, according to AIDS Reviews. The burden of HCV is particularly daunting with estimates showing that nearly one-third of the people in the United States with HCV spend at least part of the year in a correctional facility.

Standard of Care

Under US law, incarcerated persons have a constitutional right to receiving adequate health care, which is generally interpreted to mean they have a right to the standard of care that is offered in the community. Despite this law, many incarcerated persons are not receiving treatment as highlighted in a recent 2015 survey of US state correctional facilities, which found that less than 1% of inmates with HCV received treatment.

Offering the standard of care to incarcerated persons can be difficult given the high cost of drugs to treat these diseases. This is particularly true for HCV as both private and public payers grapple with the most cost-effective strategy to deliver the new costly antivirals that now offer cure. Since treatment of HCV with the new antivirals now provides cure after a limited treatment course of about 8 to 12 weeks with no need for ongoing maintenance therapy, unlike HIV that requires ongoing treatment, determining who bears the cost of treating HCV in incarcerated persons is an ongoing question.

“People are saying that the cost should be borne by correctional facilities but the benefit is to the community after release,” Anne Spaulding, MD, MPH, associate professor of Epidemiology at the Rollins School of Public Health at Emory University, said in an interview. “Therefore, this places the burden on the back of one system and the benefit on another.”

Underlying this question of cost burden, however, is the larger public health question of how best to stem the spread of infectious diseases, with HCV being the most recent concern, that exacts a severe and substantial toll on individual’s lives and societies ability to deliver fair and optimal healthcare with limited resources.

An ongoing substratum under all of this is the increasingly evident problem of high drug pricing that is forcing payers and patients to make ever tougher decisions about when and how to treat. This is all too evident in the ongoing discussion of when to treat HCV in the general public, and by extension in correctional facilities, based on level of disease—should treatment be offered in early stages of disease or wait until fibrosis and liver damage is evident.

A recent cost-effectiveness analysis that used a Markov model to assess the cost-effectiveness of sofosbuvir-based treatment regimens for incarcerated persons with chronic HCV found that sofosbuvir-based treatment is cost-effective in this setting but that affordability was a primary consideration.

“Our exploratory analyses found that the value of all-oral, interferon-sparing regimens depends heavily on their pricing, their attractiveness for uptake and adherence, and the rising bar of other effective and less costly comparator regimens,” the researchers wrote.

“Hepatitis C is now a curable disease, but it’s out of reach for many because of the outrageous price of these medications,” Gregg Gonsalves, PhD, assistant professor of epidemiology at the Yale School of Public Health, said. “When companies put outrageous mark-ups on drugs because they know that there is little we can do to stop them, that doesn’t only hurt patients but also providers, insurers, and others who must bear these costs.”

Opportunity to Treat Disease And Ease Public Health Burden

One main argument about the importance of treating incarcerated persons with infectious diseases, such as HIV and HCV, is that it provides a controlled environment in which to identify, treat, and follow treatment. To that end, a number of proposals have been offered on making it more financially feasible to treat these diseases in correctional facilities.

In the study mentioned above that looked at current HCV care practices in state correctional facilities around the US, investigators found that the price of the new HCV antivirals, which can run up to $84,000 for a 12-week course of Sovaldi (sofosbuvir;Gilead) and up to $94,500 for the combination drug Harvoni (ledipasvir/sofosbuvir; Gilead), prohibited many state corrections departments from purchasing the amount of medications needed to treat all inmates with HCV.

“State prisons and other government agencies that operate on limited annual budgets cannot afford to pay these prices, and state prisons don’t even get the discounts that state Medicaid programs and federal agencies get,” Dr Gonsalves, senior author of the study, said. “So often, they pay the highest prices for these drugs.”

To help correctional facilities afford these drugs, Dr Gonsalves and colleagues proposed various financial avenues to consider. Among these is for state correctional systems to engage with each other or with other county or state agencies such as Medicaid to pool procurements for leveraging greater purchasing power to lower drug costs. Another idea is for state correctional systems to partner with health care facilities that qualify for discounts through the federal 340B Drug Discount Program. The study found the state correctional facilities using this type of partnership were paying the lowest prices for Sovaldi and for combination Harvoni.

This last discount strategy—working through the 340B Drug Discount Program—was one suggest by Spaulding and colleagues in an earlier 2013 study in Topics in Antiviral Medicine that discussed several ways to lessen the cost burden of HCV in correctional facilities. Other strategies included developing and implementing clinical care of HCV that parallels the community and that uses resources wisely.

Dr Spaulding highlighted several challenges that remain in providing optimal care to incarcerated persons, including the need for a more holistic approach to managing HCV that takes into consideration the downstream benefits to society at large. “When the public health benefits for society and the lower lifetime costs for the whole health care system of appropriate HCV screening and treatment are taken into consideration, the short-term costs to state correctional facilities are more than offset,” the researchers wrote in the study.

Continuity of Care

Even with optimal treatment while incarcerated, however, perhaps the larger issue to stemming the prevalence of HCV and HIV is the lack of continuity of care once incarcerated persons return to the community.

“The biggest challenge to improving the transition from incarceration to the community and thereby providing cost-effective care, is insufficient and fragmented resources and communication,” Ank E Nijhawan, MD, of the division of infectious diseases at the UT Southwestern Medical Center, said.

In a recent systematic literature review in the American Journal of Public Health to assess access and outcomes of care for incarcerated persons with HIV, Nijhawan and colleagues found that health care access and clinical outcomes in HIV-infected persons improved significantly while they were incarcerated based on measures that included all stages of HIV care.

However, the study found that these improvements were lost once individuals were released from incarceration, and that the individuals did less well in terms of retention of care, receipt of antiretroviral therapy, and virologic suppression than prior to being incarcerated.

“This indicates that incarceration has a net negative impact on clinical outcomes in HIV-infected individuals,” Dr Nijhawan said.

In terms of cost, the study showed the need for more resources to help sustain the benefits of HIV treatment once an individual is released into the community.

“Improved re-entry services after release from incarceration could translate into improved health care utilization, such as linking to primary care and reduced unnecessary emergency room use and hospitalizations, and improved clinical outcomes by, for example, reducing HIV viral load,” Dr Nijhawan said.

Of critical importance, she suggested, is better communication between correctional facilities and community healthcare systems that help to provide a better continuum of care.

“The department of corrections is responsible for providing health care to individuals during incarceration,” she said. “However, they are no longer responsible for their health care after release, therefore the investment in improving the transition of health care to the community does not directly benefit the department of corrections. Similarly, those providing health care in the community, such as federally qualified health centers or safety-net providers, are typically neither aware nor involved in the health care of their patients during incarceration.”