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Diffuse implementation of hepatitis C virus (HCV) treatment is dependent on universal screening for HCV, but screening strategies are heterogenous across prisons in the province of Quebec (Canada). We sought to identify barriers and enablers to universal opt-out HCV screening and to describe the multisectoral decision-making processes related to HCV screening in Quebec provincial prisons.A multilevel, multi-theory informed qualitative descriptive approach was used to conduct semi-structured interviews. Interview guides and analyses with correctional stakeholders were informed by the Consolidated Framework for Implementation Research (CFIR) and those with healthcare professionals (HCPs) were based on the Theoretical Domains Framework (TDF). Directed content analysis was used to identify domains within CFIR and TDF reflecting barriers and enablers to opt-out HCV screening.Sixteen interviews (correctional stakeholders: n = 8; HCPs: n = 8) were conducted in April-May 2021. Twelve CFIR constructs were identified as barriers, seven as enablers, and two as neutral factors for the implementation of opt-out HCV screening. Correctional stakeholders underscored the need for political will (construct: external policy and incentives), highlighted limited resources (construct: available resources), and expressed concerns for the lack of consideration of implementation issues (constructs: trialability, planning). Six TDF domains were identified among HCPs as relevant to the implementation of opt-out HCV screening: beliefs about consequences (mixed = enablers and barriers), environmental context and resources (barrier), social influences (barrier), optimism (mixed), emotions (mixed), and behavioural regulation (barrier). The decision-making processes vis-à-vis HCV care in Quebec correctional settings were found to be hierarchical and complex.The use of CFIR and TDF was helpful in identifying barriers and enablers to HCV screening at multiple levels for people incarcerated in Quebec provincial prisons. Going forward, several political, structural, and organizational factors should be addressed through the engagement of stakeholders and people with lived experience of incarceration.

Background Implementing opt-out hepatitis C virus (HCV) screening across Canadian provincial prisons is crucial to achieving micro-elimination. Given short incarceration lengths, the most cost-effective screening strategy remains unknown. We compared the cost-effectiveness of current standard of care (venipuncture-based HCV-antibody+HCV RNA) and 13 alternative strategies in Quebec's largest provincial prison. Methods A prison cohort was simulated with a Markov micro-simulation model. Strategies differed in the biomarkers, sampling methods, and number of tests used. The model considered incarceration lengths, time to linkage to care (LTC), nursing costs, and tests’ costs, performances, acceptability and turnaround times. Outcomes included costs (Canadian dollars, CAD$), number of true positives linked to care, and incremental cost-effectiveness ratios (ICERs, additional $/additional TP-L). A one-year time horizon and health-payer perspective were adopted. Results Across all analyses, three strategies consistently provided the best value for money: venipuncture-based HCV-antibody+HCV-core antigen, venipuncture-based HCV-core antigen (base-case ICER=~ $720), and point-of-care HCV-antibody+HCV RNA (base-case ICER=$4,310). However, these strategies linked only 23%-29% viremic individuals to care. Main drivers of cost-effectiveness were the seroprevalence, proportion viremic, and time to LTC. Conclusion Alternative strategies would be more cost-effective than standard of care for implementing opt-out screening in provincial prisons. However, interventions to maximize LTC should be explored.

BackgroundIn Canada, hepatitis C virus (HCV) transmission primarily occurs among people who inject drugs (PWID) and people with experience in the prison system bare a disproportionate HCV burden. These overlapping groups of individuals have been identified as a priority populations for HCV micro-elimination in Canada, a country currently not on track to achieve its elimination targets. Considering the missed opportunities to intervene in provincial prisons, this study aims to estimate the population-level impact of prison-based interventions and post-release risk reduction strategies on HCV transmission among PWID in high HCV-burdened Canadian city, Montréal.MethodsA dynamic HCV transmission model among PWID was developed and calibrated to community and prison bio-behavioural surveys in Montréal. The, the relative impact of prison-based testing and treatment or post-release linkage to care, alone or in combination with risk reduction strategies, was estimated from 2018 to 2030, and compared to counterfactual status quo scenario.ResultsTesting and linkage to care interventions implemented over 2018-30 could lead to the greatest declines in prevalence (23%; 95% Credible interval(CrI):17–31%), incidence (20%; 95%CrI: 10–28%), and prevent the most new chronic infections (8%; 95%CrI: 4–11%). Testing and treatment in prison could decrease prevalence, incidence, and fraction of prevented new chronic infections. Combining test and linkage to care with risk reduction measures could further its epidemiological impact, preventing 10% (95%CrI: 5–16%) of new chronic infections. When implemented concomitantly with community-based treatment scale-up, both prison-based interventions had synergistic effects, averting a higher fraction of new chronic infections.ConclusionOffering HCV testing and post-release linkage to care in provincial prisons, where incarcerations are frequent and sentences short, could change the course of the HCV epidemic in Montréal. Integration of post-release risk reduction measures and community-based treatment scale-up could also increase the impact of these interventions.