Positive Populations is published by Martin Medical Services, Inc.
Martinsburg, WV and Washington, DC
Copyright 2004 by Martin Medical Services
Positive Populations is available free of charge.
For subscription information, please call (304) 262-2371 or
e-mail MMSJEL@aol.com  with your subscription request.

 

Liz Rantz, MD, Medical Director for the Montana Department of Corrections (DOC), thought she had found the ideal solution for managing her system’s growing number of hepatitis C (HCV) cases. Rantz, the DOC’s Medical Director for the past three years, was well aware of her system’s limitations – its lack of financial and clinical resources that made managing a complex disease like HCV even more difficult. In the summer of 2003, before initiating treatment for inmates with the illness, Rantz posted a notice on an on-line prison list service, asking if any of the larger correctional systems would be willing to manage and treat the DOC’s HCV cases in their respective states. The Montana DOC would pay for the care, treatment and housing of the inmates, but a larger, more experienced state DOC would take over the care of the inmates. “I thought it would be more efficient both in terms of cost and time to send them to a state that is treating a lot of people – a state that has developed a cook book approach to this,”

Rantz explained in an interview with Positive Populations. Not a single DOC accepted Rantz’s offer, leaving her a little perplexed. “I got three or four e-mails back saying, ‘Liz you can do this, it is not that hard to do.’ They thought I was being silly.” Rantz and her staff soon went to  work, borrowing an HCV protocol from the Indiana DOC and adapting it to their own system, eventually creating a comprehensive HCV screening, education and treatment protocol that has shown the inherent benefits of managing the disease in-house.

“I would advise other states to do just what we did – borrow someone else’s protocol, adapt it as you need too and then just do it,” said Rantz whose system holds 3,000 inmates, about 200 with HCV. Rantz makes it sound easy but she knows that managing HCV is a formidable task, requiring the combination of financial resources and clinical expertise.

Montana’s experience is a good example of how smaller state correctional systems – those with less than 6,000 inmates – are confronting and managing the challenges posed by HCV. Unlike HIV, HCV rates are uniformly high throughout the United States, averaging 20 to 40 percent in many correctional systems, both large and small.

“The smaller systems are no less exempt from the problem of hepatitis than the larger systems,” said Robert Jones, MD, Director of Clinical Services for the Maricopa County Public Health Department in Arizona and the former Deputy Director of Corrections of Health Services for the Arizona DOC. “In fact, some of the smaller systems actually have a higher percentage of HCV than states like Arizona which runs around 22 percent.”

Increasingly, smaller state DOCs are turning to their larger state counterparts, borrowing and adapting their  HCV protocols and learning as much as possible from the experiences of larger states. The smaller DOCs often lack the clinical in-house expertise to treat hepatitis C and as a result, many of them are contracting with specialists – infectious disease doctors and hepatologists on the outside to help manage HCV care on the inside. In many of these smaller states, the specialists make the determination on whether to conduct liver biopsies and whether to treat, using the DOC’s written protocols as a guide to help make decisions.

The Montana DOC, for example, chose to borrow and adapt Indiana’s HCV protocol because it is “extremely well written and very simple,” enabling the Montana DOC to apply a “cook book approach” to the management and care of the disease, according to Rantz. The Montana DOC has also contracted with an infectious disease doctor to consult on some HCV cases.

Not surprisingly, the biggest challenge for smaller state correctional systems involves resources – the marshalling of clinical and fiscal resources to respond to the disease. Yet, in some ways, it is easier to manage the disease in a smaller system. Even though the percentages of HCV cases are high, the actual numbers tend to be relatively low, making the caseloads easier to manage. By  the same token, smaller systems have less bureaucracy, greatly easing the decision making process. “It is a hell of a lot easier,” said one correctional medical director of a small, rural state. “We don’t have as many loop holes and the levels of bureaucracy are not as great for us as in larger states.”

Montana’s DOC consists of one large prison in Deer Lodge and four satellite facilities scattered throughout the state. Officials conduct targeted HCV testing based on risk factors; inmates testing positive for the disease are placed in the system’s treatment queue to determine if they should, in fact, receive treatment based on the protocol. Like other correctional systems, the Montana DOC has a sentence tail, requiring inmates to have at least one year left on their sentences in order to start and finish treatment. Officials have identified only nine of the system’s confirmed 200 HCV cases as qualifying for treatment and thus far, at the time of this writing in the summer of 2004, they initiated treatment for eight of the nine treatment candidates. One of the inmates tested positive for illicit drug use, disqualifying him from treatment and four dropped out because of medication side effects, leaving four of the nine treatment candidates in treatment, according to Rantz.

“Our staff works hard with inmates qualifying for treatment to help them address side effects and other issues,” commented Rantz. She noted, “when we didn’t have the treatment, the inmates were so caught up in the fact that we were not going to treat them, they didn’t want to participate in the education programs. They just wanted to be angry with us. Now, we are treating and very few are eligible or qualify for the treatments.”

Rantz is convinced that more inmates will qualify for HCV treatment in the coming months, especially with the increased use of methamphetamines in the state. That, of course, will require more resources. Richard Garden, MD, Medical Director of the Utah DOC, is well acquainted with the financial limitations of smaller state DOCs, especially as it relates to the management of HCV. “Hepatitis C comes along and effective treatments come out and suddenly in terms of resources, we are burdened quite significantly,” explained Garden. “We need to provide this treatment because it is effective and the right thing to do. But (a lack of resources) makes it very difficult for us.”

Garden said other larger state DOCs have “enjoyed appropriations to begin treatment and testing.” “In a small state like this – if you assume the same equivalent prevalence of HCV as larger states – it is much more significant for us to treat than a larger system, ”Garden said. The Utah DOC houses about 5,700 inmates state wide, holding most of the inmates at two major prisons, one in a small town called Gunnison and another outside of Salt Lake City. The latter prison serves as the system’s hub prison, providing care for inmates undergoing HCV treatment.

Officials have not conducted seroprevalence studies but they estimate that 25 to 30 percent of the state’s inmates have HCV, a relatively high number. The DOC is providing treatment to 14 inmates and has placed six others on a waiting list, spending about $250,000 to $300,000 annually on HCV diagnosis, laboratory tests, consultations and medications, significant expenses for a correctional health care budget that totals about $18 million annually.

“We had to do that out of hide – out of our own budget – meaning we have not had any legislative appropriations to address HCV specifically,” said Garden. “That is the reason why we really have to manage our resources. Those who meet our criteria for treatment tend to wait up to six months before we actually begin treatment.”

Garden describes the DOC’s HCV protocol as a “legitimate, adequate program” that provides HCV care to inmates who meet the DOC’s criteria for treatment. The DOC houses all of its HCV patients who meet the system’s treatment criteria at the hub prison outside of Salt Lake City and contracts with a hepatologist at the nearby University of Utah to provide and oversee HCV care. The DOC also employs a registered nurse to assist the hepatologist in providing HCV care.

Officials have achieved cost savings in other areas to help defray the cost of HCV care and treatment, including increases in staff productivity and decreases in emergency room use, according to Garden. Garden would like to expand the department’s HCV program by implementing universal HCV testing which would increase the number of inmates in treatment.

“There are people out there in our prison population who are hepatitis C positive and meet our criteria for testing,” Garden said. “They don’t know their positive and we don’t know their positive. But if we embarked upon wide spread testing at one time and then tested everyone who came into the prison, we are going to be inundated with increases in infected people.”

Without additional resources, the Utah DOC will have to make some difficult choices in order to expand the HCV testing and treatment program. The DOC might have to make a choice between funding an expansion of the HCV program or not paying for treadmill tests or coronary angiograms for heart patients, according to Garden.

“Where do we allocate our resources?” asked Garden, framing the issue. Like other correctional medical directors, Garden is convinced that  HCV is a public health issue, not just a problem for corrections, a fact that public health has been slow to recognize. Garden, acting on behalf of the DOC, has applied for several state public health grants in order to fund continued on page 5 HCV within corrections. The state turned Garden down each time, refusing to even consider the requests. “The health agency tells us, ‘use your own money to address HCV,’” Garden said. “The point may be missed that if we can treat hepatitis while they are in prison, then that will hugely and positively impact the community.”

In North Dakota, correctional officials also consider HCV a public health issue, not just a problem for corrections. During the past few years, correctional officials have forged close ties with public health officials in order to address the growing numbers of HCV in the state. At the same time, correctional officials have been working with their federal representatives and senators in an effort to pass federal  legislation to fund HCV care within corrections, according to Kathy Bachmeier, RN, Director of Medical Services for the North Dakota DOC. The DOC has, in addition, formed a consensus group with other state agencies to raise the level of awareness of HCV within corrections. “This is a huge public health issue and that is how we have looked at it,” said Bachmeier. “We work very, very closely with our state health department.”

The North Dakota DOC has an inmate population of 1,300, making it one of the smallest systems in the country. But the prevalence of HCV is somewhere around 10 percent, according to Bachmeier. It is important to note, however, that seven out of 10 inmates coming into the system have a history of injecting methamphetamines, a prime vector for transmitting HCV. Moreover, the number of state prison inmates has more than doubled during the past five years, jumping from 500 to 1,300. These two factors together – the high percentage of inmates injecting methamphetamines and the growing number of inmates – could lead to a dramatic increase in the DOC’s HCV caseload.

The DOC has treated 16 inmates for HCV during the past year and has spent about $200,000 in the process, money appropriated by the state legislature as part of the overall DOC’s health care budget. Officials are now treating six inmates with the disease and plan to treat 10 more during the next year. One of the keys to affording treatment is to plan for the expense, Bachmeier said.

The North Dakota DOC, like other smaller states, borrowed heavily from larger DOCs when developing its HCV protocol, making North Dakota’s protocol a “hybrid of about 10 other states,” including Wisconsin, Rhode Island and Pennsylvania, Bachmeier said. “We conducted a big research study on what other states were doing and then we did a literature review on what is out there,” explained Bachmeier.

“We also looked at the cost of drugs and then sat down with our doctor, the contract medical director and our infectious disease specialist who works in the private world.” In the process, DOC officials “knocked out a protocol” that is both “fair and equitable” and one that “ensures we are treating the people who are going to benefit the most,” Bachmeier said. The protocol is updated at least once a year.

The North Dakota DOC houses inmates undergoing HCV treatment at its main prison outside of Bismark, and like most other prison systems, it requires inmates to have at least one year remaining on their sentences in order to start and finish treatment. “We have inmates who start and then don’t want to finish,” said Bachmeier. “We really have to hammer them because once we start them we want them to finish so we don’t get drug resistant strains.”  The DOC contracts with one infectious disease specialist who resides in central North Dakota and is responsible for managing and overseeing the HCV care. He makes the final determination on whether to treat. “In this state, we have expertise that is unbelievable in terms of hepatitis,” commented Bachmeier.

The North Dakota DOC has other advantages that some other states lack. The DOC, for example, has comprehensive drug and alcohol treatment programs, including a therapeutic community, residential treatment and in-patient and out patient treatment programs. Substance abuse counselors assess each inmate on in-take, assigning the inmate to a substance abuse program based on the inmate’s needs.

“Some people go to a 60 day program or a 30 day program, a four week program or a half day program,” said Bachmeier. “There are different levels for drug and alcohol treatment.”  Any inmate with HCV assigned to a substance program must complete that program before being considered for treatment, a way of trying to ensure that the inmate does not become re-infected with HCV by relapsing into drug use. The North Dakota DOC has had only two treatment failures resulting from drug relapses, said Bachmeier.

Bachmeier acknowledged that the drug treatment requirement represents another tier or loophole that inmates must jump through in order to receive treatment. But she dismissed any suggestions that the drug treatment criteria were exclusionary or a way to deny treatment to inmates. In the final analysis, Bachmeier said, “we are just a little state trying to do the right thing and that means treating these people.”