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The Needle and the Damage Done

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

But diagnosis is no guarantee of treatment, as Terry Akers discovered. He says he was told he had hepatitis C when his liver enzymes came back "high" two years ago. But he was also told to check back in six months so that his doctor could determine if he had a chronic case. (Eighty-five percent of all hep C cases develop into chronic infections.) Six months later he was put off for another six months; his case wasn't drastic enough to fit the treatment criteria, he was told, and department policy at the time required that liver enzymes be elevated for at least one year before drug therapy would be considered.

In the fall of 1999, after a full year of delay, Akers's case was finally certified as chronic hepatitis C. According to his medical records, the levels of key liver enyzmes had increased significantly during that year. But in the DOC medical staff's opinion, Akers's body was "fighting the infection adequately," and the lab results reflected no need for immediate treatment.

"Medical evidence supports the fact that this is a lifetime disease, with terminal illness from this being very remote," medical officer Orville Neufeld wrote in a memo to Akers. "Statistically, 95 percent of individuals with hepatitis C will die from other natural causes."

Akers filed formal grievances complaining about the lack of treatment, only to discover another catch: The DOC requires that hepatitis C patients complete a year of substance-abuse classes, complete with random drug testing, before being considered for interferon. Akers wondered why no one had told him about the requirement earlier so that he could get started on the classes; he also wondered how he was supposed to get access to such a program within CSP, which only offered much shorter drug-education programs on video.

McGarry says he isn't sure when CSP began to offer the one-year substance-abuse classes; more than a dozen inmates there are now enrolled in them. The classes became a requirement for treatment only a year ago, and other inmates besides Akers have complained of getting a runaround about them at CSP. (Calls to the prison's warden, Gene Atherton, were not returned.) In any event, Akers's condition soon began to defy the cheery assessment the prison's medical professionals had given him.

Last spring his stomach became grossly distended, as if he were carrying a beach ball under his shirt. At first the doctors suspected a bacterial infection, but it was ascites, an accumulation of fluid that is one of the common symptoms of cirrhosis. The veins in his esophagus also became painfully swollen. The DOC's internal medicine specialist said he'd seen worse.

After dinner a couple of months ago, Akers began to vomit blood. A physician's assistant responded to his distress call, looked in his toilet and decided, yep, that was a lot of blood. He was rushed to one hospital, then another, as he continued to throw up "mouthfuls of blood like it was cheap beer," Akers recalls. His esophogeal varices had ruptured in five places, requiring surgery.

Neufeld's statistics aside, researchers estimate that one in five chronic hepatitis C patients will develop cirrhosis. But the process can take ten or twenty years, and McGarry says there's no evidence that earlier treatment with interferon would have any positive result in the most serious cases. Although the DOC's own literature describes interferon as "potentially curative treatment," McGarry is wary of overstating its benefits.

"The disease takes so long to manifest itself, it's difficult to have the medical trials to show the drug treatment is effective," he says. "They've never proven that any of the people who get 'cured' are people who were going to develop hypatic failure or liver cancer otherwise. It's possible that the people who respond well to treatment were going to have a benign course anyway and didn't need treatment."

Now that Akers has developed cirrhosis, the DOC considers him a poor candidate for interferon, a position that's supported by many medical authorities. But Akers has a letter from a private doctor who believes he may still benefit from the drug therapy, and other states, including Kentucky, have considered offering the drugs to cirrhosis patients as well.

Akers says he doesn't have any complaints about his nurses, the physician's assistant or Dr. Neufeld; despite his violent history, they've treated him well, and he understands their hands are tied by department policy. The real issue, he says, is that the DOC treats so few of the people who have hepatitis C. Several of his buddies at CSP scrambled to get into the drug-education classes after they saw what happened to him, but as far as Akers knows, none are receiving interferon yet.

In Colorado prisons, McGarry estimates, around 2,000 hepatitis C patients have cases serious enough to make them candidates for treatment. But because of the various requirements for treatment, including the one-year waiting period, currently there are no more than ten to twenty inmates on interferon, he says.

Even with that small percentage, Colorado still ranks as one of the more progressive states in attacking the problem. Several states offer no treatment programs at all.

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