The spectrum of chronic hepatitis C virus infection in the Virginia Correctional System: development of a strategy for the evaluation and treatment of inmates with HCV.

BACKGROUND AND OBJECTIVE: Chronic hepatitis C virus (HCV) is common in the inmate population of the United States. Long-standing HCV can progress to cirrhosis, which can contribute to significant morbidity and mortality. However, those inmates with histologically mild disease are unlikely to develop liver-related morbidity or mortality during their period of incarceration. Our objective was to develop an economic strategy for evaluation and treatment of inmates with chronic HCV. METHODS AND MEASURES: A retrospective cohort analysis of 302 inmates within the Virginia Department of Corrections (VDOC) who underwent liver biopsy for chronic HCV at the Virginia Commonwealth University Health System between 1998 and 2002 was performed. The data from this analysis was to utilized to develop a cost model for treatment of chronic HCV in this population based upon biochemical or histologic criteria. We used the perspective of the VDOC using actual costs paid to providers, hospitals, and pharmacies. The primary endpoint was cost-effectiveness of HCV treatment. RESULTS: Eighty percent of inmates with chronic HCV were genotype 1, 49% had a normal value for serum ALT at the time of evaluation, 30% had no fibrosis, and 24% had bridging fibrosis or cirrhosis. The cost to evaluate and treat 100 consecutive inmates with peginterferon and ribavirin regardless of serum ALT and liver histology was calculated to be $1,775,900 or $35,500 per sustained virologic response (SVR). Although the cost declined by 50% if only those patients with an elevated serum ALT were treated, 45% of those inmates with varying degrees of fibrosis, and 21% with cirrhosis would not have received therapy utilizing this scenario. In contrast, the cost of performing liver biopsy and treating only those patients with any degree of fibrosis was $1,367,043; a savings of slightly more than $400,000 per 100 patients evaluated. The overall cost of treatment was most influenced by the price of peginterferon and ribavirin, which declined as the histologic criteria utilized for treatment increased. CONCLUSIONS: A strategy in which inmates with chronic HCV are evaluated and a decision regarding treatment is based upon either biochemical or histologic criteria, which appears to balance both the health-care rights of the inmate and the impact of treating this disease on the financial and other resources of the correctional system.

Treatment of chronic hepatitis C virus in the virginia department of corrections: can compliance overcome racial differences to response?

OBJECTIVE: Chronic hepatitis C virus (HCV) is common in the correctional setting and there are few data on the use of interferon (IFN)/ribavirin(RVN) combination therapy in this population. Given the high proportion of African Americans (AA) in correctional facilities, which may be associated with reduced response rates, the correctional setting allows a unique opportunity to compare the response rates of AA to Caucasians (CA). The present study describes our experience of treating HCV in the inmate population of the Virginia Department of Corrections. METHODS: Of the 119 inmates evaluated between 1998 and 2000, a retrospective analysis of 59 consecutive inmates (mean age 41, 83% male, 55% CA, 73% genotype (GT)1, and 41% with advanced fibrosis) who underwent HCV therapy with IFN a-2b (3 MU TIW) and RVN (1,000-1,200 mg/d) under direct observation was performed. Patients were followed by telemedicine and the primary endpoint was sustained virologic response (SVR) defined as an undetectable HCV RNA at least 24 wk after completion of therapy. RESULTS: All but one patient completed at least 12 wk of therapy and no patient required dose reduction. By wk 24, 34 inmates (58%) responded (negative HCV RNA) which was higher in CA compared to AA (70%vs 40%; p= 0.037). Although overall SVR was higher in CA compared to AA (41%vs 28%; p= ns), we observed no difference in SVR when comparing only GT 1 CA to AA (33%vs 29%). CONCLUSIONS: HCV can be effectively treated in the correctional setting with response rates similar to, if not better than the published literature. In this controlled setting of direct observational therapy, we observed similar SVR in CA and AA.