Scott A. Allen

Opportunities to Address the Hepatitis C Epidemic in the Correctional Setting

An estimated 15%-40% of incarcerated persons in the United States are infected with hepatitis C virus (HCV). Approximately 1.4 million HCV-infected persons pass through the corrections system annually, accounting for one-third of the total number of HCV-infected persons in the United States. This high prevalence of HCV infection is due to the substantial increase in drug-related arrests over the past 2 decades. Although the hepatitis C epidemic in the corrections system may be viewed as a burden on correctional health systems, it is an important public health opportunity and an obligation. Research on the implementation of cost-effective HCV screening, prevention, and treatment programs among incarcerated persons is essential. Testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States.

Treatment outcomes with pegylated interferon and ribavirin for male prisoners with chronic hepatitis C.

Goals To report our experience with pegylated interferon and ribavirin treatment of hepatitis C virus (HCV) RNA-positive inmates at the Rhode Island Department of Corrections. Background An estimated 1 out of 3 HCV-infected individuals will spend time in a jail or prison within a 1-year period, making prisons a unique setting for management of chronic HCV. Study Chart review of all inmates identified as having initiated HCV treatment between October 2000 and April 2004. HCV-infected individuals were identified by HCV antibody screening at intake for known risk factors, elevated aminotransferase levels, or per individual request. Treatment followed standard guidelines with weight-based dosing of pegylated interferon-α2b and ribavirin. End points were completion of therapy plus 6 months for sustained virologic response (SVR), therapy discontinuation, and loss to follow-up. Results The cohort included 71 male patients, was mostly white (80%), and genotype 1 (65%). All 9 African Americans (AA) had genotype 1. Of 59 patients having liver biopsy, 41 had early stage disease. Overall SVR was 28%. Response rate was lower for genotype 1 compared with genotypes 2 and 3 (SVR 18% vs. 60% and 50%). Of inmates with genotype 1, no difference existed in treatment response by race (SVR 22% AA vs. 18% white). Thirty-three patients completed treatment, 26 stopped for side effects, and 5 for initial nonresponse. Eleven were lost to follow-up. Conclusions Acceptable HCV treatment outcomes can be achieved in prisons. Our small study indicates no difference in treatment response by AA versus white race for genotype 1.

Responding to Hepatitis C through the Criminal Justice System

From a public health standpoint, the high concentration of patients in correctional institutions with hepatitis C — now a curable contagious disease — presents a critical opportunity to curtail this epidemic.

Bad Science Used to Support Torture and Human Experimentation

Despite prior U.S. recognition of “enhanced interrogation” techniques as torture, science was misrepresented to support their use. In the wake of the September 11, 2001, attacks, the U.S. government authorized “enhanced interrogation” techniques (EITs) (i.e., prolonged sleep, sensory deprivation, forced nudity, and painful body positions) that were routinely applied to detainees in U.S. custody in at least three theaters of operation and an unknown number of secret “black sites” operated by the Central Intelligence Agency (CIA). They did this despite the fact that each EIT was considered torture by the United Nations (1), and the United States recognized them as such in its reports on human rights practices (2). Although legal sources and trained interrogation experts warned of the unreliability and questionable legality of coerced confessions (3), EITs were authorized by the CIA in January 2003 (4) and the Department of Defense (DoD) in April 2003 (3).

Cost of Hepatitis C Treatment in the Correctional Setting

Thirty-four percent of inmates are infected with hepatitis C. There are significant variables affecting the cost of disease management. This paper estimates the effects of these variables and the range of costs. Representative data from correctional systems with varying hepatitis C management protocols were assigned to each variable to estimate program cost. Depending on prevalence, whether or not vaccination is included, and which biopsy stages are treated, cost of management of a hypothetical population of 3,000 inmates ranged widely, from

Open letter to President Obama on hunger strikers in Guantanamo

646,768 to

Evaluation of the Painful Wrist

2,706,740 from diagnosis to completion of evaluation and/or treatment.

Screening for Hepatitis C Virus Infection in Adults

2166 www.thelancet.com Vol 381 June 22, 2013 That makes it imperative for them to have access to independent medical examination and advice, as they ask, and as required by the UN and World Medical Association. Many of the hunger strikers will be currently unfi t for long-distance fl ights. We endorse their request, and are prepared to visit them under appropriate conditions, to assist in their recovery and release, and certify when we are confi dent it is medically safe for them to fl y. If you keep your word (given over 4 years ago), and arrange release of detainees, they will need to become fi t to fl y before they can be returned to wherever you order your forces to send them. We have the deepest sympathy for the hunger strikers, the military doctors, and your predicaments. We off er our services to visit, examine and advise them, and to assist in any way that is acceptable to all parties.

Treatment of Chronic Hepatitis C in a State Correctional Facility

Numerous modalities are available for the evaluation of the painful wrist. Plain films will suffice in the vast majority of cases. Specialized views are ordered when the patient’s history, physical exam, or plain film evaluation indicates the need. A static wrist instability series still has a place in diagnosis of the painful wrist. CT scanning is of limited utility for most wrist pathology except for DRUJ subluxation. Bone scans are less frequently indicated, given the increasing use of MRI, but are generally indicated when evaluating complex cases with minimal findings on other tests. MRI will become increasingly common in the place of arthrography, but currently is the gold standard for the diagnosis of carpal osteonecrosis. Its role in the diagnostic armamentarium is still being defined as technology improves.

Physicians in US Prisons in the Era of Mass Incarceration

Balance of Benefits and Harms On the basis of the accuracy of HCV antibody testing and the availability of effective interventions for persons with HCV infection, the USPSTF concludes that there is a moderate net benefit to screening in populations at high risk for infection. The USPSTF concludes that there is also a moderate net benefit to 1-time screening in all adults in the United States born between 1945 and 1965.