HCV in Prisons: The Real Cost of Medical Care

Lawsuits challenge access denials to curative hepatitis C drugs among incarcerated individuals infected with the disease.

Imagine having to clean up the infected blood of a cellmate against regulations and subsequently contracting the hepatitis C virus (HCV).

Imagine having diabetes and being infected by an unsanitary needle from a medical facility in a prison. Imagine going three weeks with hyperglycemia and never even knowing it.

Should one wrong decision in your life mean you should receive subpar medical care and risk infection of serious diseases? Shouldn’t the facility responsible for your well-being adhere to that responsibility and deliver on the message that it will not administer unnecessary punishment in addition to your sentence?

This is exactly how the prisoners in the lawsuit filed against Massachusetts state prisons feel. Professor Peter Erlinder, director of the International Humanitarian Law Institute, brought the Massachusetts lawsuit under national scrutiny in May 2015. Erlinder has had a fleet of lawyers follow suit across the country as they become increasingly aware of HCV treatment in prisons.

“The standard of care that has been established by the AASLD/IDSA (The American Association for the Study of Liver Diseases/Infectious Diseases Society of America) guidelines state that if a patient presents with the virus, they should be treated,” Erlinder said. “They’re not being treated, so there must be reasons other than medicine that is causing [prison authorities] to deny [the prisoners] treatment because what they’re doing is contrary to the standard of care established by the professional agencies.”

As of June 29, 2015, the following has been approved as the standard of care across the United States:

• All patients infected with HCV should be treated immediately with the most recent FDA-approved breakthrough drugs (Harvoni and Viekira-Pak)
• All prior treatments (using interferon) are not medically recommended
• Only health care providers lacking financial resources may triage treatment of patients, giving priority to those with more serious symptoms (such as cancer, fibrosis or cirrhosis)

Despite the clear guidelines and the language of the Constitution indicating that prisoners have a right to medical care, many correctional facilities have denied treatment, even those who have contracted the disease inside prison walls, as is the case in Erlinder’s lawsuit.

One of the prisoners in the lawsuit was forcefully made to clean up his cell after his cellmate had hemorrhaged, which led to him contracting HCV. The other prisoner in Erlinder’s lawsuit is a diabetic who is insulin dependent. It is believed that he contracted the virus through an unsanitary needle used by prison facilities when administering his insulin, although this claim cannot be proven.

Perhaps an even more renowned case that has surfaced as a result of the Massachusetts lawsuit is the case of Mumia Abu Jamal in the Pennsylvania Department of Corrections. On the case in this suit is Bret Grote, representing Jamal in his hearing to acquire the new curative treatments for his HCV infection.

Jamal underwent diabetic shock in April 2015 and suffered a severe skin condition as a result of his HCV.

“[It] was painful and unlike anything that I had ever seen or any of the medical staff that had looked at him had ever seen. There was a concern that this was being caused by lymphoma or maybe some other type of cancer or autoimmune disorder,” Grote explained. “There’s been many tests that have ruled out illnesses as the underlying cause of his condition, but they still refuse to provide treatment for the one chronic disease which they know he has, which is hepatitis C.”

Clearly the instance of ignoring patient needs when it comes to HCV in prisons is prevalent in the United States, but the reason why is elusive. Grote thinks the mistreatment of prisoners has to do with the stigma that is attached to them.

“The stigma which is attached to those who are incarcerated or those who are convicted of crimes has created a culture dehumanization in which what happens to them once they’re inside jails or inside prisons is ignored,” he said. “It’s kept out of sight. It’s kept out of mind. Whenever stories do emerge, they’re often treated as aberrations or particularly grotesque examples of something that went wrong with the system, rather than its routine systemic operations.”

The effort to change those systemic operations has proven difficult for advocates nationwide.

“When a large bureaucracy is asked to change its policies in a way that has the implication that this change in medicine would require, I don’t think it’s unusual that they would try and delay,” said Erlinder of the delays in the litigation process on the part of the Department of Corrections in both Massachusetts and Pennsylvania.

The change is slow to come both due to the delays from the Department of Corrections and also due in part to the general reluctance there is to giving prisoners medical treatment as a result of the stigma attached to their incarceration.

But the high cost of the medications also is increasing the delays in litigation, as prison systems struggle to come to terms with what this new standard of care means for their budgets.

A study published earlier this year examining the cost impact from HCV drugs on Rhode Island prisons noted that the state’s prison system overall health budget is $19.9 million, with $2.7 million for pharmaceuticals.

The total cost of treating all HCV-infected inmates with at least six months of time left to serve is approximately $34.2 million, while the cost of treating only the sickest inmates is approximately $15 million, and treating the sickest inmates with at least one year left to serve is approximately $12 million.

In the least expensive scenario, which is treating only the sickest inmates at a 50% drug cost discount, would still would account for $8 million, which is more than 40% of the entire total health budget for the state prison system.

Erlinder, however, believes the dilemma comes down to a standard-of-care issue.

“Prisons do not have cost as a defense to deliberate indifference because they cannot tell prisoners, ‘We only have enough food for one of you, therefore the other two have to starve,’” Erlinder explained.

With medications costing as much as $100,000 per patient in some cases, and with at least 23% of the prison population infected with HCV, it’s easy to see how treatment could threaten to break the prison system’s budget.

But Erlinder says that studies have shown that treating HCV before it escalates into something more serious is actually cost-effective in the long run.

“There are 3 studies that say that if the overall costs and benefits are analyzed even at the high prices that have been set now, the cost of treatment are actually cost-effective right now if one considers the social benefits as well as the cost savings from not passing on the infection,” he explained.

HCV is a serious condition that can lead to liver disease, cirrhosis, and even liver cancer when left untreated. Many patients must be placed on a transplant list to await a healthy liver. Liver transplants can cost up to $500,000.

If patients were treated early instead of waiting for their disease to escalate, doing so would actually save money in the long run by avoiding more expensive medical procedures.

Not only could treating HCV reduce overall health care costs long term, it may also help to clear the disease as a public health threat in the United States into the future.

As 90% of prisoners eventually enter back into the community, these individuals also have the potential to infect the general population with HCV. In this sense, using prisons as the basis for mass cleansing could be beneficial to the general public.

“Eliminating HCV from the prison population is a very good way to eliminate transmission of the disease,” said Erlinder.

But until the prison systems adhere to the new standard of care and administer curative treatment to all prisoners who need it, HCV will stand at large as a huge epidemic among the prison population, as well as the general population.

“Our hope is that the state corrections institutions will realize that they’re going to have to convince their legislatures that this has to be funded, and eventually the price of the drugs will come down so that the treatment will be available to the people who need it, both in and out of prison,” Erlinder said.