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
 Incarceration in the U.S. and California
 Hepatitis C Epidemic among Incarcerated
 Challenges to Hepatitis C Treatment in CDCR
 Future Directions
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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
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
Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs
Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs
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
Demographics of Incarceration
in California
 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
CDCR 2007: www.cdcr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Projections/F07pub.pdf
Incarceration In The US
 1974-2001: number incarcerated for
the first time tripled
Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs
1852
San Quentin State Prison (SQ)
1880
Folsom State Prison (FOL)
Prisons in California
1852
San Quentin State Prison (SQ)
1880
1933
Folsom State Prison (FOL)
Prisons in California
California Correctional Institution -- Women (Closed) (CCI)
1852
San Quentin State Prison (SQ)
1880
1933
Folsom State Prison (FOL)
World War II
1941-1955
Prisons in California
California Correctional Institution -- Women (Closed) (CCI)
1941 - California institution for Men (CIM)
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)
1852
San Quentin State Prison (SQ)
1880
1933
Folsom State Prison (FOL)
World War II
1941-1955
Vietnam War
1961-1965
Prisons in California
California Correctional Institution -- Women (Closed) (CCI)
1941 - California institution for Men (CIM)
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)
1961 West- California Men’s Colony (CMC)
1962 – California Rehabilitation Center (CRC)
1963 - California Correctional Center (CCC)
1965 – Sierra Conservation Center (SCC)
1852
San Quentin State Prison (SQ)
1880
1933
Folsom State Prison (FOL)
World War II
1941-1955
Vietnam War
1961-1965
Reagan and
the War on
Drugs 1984-1997
Prisons in California
California Correctional Institution -- Women (Closed) (CCI)
1941 - California institution for Men (CIM)
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)
1961 West- California Men’s Colony (CMC)
1962 – California Rehabilitation Center (CRC)
1963 - California Correctional Center (CCC)
1965 – Sierra Conservation Center (SCC)
1984 – California State Prison Solano (SOL)
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)
1852
San Quentin State Prison (SQ)
1880
1933
Folsom State Prison (FOL)
World War II
1941-1955
Vietnam War
1961-1965
Reagan and
the War on
Drugs 1984-1997
Bush
2001 - 2005
Prisons in California
California Correctional Institution -- Women (Closed) (CCI)
1941 - California institution for Men (CIM)
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)
1961 West- California Men’s Colony (CMC)
1962 – California Rehabilitation Center (CRC)
1963 - California Correctional Center (CCC)
1965 – Sierra Conservation Center (SCC)
1984 – California State Prison Solano (SOL)
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)
2005 – Delano State Prison (DEL)
Prison Industry: Expenditures
U.S.
 1987: $10.6 billion
 2007: $44 billion
California
 $8.8 billion
 $2 billion health
care
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
Incarceration and Mental Illness: US
500,000
State Psychiatric
Hospital Beds
100,000
100,000
1970
1999
State Psych Beds
Bureau of Justice Statistics 2003: www.ojp.usdoj.gov/bjs
Prison & Jails
1,2000,000
Prison & Jails
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
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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.
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
High Risk Behaviors and Exposures
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Unprotected sexual activity
IV drug use
Tattooing
Violence
Sexual Assault
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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
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.
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
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
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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
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
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
Historical Challenges to HCV
Treatment in Prisons
 1) Psychiatric Illness
 2) HIV Co-infection
 3) ALT Level
- Plata vs. Schwarzenegger
- Development of Chronic Care Programs
 4) Lack of Funding - CPR
 5) Access to Subspecialty Care
 6) Transition Care
 7) Duration of Stay
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
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
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.
Hepatitis C Team Model of Care
California Department of Corrections
R & R Nurse
Hepatitis C Chronic Care Program
Primary Care Physician
Mental Health Professional
Peer Education
HCV Clinic
Coordinator
Transplant Specialist
HCV Pharmacist
HCV Treating Clinician
Hepatology
Interventional Radiology
HCV Clinic Coordinator Available
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
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
CMCN Faculty Activities

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
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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
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
Clinical Consultation:
Onsite and Telemedicine
 Established in 2005
 HIV Continuity of Care
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
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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
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
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
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
Image Courtesy of Ray Chavez and CA Prison Health Care Receivership
Transitioning Health Care
 11 million people are released from prison
and jail each year
 Given a limited supply of medication
 Little or no follow-up available in the
community
 No discharge planning from prison
 Increased morbidity and mortality
Release from Prison
High Risk of Death for Former Inmates
Retrospective cohort study of 30,237 released
inmates
12.7 times increased risk of death in first 2 weeks after
release.
3.5 times increased risk of death in first 2 years.
The leading cause of death: drug overdose,
cardiovascular disease, homicide and suicide.
I. Binswanger, et al NEJM 2007; 356:157-65
Reintegration Difficulties
 Employment: Unable to apply for certain jobs
including all forms of public employment
 Public Assistance: Prohibited from collecting
food stamps, WIC, Pell grants, federal student
aid
 Medical Assistance: Lapse in Medicaid
 Housing: Prohibited from public housing
Disenfranchisement
 48 states and the District
of Columbia prohibit felons
from voting while serving a
sentence.
 4 million Americans have
currently or permanently lost
their voting rights due to a
felony
 13% of all black men have
lost their right to vote.
 35 states prohibit felons on
parole/probation
12 states disenfranchise all
ex-offenders
Recidivism
1994 a study looking at 272,111 persons
released from prisons in 15 States.
 67.5% were re-arrested for a felony or serious
misdemeanor within 3 years.
 46.9% were reconvicted.
 25.4% re-sentenced to prison for a new crime.
California 2007, the recidivism rate = 56%
National Commission on Correctional Health Care.
The health status of soon-to-be-released inmates; a report to congress.
Vol 1 and 2. Chicago: March, 2002. Available at http://www.ncchc.org/pubs/pubs_stbr.html
Historical Challenges to HCV
Treatment in Prisons
 1) Psychiatric Illness
 2) HIV Co-infection
 3) ALT Level
- Plata vs. Schwarzenegger
 4) Lack of Funding - Development of Chronic Care Programs
- CDCR
 5) Access to Subspecialty Care - CMCN
 6) Transition Care
 7) Duration of Stay
Historical Challenges to HCV
Treatment in Prisons
 1) Psychiatric Illness
 2) HIV Co-infection
 3) ALT Level
- Plata vs. Schwarzenegger
 4) Lack of Funding - Development of Chronic Care Programs
- CDCR
 5) Access to Subspecialty Care - CMCN
 6) Transition Care
 7) Duration of Stay
Future Directions
 Build and reinforce links with community
organizations and public health departments
to support transition of care for HCV- infected
individuals
 Assess and address staffing and educational
needs of CDCR
 Expand peer education program statewide
Contact Information
Megan Mahoney, MD
Correctional Medicine Consultation Network
1940 Bryant Street
San Francisco, CA 94110
(415) 476-2041
mmahoney@nccc.ucsf.edu