The Other Infectious Disease Ravaging America’s Jails And Prisons

This piece is a commentary, part of The Appeal’s collection of opinion and analysis.

Because jails and prisons are the epicenter of COVID-19, attorneys and advocates for the incarcerated have frantically tried to free those particularly vulnerable to the virus, such as the elderly or people with underlying comorbidities like diabetes and asthma. The dismal state of correctional health care has worsened such conditions, so as COVID-19 hits facilities, new failures will combine with old ones to increase the death toll.

While it lacks the shock of a global pandemic, another infectious disease—and now, a comorbidity to COVID-19—has needlessly ravaged prisons for years: hepatitis C. In the past several years, HCV has killed more Americans than all other reportable infectious diseases, including HIV, combined. If the trend ends this year, it will only be because of the lethality of the coronavirus. Prisons are hot spots for HCV, with incarcerated people infected at roughly 20 times the rate of the general population. But HCV is only widespread in prisons because states have failed to act, just as they have failed to respond to the COVID-19 outbreak, and the death toll will only grow as more incarcerated HCV-positive patients contract the coronavirus.

That prisons are a hotbed of HCV infection rates is a policy choice. As of  2011, direct-acting antivirals have transformed the standard of care for HCV, with researchers characterizing them as “miracle drugs.” Past treatments for HCV had varied responses and severe side effects, but DAAs are well tolerated and have cure rates approaching 100 percent, regardless of disease progression. Although the drugs are expensive, researchers from Harvard Medical School, the University of Texas, and Tsinghua University found that DAAs are one of the few demonstrably cost-saving treatments in the history of medicine, meaning that they are so effective in preventing downstream problems that they pay for themselves in reduced future medical costs. With rare exceptions, such as for certain terminal patients, the American Association for the Study of Liver Diseases (AASLD), the leading organization of scientists and health care professionals committed to preventing and curing liver disease, recommends that everyone with chronic HCV receive treatment. 

Despite the obvious benefits to DAAs, many prison systems—or the private contractors through which they provide medical care—have failed to adopt this new standard of care because of the cost. Some facilities have treated some of their patients while others have treated virtually none. As of February of last year, the Missouri Department of Corrections had treated 15 of the 4,590 patients diagnosed with chronic HCV infections according to litigation documents. But many prison systems instead ration out DAAs based on “fibrosis scores,” which measure liver scarring, treating only the patients with severe liver damage.

Medical professionals find this standard of care lacking. First, HCV puts patients at risk for other serious conditions, from depression to cancer, before fibrosis reaches an advanced stage—and even if it never does. Second, fibrosis estimates are insensitive. Fibrosis progression and the eventual development of cirrhosis are unpredictable. Further, curing HCV does not undo past liver damage. Waiting to treat patients until their liver is severely harmed is therefore neither a safe nor precise exercise. On the contrary, early treatment has consistently proven more effective than later treatment. Early treatment also carries the benefit of preventing the spread of the illness for the prison population and society because individuals cured of HCV can no longer pass the disease to others. 

As early as 2015, the Centers for Medicare & Medicaid Services warned Medicaid programs that limiting treatment to those with higher fibrosis scores was inappropriate and likely illegal. Since then, many state Medicaid programs that have stuck with fibrosis limitations have faced lawsuits that indeed found them illegal. Prisons systems across the country have also faced lawsuits for denying DAA treatment based on fibrosis scores, including a lawsuit that led a federal-district court to order the Florida Department of Corrections to treat all patients with chronic HCV with DAA drugs. 

The lessons of the COVID-19 outbreak should inspire the public to fight HCV aggressively in prisons, because as the pandemic demonstrates, there is no clean separation between health care in prisons and public health at large. Similarly to the pandemic, the failure to treat HCV in prisons threatens public health outside of them. In a 2015 Annals of Internal Medicine study, researchers found that expanded HCV screening and treatment in prisons would prevent between 4,000-12,000 deaths, and that 80 percent of those prevented deaths would occur outside of prisons. Such widespread prevention can occur, because U.S. prisons are HCV hot spots where people come in healthy, get sick, and return the infectious disease to their communities, causing illness and death, just as is occurring with COVID-19. The pandemic is also a harsh lesson in what happens when we wait until people become deathly ill to treat their curable illnesses, as people deemed insufficiently sick to merit DAAs now face the prospect of contracting COVID-19 with the entirely preventable comorbidity of HCV. 

But with states loath to adequately fund prison health care, and private medical care companies protecting shareholder profits, there is the risk that treatment for COVID-19 patients will come from other correctional health spending, including on DAAs. Prison officials are already attempting to divert funds from DAAs in Florida. The state is appealing the district court’s order that it treat thousands of its patients with chronic HCV with DAAs, and asked the Eleventh Circuit Court of Appeals to release an expedited opinion. If the court obliges, the state has passed legislation that would allow the Department of Corrections to divert funding from DAAs to COVID-19 treatment. While treating incarcerated people for COVID-19 is essential, defunding hepatitis treatment will only result in more illness and death inside and outside of prisons.

There is no question that COVID-19 is devastating America’s overcrowded and unsanitary prisons, but it will not be the only infectious disease killing incarcerated people. And in the end, the coronavirus will be more deadly because of our failure to adequately treat hundreds of thousands of patients with chronic HCV. The worst of COVID-19 will hopefully pass in the coming months, and through advances in DAAs, so could the worst of HCV. But only if we summon the will to make it so. 

Samuel Weiss is the executive director of Rights Behind Bars, which represents incarcerated people in civil rights lawsuits concerning their conditions of confinement and seeks to advance laws that reform conditions of confinement.