To Cure Hepatitis C, Start With Prisons
The U.S. is in the midst of a hepatitis C epidemic with as many as 3.9 million Americans infected with the liver-damaging virus. Aggressively targeting a concentrated population with the contagious but curable disease could be the best approach to eradicating the deadly virus.
The most logical place to launch the counterattack is in the country’s jails and prisons, where the infection rate is about 17%, compared to 1% to 2% overall in the U.S., said Josiah Rich, a Brown University infectious disease physician. A recent study estimated that 1.86 million people with the virus were incarcerated.
“With more than 10 million Americans cycling in and out of prisons and jails each year, including nearly one of every three HCV (hepatitis C)-infected people,” Rich said, “the criminal justice system may be the best place to efficiently identify and cure the greatest number of HCV-infected people.”
Rich, the lead author of an opinion piece published last week in the New England Journal of Medicine, said treating prison populations could have a “substantial effect on this epidemic.”
Hepatitis C is a blood-borne virus most typically spread through intravenous drug use, transfusions and tattooing. Although it can remain asymptomatic for decades, the virus can eventually cause catastrophic liver damage, including cirrhosis, cancer, liver failure and death.
In addition to teaching at the medical school at Brown, Rich is director and co-founder of the Center for Prisoner Health and Human Rights at the Miriam Hospital Immunology Center in Providence, Rhode Island. He has raised the possibility of eradicating the disease following the government approval last year of two new medications that boost the cure rates for hepatitis C from about 45 percent for the older drugs to better than 90 percent.
But there’s a big hitch: the price tag. At $1,000 a pill for the new medicine, a single course of treatment for an individual costs as much as $84,000. Because of the high cost of the new drugs, all payers, public and private, are grappling with questions about which patients should get the new medications and how to pay for them.
Better Drugs
The new drugs, simeprevir (marketed as Olysio by Janssen Therapeutics, a division of Johnson & Johnson) and sofosbuvir (sold as Sovaldi by Gilead Sciences) offer other advantages aside from their cure rates. They can be taken orally rather than through injection. The course of treatment is much shorter than previous drugs – 12 to 24 weeks compared to 48. And they produce none of the serious side effects caused by the previous medications, including nausea, fever, headaches and insomnia.
To Rich, the advent of these drugs presents an opportunity that he insists must include correctional facilities as an essential component.
“We can invest now in treating this epidemic and curing large numbers of people and preventing a lot of illness, death, and expense,” Rich told Stateline.
“If we made a national push to avoid that death and illness and expense, we’d want to roll out as much treatment as possible in the place where we’d find the highest number of people with the virus. And that’s in the jails and prisons.”
But as Rich notes in his article, treating all the infected people currently incarcerated would cost $33 billion. He said that treating just half of the people with hepatitis C who cycle in and out of jail or prison in a year’s time would cost $76 billion. To put those numbers in perspective, total government spending for all states combined in fiscal 2013 was just under $700 billion.
Correctional systems, funded by states or localities, hardly have those kinds of resources, which is why Rich believes federal intervention will be necessary. He suggested as a precedent the Ryan White CARE Act, originally authorized in 1990, which provided federal resources to combat HIV/AIDS.
But more than three times as many Americans are believed to be infected with hepatitis C than HIV. Rich’s article does not address how to overcome the cost, but in an interview, he suggested the federal government should negotiate a rate with the pharmaceutical companies on behalf of states and their corrections systems.
“The government could come back and say, ‘You should make a profit, absolutely. But you can make a profit by selling a few doses of the medication or you could make a profit by selling a whole lot of doses.’”
Beyond Prison Walls
Rich is not an economist or an expert in drug pricing. Much of his knowledge comes from working “behind bars” for 20 years as a doctor in Rhode Island corrections.
He said that not treating infected inmates won’t isolate the impact of hepatitis C to prisons. Eventually, most prisoners with the infection will be released, and the costs of caring for them then, when the disease has advanced, will be far greater. They also could spread the infection wider once out of prison.
That is why his assertion that hepatitis C be viewed as a population-wide public health challenge, with the prisons seen as an essential component, resonates with others.
“I agree with the premise that prisons are an important point to address this problem,” said Joe Goldenson, M.D., director of Jail Health Services in San Francisco. “But this has to be addressed from an overall strategy of public health and the funding has to come out of that system. Corrections is not a place that can handle these costs.”
No correctional system in the country is currently providing the new medications on a wholesale basis to prisoners with hepatitis C.
Steven Shelton, M.D., medical director of the Oregon Department of Corrections, said that no state or locality could afford to do so. Oregon does treat inmates with the new drugs, but only if they are extremely ill with a life expectancy of less than a year. Treatment, he said, costs double the amount of the previous medications, so he is able to treat only half as many patients with the new medications. He said the corrections system has to pay as much as any other buyer for the medications.
Shelton said corrections systems are funded to address the immediate medical needs of their inmates rather than the public health in general. That, and the fact that most of those who are infected are asymptomatic, is why most inmates with hepatitis C go without treatment while in prison.
“It’s not necessarily forward-looking,” Shelton said. “We’re basically saying, ‘we don’t have to treat you now because we don’t have to worry about what happens 20 years down the road.” That becomes a public health problem, which, he said, is well beyond the resources of prison systems to address.
In Goldenson’s view, the costs are worse than prohibitive. “Any discussion about hep C does have to address the cost and to a lot of us, the cost is almost extortionist,” said Goldenson.
The manufacturers defend the pricing of their medications as significantly better than the previous anti-hepatitis C drugs. Craig Stoltz, a spokesman for Janssen, said in an email that the company continues to “work with public and private payers and health systems” to make simeprevir available to “marginalized and underserved populations,” including those in prison.
Janssen and Gilead will not have a monopoly on a cure for long. New generations of hepatitis C drugs are in the pipeline behind them, with the first likely to gain Food and Drug Administration approval later this year.
Some are hopeful the competition will drive prices down, which is one reason Rich remains optimistic. For the first time, the very idea of eradicating hepatitis C seems something less than a fantasy. “You might have to go back to the advent of antibiotics for something similar,” he says.
Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.
