Drug Reform series-Grasping the nettle: Prisons, drug use and the law

Author: Helen Tyrrell, CEO of Hepatitis Australia

Every day people are imprisoned for drug-related crimes in line with ‘tough on drugs’ policies. It’s time to face the futility and unsustainability of this approach to drug use.  

Prisons are a growth industry. In the 2016/17 Budget the NSW Government announced a $3.8 billion infrastructure plan for the state’s prison system to address current and future needs; and between 2006 and 2016 Victoria’s prison population increased by 67%.

A quick look at National Prisoner Census data reveals that on 30 June 2017 over 40,000 adults were in Australian corrective custody. They were mostly male, frequently serving a sentence for a drug-related crime and were disproportionately Aboriginal and/or Torres Strait Islanders.  Half had injected drugs before, and one-third disclosed injecting while in prison.

Studies show that injecting drug use decreases in prison, while syringe sharing increasesposing a high risk for hepatitis C transmission. Around one-third of all prisoners in Australia are living with chronic hepatitis C, a potential life-threatening liver disease. Little wonder esteemed infectious diseases physician and prison blood borne virus (BBV) expert Professor Andrew Lloyd AM said “ prisons act as incubators of hepatitis C, driving the epidemic both within the prison system and in the community at large.”

How do we turn this around? 

Drug law reform is part of the solution to the burgeoning prison population resulting in fewer convictions. Addressing the postcode lottery of inequalities and strengthening disadvantaged communities through prevention and early intervention are also critically important – particularly for young Aboriginal and Torres Strait Islander people. Based on the twin goals of safer communities and reduced incarceration, the Justice Reinvestmentapproach is a standout in this regard and is unequivocally a better option than punitive custodial environments and the unsustainable cost of building more prisons.

As we wait for a new, more logical, evidence-based, and humane approach to drug use to be constructed in Australia, we must acknowledge that no prison is ‘drug free’ and therefore we must adopt measures to reduce the harms associated with prisons and drug use.

Take provision of opioid substitution therapy (OST) as an example. The World Health Organization (WHO) recommends OST for prisoners and the United Nations Office on Drugs and Crime (UNODC) describes it as an “essential”. Australian studies have found OST is protective against acquisition of hepatitis C and HIV, and that mortality in opioid-dependent prisoners was significantly lower while in receipt of OST. Why then is access to OST restricted rather than mandated in Australian prisons?

Need and syringe programs

Bleach, used to clean injecting equipment, is only available to prisoners in three Australian jurisdictions. It is in any case a sub-optimal choice compared to Prison Needle and Syringe Programs (PNSP), as to avoid detection injecting is often rushed and groups of prisoners are sharing one ‘loaded’ syringe. The UNODC says “it is unethical to propose bleach when a more efficient means of prevention, such as PNSP, is available”.

By not providing PNSP in Australia, every day we are contravening the:  International Covenant on Economic, Social and Cultural Rights Article 12; the Universal Declaration of Human Rights, Article 25; and the human rights principle “equivalence of care” (resolution 45/111 of the United Nations Organization (“Basic principles for the treatment of prisoners”) whereby prisoners should have health care equivalent to that in the community.

The published evidence supporting PNSP is irrefutable. The Australian Prime Minister’s advisory body, Australian National Council on Drugs, reviewed the evidence and recommended an Australian trial in 2002. In endorsing the 2010-2013 National Hepatitis C Strategy, all Australian Health Ministers endorsed trialling PSNP. Since then, the Australian Capital Territory (ACT) Government under the leadership of Katy Gallagher as Chief Minister, committed to introduce a regulated PNSP at the ACT’s prison. The commitment stalled however when she left the ACT government for a career in federal politics and it was eventually ‘put to bed’ by a deed of agreement gifting power of veto over PSNP to the ACT prison union.

This provides a cautionary tale about abdicating power over public health measures to prison unions on the one-hand and over-reliance on a single strong and effective leader to stare down the rhetoric and opposition from those unions on the other. Sustained political will to implement PNSP has, for the most part, been missing in Australia.

More recently, the South Australian Government committed to investigate the feasibility of implementing “the full suite of harm reduction strategies available to the wider South Australian community in prison settings”. We remain hopeful.

In the absence of sustained political will, legal action may turn out to be the catalyst for exchanging the current unregulated needle and syringe supply programs run by prisoners throughout Australia for much safer and effective systems of regulated PNSP. Most recently legal action by Canadian advocacy groups resulted in Correctional Services Canada announcing a phased plan to implement a PNSP which subsequently commenced in mid-2018.

Treatment as prevention

For now, ‘treatment as prevention’ is the primary strategy being used to control hepatitis C in Australian prisons. This has produced remarkable results in a handful of prisons and has clear benefits for individual prisoners, society as a whole, and potentially for the elimination of hepatitis C in Australia. Acknowledging that the full range of harm reduction strategies in the community is not available inside prisons, the jury is still out on whether hepatitis C reinfections will undermine prison-based ‘treatment as prevention’ programs.

Hepatitis C treatment is expensive and OST and PNSP are cheap by comparison. Public health experts are in agreement that combining both treatment and harm reduction produces the best results. So why don’t we just give it a go in prisons?

Unfortunately, too many of those able to instigate changes put evidence-based harm reduction in prisons in the ‘too hard basket’ – along with drug law reform.

It is difficult – and the right thing to do.

Originally published: 9 August 2018 John Menadue - Pearls and Irritations


Fewer Australians are dying from hepatitis C, but thousands are still missing out on treatment

Source: ABC News - Health Author: Olivia Willis

The number of Australians dying from liver failure and liver cancer related to hepatitis C has dropped by 20 per cent in just two years, according to preliminary data released today by The Kirby Institute.

It follows the introduction of highly effective, low-cost curative drugs to the Pharmaceutical Benefits Scheme (PBS) in 2016.

"This decline reflects the high uptake of direct-acting antiviral therapies among people with hepatitis C, particularly those with more advanced liver disease," said Greg Dore from the Kirby Institute.

"Since 2016, around 60,000 Australians have been treated with the highly curative therapies, and now for the first time, we are seeing fewer people dying of hepatitis C-related causes."

The data also showed the prevalence of hepatitis C infection among people who currently inject drugs had declined from 43 per cent in 2015 to 25 per cent in 2017.

"In terms of trying to control the epidemic, that is an enormous stride forward," Professor Dore said.

It is estimated, however, that 170,000 people in Australia are still living with chronic hepatitis C.

And, recent data shows, while the uptake of life-saving antiviral therapies was strong initially, there are now fewer than half as many people accessing the drugs as there were in 2016.

Hepatitis Australia's chief executive officer Helen Tyrrell said the recent drop in treatment uptake was "a real concern" and suggested many people remained unaware of the benefits or availability of new treatments.

"It is a tragedy that hundreds of thousands of Australians are missing out on life-saving therapies which can cure hepatitis C in a matter of weeks … when these cures are readily available with a prescription from their GP," Ms Tyrrell said.

What is hep C?

  • Hepatitis C is a blood-borne virus that attacks the liver. It is spread by contact with infected blood.
  • The symptoms of chronic hepatitis C often take years to emerge, meaning liver damage can 'silently progress' for some time.
  • Left untreated, hepatitis C can lead to cirrhosis (scarring of the liver), liver cancer and liver failure — and can be fatal.
  • In Australia, hepatitis C is most commonly spread through the sharing of unsterile drug injecting equipment.

New treatments 95pc effective

While hepatitis C treatments have been available for some time, previous therapies were "very long", "very gruelling" and "not all that effective", Ms Tyrrell said.

"What changed in March 2016 was some fantastic new cures became available. It was a real revolution when the Government agreed to put them on the PBS for everyone in Australia," she said.

The new treatments, which consist of daily tablets taken for approximately eight to 12 weeks, are generally well-tolerated and cure hepatitis C in 95 per cent of people.

Australia leads world in hepatitis C treatment

Australia is leading world in hepatitis C treatment, but the virus remains more prevalent in Aboriginal and Torres Strait Islander people.

Prior to being listed on the PBS, the drugs cost upwards of $20,000. They now cost less than $40 and can be prescribed by general practitioners — removing the need for specialist care.

"Being able to access these treatments through a GP is fantastic because it opens up the ability for people to come forward if they are a bit reticent because of the stigma," Ms Tyrrell said.

Australia is one of the only countries in the world to offer hepatitis C treatments at low cost, and without restrictions based on a person's stage of liver disease or injecting drug use behaviours, said Professor Dore.

"Australia's done an amazing job over the first two years … but only 30 per cent of people living with hepatitis C in Australia have been treated, so we need to continue to raise awareness about these life-saving treatments," he said.

Reaching marginalised communities

Professor Dore said for many people, a diagnosis of hepatitis C was often compounded by a complex set of health and social problems.

Hepatitis C disproportionately affects Aboriginal and Torres Strait Islander people, people who inject drugs, and people who are incarcerated.

"Some people might be homeless, some might have major mental health issues, some may not be injecting but they're on the margins — so they're not being adequately reached," Professor Dore said.

"That's why we need more innovative strategies to reach populations that might be more marginalised."

You could be at risk if:

  • You've been tattooed or had a piercing with unsterilised equipment
  • You've had an unsterile medical procedures or vaccination, particularly in countries with high rates
  • You've had a needle-stick injury
  • You've shared injecting drug equipment, including tourniquets, spoons and needles

A lack of awareness on the part of both patients and healthcare professionals has also led to low levels of treatment uptake in some parts of the community, Ms Tyrrell said.

"Many people may still not be aware of the new treatments. People who were diagnosed 20 or 30 years ago — when there really weren't any treatments available — may have been told to just go home and not worry about it," she said.

"Then you've got people who just aren't prioritising their treatment right now because they have no symptoms, and that's really dangerous … because often symptoms don't develop until quite serious complications occur."

In addition to raising community awareness, Ms Tyrrell said it was important for GPs to prioritise hepatitis C testing and treatment and to "start conversations with people they know may be at risk".

Stigma persists

Sydney man Grenville Rose contracted hepatitis C in the late 1970s and lived with the virus for almost 40 years, before being successfully treated with the new, highly curative oral therapies in 2015.

"I've been lucky to have the support of friends and family, but that's certainly not a universal experience for people with hepatitis C," he said.

Grenville said many people faced stigma and discrimination when disclosing or discussing their illness with family, friends or healthcare professionals.

"I've heard some really awful stories," he said.

"I once sat in front of a GP … she looked me in the face and said she really hated junkies and that they were a waste of space."

Ms Tyrrell said such stigma continued to be a significant barrier to people seeking treatment today.

"It is really disappointing sometimes that you get those attitudes," she said.

"Hep C is a health condition like any other. It doesn't matter how you got it — the important thing is that people are cured."

Australia on track to meet WHO targets

Despite the recent drop in treatment uptake, Professor Dore said Australia was in a good position to meet World Health Organisation elimination targets — to reduce hepatitis C deaths by 65 per cent and new infections by 80 per cent before 2030.

"We are somewhat concerned that things have declined in 2018 … but we are on track to probably treat 15,000 to 17,000 people this year," he said.

"There's no doubt the more people we treat, the faster the uptake is — particularly in those high-risk populations — the quicker we'll get to those elimination goals."

In July, the Federal Government announced $1 million in funding to "continue education and awareness activities" to improve hepatitis C testing and treatment uptake.

Call for action on hepatitis C elimination: Australian GPs pledge to raise number of people treated by GPs to over 10,000 per year by 2025

12 August 2018 Adelaide, South Australia

Empowering primary care has been the central theme underpinning a one-day forum held in Adelaide today, where a delegation of 50 general practitioners (GP) from all Australian States and Territories called their fellow primary care providers to action through the launch of the Aus GPs End Hep C statement.

General Practitioner Dr Joss O’Loan said the delegation is committed to empowering GPs to treat people with hepatitis C (hep C) in primary care and priority settings, by setting goals and sharing strategies for success.

“The Aus GPs End Hep C statement is calling for action to address the urgent need for many more Australian primary care providers to get on board with the screening, treatment and management of hepatitis C,” said Dr O’Loan, the statement's primary author and one of its founding signatories.

“This is the first time a collective of GPs from around Australia have stood up together to take ownership of this pressing issue. Our role at the frontline of primary health care in Australia is critical if we are to achieve the target of hep C elimination [as set by the World Health Organisation] by 2030.”

“Australia’s access to direct acting antiviral (DAA) therapy is the envy of primary care physicians around the world, and yet, currently only 10% of GPs in Australia have written a DAA script. Through the Statement, we commit to an ambitious goal of raising this to 20% by 2020 – and bringing the number of patients with hep C being treated by GPs to more than 10,000 per year by 2025.”

“We are now calling on our primary care peers to get involved and work towards these goals. It falls on GPs to raise our game, keep our shoulders to the wheel and liberate our patients from the tyranny of hepatitis C.”

Infectious diseases physician Professor Greg Dore, Head of the Viral Hepatitis Clinical Research Program at The Kirby Institute, UNSW Sydney, continues.

“Australia has laid the foundation for HCV elimination, particularly with involvement of GPs in prescribing. Greater investment is required, however, to increase GP prescribing, and turnaround declining treatment numbers. GPs are essential to meet our ambitious but achievable goals.”

Dr Sam Elliott, another of the Statement’s founding signatories, concurs with the responsibility of GPs in improving the cascade of care for people living with hepatitis C.

"For people living with hep C, receiving treatment in familiar environments with their trusted, accessible, long-term doctor removes an important barrier to treatment. Treatment in primary care is suitable for the majority of people living with hep C, yet currently only around 40% of DAA scripts are written by GPs. Through the Statement, we are setting a goal to raise this to 75% by 2025. We need Australian GPs to acknowledge that hep C screening and treatment is now core general practice work, sitting alongside diabetes, skin cancer and mental health.”

CEO of Hepatitis Australia Helen Tyrrell adds her voice addressing the need to remove barriers of stigma and discrimination as experienced by those living with hepatitis C accessing health-care settings.

“The stigma surrounding hepatitis C can often act as a barrier to care. However, stigma may be less of a concern once people know they can see their GP to access treatment. The trust relationship between GPs and their patients is absolutely vital to improving access to care. We want GPs to take up the challenge and be much more involved in identifying and treating people with hepatitis C, and by doing so they will be contributing to the goal of eliminating hepatitis C in Australia.”

Access the Aus GPs End Hep C Statement

• GPs and primary health care can find out more and/or become a signatory to the Aus GPs End Hep C Statement at bit.ly/AusGPsEndHepC

Links to Clinical Resources supporting the hepatitis C workforce

• ASHM support the primary health workforce in hepatitis C with best practice in guidelines, training and resources – visit http://ashm.org.au/HCV/ 

• Australian medical practitioners who are not experienced in hepatitis C treatment can gain specialist approval or further guidance to initiate DAA therapy for their patients in 24 hours by completing the REACH-C online form – visit http://www.reach-c.ashm.org.au/