1. Jack Stone, April Young, Jennifer R. Havens, Peter Vickerman
Modelling the Role of Incarceration in HCV Transmission and Prevention Amongst People Who Inject Drugs in Rural Kentucky
Jack Stone, April Young, Jennifer R. Havens, Peter Vickerman

2. Declaration
No conflicts of interest to declare.

3. Introduction

4. HCV, Incarceration and People Who Inject Drugs
Globally, 58% PWID have ever been incarcerated 1
History of incarceration frequently associated with prevalent HCV and HIV infection amongst PWID 2
Previous modelling suggests incarceration could contribute significantly to HCV and HIV transmission amongst PWID3,4,5
[1] Degenhardt Lancet Glob Health 2017; [2] Jurgens J Int. AIDS Soc. 2011
[3] Csete Lancet 2016; [4] Altice Lancet 2016; [5] Stone Addiction 2016;

5. Recent Incarceration and HCV Acquisition Risk
Overall (I2=57.3%, p=0.002)
1.62 (1.28,2.05)
Increases Risk
Decreases Risk
Recent incarceration and risk of hepatitis C and HIV transmission
amongst people who inject drugs: a systematic review and meta-analysis.
Jack Stone; Paper Session 16, Lisbon Addictions 2017

6. US and HCV
The US has the largest prison population and one of the largest PWID populations (~ 2.2 million PWID) in the world 1,2
Injecting drug use is the primary route of new HCV infections 3
65.5% anti-HCV prevalence amongst PWID 1
82.8% PWID have ever been incarcerated 1
Recent increases in the numbers of PWID linked to prescription opioid epidemic 4
HCV incidence increasing - particularly amongst young persons living in non-urban areas 4
HIV/HCV prevention has been extremely limited in rural settings
Recent HIV outbreak in rural Indiana linked to injecting of prescription opioids 5
[1] Degenhardt Lancet Glob Health 2017; [2] Walmsley World Prison Brief 2017; [3] Edlin Antiviral Res 2017; [4] Zibbell Morb Mortal Wkly Rep 2015; [5] Peters N Engl J Med 2016

7. HCV amongst PWID in Perry County
HCV prevalence: 58%
HCV incidence: 21 per 100py
OST coverage: 4.7%;
No NSP
86% ever incarcerated
Average incarceration length: 3.4 months
Data for Perry County from Social Networks Among Appalachian People study (SNAP):
Young Drug Alcohol Depend 2014; Young Epidemiol Infect 2012;
Young AIDS Behav 2012; Havens Am J Pub Health 2013

8. Methods

9. Model Structure
Incarceration component
HCV transmission component

10. Model Structure – OST & NSP
PWID leave OST & NSP upon incarceration

11. Model Parameterisation and Calibration

12. Model Parameterisation and Calibration
Calibrated injecting initiation and cessation so that 8x more PWID started injecting in 2000 than 1990.
x increase in PWID initiation rates over
HCV transmission rates were calibrated to HCV prevalence ( %) in 2009 and HCV incidence ( per 100py) in 2011, assuming:
1.9-fold elevated risk amongst currently incarcerated and recently released (<6 months) PWID compared to other PWID (aIRR: 1.93; 95% CI: )
Stable HCV epidemic before increase in PWID initiation
OST introduced between reaching a stable coverage of % in 2009.

13. Model Projections
Contribution of incarceration to HCV transmission (PAF) - by setting transmission risk during and post-release to that of never/non- recently incarcerated PWID.
Impact of reducing incarceration rates – either by decriminalisation or diverting to-be-incarcerated PWID to OST.
Impact of scaling-up NSP and OST to 50% coverages amongst community PWID
Additional impact if OST reduces incarceration rates by 30 or 60%
Additional impact if OST also introduced into prisons/jails.

14. Results

15. Infections Averted over 2017-2032

16. Impact of Scaling-up OST & NSP Amongst Community PWID

17. Significant Additional Impact if OST is Available in Prison/Jail
Assumes no impact of OST on incarceration rates

18. Significant Additional Impact Even if Community OST Reduces Incarceration Rates

19. Conclusions

20. Discussion
Incarceration is likely to be an important contributor to HCV transmission amongst PWID in Perry County.
Further research is required to the mechanisms through which incarceration increases the risk of HCV transmission.
This is the first study to consider the effects of OST on reducing incarceration
Can provide important additional prevention benefits and could increase both the effectiveness and cost-effectiveness of scaling-up OST.
Further research is needed to better quantify the effect of OST on incarceration rates amongst PWID.

21. Discussion
Scaling-up OST and NSP in the community alone could have limited impact.
A comprehensive approach that includes prison/jail-based OST could halve the number of infections over
In most US jurisdictions, OST is abruptly stopped on incarceration, with exceptions sometimes made for pregnant women or people with HIV 1,2
Globally, OST is available in prisons in ~ 50 countries - coverage is often very low and not available in all prisons within a country 3
Without a comprehensive approach to harm reduction, HCV infections and re-infections within jails/prisons and following release may undermine future efforts to achieve HCV elimination goals.
[1] Rich Lancet 2015;
[2] Fiscella J Urban Health 2004;
[3] The Global State of Harm Reduction 2016

22. Acknowledgements April Young – University of Kentucky, USA
Jennifer R. Havens - University of Kentucky College of Medicine, USA
Peter Vickerman – University of Bristol, UK

23. Opiate Substitution Therapy
Reduces HCV acquisition risk amongst PWID by 50% 1
Evidence OST reduces incarceration rates by 20-36% and crime by 61% 2,3,4
Could lead to additional impact on HCV and HIV transmission amongst PWID.
No modelling has considered the additional impact that reduced incarceration rates whilst on OST may have on HCV/HIV transmission.
[1] Platt Cochrane Database Syt Rev 2017
[2] Larney Addiction 2011
[3] Werb Eur Addict Res 2008
[4] Mattick Cochrane Database Syt Rev 2009