Barriers and enablers to opt-out hepatitis C screening in Quebec’s provincial prisons

A CanHepC study explores the barriers and enablers to implementing opt-out hepatitis C screening in Quebec’s provincial prisons.

While eliminating hepatitis C is now possible due to the advent of direct-acting antiviral therapy, achieving elimination will require specific efforts directed to the populations that are most disproportionately affected by the virus. In Canada, hepatitis C is much more common among people in prisons (PIP) than in the community making them a priority population to focus efforts on. Studies show that PIP are more likely to access healthcare providing an opportunity to link them to hepatitis C care while they are incarcerated but for this to happen they first need to be screened for hepatitis C.  

In this study, authors aimed to assess the barriers and enablers that impact the implementation of a screening strategy whereby PIP are informed that hepatitis C testing is performed unless they decline or ‘opt-out’ of testing in Quebec’s provincial prisons. Opt-out screening is considered the gold standard of screening strategies offering the most potential to increase hepatitis C diagnosis and linkage to care for PIP. Currently, hepatitis C screening is sub-optimal in Quebec’s provincial prisons and mostly offered on a risk-based assessment or on-demand often resulting in missed opportunities to identify hepatitis C cases and subsequent linkage to care to be initiated.

In this study, authors conducted qualitative interviews with 8 correctional (e.g. government, public health or regional authority representatives) and 8 healthcare professionals (e.g. nurses or prison-based physicians) stakeholders in 4 Quebec provincial prisons. They used implementation guiding frameworks to frame the interview methods, questionnaires and analyse responses received drawing specific determinants of implementation of opt-out hepatitis C screening. They also described the multisectoral decision-making processes related to hepatitis C screening in Quebec’s provincial prisons.

For correctional stakeholders, the lack of political will was identified as a barrier. They underlined the absence of formal recommendations on the preferred hepatitis C screening strategy to adopt in provincial prisons and were concerned that PIP were omitted as a priority population in regional guidelines. Furthermore, in prisons where health services are administered by the public security ministry there is a disincentive to screen people for hepatitis C as the cost of treatment (>$60,000 CAD) would have to be subsequently assumed by them. The limited availability of personnel was also perceived as an obstacle to the implementation of opt-out screening for correctional stakeholders as well as the lack of consideration for implementation issues, hepatitis C screening having never been piloted in Quebec’s provincial prisons.

Healthcare professionals expressed mixed feelings about implementing opt-out hepatitis C screening in prisons. If they were enthusiastic about potentially detecting more hepatitis C cases, decreasing transmission and harm they were also pessimistic about feasibility. The potential for increased workload, the dependence on correctional staff who are not always supportive and in some cases even adversarial, the lack of resources and support from upper management and other competing priorities brought on by the COVID-19 pandemic represented important barriers to overcome.

In terms of the decision-making processes related to hepatitis C care in Quebec prisons, they were found to be hierarchical and complex. For example, provincial guideline documents pertaining to sexually transmitted blood borne infections (STBBI) care are adapted and operationalised by each autonomous regional health authority resulting in differential access to STBBI nurses and variations in the deployment of STBBI screening (including hepatitis C screening) in provincial prisons.

This study identified cross-cutting themes and systemic issues pertaining to the implementation of opt-out hepatitis C screening in Quebec’s provincial prisons. Authors underlined the importance of considering stakeholder engagement including people with lived experience of incarceration in the implementation of hepatitis C opt-out screening. This study identified several political, structural, and organizational factors to address which will need to be prioritized by all stakeholders involved going forward.

Read the article:

Identifying barriers and enablers to opt-out hepatitis C virus screening in provincial prisons in Quebec, Canada: A multilevel, multi-theory informed qualitative study with correctional and healthcare professional stakeholders. Ana Saavedra Ruiz, Guillaume Fontaine, Andrea M. Patey, Jeremy M. Grimshaw, Justin Presseau, Joseph Cox, Camille Dussault, Nadine Kronfli. International Journal of Drug Policy, Volume 109, 2022, 103837, ISSN 0955-3959.