Many of the barriers to HCV screening and treatment in prisoners identified in this study have been reported previously in earlier studies conducted in the pre-DAA era [24, 25]. As outlined in the introduction these include lack of knowledge and awareness of HCV, poor motivation, fear of treatment, liver biopsy and stigma, competing priorities and prison bureaucracy. Lack of information regarding HCV and its management and fear of treatment are recognised as challenges to HCV elimination in PWID and prisoners [20, 24]. Much of the fear surrounding treatment is related to interferon-based therapies and the historical requirement for pre-treatment liver biopsy [34]. Pan-genotypic DAA and non-invasive mobile elastography have simplified HCV treatment [35, 36]. The findings from this study, the first conducted on this issue in the DAA era, supports the need for a program of education to disseminate this information among PWID and prisoners, who still report fear as a barrier to engagement.

Participants identified peer educators as a facilitator to engagement with health services while incarcerated and important sources to access health information. The importance of peer to peer education is well documented [37]. Peer education has been adopted in health promotion in various settings because of its cost-effectiveness over professionally delivered services [38]. Furthermore, peers are seen by other prisoners as a credible source of information and have the potential to address the lack of HCV-related knowledge and stigma reported among prison populations [38].

Study participants experienced delays in accessing HCV screening and in receiving results. It is recognised that HCV screening programs in prisons are often ad hoc, inconsistent and incomplete [18, 39,40,41]. This research found an inconsistent approach to HCV screening with many prisoners only being tested at their own request. Consideration should be given to introducing an opt-out screening program on committal to prison in Ireland [18, 40, 41]. This screening strategy has been shown to be cost effective and has the potential to reduce HCV transmission and HCV-related liver disease primarily in the community [40, 42]. It was also supported by many of the focus group participants. Importantly, it has the potential to reduce stigma [41, 43]. There was widespread support for opt-out screening at committal from the participants. The routine and structured nature of the committal process was seen as a means to embed HCV screening as a routine part of prison health care. A small number of participants expressed concerns about adding screening into an already stressful time for new committals that might be struggling with withdrawal symptoms. This concern has been reported previously in the literature [40, 44].

Research shows prison-based HCV treatment to have equivalent or better outcomes to community and hospital-based treatment if the prisoner was not released or transferred during treatment [12, 31]. Despite their high cost, the use of DAAs in prison populations, are shown to be cost effective [45]. In Ireland, in-reach hepatology services exist in three institutions and two of these are included in this study. Prisoners identified these services as enablers to screening and treatment. These services reduce the need for hospital appointments, save on prison escorts, reduce risk to the general population and the embarrassment and stigma experienced by prisoners when attending these services while hand cuffed. In Ireland, the handcuffing of patients for hospital visits only occurs in the male prison population. In this study, the female prison focus group did not experience the same stigma and embarrassment as their male counterparts when attending for hospital appointments, with many enjoying ‘the day out’ as break from the monotony and boredom of prison life. Reviewing this policy may have an impact on compliance and uptake of HCV treatment.

Consideration should be given to piloting in an Irish setting other prison HCV treatment delivery models, shown to be effective in other jurisdictions. These include nurse-led clinics, teleconferencing and upskilling prison general practitioners and addiction doctors [46,47,48]. Different models may work best for different prisons depending on HCV prevalence, the structure and skill set of local health care teams and the availability and relationships with specialist hepatology services.

Any HCV screening and treatment model adopted by the IPS needs to take into consideration the need for continuity of treatment in the event of an inter-prison transfer or community release both identified as barriers to completing HCV treatment. Prisoners are often released without notice or pre-release planning. Linking community and prison in-reach hepatology will reduce the risk of patient drop-out on release. Inter-prison transfers need to be organised in a way that ensures prisoners on HCV treatment are only transferred to prisons where their treatment can be continued. Continuity of treatment is a key component to the cost-effectiveness of active case finding and treatment in prisons and transitioning back to the community is now considered a high risk period for HCV transmission in prisons [49]. Focus group participants described the negative impact that transition back to the community with homelessness, unemployment, drug user and other competing impacts can have on HCV treatment compliance. HCV treatment is seen as a relative need and often not the most pressing in PWID’s life in the community [50].

A consistent theme expressed in all the focus groups was the stigma and shame felt by many of the prisoners who were HCV infected or had a history of drug use. This is well recognised in the literature [20, 24, 51]. Repeated concerns were voiced in the focus groups around confidentiality. Many prisoners believed that prison officers had access to their computerised health records. Some prisoners identified that having bloods taken or seeing certain staff members linked with hepatology services identified them among their fellow prisoners as drug users. Prisoners described being publicly called on their landings for certain appointments which were clearly associated with being assessed or treated for HIV/HCV infection. Many HCV-infected patients are also in receipt of methadone maintenance treatment (MMT). The provision of MMT in both study locations is a large daily operational exercise making it impossible to protect the confidentiality of those attending the services. Maintaining absolute confidentiality is difficult in prison settings [52, 53]. Despite such limitations every effort should be made to ensure medical confidentiality by educating and training of both clinical and non-clinical staff on the issue and having appropriate information sheets for prisoners on how their medical records are stored and who has access to them.

All participants favoured peer worker involvement in HCV management in Irish prisons. Peer educators are often used in prison setting to deliver education and training programs [54]. The model has also been shown to be effective in increasing HCV screening and treatment in community settings [23, 29]. Research shows high levels of satisfaction among service users and staff in community-based drug treatment clinics with this role [55]. There is further evidence to suggest that engagement in HCV care may be facilitated by the influence of peers who completed treatment [56]. The ETHOS Study in Australia reported a very strong positive response to peer workers by staff and service users which lead to improved access to services, a more client-friendly treatment environment and increased support to service users with assessment and engagement with HCV treatment [56]. Involving peer educators helps to dispel many of the myths regarding HCV treatment. It is also a very effective vehicle to develop education programs around HCV infection and treatment options. Peers can also be an effective support system for patients on treatment particularly in prison settings where traditional family and community support structures are absent. Many of the focus group participants identified the presence of a peer support network as an enabler to HCV screening and treatment.

The strength of this study is that we were able to evaluate how different groups discussed HCV together and how they debated the merits and weaknesses of identified blocks including their own experiences. The use of the focus group methodology allowed for the engagement of large numbers of prisoners with limited use of prison staff. This is an important consideration for any research conducted in real-life prison settings with limited staff resources and competing priorities. The engagement of both male and female prisoners was identified as a strength and increased the generalisability of the findings both nationally and internationally. There are a number of limitations to this study including; participants may not have revealed their complete HCV narrative in the presences of others, researcher 1 was known to the male participants and the involvement of only two of the 15 prisons located in the ROI. Apart from age and gender other demographics on focus group participants were not collected. Knowledge of incarceration and drug use history along with HCV status and treatment history of the participants could have increased the interpretation and understanding of the focus group narratives. While the focus groups were conducted in only two locations, many of the participants had experience of other prisons and contributed these during the interviews. This may increase the generalisability of the findings to prisons outside of Dublin.