Wednesday September 5, 2001

PITTSBURGH - When Charles White was sentenced to prison in Oregon for robbery five years ago, he knew nothing about hepatitis C. It was only after his release in December that he found out he was infected with the blood-borne virus.

A prison doctor had told him he had high liver enzymes - a telltale symptom of the sometimes-fatal condition - and cautioned him against taking aspirin or drinking coffee. Nothing more. "I asked him, `What does that mean?'" White said. "He didn't answer my questions, he didn't tell me about hepatitis C, he didn't counsel me."

Inmate advocates say White's experience is common in America's prisons, where a

staggeringly high 18 percent of inmates are infected, compared with 1.6 percent of the overall population, according to the Centers for Disease Control and Prevention. That translates into about 360,000 out of the nation's 2 million inmates.

Hepatitis C is spread by intravenous drug use and, in rare instances, transfusions or sex. It can cause jaundice, fatigue, pain and vomiting and gradually affects the liver, leading to cirrhosis and liver cancer.

About 4 million Americans are infected and about 8,000 people die of the disease each year.

The problem in prisons may be bigger than the numbers themselves: Health care experts still do not agree whether prevention counseling or treatment is the best way to fight the epidemic in prisons.

That is because the liver infection develops slowly and can now be treated only with expensive drugs that have potentially serious side effects and sometimes low rates of success. Liver transplants are an option, but waiting lists are long.

"It's almost distracting to talk about treatment - the much larger issue is prevention," said Dr. Robert Greifinger, a medical consultant who helped study the infection rate of state prison inmates for the CDC and the Justice Department. "It's easy to diagnose the infection, but it can take 20 or 40 years before some people develop symptoms," and some people never do. Hepatitis C drugs can cost $12,000 to $14,000 per person per year and often induce side effects ranging from intense flu-like symptoms to severe suicidal thoughts. The drugs are not effective unless they are taken for six to 18 months, so many inmates are denied treatment because they will or could be released from prison before their treatment would be complete.

As a result, budget-minded prison administrators and inmate advocates cannot agree on whether to test all inmates for the infection and on when those who test positive should be treated. "It's been my experience that any type of expensive treatment like this tends to be rationed by inconvenience," said Dr. Anne De Groot, who helps publish the HIV and Hepatitis Prison Project News. "Eventually you run out of time as an inmate."

States vary widely in how they are addressing the issue.

Pennsylvania began testing all 37,000 inmates in February, while New Jersey does not test inmates until they exhibit symptoms of liver disease - which inmate advocates and some physicians say is too late. Other states fall in between. Oregon this year tested a 10 percent sample of its 9,600 inmates and found that 30 percent were infected.

Corrections officials now meet monthly to debate strategies to fight hepatitis C with state legislators, health officials and inmate advocates, like White, who runs an HIV/AIDS Awareness Project.

More states are educating their inmates about the virus and considering broader testing because of the public health risk and the threat of class-action lawsuits by infected inmates.

Dr. Richard Cevasco, assistant director of the New Jersey Corrections Department, said there are about 800 known infected inmates out of around 23,000, and about 10 in treatment.

Those not treated either refused, were turned down for a medical reason, or - most likely - did not have sufficient time left on their sentence to complete treatment, Cevasco said.

"I think the analogy can be made with HIV. I think 12, 14 years ago when the HIV stuff started, we had the same questions" about the costs and effectiveness of treatment, Cevasco said. "But now I think the HIV care in prisons is a lot better and a lot more consistent. I think the problem with 'Hep' C is there's no one (generally accepted) course of action."