HCV test and treat in two Milan prison institutions: an effective strategy to achieve micro-elimination.

Background: People in prison represent a crucial high-risk population for HCV and other blood born infections control due the overrepresentation of people with a history of intravenous drug use, psychiatric patients and other vulnerable populations who have often reduced access to healthcare. With the advent of new direct antiviral agents (DAAs) HCV micro-elimination in prison setting became a feasible strategy. We studied the impact of an expanded HCV treatment program in Milan prisons between 2017 and 2018. Methods: We conducted in 2017 and 2018 a cross-sectional evaluation of HCV treatment cascade in one detention prison, Opera (OP), and one pre-trial detention center, San Vittore (SV) in Milan. A dedicated protocol for HCV eligibility and care was applied. We collected data on demographic (sex, date of birth, origin country, drug addiction), HCV testing and treatment (HCV antibodies, HCV-RNA, previous therapies, treatment outcomes on all inmates present at 31st October 2017 and 2018. Data collection was closed on 31st December of each respective year. Results: At 31st October 2366 inmates lived in the two facilities in 2017, 2369 in 2018, of the latter 1036 (43,7%) were already present in 2017 (28,7% in OP; 71,3% in SV). In 2017 and 2018 the majority were men (95.4%; 96,4%) with a median age of 41 years (IQR= 31-51) and were Italian nationals (57%; 61,9%). Prevalence of reported previous or current use of drugs remained high in the study period (46,5%; 44,2%). Screening for HCV was offered to all inmates, reaching a coverage rate of 89% in both years, while HCV-RNA test coverage increased over time (90,6%; 99%). HCV sero-prevalence was stable (212, 10.1%; 194, 9,2%). Considering last available viremia at 31st December, in 2017 41 inmates (19,3%) were still viremic, with a difference between OP (16.1%) and SV (24,4%); in 2018 13 inmates (6,7%) had still positive HCV RNA, of which only one in OP (<1%). Regarding outcomes recorded at 31st December, 8 (3,8%) individuals had their eligibility process ongoing in 2017 and 3 (1,5%) in 2018, 30 (14,1%) individuals were on treatment in 2017 and 5 (2,6%) in 2018; 90 (42,4%) and 106 (54,6%) completed DAAs in prison, of which 38 (17,9%) and 76 (39,2%) achieved SVR respectively in 2017 and 2018. On 31st December 2017 and 2018, 151 (71,2%) and 179 (92,2%) patients were HCV-RNA negative, including 38 (17,9%) and 43 (22,2%) who had spontaneously cleared the infection. Inmates who were not initiated on DAAs decreased over time: 11 (5,2%) in 2017, 3 (1,5%) in 2018, mostly for psychiatric conditions. Conclusion: Our study demonstrates the success of the HCV test and treat strategy to achieve HCV microelimination in a prison setting. These results show an increase of DAAs treatment coverage during 2017-2018 and consequently a significant drop of the pool of viremic individuals. However, high turnover of inmates in the pre-trial detention center remains a barrier for treatment initiation and elimination.