Themed Collections: World Cancer Day 2023

World Cancer Day 2023

Each year, World Cancer Day is 4^th February. This year, for the month of February, WEPHREN’s focus will be on cancer prevention in prisons, specifically reducing the incidence and prevalence of Hepatitis C (HCV) infection in imprisoned people; the prevalence of HCV is much higher in prison populations compared to the general population.

A number of infections are known to increase people’s risk of certain cancers, and for prison populations, Human Papilloma Virus (HPV) and HCV are of particular relevance. Previous work has shown that imprisoned women are at higher risk of cervical cancer and HPV infection. This year we are focusing on the prevention and treatment of HCV testing in prisons – this is an important way to reduce the risk of a specific type of liver cancer (hepatocellular) in imprisoned people. As our authors point out, about three million people with HCV are imprisoned in any given year and HCV is a leading cause of hepatocellular cancer.

In the blogs below, Dr Matthew Akiyama highlights the importance of addressing HCV infections in imprisoned people in low and middle income countries. Eszter Kiss-Farina describes her work which demonstrates that the benefits of HCV case-finding and treatment of imprisoned people accrue not just to the individual who is infected but to the whole of society.

Addressing HCV infections in imprisoned people in low and middle income countries

Globally, an estimated 58 million people have chronic hepatitis C virus infection, 80% of whom live in low-income and middle-income countries (LMICs). HCV is the most prevalent infectious disease in prisons internationally with a prevalence that is usually several times higher than surrounding communities. An estimated 3 million people with HCV are incarcerated in any given year. 

High risk behaviors before and during incarceration coupled with low access to testing and treatment creates a perfect storm of spread of HCV among people involved with the criminal legal system. If untreated, chronic HCV can lead progression of fibrosis, cirrhosis, end stage liver disease, and liver cancer. Hepatocellular carcinoma is a leading cause of liver-related death worldwide with high morbidity and mortality. Highly curative direct-acting antiviral therapies have revolutionized the field of HCV and made HCV elimination an achievable goal. Yet, there is currently a lack of integration of prisons systems into country-specific HCV elimination plans.

Because prisons have largely been left out of global elimination efforts, particularly in LMICs, protocols are needed in prison systems to test for HCV and provide effective treatment and prevention services. This is critical to improve personal health outcomes including long-term impacts such as hepatocellular carcinoma, minimize risk to others in prison and the community, and advance health equity.

This commentary was born out of a stakeholder meeting at The International Network on Health and Hepatitis in Substance Users (INHSU)’s Africa regional conference held in Cape Town, South Africa in February 2020. Key stakeholders included individuals working in the prison healthcare sector from different countries across Africa with a goal to share strategies for and experiences with prison-based viral hepatitis services. In it, we call for more attention and stakeholder involvement to combat this serious public health problem.

In another review, we highlight seven priority areas and best practices for improving HCV care in correctional settings: changing political will, ensuring access to HCV diagnosis and testing, promoting optimal models of HCV care and treatment, improving surveillance and monitoring of the HCV care cascade, reducing stigma and tackling the social determinants of health inequalities, implementing HCV prevention and harm reduction programmes, and advancing prison-based research.

If we are to reduce the more proximal and downstream impacts of HCV, we need to gather the political will to allocate more resources and attention to this often overlooked and stigmatized population. 

Dr. Matthew Akiyama is an Associate Professor of Medicine at Albert Einstein College of Medicine in New York. In addition to providing care and treatment to people living with HIV, viral hepatitis, and substance use disorders, Dr. Akiyama conducts research focusing on HCV among socioeconomically marginalized populations with particular emphasis on the intersection of HCV in the criminal legal system. Dr. Akiyama completed his Infectious Diseases Fellowship at New York University/Bellevue Hospital Center and a Master of Science in Medical Anthropology at University College London in London. He is a vice chair of INHSU Prisons.

Flying the Flag for Hepatitis C Elimination in Prisons

Hepatitis C virus (HCV) infection causes a slow and progressive liver disease that can lead to hepatocellular carcinoma (HCC). HCV is one of the leading causes of liver cancer. It excessively affects people living in detention (PLD) where the principal risk factors are injecting drug use and high-risk sexual behaviour exacerbated by proximity. [1]

It is shocking and unjust that one in four PLD should have Hepatitis C at one point in their lifetimes and PLD are 9-13 times more likely to catch HCV than the general population. [2] The WHO have joined forces to eliminate viral hepatitis as a public health threat by 2030.  Today we give prominence to the elimination of HCV in prisons as a preventative measure against cancer both for imprisoned people and the general population.

Here I describe the findings of the scoping review I carried out which asked the question, ‘What evidence is there in the international literature of a community dividend resulting from testing and treating hepatitis C infection in people living in detention?’

What does the catchy phrase, community dividend, mean? Well, it does not bring up many results in web searches today but watch this space. It is the benefit of a prison-related intervention - in this case testing and treating an infectious disease - for general population health. [3]

Nineteen peer-reviewed articles and two conference abstracts were identified and underwent descriptive analysis with very positive findings for interested parties. Results clearly showed that there is a community dividend from testing for HCV in places of detention and treating chronic hepatitis C infected incarcerated individuals The outcomes demonstrating community dividend could be placed into three domains: economic, clinical, and/or epidemiological. Case-finding and treatment of imprisoned people is a cost-effective strategy and increasingly so with the recent availability of DAAs; it is a good investment of taxpayers’ money and results in savings in long-term health expenditure. The cost is amply compensated by individual and collective benefits: it reduces the incidence of HCV-related liver complications, increases survival, improves quality of life for both the prison population and the general population and reduces infection transmission. Most of the benefits are realised in the community following release.

These findings provide important evidence to support investment in HCV case-finding and treatment of imprisoned people: the benefits accrue to the whole of society. 

If you would like further information, please contact Eszter Kiss-Farina Eszter2.Kiss-Farina@live.uwe.ac.uk

Eszter Kiss-Farina gained an MA in Hungary and teaching qualifications to be a secondary school teacher. She worked in Italy and Hungary before coming to the UK. She has been an Associate Practitioner in a PHE/UKHSA Virology lab for more than 10 years and was sponsored by PHE to undertake an MSc in Public Health at the University of West of England in Bristol.