Hepatitis C Treatment as Prevention in Custodial Settings
Hepatitis C remains a major communicable disease affecting people in custody, with Australian prevalence estimates among the highest globally. Correctional centres across Queensland, New South Wales, and Victoria record antibody positivity rates that dwarf those seen in the wider community, reflecting the criminalisation of drug use and the over-representation of people who inject drugs. Addressing this burden requires a public health lens in which treatment itself becomes prevention.
The arrival of direct-acting antiviral therapies has shifted what is possible inside prisons. Where older interferon regimens demanded months of difficult side effects, modern oral treatments achieve cure rates above 95% within eight to twelve weeks. This therapeutic shift has allowed health services to borrow treatment-as-prevention models from HIV research, in which reducing the viral reservoir in a defined population lowers transmission for everyone.
Translating research into practice is the central mission of organisations working at the interface of discovery and clinical delivery. Networks linking universities, hospitals, and primary care providers offer a practical bridge for evaluating how elimination strategies perform in real-world conditions, including the ethically complex environment of prisons where consent and confidentiality must be balanced against operational constraints.
The Burden of Hepatitis C in Australian Prisons
Australian prisons house roughly 44,000 adults on any given day, and seroprevalence studies show that 20% to 40% of these individuals live with chronic hepatitis C. Aboriginal and Torres Strait Islander people are dramatically over-represented, accounting for around one-third of the prison population while comprising less than four percent of the broader community. Risk factors accumulate through shared injecting equipment, unsafe tattooing, and uneven access to opioid agonist therapy.
Queensland Health has worked with correctional authorities to expand testing at reception, yet many people cycle through remand and short sentences without completing treatment. Each release potentially seeds new community transmission, turning the prison itself into a critical intervention point where treating infection inside becomes an act of public health extending beyond the wire.
Direct-Acting Antivirals and the Shift to Prevention
Modern pan-genotypic regimens such as sofosbuvir-velpatasvir and glecaprevir-pibrentasvir have simplified prescribing so specialist oversight is no longer required in every case. Sustained virological response at twelve weeks post-treatment is considered equivalent to cure, and side effects are mild enough that most people complete therapy without disruption. The PBS listing makes these medicines affordable for everyone with a Medicare card, including those in custody.
The mathematical logic of treatment-as-prevention rests on shrinking active infection. When enough individuals within a network are cured, the probability that any exposure leads to transmission falls sharply. In prisons, where injecting networks are small and identifiable, this threshold can be reached relatively quickly, protecting cellmates, partners, and downstream community networks after release.
Micro-Elimination as a Feasible Goal
The concept of micro-elimination acknowledges that reaching the World Health Organization's 2030 viral hepatitis targets in Australia requires focus on defined subpopulations. Custodial settings are an obvious candidate: bounded, with a captive population engaged with health services at reception and discharge, and prevalence high enough that moderate coverage yields substantial reductions in new infections.
Programs in the Australian Capital Territory and parts of Victoria have shown that opt-out testing at reception, combined with on-site treatment, can identify and cure the majority of cases within twelve months. Embedding hepatitis C nurses within correctional primary care teams removes many historical barriers and accelerates momentum.
Real-World Evidence and Ethical Considerations
Evaluating treatment-as-prevention in prisons relies on real-world data drawn from clinical records, correctional health databases, and linkage studies that follow individuals across custody and community. Such work raises important questions about consent, privacy, and the appropriate use of routinely collected health information. Engaging people in custody as partners strengthens both the science and the legitimacy of the findings.
Reinfection is often cited against scale-up, with critics suggesting that curing individuals only to see them re-acquire the virus represents poor value. Evidence from Australian and international cohorts suggests otherwise: reinfection rates are lower than primary infection rates in the same populations, and cost per cure remains within accepted thresholds for public health investment.
Continuity of Care Beyond Release
Treatment outcomes achieved in custody are only durable if people can continue care in the community after release. Prison-based programs that include active referral to community clinics and discharge summaries consistently outperform discharge with only a prescription. In Brisbane, partnerships between Hospital and Health Services and community organisations have shortened the gap between release and first community appointment to under two weeks.
Embedding hepatitis C follow-up within primary care, mental health services, and Aboriginal Community Controlled Health Organisations offers a realistic pathway. A recent case study illustrates how integrated mental health care can respond to overlapping needs. People leaving custody face competing priorities, and mental wellbeing shapes whether someone can sustain a treatment plan.
Scaling Up Across Jurisdictions
Australia's federated health system means that scaling prison-based elimination requires negotiation with state and territory corrections authorities, each with its own framework. National leadership through the Australian Government Department of Health and Aged Care, combined with state-level implementation agreements, has accelerated progress in several jurisdictions. Funding models that recognise the public health benefit outside prison continue to evolve, and stronger cross-portfolio collaboration between justice and health would help.
Nurse-led care has proven highly effective, particularly when supported by telehealth access to hepatologists. Training correctional officers and peer workers in hepatitis C literacy reduces stigma and improves uptake; several Queensland sites now run peer-led education.
Sustained Investment and System Reform
For treatment-as-prevention to fulfil its promise, Australia must maintain commitment beyond initial enthusiasm. The PBS has made medicines affordable; what remains is operational investment in nurses, peer workers, data systems, and harm reduction services inside prisons. Sustained funding signals to correctional authorities that hepatitis C is a priority and gives clinical teams the security to plan multi-year programs.
Linking custodial health records with Medicare and primary care data, with appropriate safeguards, would provide the evidence base for ongoing refinement. Partnerships between research institutes, universities, and health services across Queensland and beyond offer ready infrastructure for this work, ensuring that policy decisions are grounded in the realities of Australian custodial settings.
Practical Steps to Strengthen the Response
- Adopt opt-out hepatitis C testing at reception into Australian correctional facilities, with immediate linkage to treatment where infection is detected.
- Fund dedicated hepatitis C nursing positions within each state and territory correctional health service to coordinate testing, treatment, and follow-up.
- Standardise electronic health records that follow individuals across custody and community, including automated reminders for post-release follow-up.
- Embed hepatitis C care within Aboriginal Community Controlled Health Organisations and primary care clinics receiving people after release.
- Maintain universal access to direct-acting antivirals through the Pharmaceutical Benefits Scheme and remove remaining prescriber restrictions in custodial settings.
- Sustain and expand harm reduction measures alongside treatment, including opioid agonist therapy and access to sterile injecting equipment where permitted.
- Evaluate programs continuously using linked data and partnership-based research that involves people with lived experience of incarceration.
Queensland and Australia more broadly have a real opportunity to lead the world in hepatitis C elimination, and prisons are where that leadership will be judged. Clinicians, researchers, and policymakers working in correctional health, infectious disease, or public health can support this effort by connecting with collaborative networks that translate evidence into action across the state's health system.
