This is the first study that evaluates the impact of an HCV care program among newly admitted inmates in Iran, and one of the first studies that investigate the post-release engagement with HCV care worldwide. The prevalence of HCV antibody in this study was lower than the national estimations within prisons (5.2% vs. 8% to 28%) (28, 29), which may indicate the lower HCV infection rate among new inmates to the entire prison population. The overall engagement in treatment with 89% uptake and 85% completion rate was high, indicating the feasibility of HCV interventions among people in custody. The majority of patients who were released before or during treatment were linked to care (68%) and completed treatment (70%) in community. In comparison to retrospective studies that showed 10 to 25% linkage to HCV care after release (11, 12, 30), these findings and encouraging cure rates in our study indicate that HCV programs can be strengthened remarkably by accurate post-release patient navigation.
HCV testing and treatment history
One-sixth of patients with available data had a history of testing, and only 5% had received treatment, indicating the missed opportunities for HCV care in correctional settings. These low rates are comparable to previous reports from Iran as well as several high-income countries (12, 31, 32). According to a 2020 report, among people incarcerated in US prisons, only 3% have access to HCV treatment, which underlines the necessity of escalating prison-based screening and linkage to care programs (33). Although general knowledge around HCV infection was extremely poor, willingness to initiate treatment was promising; educational initiatives during imprisonment are highly recommended and may persuade people to seek their infection status post-release.
HCV prevalence and risk behaviors
The prevalence of HCV RNA among new inmates in this prison was slightly lower than our previous study (3.4 vs. 4.8%), which had been estimated among both new inmates and residents in Northern Iran (32). Despite the other Iranian reports, genotype 3a was more frequent than 1a in our study population (34). Drug-related charges were common among all patients, and the majority had high-risk friendship networks or household members. Indicators of socioeconomic marginalization and risk behaviors in the previous month were less commonly seen among people who attended SVR assessment. Combined harm reduction services, including social support and stable housing, together with expanded opioid agonist therapy (OAT) programs, are crucial to control HCV epidemic in Iran (35, 36).
HCV treatment uptake and completion
Evidence surrounding prison-based HCV care interventions in the DAA era is scarce (37). High treatment uptake and completion achieved in our study indicates the great willingness towards treatment among people with HCV in prisons; these outcomes are comparable with another DAA-based prison study from Italy (38). However, due to the heterogeneity of correctional settings and release patterns, effective intervention in a single prison may not be applicable in another. The median length of stay ranges from less than 48 hours in jails to long-term housings in prisons, which highlights the necessity of adopting different healthcare strategies (39). According to a US study, people who were released on parole were more likely to fill an antiretroviral therapy prescription than those with a standard release (40). Thus, HCV programs should be tailored to the peculiar characteristics of the environment in which they are introduced (32, 39).
HCV treatment outcomes
Previous DAA-based studies have observed high cure rates among current and former prison inmates that are consistent with our results, such as a recent report from New South Wales (NSW) (ITT 57%, mITT 92%). The lower ITT SVR in this study (42%) compared to the NSW can be explained by our two-fold higher release rates (41). Similarly, although Pontali et al. have reported a higher ITT SVR (91%) in an Italian prison, only 6% of their patients discontinued treatment due to release. In a Scottish research, SVR assessment showed similar results for people who initiated treatment in community and prison (63% vs. 61%) (42), and a higher response was observed among people who were not released or transferred, compared to those who were released during treatment (75% vs. 45%). We observed slightly better ITT outcomes for those who commenced therapy in the community than prison (45% vs. 35%), which can be partly explained by a higher likelihood of adherence to treatment for people who are reached by the health networks after community return, compared to all released inmates. The ITT SVR among former inmates who initiated treatment in community was similar to a study from New York City jails (45% vs. 41%); however, mITT SVR in our study was higher than their observed cure rates for community initiates (100% vs. 78%) (15). This difference may suggest a lower risk of reinfection or treatment failure in the Iranian community compared to the United States. These comparisons highlight the significant impact of release patterns on treatment response assessment and its interpretations in different settings, which could incorporate into a better prison- and community-based HCV planning.
Post-release HCV care
There is a growing body of evidence on successful transitional programs to engage patients with healthcare services after release –mainly conducted by community-based providers and NGOs- ranging from reminder calls to intensive case management (43). Three studies from the United States have reported that only one-quarter of patients who returned to the community were linked to HCV care after incarceration (15, 30, 44). However, we showed that more than two-thirds of patients could be linked to care following release, highlighting the critical role of active patient navigation in engaging patients with post-release care. The period of leaving incarceration is a particularly vulnerable time, and many people may not receive sufficient long-term support during this period, which may lead to poor health outcomes, including the risk of treatment failure and reinfection (45). Retention in treatment is also essential to prevent the risk of developing drug resistance (46). Due to the similar competing priorities, factors that are considered as facilitators among people with HIV can be applied to the formerly incarcerated population with HCV to obtain synergistic effects. These include treatment for substance use and mental disorders, transportation assistance, offer drug-free transitional housing, and peer support (11, 22, 47). Unfortunately, we were not able to provide such facilities in our study due to budget limitations.
The main limitation of this work was the lack of close observation on the study procedures. To provide real-world information, we aimed to assign the entire work to prison staff and community providers, which resulted in some shortcomings in patient navigation and data collection, including the loss of several medical records. Some staff changes in prison interrupted our data collection process, and tracking down all questionnaires was impossible due to peculiar restrictions of the prison environment. Consistent with the WHO report on Prisons and Health, the penitentiary healthcare system should work in close collaboration with community providers to ensure that treatment is not interrupted when people enter or leave prison and also transferred within the justice system (46). As we only recruited newly admitted inmates, the interpretation of our results for prison residents should be with caution. Besides, women were underrepresented in this study.