The Needle and the Damage Done

In prison, getting hepatitis C is easy. Getting treatment isn't.

The Colorado Department of Corrections is considered to be ahead of the curve in dealing with hepatitis C. The DOC has screened its inmate population for liver abnormalities since the 1970s, long before hepatitis C was identified as such. The DOC also claims a lower incidence of the virus among its population than most other state prison systems; 15 percent of the inmates coming into the DOC this past year have tested positive for hepatitis C. But Akers and several other prisoners have filed grievances about the hep C program, claiming that the agency's foot-dragging is costing them their health and possibly their lives.

The DOC's doctors knew he had hepatitis C two years ago but refused to put him on drug therapy, Akers says, even after tests revealed his rapidly deteriorating condition. Now that he's developed cirrhosis, he's no longer eligible for the drugs. "The whole time, I kept asking for treatment," he remembers. "I didn't know very much about it, but I knew that the sooner they treated it, the more chance there was that the treatment would be successful. They told me I didn't meet the criteria."

Joseph McGarry, the DOC's chief medical officer, says the agency's requirements for hepatitis C treatment are reasonable -- particularly since no one knows if the drugs help in the most serious cases, anyway. "We don't have any evidence that the stuff we're doing affects mortality at all," he says. "I don't think a delay in treatment is going to have any demonstrable effect, because the treatment itself hasn't been proven effective."

Inmate Grant Brown
Inmate Grant Brown
One small catch: After two years of delays, Terry Akers is no longer eligible for interferon treatment.
Brett Amole
One small catch: After two years of delays, Terry Akers is no longer eligible for interferon treatment.

Akers acknowledges that a killer's aches and pains aren't something that causes public-health officials to storm the gates. Few people will mourn his passing, he suspects, and that situation allows prison authorities wide latitude in his treatment. "What do they care?" he says. "No one's going to listen to us anyway."

Yet the way he sees it, while treating hepatitis C in thousands of prisoners may be expensive, ignoring it could be even costlier.

"They say 20 percent of the prison population has this, but how many are actually getting treatment?" he asks. "This disease may get to me, but most of the others are going to be back on the street and spread it to other people out there."

The surging number of hepatitis C cases in prisons is partly a matter of more diligent testing, but the scope of the problem managed to catch corrections health officials by surprise. Many agencies were still struggling to find the resources to cope with their AIDS population when they were confronted with a flurry of reports concerning another virus -- which, until 1989, was generally referred to as "non-A, non-B type hepatitis." It wasn't until five years ago that researchers developed a treatment protocol for the disease, and even the drug therapy now recommended in chronic cases is considered an "evolving" area of clinical practice.

The chief drug used to combat hepatitis C is interferon, a virus-fighter produced by white blood cells. In high doses, interferon has proven successful in ridding the body of detectable levels of the virus in up to one-fourth of the patients treated. However, the drug also has a range of potential side effects, from hair loss to flu-like symptoms to depression, and relapses aren't uncommon when the patient stops taking interferon. A combination of interferon and another drug, ribavirin, which was approved by the Food and Drug Administration in 1998, has achieved a success rate of around 40 percent, but long-term effects are still uncertain.

Eyeing both the cost of the drugs and their limited effectiveness, many states have been reluctant to fund treatment programs for prisoners, prompting lawsuits and accusations of stonewalling. Under pressure from a federal judge, the Kentucky Corrections Department recently backed off a tightfisted policy that excluded virtually all of its infected prisoners from treatment. That state's new medical plan will provide drugs for up to a thousand inmates already known to carry the hepatitis C virus and could cost the state as much as $25 million over the next two years.

Colorado was one of the states Kentucky officials contacted for advice in revising their plan. The DOC has its own elaborate protocol for deciding who will receive interferon or ribavirin -- one that's not as restrictive as the old Kentucky policy but has a few inflexible requirements of its own. For example, patients who are less than two years away from their discharge date, older than 65 or have a life expectancy of less than twenty years are not eligible for the drugs; nor are those who have already acquired cirrhosis, are still using illicit drugs or drinking, or have demonstrated "an established pattern of refusing to comply with medication contracts."

Medical chief McGarry says his department revised the protocol extensively last year in order to mount a more aggressive response to the virus. In the past, when a prisoner's medical tests revealed abnormally high liver enzymes, the agency used to wait six months to see if the levels persisted before running specific tests to detect the presence of hepatitis C. Now the hepatitis screening is done right away. "We're doing it sooner, and that streamlines how fast we're able to know if someone has hepatitis C," McGarry says.

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