Participants found point-of-care testing delivered timely diagnoses, normalised screening and facilitated care.
People entering custody considered on-the-spot testing for hepatitis C beneficial for facilitating treatment, new qualitative research has found.
Hepatitis C is an inflammation of the liver caused by the hepatitis C virus. The virus can cause both acute (short-term) and chronic illness, including liver disease, liver cirrhosis and liver cancer.
Early detection and treatment can prevent serious liver damage. Despite oral antiviral medication having a success rate of more than 95%, annual rates of testing and treatment uptake are declining.
“People at greater risk of hepatitis C, including people who inject drugs, may be less likely to test due to barriers, such as poor access to veins, and stigma and discrimination from healthcare services,” says research lead Associate Professor Lise Lafferty from the UNSW Centre for Social Research in Health (CSRH) and the Kirby Institute.
Traditional pathology can take several days and multiple patient visits to receive your results. “This can be difficult to navigate when people are managing competing priorities.” By contrast, fingerstick point-of-care testing uses blood from a finger prick for rapid same-day diagnosis.
“Our previous research in the prison setting showed that people who cycle through community-prison-community prefer to engage in hepatitis C treatment in prison compared with community-based care,” A/Prof. Lafferty says.
“We wanted to know if testing and treatment during the first week of prison intake would be acceptable for people entering into custody.”
The study used semi-structured interviews with 24 men who had undergone fingerstick point-of-care testing to explore whether routine testing at intake reduced barriers to care within the prison setting. Participants typically received same-day diagnoses and access to treatment within six days.
“There’s a lot going on for people coming into prison. They can be considering when they’ll next see their families; whether they might lose their social housing; and when they might be released.
“Despite prior assumptions that people might feel overwhelmed by their circumstances and reluctant to engage in hepatitis C care, participants widely reported point-of-care testing on intake could reduce many barriers to treatment.”
Adopting routine opt-out – rather than opt-in – testing was regarded as an important strategy for normalising hepatitis C testing, the research found. Participants also identified that the testing’s timely diagnosis and fast-tracked access to treatment could help in reducing incidence and prevalence within the prison.
“The research identifies point-of-care as an opportunity to vastly increase hepatitis C testing and treatment uptake and make an important contribution to national elimination strategies.”
The research is part of the PIVOT study. The PIVOT study used a one-stop-shop model with fingerstick point-of-care testing, liver disease assessment and treatment at a reception prison (receiving those newly incarcerated from the community) in New South Wales.
The PIVOT study is a partnership between the Kirby Institute, CSRH, Hepatitis NSW, the Justice Health & Forensic Mental Health Network, NSW Corrective Services, NSW Health and NSW Users and AIDS Association (NUAA).
The PIVOT study was supported by the National Health and Medical Research Council (NHMRC), AbbVie and Cepheid (provision of GeneXpert equipment and Xpert Fingerstick HCV Viral Load cartridges). The qualitative sub-study was also funded by the NHMRC through the RAPID Point of Care Research Consortium for infectious disease in the Asia Pacific.
While no participants had previously undergone point-of-care fingerstick testing, 14 participants had prior experience of hepatitis testing via standard blood collection. Seven participants received a positive result.
Participants were asked about their knowledge of and experiences with hepatitis C testing and treatment services in prison; the timing of testing; attitudes toward the intervention model used in PIVOT; and the acceptability of point-of-care testing.
“The research placed consideration for participants at its core,” A/Prof. Lafferty says. “The framework used allowed exploration of whether participants viewed themselves as patients worthy of and requiring care (self-candidacy) and the ease of access to care services.
Fingerstick point-of-care testing uses blood from a finger prick for rapid same-day diagnosis. Photo: Conor Ashleigh.
The study also explored perceived judgements or decisions by health providers that inhibit care; and situations where participants decline offers of care.
The research responds to the need for greater promotion and availability of hepatitis C treatments in prisons which remain environments of increased hepatitis C transmission.
The World Health Organization has set targets to eliminate hepatitis C as a global public health threat by 2030, with prisons identified as a key setting.
There are an estimated 68,890 people living with hepatitis C in Australia, around 0.3% of the population. Almost one in 10 people incarcerated in Australia have a current hepatitis C infection.
Hepatitis C is predominantly transmitted through shared unsterile injecting equipment, A/Prof. Lafferty says. “Because of the criminalisation of injecting drug use, and subsequent widespread incarceration of people who inject drugs, the chronic disease burden is disproportionately borne by people in prison.
“While testing and treatment are available in prisons, system barriers can inhibit progress.”
Frequent transfers between prisons and release to the community after very short stays disrupt care, with standard pathology results sometimes taking longer for a patient to receive than they are incarcerated.
Of the PIVOT model, one participant, Brendan, said: “For the first time in five years, I'm actually progressing through it and I'm not just getting blood taken and getting told that we can't …
“Even though we've taken all the blood and we've got every bit of paperwork we can possibly take off you, we still can't give you treatment, because we can't get a [genotype, referring to previous requirements for antiviral treatment].”
For some, testing was a self-imposed part of their entry into prison, with a smaller number of participants reporting previously seeking testing before release during prior incarcerations. These responses showed participants self-identified as being eligible and in need of care (self-candidacy) as well as being indicative of the “revolving door” of incarceration.
One participant, Jorge, said: “I don't know how long I'm going to be here, so I'm glad I got that over and done with, so, and I know it's a worry off my shoulders that I'm clear of it.”
The survey explored judgement and explicit/implicit gatekeeping as barriers to care, including via prison personnel.
“People in prison, particularly those in prisons with higher security classifications, rely on officers for movement within prison – such as to the clinic to see a nurse,” A/Prof. Lafferty says.
“Participants perceived correctional officers as generally supportive of testing in prison. Occupational health and safety concerns were widely regarded as the primary motivator for this support.”
A participant, Antoine, said the PIVOT model was a good thing to have: “They [correctional officers] would be worried about getting like pricked or something you know what I mean …
“If everyone is getting tested … they wouldn't have to come to work and worry about getting it, you know what I mean?”
A/Prof. Lafferty says: “Given the scrutiny of actions and movements in prison environments, people accessing care may encounter judgement, for example from peers and healthcare providers.”
While concerns or anticipations of judgement within community health settings were apparent – one participant, Brendan, expressed a sense of vulnerability of being perceived as a ‘junkie’ by his regular doctor – the non-judgemental approach of prison health staff facilitated care engagement, the research found.
A participant, Garth, noted that prison nurses had to “deal with it more on the inside”: “It’s part of your job to deal with it [hepatitis C] you know what I mean? […]
“Part of your job not to criticise us for having hep C or stuff like that, like if I’m out [in the community] and I go to a clinic, I feel like they are criticising me whether they are not or they are, but like either way, that’s just the way I feel so I won’t even bother.”
When asked what he liked about the way prison health staff approached things, a participant, George, said: “Just the way youse come and approached us and talked to us about it and how everything was worked out and that [the treatment] had a 95% success rate and you know hearing that is like good news you know what I mean.”
The research findings will help inform correctional health systems as well as policy and clinical practice more broadly, A/Prof. Lafferty says.
“Acquisition of hepatitis C infections whilst in prison is a significant threat, particularly to those who engage in high-risk behaviours in which blood borne viruses can be transmitted.
“The research helps us understand attitudes to testing to better facilitate care. This improves the health of all people who are incarcerated and those in community by increasing testing and treatment and encouraging prevention of further transmission.”
Centre for Social Research in Health | Kirby Institute
Associate Professor Lise Lafferty
Pillar 8: Enable healthy lives
