By Taylor Knopf
On the second floor of the early 20th century Durham post office building is a federal courtroom where the state prison system’s Hepatitis C screening and treatment policies are under scrutiny.
In June, three state prisoners sued the N.C. Department of Public Safety (DPS) arguing that they were denied treatment for their Hepatitis C virus, a highly contagious disease that targets the liver.
“DPS refuses to provide medically necessary treatment simply to avoid the associated costs,” reads the lawsuit, filed by the American Civil Liberties Union of NC and Prisoner Legal Services on behalf of the three plaintiffs.
Because prison officials are responsible for the health of those in custody, the plaintiffs’ counsel argued that refusing treatment violates the Eighth Amendment to the U.S. Constitution, which bans cruel and unusual punishment.
In the past, Hepatitis C treatments were expensive and not always effective. But now it’s curable in almost every patient due to new medications, known as direct-acting antiviral drugs.
On Monday, attorneys Daniel Siegel and Michele Luecking-Sunman with Prison Legal Services detailed the plight of the three inmates who sought Hepatitis C treatment who were initially denied due to prison policies.
The plaintiffs’ counsel is seeking a class-action ruling, arguing that DPS should be universally screening all inmates that enter the system and treating everyone who tests positive. This would help inmates by stopping continued damage to the liver and subsequent symptoms and possibly prevent cases of liver cancer down the road, something that’s been correlated with long-term Hepatitis C infection.
Determining best practice
DPS policy is to only screen “at-risk” inmates for Hepatitis C and only to treat inmates once they have reached a certain level of fibrosis, or liver scarring.
The policy also disqualifies inmates for treatment for other reasons for which the lawsuit claims there is “no medical justification,” such as a mental health condition or fewer than 10 years of remaining life expectancy.
Hepatitis C is more prevalent among the incarcerated population. It’s frequently spread through sharing of needles from injection drug use or tattooing. As heroin use has increased across the state and the country, so has the rate of HCV infection.
Anyone who has ever been incarcerated should be tested for Hepatitis C, according to screening guidelines from the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases.
The plaintiffs’ brought one expert witness to the stand on Monday: Andrew Muir, chief of the Division of Gastroenterology at Duke University Medical Center and professor at Duke’s medical school.
Muir testified that DPS is not following what is considered the “best practice” for the screening and treating of Hepatitis C.
He said the fibrosis scale and testing DPS uses — and by which it determines necessary treatment — is outdated. Muir said he cannot determine how advanced the disease is by that measurement. He noted that Duke University and the practices he supervises across the state no longer use it.
He added that the North Carolina Medicaid system also used this same scoring to determine when to treat until recently. He urged DPS to follow suit.
From a public health perspective, it makes sense to want to treat these patients who will one day be released, Muir said. He added that the public health goal is to eliminate Hepatitis C in communities, with broad screening and treatment of the incarcerated population being the best way to start.
Muir said he manages the liver clinic at the Durham Veterans Affairs Medical Center, and that the VA plans to close it because the clinic has successfully treated North Carolina’s veteran population with Hepatitis C.
After hearing the larger public health arguments, the lawyer for DPS, Orlando Rodriguez, said the court needed to refocus on the three plaintiffs in the case.
He argued that these three inmates would not benefit from universal Hepatitis C screenings at DPS because they have already been screened and know that they are positive for the disease.[sponsor]
Rodriguez said that to prove DPS violated the Eighth Amendment, the plaintiffs’ counsel needed to prove “deliberate indifference” and “irreparable harm.”
“We don’t believe they have come close to proving that,” he said. “At best, they are building a negligence claim.”
Prison Legal Services attorney Siegel rebutted, saying that the prison population is “riddled with this infection” and that his clients risk reinfection. He argued they would benefit if more inmates were screened and treated.
“The vast majority of the North Carolina population with Hepatitis C is in state prison,” Siegel said. “We have the chance to screen, treat and eradicate it. How this could not be of public interest is beyond me.”
The judge said he would hear the arguments to expand this case to a class-action hearing on Monday at 10 a.m. at the U.S. District Court in Durham.
An estimated 110,000 North Carolinians are living with Hepatitis C, and about 75 percent of those people don’t even know it.
The number of acute Hepatitis C cases has increased fourfold since 2009, according to Zack Moore, state epidemiologist with the N.C. Department of Health and Human Services.
There are two classifications of Hepatitis C: chronic and acute. Until January 2017, the state only tracked acute Hepatitis C, cases that are newly identified with active symptoms.
Historically, the virus wasn’t always curable. The medications were expensive and treatment took up to a year to complete. But that has changed. There are new medications, known as direct-acting antiviral drugs, that completely cure HCV; insurance companies, as well as Medicaid and Medicare, are covering it.
When the direct-acting antiviral drugs were first introduced their prices were extraordinary. However, in the past few years, prices have come down considerably. NC Health News has reported patients spending anywhere from $8 to $50 per month for their Hepatitis C treatment after insurance.