Treating Infectious Diseases In Prisons: Controlling Epidemics and Reducing Costs
During a session at AMCP Nexus 2017, Steven Miller MD, chief medical officer of Express Scripts summarized the threat posed by untreated infectious diseases in prisons.
“We have a million people that are incarcerated who have hepatitis that are not being managed, so we as a society are not smart enough to realize, they are the reservoir that is going to reinfect the population,” he said.
Treatment of infectious diseases in people who are incarcerated is an important issue given the high prevalence of infectious diseases, particularly hepatitis C viral (HCV) infection and human immunodeficiency viral (HIV) infection, in this population. It is estimated that more than 10 million people are incarcerated in the United States, and of these 17% have HCV and about 1.3% HIV, according to AIDS Reviews. The burden of HCV is particularly daunting with estimates showing that nearly one-third of the people in the United States with HCV spend at least part of the year in a correctional facility.
Standard of Care
Under US law, incarcerated persons have a constitutional right to receiving adequate health care, which is generally interpreted to mean they have a right to the standard of care that is offered in the community. Despite this law, many incarcerated persons are not receiving treatment as highlighted in a recent 2015 survey of US state correctional facilities, which found that less than 1% of inmates with HCV received treatment.
Offering the standard of care to incarcerated persons can be difficult given the high cost of drugs to treat these diseases. This is particularly true for HCV as both private and public payers grapple with the most cost-effective strategy to deliver the new costly antivirals that now offer cure. Since treatment of HCV with the new antivirals now provides cure after a limited treatment course of about 8 to 12 weeks with no need for ongoing maintenance therapy, unlike HIV that requires ongoing treatment, determining who bears the cost of treating HCV in incarcerated persons is an ongoing question.
“People are saying that the cost should be borne by correctional facilities but the benefit is to the community after release,” Anne Spaulding, MD, MPH, associate professor of Epidemiology at the Rollins School of Public Health at Emory University, said in an interview. “Therefore, this places the burden on the back of one system and the benefit on another.”
Underlying this question of cost burden, however, is the larger public health question of how best to stem the spread of infectious diseases, with HCV being the most recent concern, that exacts a severe and substantial toll on individual’s lives and societies ability to deliver fair and optimal healthcare with limited resources.
An ongoing substratum under all of this is the increasingly evident problem of high drug pricing that is forcing payers and patients to make ever tougher decisions about when and how to treat. This is all too evident in the ongoing discussion of when to treat HCV in the general public, and by extension in correctional facilities, based on level of disease—should treatment be offered in early stages of disease or wait until fibrosis and liver damage is evident.
A recent cost-effectiveness analysis that used a Markov model to assess the cost-effectiveness of sofosbuvir-based treatment regimens for incarcerated persons with chronic HCV found that sofosbuvir-based treatment is cost-effective in this setting but that affordability was a primary consideration.
“Our exploratory analyses found that the value of all-oral, interferon-sparing regimens depends heavily on their pricing, their attractiveness for uptake and adherence, and the rising bar of other effective and less costly comparator regimens,” the researchers wrote.
“Hepatitis C is now a curable disease, but it’s out of reach for many because of the outrageous price of these medications,” Gregg Gonsalves, PhD, assistant professor of epidemiology at the Yale School of Public Health, said. “When companies put outrageous mark-ups on drugs because they know that there is little we can do to stop them, that doesn’t only hurt patients but also providers, insurers, and others who must bear these costs.”
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