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HCV Care & Treatment in Mass & S Dakota Prisons
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Infected inmates wait for drugs: Budget limits dictate which state prisoners with hepatitis C get expensive treatment
By SUE REINERT
The Patriot Ledger
State prisons are rationing medication for inmates infected with hepatitis C, a contagious and deadly liver disease.
Prison physicians have put 150 inmates on a waiting list for treatment. Nearly 1,500 inmates are known to be infected, and the actual number may be double.
Of the 1,472 state prison inmates who have tested positive for the hepatitis C virus, 62 are receiving the recommended combination of two antiviral drugs, interferon and ribavirin.
The cost for 48 weeks of care is $18,000 to $25,000. This year's state budget includes about $1 million for hepatitis C drugs for prisoners.
Every month, up to 10 of the most seriously ill prisoners are chosen to be treated for the liver disease. But the number who actually start the drugs is dictated by how much money is available, an internal policy document says.
Officials insist that prisoners will get the expensive drugs when they need them.
The state policy came to light in a federal lawsuit filed by a 41-year-old inmate at the Norfolk prison. Kerry M. Castello, formerly of New Bedford, says prison doctors recommended treatment for him more than two years ago but he is still waiting.
Without the drugs, 10 to 15 percent of infected people may develop severe liver disease that can lead to cancer - the percentage is even higher for men, people infected with HIV and heavy drinkers.
Inmates with the virus could also infect others when they get out of prison.
The University of Massachusetts School of Medicine in Worcester provides medical services in state prisons. University spokesman Mark Shelton says that treatment is never denied for budget reasons.
''Because this is an expensive medication and a commitment to treat can last a year, we pay close attention to monitoring the use of an expensive resource,'' Shelton said.
Leslie Walker, director of Massachusetts Correctional Legal Services, a non-profit legal advocate for prisoners, said the group receives many calls from prisoners seeking treatment.
''It would be a real step forward to treat these men and women while they're incarcerated,'' she said.
Michelle R. Burrows, a Portland, Ore., lawyer who represented prisoners with hepatitis C in a class action lawsuit in Oregon, said a Supreme Court decision bars authorities from denying needed treatment for financial reasons.
''Prisoners are vulnerable and they do not have any choices,'' Burrows said. ''The standard has to be - what would a person get in the community? What if you went to your doctor and he says, eYou need treatment but I'm putting you on a waiting list'?''
Not everyone who is infected requires weekly injections of anti-viral drugs. The medicine works for only about half of patients with the most common type of the virus.
Hepatitis C leaves many patients with no damage and can take years to worsen. Treatment exposes people to dangerous side effects, including depression, suicidal behavior, blood problems and flu-like symptoms.
The standard recommendation, which the state says it follows, is to wait until patients have moderate to severe liver damage before treating them. But some doctors urge treatment while the disease is mild, saying the drugs are more effective then.
The virus is spread mainly through blood exposure, mainly from shared needles, and very rarely from sexual contact.
Because so many prisoners have used needles to inject illegal drugs, inmates are three to five times more likely than the general population to be infected with the virus, the Centers for Disease Control and Prevention says.
Health officials estimate that 30 percent of the 10,000 state prisoners are probably infected with the disease, but only half have been diagnosed.
Even less is known about the 14,000 county prisoners in Massachusetts. They are rarely tested and almost never treated in jail because most will get out before they can complete 48 weeks of medicine, officials say.
Public health officials view prison as a chance to treat people who rarely get medical care outside.
''It's much easier to take care of people in prison than on the street,'' said Dr. Alfred DeMaria, director of communicable diseases at the state Department of Public Health. ''The more people we treat in prison the better off we would be, if we had the resources.''
DeMaria, who helped develop the state prison protocol for treating hepatitis C, said prison authorities and the University of Massachusetts Medical School are making a good-faith effort to provide inmates with the care they need.
''Most people can wait for treatment,'' he said.
Castello, the Norfolk inmate who sued over the delay in receiving treatment, was placed on the waiting list for medicine in October 2003.
Prison doctors found the hepatitis C virus in his blood in 2001, court papers filed in his suit say.
In 2003, blood tests showed abnormal levels of a liver enzyme, and a liver biopsy found inflammation but no scarring. He says he suffers from fatigue and joint pain and faces permanent liver damage.
Castello, who is representing himself, sued Feb. 7, claiming that the failure to treat his infection constitutes cruel and unusual punishment.
The state replied that Castello has only mild liver disease and other prisoners with more damage should get drugs first.
''While there are many patients with Hepatitis C currently awaiting treatment ... due to the Massachusetts Department of Corrections finite resources, combination therapy is offered first to inmates with the greatest medical need,'' a state brief said.
A federal judge is considering motions by both sides to decide the case without a trial.
Castello is serving two consecutive sentences of 13 to 15 years for attacking an 81-year-old Mattapoisett woman who caught him burglarizing her home in 1993.
Few in jails treated for hepatitis C: Virus common, but inmates leave too soon to finish drugs
The 14,000 men and women in county jails are just as likely to be infected with hepatitis C as are state prison inmates, experts say.
But few are tested and treatment with medication is even rarer, mostly because most prisoners leave jail too soon to finish the drugs, officials say.
Public health experts estimate that three out of 10 people in prisons and jails are infected but at least half don't know it.
Roughly 120 to 150 of the 1,500 inmates at the Plymouth County Correctional Facility have tested positive for the virus, spokesman John Birtwell said. Four or five are receiving drugs for the disease, he said.
Birtwell said most inmates with hepatitis C reject treatment because of the side effects, which can include depression, blood disorders and fatigue.
The Norfolk County House of Correction tests inmates only if they come to jail already on medication for hepatitis C or they show symptoms of the infection, said David Falcone, spokesman for Norfolk County Sheriff Michael Bellotti.
The Hampden County Correctional Center, viewed as a model by many prison health authorities, has identified about 200 inmates infected with the virus out of a population of 2,000, said medical director Dr. Thomas Lincoln.
The jail urges inmates to get tested if they have high levels of a liver enzyme that points to hepatitis C, he said. Last year 51 percent of the 308 inmates who were tested were found to be infected.
Like other jails, Hampden County treats a tiny number of inmates, just two currently, Lincoln said.
The jail operates a program that links inmates to community health centers.
Doctors and nurses from the centers spend time at the jail. When inmates get out, they're referred to a center for follow-up medical care, Lincoln said.
Sue Reinert may be reached at sreinert@ledger.com.
Copyright 2005 The Patriot Ledger
Transmitted Tuesday, December 27, 2005
Physicians collecting data on drug at prison
By KATIEBROWN
Bismarck, North Dakota Tribune
Four Bismarck physicians are in the process of collecting data on the treatment of hepatitis C in North Dakota prisons.
Jeff Hostetter, Kent Martin, John Hagan and Olimpia Rauta presented initial findings at the Centers for Disease Control's National Viral Hepatitis Conference on Dec. 8 in Washington, D.C.
Hostetter, the medical director for North Dakota prisons, said initial data was sent to the CDC, which asked the four physicians to present their research. After presenting, Hostetter said they received approval to continue collecting data for further reports.
Hepatitis C is a blood-born pathogen transmitted mostly through needles during drug use or if a medical professional gets stuck by a needle.
Hostetter said the pathogen can be transmitted through sexual contact if bleeding occurs.
Martin and Hagan have been treating inmates for hepatitis C using a drug called Consensus Interferon instead of Peginterferon, the drug typically used to treat the disease.
Hostetter said their findings have been positive. He said the reason most patients with hepatitis C are not treated with Consensus Interferon, which is less expensive and has fewer side effects, is that Peginterferon only needs to be administered once a week.
Consensus Interferon must be administered three times a week, which Hostetter said is possible for inmates. The state decided to use the drug because it is less expensive.
"For other people, it is difficult to do the three injections per week," he said. "They forget or just don't come in for the shot. It's not effective if they don't get them."
He said the data he, Martin, Hagan and Rauta have presented and will continue to collect may show that Consensus Interferon should be used instead of Peginterferon.
"If you ask people, they'd rather have the inconvenience of three shots a week than the side effects of the Peginterferon," Hostetter said. "The problem is it doesn't work because people don't get the shots as often as they need to."
The side effects include a variety of ailments because Peginterferon stays in the body and acts as a toxin.
Hostetter said the data is simply medical charts that would be collected even if a study was not being conducted.
"We're not doing anything that wouldn't be done anyway," he said. "It's important to realize we're not experimenting on prisoners."
An increase in methamphetamine use is blamed for the rise in hepatitis C cases. Hostetter said in 2000, 10 percent of inmates in the North Dakota State Penitentiary were meth users. This year, 62 percent of inmates in the penitentiary are meth users.
"People who use meth have high-risk behavior," Hostetter said. "When they're tweaked out on meth, they don't care about having clean needles."
He said due to the increase in hepatitis C, employees and inmates at North Dakota prisons are educated on keeping themselves safe. When inmates begin their sentences, they go through an hourlong course informing them of how to avoid coming into contact with the disease.
Medical professionals at the prison and all other facilities are advised by the CDC to practice "universal precaution," meaning they handle every patient as if he or she could have hepatitis C or HIV.
Hostetter said 20 percent to 30 percent of hepatitis C patients get extremely sick right away and pass the disease through their system. The rest have it for life.
"You can live a relatively normal life with hepatitis C if you take care of yourself,"he said. "If you drink alcohol, you have almost a 100 percent chance of eventually developing liver cancer."
Hostetter said there may be a way for Consensus Interferon to be used more effectively than Peginterferon.
He said using a pump put in the body to deliver the injection on time is an option. So is having public health officials go out and give the injections to patients to be sure they get them on time.
"It's an ethical dilemma," he said. "Should we be letting patients deal with more side effects because it's more convenient?"
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