(This story has been updated with a comment from the Pennsylvania Department of Corrections.)
In 2013, a cure for hepatitis C — a chronic viral infection that, if untreated, can lead to fatal liver disease — was brought to market. But who would get the $100,000 lifesaving treatment? That's been a subject of political and legal battles ever since.
In May 2017, the Wolf administration announced that Pennsylvania would expand Medicaid coverage of the treatment to anyone with hepatitis C, instead of treating only those with signs of liver damage.
Now, through a legal settlement filed for approval Monday in federal court for the Eastern District of Pennsylvania, approximately 5,000 incarcerated Pennsylvanians who have hepatitis C would also have access to direct-acting antiviral drugs, which are effective in about 95 percent of cases.
"We believe that this settlement, if approved by the court, will be a landmark in medical care in our state prisons and will greatly advance public health in Pennsylvania. The Pennsylvania [Department of Corrections] has taken an important step in health care that puts them at the forefront of care for people with chronic hep C," said David Rudovsky, a Philadelphia civil-rights lawyer who filed the lawsuit with the Pennsylvania Institutional Law Project and the Dechert law firm.
It will, in fact, make access to hepatitis C treatment in Pennsylvania prisons better than what's available to those on Medicaid in some states.
Treatment, which will begin with the most advanced cases, will extend to everyone with hepatitis C in prison by June 30, 2022, under the agreement.
It's the result of a four-year-long class-action lawsuit filed on behalf of plaintiffs including Salvatore Chimenti, whose disease had evolved into stage-four cirrhosis of the liver, along with a slew of other health problems, but who was denied the hepatitis C treatment for more than two years. He and others alleged that the prisons had violated their rights under the Eighth Amendment prohibition of cruel and unusual punishment. In July 2018, Judge John Padova issued a memorandum indicating he believed the prisons were legally required to provide treatment.
"He almost immediately said, if somebody's sick, they've got to get treated. That's what the law required," said Angus Love of the Pennsylvania Institutional Law Project.
The settlement also was probably helped along by a drastic drop in the price of the medication, which now costs the Department of Corrections about $20,000 per course of treatment.
Amy Worden, a spokesperson for the Department of Corrections, said the department had acted ahead of the settlement to treat some of the most seriously ill prisoners. "Providing quality health care to all inmates is a priority for the Department of Corrections," she said in an email.
The department budgeted $13.2 million in its 2018-19 fiscal year for treatment, she said; 650 prisoners with advanced liver damage have already received the drug, and 105 more are now undergoing treatment. The department this year also partnered with Temple University to provide treatment and follow-up care after release.
Chimenti, 66, who received treatment in 2016, said he's not feeling any better as a result: "I was too far gone." He said that unless he gets a liver transplant, which he doesn't expect to receive while incarcerated, he'll die. Chimenti, of Philadelphia, is serving a life sentence at the Chester state prison for a 1982 murder.
But for others, he said, "it's going to be fabulous. A lot of people have been asking to get treatment, and they keep telling them, 'Your liver is not that bad yet.'"
Dr. Stacey B. Trooskin, director of the Viral Hepatitis Program at Philadelphia FIGHT and a professor at the University of Pennsylvania's medical school, said that until now, access to treatment in Pennsylvania prisons — as in many other prison systems around the country — has been substandard.
The guidelines put forward by medical associations are clear, she said: "Everybody deserves a cure. If you have a chronic hepatitis C infection and you're going to live longer than one year … you should be treated."
She said effects of the disease include everything from diabetes to skin manifestations, depression, and fatigue. Over time, a person's liver can become covered with scar tissue, reducing its ability to function and increasing risk for cancer.
Moreover, given the high prevalence of the disease in jail and prison populations — an estimated 30,000 Philadelphians reenter the community each year from institutions — she said treating them is a public-health opportunity and an essential part of an ongoing effort to stop the spread of hepatitis C in the city.
"We have to be looking to treating individuals who are incarcerated," she said. "If we're really going to be talking about eliminating hepatitis C from our community, it is a critical piece of it."
The rate of infection nationwide hit a 15-year high, the Centers for Disease Control and Prevention announced last May, as a result of the rise in intravenous drug use. Hepatitis C is a blood-borne infection that can be spread by sharing needles.
According to Mandy Altman, program manager for the National Hepatitis Corrections Network, a project of the Seattle-based Hepatitis Education Project, prevalence of the infection in prisons is estimated to be around 17 percent, compared with less than 2 percent of the U.S. population. But many states don't test inmates at all, likely because they aren't offering treatment.
That's changing, though: "Some places are taking steps to get it done as the price has come down, and at the same time there are a lot of lawsuits and advocacy efforts happening," Altman said.
Massachusetts agreed in March to provide treatment to inmates with advanced disease, and a Florida judge ordered treatment for many sick prisoners there as well. California passed a budget this year to allocate $106 million to treat 22,000 prisoners with the disease.
Altman said it's estimated that 30 percent of those who have hepatitis C pass through a prison or jail each year.
"The World Health Organization goal is to eliminate hepatitis by 2030," Altman said. "The only way you can do that is to treat correctional populations."