Advances in HCV treatment and increasing access in the community setting to HCV care have led to a step change in treatment and outcomes; many prisoners do access HCV care. Treatment of HCV for prisoners is limited in Germany, increasing but limited in some areas in England, France, and Italy. In Spain there is wider access to care with still further progress needed.

Analysis of prison populations in 5 selected countries in Europe identifies 35,000 (25–45,000) prisoners potentially requiring HCV treatment. In each country estimated prisoner HCV populations identified are England and Wales, 9000 (range: 5–13,000), France, 8000 (4–12,000), Spain, 6000 (6–8000), Italy, 6000 (3–6000), Germany, 6000 (6–8000). Evidence describing prisoner HCV population is often limited and varying data is reported. Number of patients requiring treatment in this work is estimated based on an interpretation of the available studies and experience of experts actively engaged in the treatment system for each respective country. The number is an estimate based on best available sources and it is reasonable to assume from assessing evidence from published sources identified here. The range of population size is stated based on available sources; in each case the most likely value for a country was determined by final expert decision. Experts have extensive experience in prison healthcare and the evidence of appropriate population size.

There is important opportunity to improve outcomes for this group for whom access to care can be limited. Policy development and implementation of optimal clinical practice with improved engagement is key for success (e.g. providing education alongside streamlined, efficient screening programs using modern tools to reduce inconvenience and provide essential diagnostic information without excess delay). Sentence or custody length may present a barrier for prisoner assessment and inclusion in HCV care programs, which can be addressed. Policy and clinical guidelines should ensure that there is equity of selection for prisoners and that sentence length is not used inappropriately to limit treatment. In addition, optimizing treatment process to reduce time and facilitate treatment continuity can make treatment a reality for another 15,000 prisoners with short periods of custody. The right to prescribe modern DAA therapy should be as wide as possible to address access to specialists. Learning from the approach to HIV medicines prescribing is important – non-physician prescribing should be considered where locally possible including models of oversight to enable other HCP to commence therapy.

Successful treatment of HCV in the prisons is based on clear policy defining equity of access, linked to an integrated treatment approach, which directly addresses potential barriers to success. In locations where policy and treatment approach are aligned and optimal, many prisoners with HCV have been treated and prison acts as an important contact point for HCV care engagement.

The following principles should be considered as a key part of the approach to providing treatment and improving prisoner HCV care:

1. Develop and update policy through national and/or relevant regional (1) HCV care guidelines and (2) prison healthcare guidance to include screening, testing, and treatment of HCV for prisoners 2. Adopt innovative, local clinical practice guidance including choices to improve engagement and screening, and to make the prisoner HCV treatment as easy and effective as possible 3. Implement standards and metrics for measuring and reporting activity and outcomes of prisoner HCV screening and treatment 4. Plan for integrated care models between the community and prison with healthcare record sharing to make treatment continuity the norm during prisoner release 5. Endorse a holistic approach to prisoner health including equitable access to integrated treatment programs for OUD.

Providing a treatment service in prisons consistent with these principles defines a gold standard. In this analysis no prisoner with HCV across any one country achieves full access to HCV care in prisons. Based on observations, it is noted that care is very limited in many areas in Germany, sometimes limited but increasing with areas of success in some areas in Italy, France and England and more commonly available in regions of Spain. All prisoner health services should aim to reach the gold standard of HCV care.

This work is based on an assessment of current approaches to prisoner HCV care from 5 countries in Europe. It is likely that these observations are applicable elsewhere: further work to assess the situation in other locations is recommended. Additional input from prison health, OUD and HCV specialists from other countries can add further to the understanding; many of the challenges and successes identified here may apply generally. Consensus on the size of relevant populations is reached based on the available evidence and expert familiarity with the treatment area. It is likely that the consensus represents a strong estimate of population size but this approach is limited - further measurement of prevalence of HCV in prisons should be undertaken in all settings to confirm the validity or improve this approach.