The present study highlights the difficulties encountered in a screening process for HCV in a prison setting, despite dedicated personnel to this specific duty, roughly 30% of subjects did not receive the screening test, eventually only a minority of them denied the consent to participate. The problem of HCV infection in prison is extensive and troublesome, but both in US and in Europe [11, 12], according to directives, correctional facilities should seriously cope with the problem of HCV infection. The CDC estimates that 12% to 35% of US inmates had chronic HCV infection , the majority of these patients being represented by IVDU and/or tattooing [13, 14]. According to different studies, the burden of HCV infected prisoners in Italy varies between 20 and 40%, therefore considering an inmate average number of 65000 , roughly 10000 to 20000 patients in prison potentially need treatment (considering that roughly the 20% of patients testing antibody positive doesn’t need treatment). These data emphasize the importance of surveillance in prison , and counseling of patients affected from HCV infection about prevention strategies and treatment options [7, 8].
The difficulties associated with HCV screening procedures in a prison setting as Opera is, are principally related to severe limitation due to a complex array of problems. First, institutional regulations and organization which cause the mobility of prisoners, who are moved from prison to prison for different reasons such as trial in cities far from the residence prison. Second, logistic problems (i.e. all the blood examination are performed outside the prison, and require time-expensive procedures to be activated) which translate into long time span between the HCV test prescription and its execution. As a consequence, despite it should be mandatory to test for hepatitis viruses and HIV all inmates, these tests are not routinely performed on admission, or, even when performed, their results can be lost during prisoner’s relocation.
Compared to Italian, foreign prisoners showed a lower prevalence of HCV infection, with African born patients, among foreigners, demonstrating the highest one, as published elsewhere . Not surprisingly, women had a higher prevalence of HCV infection than men, as higher rates of Hepatitis B and C, HIV, and sexually transmitted infection, estimated at 2–10 times that of the general population were observed among imprisoned women, moreover, women had a significantly higher prevalence of all medical and psychiatric conditions and drug dependence when compared with imprisoned men .
In our study even if only 18% of total HCV-RNA positive inmates refused the treatment, 35 subjects (26%) eventually were treated. Twenty per cent were untreated as they did not had specialist consultation and/or did not complete diagnostic procedures mainly due to organizing deficit and logistic problems. An interplay between medical and security staff should be implemented, in order to better organize the management of health needs of patients. Even if on 35 patients only, a 43% of SVR was observed, value that is comparable to data of SVR reported in the literature , confirming that in prison HCV treatment is an important option to be offered to inmates. HCV prognosis is worse if not appropriately treated, as evidenced by reduced mortality in patients successfully treated . In a recent study conducted in Texas, end stage liver disease mortality in prison population is approximately three times higher than that of the general population, reflecting elevated rates of HCV and HIV/HCV co-infection among prisoners . Finally 14% of our treated subjects, released during treatment, were lost to follow up. As releasing from jail in Italy most of times take place with no forewarning, our patients were released without any therapeutic record and no practical possibility to continue treatment out of jail. We strongly suggest Italian correctional system to improve guidelines to release inmates with sanitary records so that they can continue any treatment once free.
The highest prevalence of HCV infection was observed among HIV positive patients. HIV-HCV-coinfected patients have higher levels of serum HCV RNA , an accelerated progression to end stage liver disease and a more rapid development of liver fibrosis and cirrhosis compared to those infected with HCV alone , moreover, when treated with antiretroviral treatment for HIV, they may show a decreased immune recovery . Given the complex interplay of the two virus, HIV and HCV, it should be mandatory that HIV/HCV confected patients receive appropriate treatment for either HIV and HCV as soon as they need it. To further complicate HCV treatment in prison setting, an association between psychiatric disorders and hepatitis virus prevalence among inmates has been described , as result of intravenous drug abuse. Report of patients with chronic hepatitis C and psychiatric diseases treated in prison with interferon and ribavirin suggest that the treatment is possible and can be associated with discrete rate of virologic success [6, 7, 9, 24]. An integrated approach with psychiatric support, has been described to favorably overcome the problem of psychiatric disorders in correctional settings  and should be advocated for all HCV patients with psychiatric co-morbidities.
The principal limitation of this study is represented by its being a single center study, so that the extent of generalizability of our findings to the prisoner’s population thus remains unclear, despite the fact the Opera represents one of the larger Italian prisons. Data on HCV prevalence reported by other Italian authors are slightly higher than the ones reported in the present study [3, 4]. The reason for this difference may be explained by the fact that the population detained in Milano Opera is different from those of smaller prisons, as in Milano Opera are detained those prisoner sentenced for a period longer than three years collected from all the Country for different major crimes (that are not strictly associated with illicit drug abuse) and in smaller prisons are detained prisoners for minor offences (usually intravenous drug abusers). Moreover, despite roughly 30% of patients restricted at the time of survey were not test for HCV infection, demographic differences between those tested and not tested were not observed, not altering the reproducibility of the data. Other studies [3, 4] report data on a subset of the examined population (less than 50%) and this might have biased the reproducibility of the results. Another limitation is the absence of adequate follow up as a longer observation period, including also released patients, would have been useful to evaluate the response rate to treatment.