by Natalie Davies, co-editor of Drug and Alcohol Findings


‘Find the Missing Millions’

The theme for World Hepatitis Day 2020 is Find the Missing Millions, referring to the many millions of people worldwide who are unaware that they are living with viral hepatitis. In few settings is this call to action more pertinent than in prisons, where undiagnosed and untreated hepatitis C is endemic.

What is hepatitis C?

Hepatitis C is the most common type of viral hepatitis in the UK, and is a major public health problem for people who inject drugs – around a quarter of whom are believed to be currently infected. In the early stages of contracting hepatitis C most people either do not experience noticeable symptoms or they experience symptoms that are similar to many other short-term infections and so may not seek medical attention. A small proportion of people infected with hepatitis C will naturally clear the virus from their body in the first 6 months, but around 3 in 4 people develop a chronic infection. While chronic hepatitis C can lead to serious health problems such as cirrhosis and liver cancer, it can be successfully treated with direct-acting antiviral medications, which have fewer side effects than earlier interferon-based treatments.

Addressing hepatitis C in custodial settings

Prisons are high-risk environments for the transmission of blood-borne diseases due to overcrowding, poor sanitation, inadequate health care, and a greater likelihood of sharing injecting equipment (with more people). Although the evidence suggests that harm reduction is key to minimising the spread (1 2), prisons are not achieving parity of services with the wider community (1 2), which arguably places more weight on the testing and treatment parts of the equation.

In the past year Drug and Alcohol Findings analysed two studies about innovative interventions for combating hepatitis C in custodial settings:

  • Study one was set in an Irish men’s prison and found that training prisoners as peer educators could improve the uptake of testing and treatment. Peer workers accompanied prisoners to screening sites and promoted testing and treatment on the landing areas of the prisons. The intervention was successful in testing a large number of prisoners for hepatitis C. Of the 419 prisoners screened, 87 tested positive for hepatitis C antibodies and 50 tested positive for an active hepatitis C infection, of whom 19 were ‘new cases’ (i.e. had not been identified on arrival at prison).

Involving peers in the delivery of healthcare may not only help to build trust in services, and dispel fear and stigma associated with hepatitis C and treatment, but it could also alleviate the strain on prison staff, who may see facilitating access to healthcare as just one of many competing priorities in their day-to-work, and something that comes second to ensuring the security of the prison.

  • Study two based in prisons in the North East of England found support for offering ‘dry blood spot testing’ – less invasive than drawing blood from a vein – to all new prisoners. This substantially increased testing rates and led to many new diagnoses of hepatitis C. However, the rate of prisoners declining the offer remained high. The study also found that using digital technology to facilitate healthcare consultations could increase access to treatment.

Since 2014, NHS England, the National Offender Management Service and Public Health England have maintained a commitment to implement an ‘opt out’ policy of testing for blood-borne viruses (1 2). In practice, this means that every new prisoner should be offered a test at, or near, admission, and at several points thereafter. Guidance from the Hepatitis C Trust states that testing should be offered to all prisoners who can consent within 7 days of entering the prison – not just limited to prisoners who screen as high risk for blood-borne viruses – and should be continuously offered throughout their prison stay when appropriate.

Drug and Alcohol Findings has a strong history of bringing attention to the injecting-related hepatitis C crisis in the UK. Much of this work has been brought together under an Effectiveness Bank hot topic entitled, “Hepatitis C ‘giant’ still growing”.

#WorldHepatitisDay #WorldHepDay #FindTheMissingMillions


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