July 28 is World Hepatitis Day. This year’s campaign theme is ‘I can’t wait,’ highlighting the need to accelerate the fight against viral hepatitis and the importance of testing and treatment among people who need it. One such group is people who are incarcerated. While it is known that they are disproportionately affected by sexually transmitted and blood-borne infections (STBBIs), such as hepatitis B and C, they continue to face a number of barriers to care.
In an effort to overcome these barriers, CTN Investigator Dr. Sofia Bartlett recently led a team of researchers, community members, and other stakeholders to produce ‘You Matter: Pathways to Care for STBBIs,’ guidelines and policy recommendations for hepatitis and STBBI testing and linkage to care in B.C.’s provincial correctional centres. They were developed in collaboration with health care workers, corrections staff, community groups, researchers, and importantly, people with living or lived experience of incarceration.
“People who experience incarceration are silenced and excluded from a lot of things; they don’t often get the opportunity to give input to decisions that will directly affect their care,” explained Dr. Bartlett, a senior scientist at the BC Centre for Disease Control. “Creating opportunities for them to be part of developing guidelines like these not only helps give them a voice, but it also gives us a much better idea of what clients actually want.”
The You Matter guidelines and recommendations cover the entire STBBI care pathway for people who are incarcerated, from addressing stigma and improving education, through to testing and linkage to community care after release.
To improve prevention and care for STBBIs and hepatitis among people who are incarcerated, we must first eliminate the stigma.
The You Matter guidelines recommend a holistic approach to help achieve this:
- Ongoing STBBI education for staff and clients that emphasizes that hepatitis and STBBIs are easily treated medical conditions.
- Fostering respectful and person-centred language related to STBBIs among both staff and clients.
- Emphasizing privacy and confidentiality in STBBI testing and care through policies, including private areas for STBBI testing and consultations and discreet educational pamphlets with general titles.
Ongoing education around hepatitis and STBBIs is recommended for corrections staff, health care workers, and people who are incarcerated. This could be in the form of printed materials, like posters and pamphlets, as well as regular educational programs.
“While developing these guidelines, we launched a few new training options for corrections staff and health care workers,” said Dr. Bartlett, who was recently appointed as Co-Director of the Canadian Collaboration for Prison Health and Education. “They are self-paced online modules available through the PHSA Learning Hub. Each module was created with help from people who have actually worked as correctional officers or nurses in prisons.”
For those who are incarcerated, You Matter offers other educational resources like videos and decks of playing cards with hepatitis and STBBI facts. These were designed in collaboration with people who have lived experience of incarceration.
Testing and beyond
When people are incarcerated, they undergo an intake health assessment. This is a great opportunity to explain that STBBI and hepatitis testing and treatment is available and can be provided then or at a later date by a health care worker. But the offer of testing shouldn’t end there.
Dr. Bartlett explained that testing should be offered at as many opportunities as possible to reinforce the ‘normalization’ aspect of testing, while increasing the chance that everyone will accept testing eventually.
“We need to normalize hepatitis testing. Being tested for viral hepatitis in prison should be as normal as getting blood pressure checked. There’s no shame in being tested. It’s a totally normal thing that everyone should be doing!” she emphasized.
Consideration also needs to be put into transitioning from correctional settings back into the community to help ensure any STBBI care is maintained. To support this, corrections staff and health care workers should determine the client’s interest in peer support programs and facilitate connections; arrange for the transfer of prescriptions to a pharmacy or clinic of the client’s choice; pull together any necessary documentation about their STBBI or hepatitis treatment and required follow up; and generally counsel clients on any next steps ahead of, during, and following release.
“Initiating connection to care in the community as early as possible before release from custody will give the greatest chance at maintaining people on treatment and ensuring they get appropriate follow up after release,” said Dr. Bartlett. “The vast majority of people in prison will be released into the community and, in the provincial system, this is often happening quite fast. The earlier we make the connections to community care providers, the better.”
You Matter provides detailed suggestions around how correctional centres can best implement and maintain these new recommendations and guidelines. In short, they recommend each correctional centre forms an STBBI working group to oversee the rollout of changes and review needs and priorities. In addition, a Correctional Health Services manager should train clients and staff on the new policies and guidelines, including regular refresher training and education. Finally, an annual report on STBBI testing and linkage to care should be published, and regular knowledge exchange events should be held to encourage sharing of lessons learned, progress, needs, and priorities.
Researchers and clinician–researchers who do not typically work directly with people who are incarcerated can also help.
“One of the critical roles that researchers can play is in generating evidence that can be used for monitoring and evaluation,” said Dr. Bartlett. “So, thinking about how ongoing or future research could capture data that can be used to measure either the adherence to these guidelines or their impact will be critical to guiding the implementation efforts.”
“In an ideal world where we had unlimited resources and there was no COVID-19 or unregulated drug poisoning crisis, Correctional Health Services in B.C. would be able to take these guidelines and incorporate all the recommendations into their protocols and processes immediately,” said Dr. Bartlett. “This would mean that all people entering provincial corrections in B.C. would be offered viral hepatitis and STBBI testing within six days of intake to custody, they would have the opportunity to ask questions and speak to a nurse before deciding if they want to have the tests, and all people with a diagnosed STBBI receive their result and would be offered treatment within four days. In addition, corrections staff would have annual education on STBBIs including stigma, person-centred care, and trauma-informed practices.”
Instead, Correctional Health Services in B.C. will implement the guidelines in a staggered fashion starting with three pioneer sites across the Lower Mainland and Vancouver Island rolling out protocols that adhere to the guidelines over the next six months. In 2023, additional sites will join the rollout until all ten correctional centres in the province follow protocols that adhere to the You Matter guidelines.
“Ultimately, we hope that other provinces and territories in Canada will also start looking to these guidelines as the benchmark for the standard of care that should be provided for STBBIs in prisons,” said Dr. Bartlett. “This will likely take much longer and is probably the area where fellow CTN Investigators can have the most impact in supporting!”
Click here to download a PDF of the detailed You Matter recommendations and guidelines, which also includes important considerations for key populations.
Click here to find additional hepatitis C and B training and resources from CATIE.