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Hepatitis C and Corrections

Hepatitis C and Corrections. Megan Mahoney, MD Correctional Medicine Consultation Network Department of Family and Community Medicine University of California, San Francisco. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership. Objectives.

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Hepatitis C and Corrections

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  1. Hepatitis C and Corrections Megan Mahoney, MD Correctional Medicine Consultation Network Department of Family and Community Medicine University of California, San Francisco

  2. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  3. Objectives • Incarceration in the U.S. and California • Hepatitis C Epidemic among Incarcerated • Challenges to Hepatitis C Treatment in CDCR • Future Directions

  4. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  5. Incarceration in the U.S. • 2.3 million people in prisons and jails1 • Highest per capita incarceration rate in the world 750/100k2 • More than one in every 100 adults is now incarcerated3 • 1 in 37 adults have been incarcerated4 1-3. Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs 4. Pew Report 2008: www.ncjrs.gov/App/Publications/abstract.aspx?ID=243732

  6. International Comparisons

  7. Incarceration in the U.S. Lifetime chance of incarceration Black males 1 in 3 Latino males 1 in 6 White males 1 in 17 Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  8. Who's Behind Bars Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  9. Who's Behind Bars Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  10. Incarceration in California • 173,000 current; 302,000 total per year • Commitment rate: 456/100,000 • 32,400 life sentence, 660 condemned • Offenses: 50% persons, 21% drugs, 21% property • Avg. sentence: 4.5 years, 2 years served • Reading level: 7th grade CDCR 2007: www.cdcr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Projections/F07pub.pdf

  11. 93 % male, 7% female 29 % African American 7 % of general population 37 % Latino 36 % of general population 29 % white 77 % of general population Average age= 36 Demographics of Incarceration in California CDCR 2007: www.cdcr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Projections/F07pub.pdf

  12. Incarceration In The US • 1974-2001: number incarcerated for the first time tripled Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  13. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880

  14. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880 California Correctional Institution -- Women (Closed) (CCI) 1933

  15. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880 California Correctional Institution -- Women (Closed) (CCI) 1933 World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men’s Colony (CMC) 1955 - California Medical Facility (CMF) 1954 - California Correctional Institution – Men (CCI)

  16. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880 California Correctional Institution -- Women (Closed) (CCI) 1933 World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men’s Colony (CMC) 1955 - California Medical Facility (CMF) Vietnam War 1954 - California Correctional Institution – Men (CCI) 1961 West- California Men’s Colony (CMC) 1961-1965 1962 – California Rehabilitation Center (CRC) 1963 - California Correctional Center (CCC) 1965 – Sierra Conservation Center (SCC)

  17. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880 California Correctional Institution -- Women (Closed) (CCI) 1933 World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men’s Colony (CMC) 1955 - California Medical Facility (CMF) Vietnam War 1954 - California Correctional Institution – Men (CCI) 1961 West- California Men’s Colony (CMC) 1961-1965 1962 – California Rehabilitation Center (CRC) 1963 - California Correctional Center (CCC) 1965 – Sierra Conservation Center (SCC) Reagan and the War on Drugs 1984 – California State Prison Solano (SOL) 1984-1997 1986 – California State Prison, Sacramento (SAC) 1987 – Avenal State Prison (ASP) 1987 – Mule Creek State Prison (MCSP) 1987 – R.J. Donovan Correctional Facility at Rock Mountain (RJD) 1987 - Northern California Women’s Facility (NCWF) 1988 – California State Prison, Corcoran (COR) 1988 - Chuckawalla Valley State Prison (CVSP) 1989 – Pelican Bay State Prison (PBSP) 1990 – Central California Women’s Facility (CCWF) 1990 – Waco State Prison (WSP) 1992 – Calipatria State Prison (CAL) 1993 – California State Prison, los Angeles County (LAC) 1993 – North kern State Prison (NKSP) 1993 – Centinela State Prison (CEN) 1994 – Ironwood State prison (ISP) 1994 – Pleasant Valley State Prison (PVSP) 1995- Valley State Prison for Women (VSPW) 1992 – Calipatria State Prison (CAL) 1995 – High Desert State Prison (HDSP) 1996 – Salinas Valley State Prison (SVSP) 1997 – California Substance Abuse Treatment Facility (SATF)

  18. Prisons in California San Quentin State Prison (SQ) 1852 Folsom State Prison (FOL) 1880 California Correctional Institution -- Women (Closed) (CCI) 1933 World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men’s Colony (CMC) 1955 - California Medical Facility (CMF) Vietnam War 1954 - California Correctional Institution – Men (CCI) 1961 West- California Men’s Colony (CMC) 1961-1965 1962 – California Rehabilitation Center (CRC) 1963 - California Correctional Center (CCC) 1965 – Sierra Conservation Center (SCC) Reagan and the War on Drugs 1984 – California State Prison Solano (SOL) 1984-1997 1986 – California State Prison, Sacramento (SAC) 1987 – Avenal State Prison (ASP) 1987 – Mule Creek State Prison (MCSP) 1987 – R.J. Donovan Correctional Facility at Rock Mountain (RJD) 1987 - Northern California Women’s Facility (NCWF) 1988 – California State Prison, Corcoran (COR) 1988 - Chuckawalla Valley State Prison (CVSP) 1989 – Pelican Bay State Prison (PBSP) 1990 – Central California Women’s Facility (CCWF) 1990 – Waco State Prison (WSP) 1992 – Calipatria State Prison (CAL) 1993 – California State Prison, los Angeles County (LAC) 1993 – North kern State Prison (NKSP) 1993 – Centinela State Prison (CEN) 1994 – Ironwood State prison (ISP) 1994 – Pleasant Valley State Prison (PVSP) 1995- Valley State Prison for Women (VSPW) 1992 – Calipatria State Prison (CAL) 1995 – High Desert State Prison (HDSP) 1996 – Salinas Valley State Prison (SVSP) 1997 – California Substance Abuse Treatment Facility (SATF) Bush 2005 – Delano State Prison (DEL) 2001 - 2005

  19. U.S. 1987: $10.6 billion 2007: $44 billion California $8.8 billion $2 billion health care Prison Industry: Expenditures

  20. Burden of Disease:Mental Illness • 700,000 people with severe mental illness are admitted to U.S. jails and prisons each year • NYC and LA county jails are the largest inpatient psych units in the country • Mentally ill inmates report longer criminal histories than other inmates Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  21. 500,000 State Psychiatric Hospital Beds Incarceration and Mental Illness: US 100,000 Prison & Jails 1970 1,2000,000 Prison& Jails 100,000 StatePsychBeds 1999 Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  22. Summary Pew Center Public Safety Performance Project 2007 States in the U.S. are spending more and more on inmates who are less and less a threat to public safety

  23. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  24. Hepatitis C Epidemic in Corrections in U.S. • HCV prevalence high in prisons- 15%-40%1 1.8% prevalence in general population • Intravenous drug use leading risk factor • Women incarcerated for IDU-related criminal offenses2 1Boutwell, Allen, Rich. Opportunities to Address the Hep C Epidemic in the Correctional Setting. Clinical Infectious Diseases. 2005;40:S367-72. 2Harrison PM, Karberg JC. Prison and jail inmates at midyear 2002. National Criminal Justice document 198877. Washington, DC: Bureau of Justice Statistics, 2003.

  25. Substance Abuse • Newly sentenced state prisoners convicted of drug offenses 1985 13% 1990 32% • 65-80% of prisoners with history substance use and abuse • Only 25-33% with history of treatment for substance abuse Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs

  26. High Risk Behaviorsand Exposures • Unprotected sexual activity • IV drug use • Tattooing • Violence • Sexual Assault

  27. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  28. Historical Challenges to HCV Treatment in Prisons in U.S. • 1) Psychiatric Illness • 2) ALT Level • 3) HIV Co-infection • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay

  29. Recent Evidence • 1) Psychiatric Illness and Substance Use: Not a barrier if remote or adequately treated1 • 2) ALT Level: Pts w/normal ALT may deteriorate histologically and respond to tx2 • 3) HIV: Coinfection common (1.4% prevalence). Pts respond to treatment3 1 Paris JE. Potential legal pitfalls of HCV management in corrections and how to avoid them. Infectious Diseases in Corrections Report. September 2007. Spotlight Article. 2 Pearlman B, Paris JE. Hot Topics in Hepatitis C. HEPP Report on Infectious Diseases in Corrections. 2004;7(6):1-4. 3Cengiz C, Park JS, Sarah N et al. HIV and Liver diseases: Recent clinical advances. Clinics in Liver Disease. 2005;9:647-66.

  30. Hepatitis C Treatment Guidelines 2008 • CDCR had similar to barriers seen nationwide • California Department of Corrections and Rehabilitation revising guidelines based on new evidence • HIV/Hepatitis Advisory Committee, chaired by Dr. Joseph Bick • Previous restrictions due to Hx of Substance Use, Normal ALT, and Age reexamined

  31. Historical Challenges to HCV Treatment in Prisons • 1) Psychiatric Illness • 2) HIV Co-infection • 3) ALT Level • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay

  32. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  33. Prisoners are one of the only groups in this country with a constitutional right to health care. [The] principles [behind the guarantee against cruel and unusual punishment] establish the government’s obligation to provide medical care for those whom it is punishing by incarceration. An inmate must rely on prison authorities to treat his medical needs; if the authorities fail to do so, those needs will not be met. US Supreme Court, Estelle v. Gamble (1976) Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  34. Plata v. Schwarzenegger Largest ever prison class action lawsuit in the US Prisoners alleged that California officials inflicted cruel and unusual punishment by being deliberately indifferent to serious medical needs. Settlement agreement 2002: Requires the California Department of Corrections and Rehabilitation to completely overhaul its medical care policies and procedures

  35. California Prison Receivership • Second time in U.S. history that a federal receiver has presided over a correctional system • Receiver has access to resources and ability to override usual procedures

  36. Historical Challenges to HCV Treatment in Prisons • 1) Psychiatric Illness • 2) HIV Co-infection • 3) ALT Level • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay - Plata vs. Schwarzenegger - Development of Chronic Care Programs - CPR

  37. Historical Challenges to HCV Treatment in Prisons • 1) Psychiatric Illness • 2) HIV Co-infection • 3) ALT Level • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay

  38. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

  39. HCV Epidemic in CDCR • Hepatitis C Care on the inside • Subspecialty care onsite or telemedicine through Chronic Care Program • Primary Care Physicians with HCV Expertise • HCV prevalence in CA prisons ~ 34%1-2 • 175,000 x .34 ≈60,000 • 60,000 x .80 = 48,000 1. Ruiz JD, Molitor F, Plagenhoef, JA. Trends in hepatitis C and HIV infection among inmates entering prisons in California, 1994 versus 1999. AIDS. 2002, 16:2236-38. 2. Fox RK, Currie SL, Evans J, et al. Hepatitis C virus infection among prisoners in the California state correctional system. Clin Infect Dis. 2005; 41:177-186.

  40. Hepatitis C Team Model of Care

  41. Correctional Medicine Consultation Network Who are we? Program of Department Family and Community Medicine, University of California, San Francisco In collaboration with: CDCR California Prison Health Care Receivership UCSF Faculty in prison: Primary Care Specialists

  42. CMCN Overview Improve quality of patient care through: • Peer education and professional development • Consultation for chronic care, high risk patients, and specialty patients • Recruitment of new clinical staff • Multidisciplinary team development • Evaluation of medical care delivery system components

  43. CMCN Faculty Activities • Professional Development: Provider staff • Training Peer Educators • Collaboration with management team • System evaluation and quality improvement • Introduce technology • Focused reviews to determine cost saving and outcomes improvement strategies for: specialty consultations, pharmacy, laboratory, hospitalization, and emergency services

  44. CMCN Academic Training • UCSF Primary Care Medicine Residents • UCSF Family Medicine Residents: Geriatrics • Elective rotations: Residents and medical students Primary Care, HIV, Transgender • Nurse Practitioner student continuity clinics • Advanced Practice Nurse Training- CNS, Masters and PhD Projects • UCSF Medical Students: core family medicine rotation • AIDS Education and Training Center Collaboration

  45. Clinical Consultation:Onsite and Telemedicine • Established in 2005 • HIV Continuity of Care • Collaboration with PCP • Training of PCP • Periodic on site direct consultations • 1200 patients with HIV, 7 prisons • Transgender Care • 150 patients, 5 prisons • Primary care consultation

  46. Clinical Consultation:Onsite and Telemedicine • Established 2007 • Pain Consultation • Established 2008 • HCV Continuity of Care • Collaboration with PCP • Training of PCP • Periodic on site direct consultations

  47. Historical Challenges to HCV Treatment in Prisons • 1) Psychiatric Illness • 2) HIV Co-infection • 3) ALT Level • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay - CDCR - CMCN

  48. Historical Challenges to HCV Treatment in Prisons • 1) Psychiatric Illness • 2) HIV Co-infection • 3) ALT Level • 4) Lack of Funding • 5) Access to Subspecialty Care • 6) Transition Care • 7) Duration of Stay

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