National Assembly for Wales Health, Social Care and Sport Committee
Inquiry into the provision of health and social care in the adult prison estate in Wales
Gilead Sciences
Gilead Sciences is a research-based biopharmaceutical company that discovers, develops and commercialises innovative medicines in areas of unmet medical need. We strive to transform and simplify care for people with life-threatening illnesses around the world. Gilead's portfolio of products and pipeline of investigational drugs includes treatments for HIV/AIDS, liver diseases, cancer, and inflammatory and respiratory diseases. Gilead has three sites in the UK: our international regulatory headquarters in Cambridge, our commercial office in London, and our EMEA regional office in Uxbridge. Together people working from these sites provide approximately 1,000 jobs in the UK, with a portion of the work force based locally across Wales, England, Scotland and Northern Ireland.
Over the past 4 years Gilead has been working in partnership with multiple stakeholders across Wales supporting educational initiatives with a focus on the development of simplified hepatitis C care pathways across a variety of diverse community based settings (including prisons). The key aim of this partnership has been to increase access to testing & improve linkage to care and treatment.
Summary
Gilead Sciences welcomes the opportunity to contribute written evidence to support the inquiry into the provision of health and social care in the adult prison estate in Wales, being undertaken by the National Assembly’s Health, Social Care and Sport Committee. This submission of evidence will focus primarily on the management of the physical health of prisoners with long-term conditions, in particular the Blood-Borne Viruses (BBV) hepatitis C, hepatitis B and HIV/AIDS, areas of Gilead expertise. However, in dealing with the subject area of BBVs, it will cover a number of the themes examined in the inquiry’s scope, including how effective current arrangements are, what the current demand and delivery pressures are and what the barriers currently are to improving the prison healthcare system in Wales.
While the Criminial Justice System remains a Reserved Matter, the healthcare system within the Welsh secure estate is a competence that has been develoved to the National Assembly for Wales and is therefore a responsibility of Welsh Ministers, in partnership with other key public agencies, like NHS Wales, Public Health Wales and local government.
People in contact with the Criminal Justice System, including those in prison and on probation, tend to be in poorer health than the general population and have a greater need for health and care. For many people detained in prison, their poor health status arises from, and/or has been exacerbated by, early Adverse Childhood Experiences (abuse, neglect and trauma) social circumstances (problems with housing and employment) and higher rates of smoking, alcohol and substance misuse. Therefore, a period of imprisonment presents a unique opportunity to turn around their health outcomes and life chances.
While the majority of adult prisoners within the Welsh Secure Estate are from England, it is no doubt the intention of the Welsh Government for any prisoner secured in Wales to be able to experience the same level of healthcare as the general population in line with European legislation, and World Health Organisation recommendations, most recently set out in their report Prisons and Health from January 2019.[i] Unfortunately, while there are ‘hot spots’ of excellent care in Welsh prisons for those with BBV infections, variations in approach mean that we cannot currently say that prisoners within the Welsh Secure Estate do experience equivalent healthcare to the general population.
If the Welsh Governement is aspiring for parity in terms of access and quality, the healthcare system in Welsh prisons needs to ensure:
· The extension of BBV opt-out testing - in line with existing guidance - to ensure that all new prisoners are offered a test (including agreed frequency of testing eg: 6 monthly);
· Roll out of a “test and treat” model, initiating treatment for BBVs as soon as a positive diagnosis is made and, in the case of the Hepatitis C Virus (HCV), without the need for genotyping or fibroscanning which can delay the start of treatment;
· Continuity of care for patients who move or leave prison during a course of treatment, crucial for both HCV and HIV. This will require close working with Community Rehabilitation Companies (CRCs) and secondary care planners in the community;
· That there are clear, public healthcare targets (Key Performance Indicators) which prisons must meet, and clear accountability from Prison Governors to ensure that testing and treatment for BBVs is delivered to all who need it;
· That all parties involved in healthcare of Welsh prisoners have access to the relevant data and informatics systems to facilitate continuity of care;
· The provision of peer engagement to encourage the take up of BBV testing and treatment and to support those diagnosed with a BBV while in prison (including an option to refer to psychology services for people who require additional support).
These recommendations are in line with very good reports from The Hepatitis C Trust (“Guidance - Hepatitis C prevention, diagnosis and treatment in prisons in England”[ii]) and the and National Aids Trust’s Framework on Blood-Borne Viruses[iii] – which include clear guidance about the prevention, diagnosis and treatment of BBVs in prisons.
Testing in Prisons
Around 90% of hepatitis C cases in the UK are people who have injected[iv] or are currently injecting illicit drugs, while almost a third of people in prison are believed to have injected drugs in their lifetime.[v] Testing in prison therefore provides a unique opportunity to reach this community. Prevalence of the HCV in prisons has been estimated at around 7% , while a recent Gilead project suggests it could be as high as 10-15% in places, compared to 0.7% in the general population.
Despite it being the most prevalent infection diagnosed in prison, the testing rate for HCV in prisons has, historically, been very low. This is attributed to a culture of poor confidence in and understanding of HCV treatment, as well as stigma surrounding treatment amongst prisoners. There are also wider challenges with HCV awareness amongst prison healthcare staff. Public Health Wales, The Hepatitis C Trust, British Liver Trust and National AIDS Trust, all recommend an ‘opt-out’ testing programme national screening programme for all new inmates to be tested for BBVs in Welsh prisons. In addition, guidance from NICE is clear that people entering or transferring between prisons should be tested for BBVs within 7 days of arriving at the prison and, if diagnosed with one of these viruses, should be offered specialist referral, treatment and support.
Welsh prisons have been routinely testing for blood-borne viruses (BBVs), including hepatitis C, since 2010. In November 2016, Wales moved to opt-out testing where all men in prison are offered BBV testing within the first few days of imprisonment. BBV specialist services from local health boards run clinics in every prison, providing treatment for hepatitis C, hepatitis B and HIV. In 2017, more than a third of prison admissions were tested, a significant increase since the move to opt-out testing. Around 10 per cent of men tested in prisons were found positive for hepatitis C antibodies.[vi]
However, part of the Welsh Government’s elimination commitment is to make prisons HCV free, which is achievable but requires additional staff resource. While testing in prisons is improving, two key challenges remain: - current work force capacity and throughput of prisoners (the speed of through-put and transfer of prisoners can be challenging, so there is a need to get prisoners tested and on a care pathway quickly before they are moved). The need for a BBV nurse in each prison (like the one based in Parc Prison, Bridgend) will encourage normalisation of BBV testing in the prison setting and allow inmates to be tested and treated quickly. Without additional clinicians on the ground, stemming the reservoir of infection while prisoners are in custody will not be achieved.
Treatment
Key to treating hepatitis C in prisons is ensuring the gap between diagnosis and the start of treatment is as small as possible. People who inject drugs prior to incarceration may only stay in prison for a few months. Previously, the need for patients to undergo genotype testing and have a fibroscan of their livers has delayed the start of treatment for hepatitis C. However, with Direct Acting Antiviral (DAAs) now available for the treatment of all genotypes, such pre-treatment procedures are no longer necessary and there is no longer any reason to delay the start of treatment. We need to move rapidly to a “test and treat” model in prisons so that prisoners are not only offered an ‘opt-out’ test within 7 days of arriving in prison but can, where infection is confirmed, immediately access the necessary DAAs.
Where prisoners do move prison or are released during a course of treatment, more must be done to ensure continuity of care for hepatitis C and HIV including – where appropriate - clear service requirements of Community Rehabilitation Companies and protocols for the transfer of care into community settings, as well as creating access to the relevant data to facilitate this. To underpin both testing and treatment protocols, data on the performance of individual prisons must be used to drive improvements and ensure that testing and treatment for BBVs is prioritised across the prison estate.
HIV treatment programmes in prisons should already be integrated into or linked to general HIV treatment programmes delivered by Health Boards. These programmes must ensure that British HIV Association (BHIVA) clinical guidelines[vii] are also followed and inmates are offered:-
• annual treatment reviews linked to yearly health checks in line with BHIVA guidelines
• psychology services to provide support to those who need it
• advice on disease prevention (including access to educational materials, condoms and PrEP)
Conclusion
While the responsibility of the Welsh prison estate and its staff are the concern of the UK Government, the provision of health care to prisons is the responsibility of Welsh Government and its partners. Therefore, both governments have a duty of care towards people detained in Welsh prisons and both need to do more to ensure that prisons remain healthy and safe while they are being detained by the state.
Developing a range of Hepatitis C micro-elimination strategies for prisons which includes opt-out screening in all prisons, coupled with increased investment in clinical staff and accountability for delivery of KPIs, prisoners would be afforded the best opportunity to start and maintain, an appropriate treatment pathway.
Achieving this requires strong working relationships between agencies and the Third Sector (drug and alcohol treatment services), both within and outside of the prison estate. This multi-agency approach is not only beneficial to prisoners’ healthcare whilst being incarcerated, it is hugely beneficial in the transition process from prison into probationary services, ensuring that treatment pathways and person-centred outcomes are not eroded during what can be, a challenging period of reintroduction into the community and wider society.