A recent Yale study reveals the inability of state correctional facilities to treat inmates with hepatitis C, a common bloodborne illness.

Researchers surveyed 41 state correctional facilities on their number of hepatitis C patients, the percentage of these patients treated and the discounted cost of the two most common antiviral drugs for these facilities. In total, 10 percent of all reported inmates were known to have hepatitis C, with only 0.89 percent of these inmates undergoing treatment for the disease. Prices for the two treatment options varied among states, from $43,418 to $93,500.

“We expected that many state prison systems would have difficulty providing broad access to these novel hepatitis C therapies,” first author Adam Beckman ’15 said. “We did not anticipate the scope of the limited access.”

Viral hepatitis is a silent epidemic, according to the U.S. Department of Health and Human Services. It is the leading cause of liver cancer nationwide, but upwards of 75 percent of American hepatitis C patients going undiagnosed. Approximately one out of three incarcerated Americans have hepatitis C, Director of the Yale Viral Hepatitis Program and study co-author Joseph Lim said.

The study, which was published in the October issue of Health Affairs, collected patient data and drug costs as of Jan. 1, 2015, by way of self-reported survey modules.

While the study found that overall, fewer than 1 percent of known hepatitis C patients were being treated, statewide medians varied from 0 percent to 5.9 percent.

Connecticut, for example, only reported four hepatitis C-infected inmates, all of whom were receiving treatment, whereas Massachusetts reported 1,505 inmates with hepatitis C, 60 of whom, 3. 99 percent, were receiving treatment.

Current antiviral drugs have cure rates of over 90 percent, and non-incarcerated Americans have much better access to these treatments, Lim said.

“Any patient that we are seeing here at Yale who has Connecticut Medicaid can receive treatments, whereas if the same patient is incarcerated in Connecticut state prison, it is very unlikely that they’ll have the same access to treatment, and that’s discriminatory,” he said.

One of the reasons hepatitis C treatment may be so thinly distributed to prisoners is the high and variable cost of antiviral drugs for state correctional facilities. According to the study, at least $39 million was spent in 2014 on hepatitis C treatment by the 41 participating correctional facilities.

Inmates with hepatitis C should be treated while in prison and referred  to outside care when they get out, according to Rich Feffer, correctional health programs manager of the Hepatitis Education Project, but this treatment is hindered by three main factors.

First, correctional facilities have a disproportionately high number of inmates with hepatitis C in conjunction with limited budgets, so it is not affordable to treat everyone. Second, most prisons and jails do not test everyone for hepatitis C, so many at-risk inmates are not diagnosed. Finally, there is a lack of communication between prisons, jails and community-based health care systems.

According to an Oct. 4 press release published by Yale Law School, the Yale study was the first peer-reviewed analysis in over 10 years that examined the scope of hepatitis C medical care in state prisons.

“We did know about the high rates of hepatitis C in prisons, and I think we knew from individual states and talking to people that not a lot of people were getting treatment, but this was one of the first studies that really quantified that at a macro level,” Feffer said. The research also affirmed that hepatitis C in prisons is still not treated well, despite the fact that new drugs are making it easier, he added.

Some of the solutions the study suggested were expanding state correctional facilities’ budgets for the treatment of hepatitis C and instituting standardized medication discounts from pharmaceutical companies.

Feffer, however, said that at least some of the policy changes will have to come at the federal level. He added that one solution could be exempting correctional facilities from Medicaid’s “best price rule,” which mandates that brand-name drug manufacturers provide drugs to the general market at the same price at which they provide them to prisons.

According to a June 2016 Hepatitis Education Project webinar, this rule “discourages pharmaceutical companies from negotiating lower prices with correctional entities because that could impact all state Medicaid prices.”

Another possible solution would be earmarking federal funds for state correctional facilities’ treatment of inmates, but that is very unlikely to happen, Feffer said.

“That was probably pie in the sky before the new administration, but I don’t imagine Donald Trump will be paying more for prisoner health care anytime soon,” he said.

Feffer and Beckman said the research has garnered national media attention and spread awareness about an important and little-known issue.

The research received coverage in the national media, including from FiveThirtyEight, Stat News and Mother Jones, Beckman said.

A potential limitation of the study was the volatility of the data, Feffer said. Policies can change quickly and new protocols can come into place, rapidly changing the number of inmates treated. He added that it is difficult to validate the team’s data.

The study’s most important limitation from a medical perspective arose from looking at one point in time, Lim said.

“It is possible, although unlikely, that a proportion of these patients have already been treated outside the prison system, and that would not have been taken into consideration here,” he said.

By looking at two of the major treatment options, the study may have omitted inmates in their analysis who may have been offered an older treatment, Lim added.

“A lot of the time, it depends who in the prison you ask and how you ask the question,” Feffer said. “Prisons aren’t usually very forthcoming about a lot of this information, especially because a number of them are under lawsuits.”

Hepatitis C affects an estimated 2.7 million to 3.9 million adults nationwide, according to the Centers for Disease Control and Prevention.