Selected and summarized by Ronald O. Valdiserri, MD, MPH, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, and Co-Chair of HepVu.
Dr. Valdiserri reviews significant articles on prevention, public health, and policy advances in viral hepatitis. This month, he highlights “Best practice guidelines for viral hepatitis service delivery in prisons“
What question(s) does this study address?
In the United States and elsewhere around the world, the prevalence of substance use disorders among incarcerated persons is extremely high. A recent analysis estimated that globally, 12% of incarcerated persons have ever injected drugs—over 50 times higher than rates found in the general population. In the United States, as many as one in five (20%) state prisoners has a history of injection drug use. Given these statistics, it’s not surprising that blood-borne infections, including HIV, Hepatitis C and Hepatitis B virus, are highly prevalent in incarcerated populations. A 2023 analysis estimated that HCV prevalence among state prisoners in the U.S. was nearly 9-fold greater than in the US general population. The 2025 Hepatitis B Foundation white paper on expanded screening for and prevention of Hepatitis B in carceral settings cited an HBV prevalence among incarcerated persons in the U.S. ranging from .9% to 11.4% compared to the estimated national prevalence of .3%.
Eliminating viral hepatitis in our nation and globally will require substantial improvements in the prevention, diagnostic and treatment services currently provided in carceral settings. These best practice guidelines were developed in order to standardize prison-based viral hepatitis service delivery with the goal of furthering viral hepatitis elimination efforts. Technical experts, providers, policy makers, advocates, persons with lived experience of incarceration, and people living with viral hepatitis reviewed and synthesized evidence from a systematic literature review to develop, refine, and grade practice recommendations in 8 domains: policy, testing, treatment, continuity of care, prevention and harm reduction, education, consideration of minority populations, and monitoring and evaluation.
What are the major findings of this report/article?
- A total of 8396 published articles were identified. After screening and removing duplicates, 703 articles were included for analysis. More than half (n=444) were focused exclusively on HCV; 84 dealt with HBV and 168 dealt with more than one hepatitis virus.
- The majority of the 703 articles addressed efforts in high income countries, only 16 studies were from lower-middle-income countries.
- In total, 30 best practice recommendations were developed and graded. Among the recommendations with an A (strong recommendation) or B (moderate recommendation) grade were the following:
- Universal opt-out testing for HCV and HBV should be adopted upon entry for all people who are newly incarcerated.
- Universal access to DAAs (direct acting antivirals) should be available to all persons in prison living with HCV infection.
- Universal access to HBV management should be available to all people in prison with chronic HBV infection.
- People with chronic viral hepatitis should be linked to community-based care upon release.
- All people in prison who were on medication assisted treatment (MAT) for opioid use disorder in the community or who request such treatment and are deemed eligible should receive access to MAT within 24 hours of admission or request.
- Opt-out HBV vaccination should be offered to anyone who does not show evidence of immunity upon entry.
- The development of these best practice guidelines was informed by available evidence, although the authors acknowledged the need for additional research, noting the “dearth of prison-related viral hepatitis research.”
What are the implications for the prevention and control of viral hepatitis?
- The authors of these best practice guidelines emphasize that country and region-level viral hepatitis elimination policies and plans should prioritize people living in prisons. In its recently released 2030 Strategic Plan to eliminate viral hepatitis in the U.S., the Centers for Disease Control and Prevention calls for the expansion of hepatitis B and hepatitis C prevention, testing, and treatment services in carceral settings.
- A mathematical model that assessed the impact of expanding HCV treatment among prisoners in Australia predicted a sharp decline in new HCV infections and indicated that DAA therapy was “increasingly cost effective with increasing coverage,” recommending that universal access to DAAs “should be a government priority for the global elimination effort.”
- These guidelines are specific to viral hepatitis, but the circumstances underlying their development are applicable to preventing and treating other chronic health conditions found among incarcerated populations, including the following considerations:
- Carceral facilities are important targets for disease prevention and treatment efforts given the substantial prevalence of chronic health conditions found among their populations;
- Although incarcerated populations have a constitutional right to health care, absent or inadequate care is often the norm;
- Policies and practices supporting continuity of care, such as actively facilitating linkages to post-release care, are necessary to prevent interruptions in treatment; and
- Broad systemic reforms, such as the repeal of the Medicaid Inmate Exclusion Policy (this policy prohibits the use of federal funds for ambulatory care services and medications for incarcerated persons) would help to support the expansion of chronic disease services for incarcerated populations.
