THE ROLE OF PRIMARY CARE PROVIDERS IN HEPATITIS C TREATMENT FOR
PEOPLE IN CANADIAN PRISON SYSTEMS
by
Adam Christopher Biff Beaumont
B.Sc.N., University of Victoria, 2010

PROJECT SUBMITTED IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN NURSING
FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
July 2025
© Adam Beaumont, 2025

Abstract
People in custody in Canadian provincial prisons experience disproportionately high rates
of hepatitis C virus infection. Despite national and international calls for hepatitis C elimination,
treatment access remains inconsistent within correctional settings. This integrative review
examines the barriers primary care providers face in delivering hepatitis C care to people in
custody in Canada. Following Whittemore and Knafl’s (2005) five-step framework, nine peerreviewed studies published between 2015 and 2024 were analyzed using thematic synthesis.
Studies included qualitative, quantitative, and mixed method designs, and were drawn from
Canada, Australia Austria, the United States, and international contexts. Five global themes
emerged: (1) inconsistencies in screening, treatment access, and healthcare systems across
institutions; (2) variable access to opioid agonist therapy and harm-reduction services; (3)
challenges in implementing opt-out hepatitis C screening; (4) poor linkage to care post-release;
and (5) education gaps among both providers and people in custody. Barriers were found to be
compounded by the coercive nature of correctional environments, institutional fragmentation,
and limited continuity of care. The review supports recommendations for transferring healthcare
oversight to public health authorities, expanding nurse practitioner-led care, implementing harm
reduction practices, and strengthening intersectoral collaboration to improve system level
coordination. Addressing these systemic issues is essential to meeting hepatitis C elimination
targets and improving health equity for incarcerated populations.

Keywords: hepatitis C, incarceration, primary care, barriers, nurse practitioners, correctional
healthcare, Canada.

ii

TABLE OF CONTENTS

Abstract.........................................................................................................................................................................ii
TABLE OF CONTENTS.............................................................................................................................................iii
Territorial Acknowledgment ........................................................................................................................................ v
Dedication .................................................................................................................................................................... vi
List of Tables .............................................................................................................................................................. vii
List of Figures ............................................................................................................................................................ viii
Acknowledgments ....................................................................................................................................................... ix
Glossary ........................................................................................................................................................................ x
Introduction .................................................................................................................................................................. 1
Chapter One ................................................................................................................................................................. 3
Background ............................................................................................................................................................... 3
Chapter Two ............................................................................................................................................................... 10
Methods ...................................................................................................................................................................... 10
Step 1: Problem Identification ................................................................................................................................. 10
Step 2: Literature Search Strategy ........................................................................................................................... 11
Step 3: Eligibility Criteria ....................................................................................................................................... 14
Step 4: Critical Appraisal ........................................................................................................................................ 15
Step 5: Data Analysis .............................................................................................................................................. 17
Analysis Framework ................................................................................................................................................ 18
Search Limitations ................................................................................................................................................... 20
Chapter Three ............................................................................................................................................................ 22
Findings ...................................................................................................................................................................... 22
Study Characteristics and Populations .................................................................................................................... 22

iii

Introduction to Data Appraisal ................................................................................................................................ 25
Participant Samples and Data Scope....................................................................................................................... 26
Broader Context and Timeline ................................................................................................................................. 27
Thematic Synthesis .................................................................................................................................................. 27
Standardization of Systems ...................................................................................................................................... 28
OAT and Harm-Reduction Supplies ......................................................................................................................... 30
Opt-Out Screening ................................................................................................................................................... 32
Linkage to Care Post-Release From Custody........................................................................................................... 34
Education for Providers and Patients ...................................................................................................................... 35
Chapter Four .............................................................................................................................................................. 37
Discussion ................................................................................................................................................................... 37
System Standardization ............................................................................................................................................ 37
Harm Reduction and OAT ....................................................................................................................................... 38
Opt-Out Screening and Choice in Care ................................................................................................................... 38
Linkage to Care and Transitional Support ............................................................................................................... 39
Education for Providers and Patients ...................................................................................................................... 39
Synthesis and Implications for Nurse Practitioners ................................................................................................. 40
Chapter Five ............................................................................................................................................................... 43
Conclusion .................................................................................................................................................................. 43
References ................................................................................................................................................................... 46
Appendix A: Search Terms and Results from October 3, 2024 ................................................................................ 51
Appendix B: Search Terms and Results from October 12, 2024 .............................................................................. 53
Appendix C: Data Extraction Table .......................................................................................................................... 55
Appendix D: Mixed Methods Appraisal Tool ........................................................................................................... 59

iv

Territorial Acknowledgment
I would like to acknowledge that I am an uninvited settler, living on the traditional and
unceded territory of the T’Sou-ke Nation. I am truly grateful for their everlasting stewardship of
these lands, and hope that I can live and interact with this community in a way that is healthy and
always in communion with mother earth.

v

Dedication
For my family. It has always been for you.

vi

List of Tables
Table 1: Criminalized Hepatitis C Transmission Risk Behaviours
Table 2: PRISMA Flow Diagram
Table 3: Critical Appraisal Summary Using Appropriate Tools
Table 4: Summary of Research Studies on Hepatitis C in Correctional Settings

vii

List of Figures
Figure 1: Example of Thematic Networks

viii

Acknowledgments
I would like to thank my project supervisor, Dr. Catharine Schiller, for her thoughtful
guidance, steady support, and critical insight throughout the development of this project. Your
feedback consistently pushed me to think more deeply and write with greater clarity.
Thank you to Carrie, for your love, patience, and encouragement during this process.
Your support reminded me to stay grounded and focused, even in the most challenging moments.
Thank you also to Randy, for your perspective and willingness to listen while I worked through
my ideas, often out loud and at length.
A special thanks to Sarah, for helping me set realistic goals, offering perspective when I
lost sight of the bigger picture, and showing up as a soundboard, with unwavering support when
it mattered most.
Finally, and most importantly, I extend my deepest gratitude to the individuals and communities
affected by hepatitis C, particularly those living and working within correctional systems.
Your experiences, resilience, and advocacy continue to inform and inspire efforts toward more
equitable care.

ix

Glossary
Custody
The state of being kept in detention by legal authority, especially while awaiting trial or
sentencing. In the correctional context, it refers to the physical detainment of a person by law
enforcement or correctional institution (Merriam-Webster, n.d.).
Direct-Acting Antivirals (DAA)
A class of medications used to treat chronic HCV infection. They target proteins in the virus that
are essential for the replication, inhibiting its ability to reproduce. These medications are
administered orally, and have drastically changed the treatment landscape for HCV, with cure
rates over 95%, shorter treatment durations of 8-12 weeks, and improved tolerability compared
with previous therapies (Centers for Disease Control and Prevention, 2025b).
Hepatitis B Virus (HBV)
A contagious virus that infects the liver and can cause both acute and chronic liver disease,
including cirrhosis and liver cancer. HBV is transmitted through contact with infected body
fluids, such as blood, semen, or vaginal secretions, commonly through perinatal transmission,
unprotected sex, or sharing needles. Vaccination for HBV is available and effective in preventing
HBV infection (Centers for Disease Control and Prevention, 2025a).
Hepatitis C (HC)
An infectious disease caused by the hepatitis C virus. It happens when the virus enters the body
and starts multiplying in the liver. The infection can be short term (acute) or long-lasting
(chronic), and if left untreated can cause serious liver damage (Centers for Disease Control and
Prevention, 2025b).

x

Hepatitis C Virus (HCV)
A bloodborne virus that infects the liver and can cause both acute and chronic inflammation of
the liver. The virus is primarily transmitted through exposure to infected blood, such as through
injection drug use, unsafe medical practices, or transfusions of unscreened/infected blood
(Centers for Disease Control and Prevention, 2025b).
Human Immunodeficiency Virus (HIV)
A virus that attacks the body’s immune system, specifically the CD4 (T cells), which help the
immune system fight infections. Untreated, HIV can lead to acquired immunodeficiency
syndrome (AIDS). HIV is transmitted through contact with certain body fluids such as blood,
semen, vaginal fluids, rectal fluids, and breast milk, most commonly during unprotected sex or
through sharing needles. There is no cure for HIV, but it can be controlled with medications and
medical care (Centers for Disease Control and Prevention, 2025c).
Nurse Practitioner (NP) A registered nurse with advanced training who provides primary and
specialized healthcare services, including diagnosis, treatment, and medication management.
Opioid Agonist Therapy (OAT)
A medical treatment for people with an opiate use disorder that involves the use of long-acting
opioid medications, like methadone, buprenorphine/suboxone (suboxone), or sublocade, to
reduce cravings and withdrawal symptoms. The goal with this therapy is to stabilize people who
would alternatively be using opioids, reducing the risk of overdose and helping to support
recovery (Health Canada. 2024).
Primary Care Provider (PCP)
Frequently used abbreviation in this paper to reference NPs and physicians.

xi

People in Custody (PIC)
Frequently used abbreviation in this paper to reference a group of people, or a person,
incarcerated in a jail or prison.
Remand
Court ordered temporary detention of a person, following the issuance of a Remand Warrant,
where they will await trial or sentencing, or before the beginning of a long-term-sentence
(Statistics Canada, 2015). Individuals on remand have been charged with a criminal offence but
have not been convicted. They are typically held in provincial or local correctional facilities.
This remand status can impact access to health care services, including screening and treatment
for conditions like hepatitis C, due to the unpredictability and potentially short duration of
incarceration.
Sentence/Sentenced
In Canada, being sentenced means a court has officially determined the punishment for a person
found guilty of a criminal offense. A sentence can involve time in custody or alternatives like
probation or fines. Custodial sentences of less than two years are served in provincial or
territorial jails, while sentences of two years or more are served in federal prisons (Correctional
Service Canada, 2025).
Sexually Transmitted Blood Borne Infections (STBBI)
Infections transmitted through sexual contact or exposure to infected blood. Includes HIV, HBV,
HCV, chlamydia, gonorrhea, syphilis, and human papillomavirus (HPV). STBBIs can be spread
through vaginal or anal sex, sharing of needles, or from mother to child during pregnancy,
childbirth or breastfeeding (Public Health Agency of Canada. 2018).

xii

Sustained Virological Response (SVR)
A term used to indicate the absence of detectable HCV RNA in a patient’s blood sample, 12
weeks after completing antiviral treatment. Achieving SVR signifies the eradication of the virus
from the body and is considered equivalent to a cure for chronic HCV infection (Centers for
Disease Control and Prevention, 2025b).
World Health Organization (WHO)
A specialized agency of the United Nations responsible for international public health,
connecting people around the world to promote health, keep the world safe, and to serve
vulnerable populations (World Health Organization, 2025a).

xiii

Introduction
Despite the availability of highly effective curative therapies, hepatitis C (HC) continues
to disproportionately affect people in custody (PIC), a population who are frequently overlooked
in mainstream healthcare systems but who remain a target population requiring testing and
treatment for HC, as identified by the World Health Organization (WHO, 2019). Globally, over
25% of incarcerated individuals are estimated to be living with HC (WHO, 2018), yet many
remain undiagnosed or untreated, reinforcing cycles of poor health and marginalization.
In 2016, the WHO established a global strategy to eliminate HC as a public health threat
by 2030. This strategy defined the ‘elimination’ target as a 90% reduction in new chronic
infections and a 65% reduction in related mortality, relative to 2015 levels (WHO, 2018).
Achieving those goals requires that 90% of people with HC be diagnosed and 80% of those
diagnosed be receiving treatment. However, progress has stalled (Tian et al., 2024), particularly
with respect to high-risk populations such as incarcerated individuals, due in part to testing
plateaus and gaps in care delivery (WHO, 2021).
In Canada, the structure of the correctional system adds complexity to healthcare access.
Federal institutions house individuals serving sentences of more than two years, while provincial
and territorial facilities manage those serving shorter sentences or who are being held on remand
(Government of British Columbia [BC], 2024). These jurisdictions differ across the country in
terms of healthcare governance and delivery, but the entity that is responsible for providing each
prison’s healthcare should be providing for all healthcare needs of those in their custody,
including chronic disease management, addiction treatment, mental health support, and public
health services (United Nations [UN] General Assembly, 2015).

1

Despite these intentions and responsibilities, the uptake and delivery of HC treatment in
correctional settings remains uneven. Barriers that are present in custodial systems complicate
efforts by primary care providers (PCPs) to deliver healthcare treatment in a consistent manner.
Understanding these barriers can move the system closer to reaching global HC elimination
goals and aid in improving healthcare access for one of Canada’s most marginalized populations.
From a public health perspective, if such barriers can be addressed, there is an increased
likelihood of improving health outcomes of PIC, reducing hepatitis C virus (HCV) transmission
rates after release from custody, and supporting equitable public health systems.
This integrative review addresses the question: what barriers exist for primary care
providers in providing HC treatment to PIC in Canada? By examining this question through a
public health lens, this research will contribute to a better understanding of the ways in which
correctional healthcare systems can evolve to meet the needs of PIC as well as support PCPs in
providing quality care.

2

Chapter One
Background
HC is a liver infection caused by the bloodborne HCV, which spreads mainly through
contact with infected blood. In most cases, this occurs when people share needles or other
equipment used to inject drugs, though transmission can also occur through poorly sterilized
medical equipment during procedures or unscreened blood transfusions (Centers for Disease
Control and Prevention, 2025b; WHO, 2025b). In high-income countries, groups such as people
who inject drugs and men who engage in sex with other men, especially those living with human
immunodeficiency virus (HIV), face a higher risk of contracting the HCV (Martinello et al.,
2023). After initial infection, most people show no symptoms, yet around 70-80% will develop
chronic HC (Centers for Disease Control and Prevention, 2025b; WHO, 2025b). Without
treatment, the disease can silently progress over decades, eventually leading to liver conditions
such as cirrhosis, liver failure, or hepatocellular carcinoma (Martinello et al., 2023). Fortunately,
direct-acting antivirals (DAAs) now offer a highly effective cure in more than 95% of cases,
typically with few side effects and a short treatment duration (Centers for Disease Control and
Prevention, 2025b). Treating the infection not only improves long-term health outcomes but also
reduces the risk of transmission to others. While DAAs are effective, if left untreated, HC can
cause lasting liver damage and significantly increase the risk of life-threatening complications
(WHO, 2025b).
HCV infects approximately 50 million people worldwide, with an additional 1 million
new infections occurring each year (WHO, 2025b). Prisons are an environment of high HC
prevalence and have been recommended as a target population for HC screening, treatment with
medications, education about prevention, and linkage to care upon release from custody (WHO,

3

2025b). PIC are at particularly high risk for HCV transmission due to the communal living
environment, engagement in high-risk behaviours, such as the use of substances via routes
exposing them to blood borne illnesses, and their reluctance to engage with specialist healthcare
(Overton et al., 2019). An exploration of these high-risk behaviours can be found in Table 1.
Arain et al. (2014) found that substance use typically continues while in custody, though with
decreased access to sterile equipment, placing PIC who use drugs at further increased risk of
acquiring HCV. The WHO (2019) found that one in four of all PIC worldwide are HCV positive,
with one in three deaths and 23% of new infections attributed to injection drug use. HCV
infection puts people at risk for developing liver cirrhosis and liver cancer; it can also lead to
liver failure requiring transplant when HC is left untreated, leading to an early death (FaladeNwulia et al., 2017).
Table 1
Criminalized Hepatitis C Transmission Risk Behaviours
Population/Behaviour
People Who Inject Drugs

Criminalized or
Illegal Activity

Associated HCV
Transmission Risk

Possession/use of
illicit drugs

High risk from sharing
contaminated needles
or injection equipment

Sex Workers

Sex work, solicitation

Risk from unprotected
sex with multiple
partners

Men Who have Sex with
Men

Criminalized in some
jurisdictions

High risk from
unprotected anal sex
and high prevalence of
co-infections

Contextual
Factors in
Prison
Limited harmreduction;
injection often
continues in
custody
Stigma, limited
condom access,
coercive or
transactional
sex
Stigma, risk of
sexual
violence, lack
of prevention
options

4

Population/Behaviour

Criminalized or
Illegal Activity

Associated HCV
Transmission Risk

Tattooing and Body
Modification

Unauthorized
practices in most
prisons

High risk from shared,
non-sterile tattooing
equipment

Disruption of Support
Networks

(Consequence of
incarceration)

Increases vulnerability
to high-risk behaviour;
decreases continuity of
care

Lack of Harm Reduction
Services

Policy and
institutional barriers

Increases HCV
transmission due to
absence of sterile
supplies and health
education

Contextual
Factors in
Prison
Tattooing
common due to
cultural and
identity
expression;
lack of sterile
tools
Mental health
declines,
weakens postrelease
reintegration
Prevalent in
many Canadian
federal and
provincial
institutions

Note. Sources: Courtemarche et al., 2018; Hoy, 2020; Kronfli et al., 2019a; Kronfli et al., 2021;
Silbernagl et al., 2018; Wanamaker et al., 2024.
Direct-Acting Antivirals
The introduction of DAAs in 2013 marked a turning point in HC treatment. These
medications target specific viral proteins required for replication, thereby halting the infection
(Geddawy et al., 2017). DAAs are well tolerated, require only short courses of treatment, and
have cure rates exceeding 95%, significantly outperforming previous interferon-based therapies
(WHO, 2025b). Studies have shown that successful treatment also reduces liver-related
complications and may lower risks related to other health conditions, such as cardiovascular and
mental health issues (Jeong et al., 2024).
In most case, DAAs can cure HC, even in people with advanced liver disease. Cure is
defined as sustained virological response (SVR), which means the virus is undetectable in the

5

patient’s body 12 weeks after treatment. These medication regimens are typically simple to
prescribe, with few side effects, making them well-suited for use in primary care settings.
Cost of Hepatitis C
The impact of HC goes well beyond a person’s liver health, as it can carry additional and
lasting costs, both financially and in humanitarian terms. When left untreated, the infection can
progress silently for years, eventually leading to serious health implications. Managing the
advanced stages of liver disease is expensive and places a considerable burden on public
healthcare and systems (WHO, 2018). Globally, the economic burden of HC is substantial; Blach
et al. (2017) estimated the total annual cost related to HC, including direct medical expenses and
productivity losses, exceeds $10 billion (in United States currency).
Curative treatments such as DAAs are widely available and relatively cost-effective in
the long run; however, there remains costs for people trying to access treatment. The up-front
costs of these medications can be a barrier to access, especially for individuals without consistent
healthcare coverage and support, or without access to healthcare (Martinello et al., 2023). In
many cases, it is not simply about the monetary cost, there are valid and important concerns
about who is treated and who is not.
Beyond economics, the human cost is harder to quantify but just as important. HC tends
to affect people who are already marginalized, such as those living with unstable housing, people
who use drugs, or individuals in the criminal justice system. Many of the marginalized
populations also face stigma and systemic barriers that prevent them from obtaining the care they
need (Centers for Disease Control and Prevention, 2025a). For these individuals, the virus is not
just a medical condition, as it reflects broader issues of exclusion, inequity, and lost potential.

6

Without targeted and inclusive approaches, the goal of eliminating HC by 2030 may remain out
of reach (WHO, 2021).
Worldwide HCV Targets
In 2016, the WHO (2018) endorsed guidance and recommendations to eliminate HC as a
public health concern by 2030. Elimination was defined as a reduction in new chronic infections
by 90%, and a 65% reduction in HC-related mortality, compared with 2015 baseline rates
(WHO, 2018). Achieving these targets will require diagnosing 90% of people infected with the
HCV and providing treatment to 80% of those diagnosed with HC. The WHO (2021) articulated
specific methods to achieve these targets, including: treatment with DAAs, access to harmreduction, and treating all HCV-infected persons, regardless of any form of prioritization or
group (WHO, 2018). However, the WHO also noted that testing had plateaued and there were
challenges in reaching the marginalized populations of men who have sex with men, people who
inject drugs, people in prisons, transgender people, and sex workers, who all have particularly
high HCV infection rates.
Canadian Prison System
In Canada, there are two primary types of imprisonment: federal and provincial. The
federal system supervises individuals who have received sentences of more than two years as
well as those who have been released back into the community when their sentence is complete
or who have been paroled (Government of BC, 2024). The provincial system is comprised of
people who have been remanded into custody while awaiting trial, and people who have been
sentenced to less than two years. Individuals who have been released from custody on bail, or
who are serving their sentences in the community, are also under provincial jurisdiction
(Government of BC, 2024). Some provincial prisons are exclusively remand; exclusively

7

sentenced, and others house a mix of remand and sentenced individuals. In addition to the federal
and provincial prison systems, there is also short-term holding which occurs in police stations
after an individual has been arrested. This third type of short-term incarceration will not be
included in this integrative review.
In BC, responsibility for the provision of PIC healthcare lies with the Provincial Health
Services Authority (British Columbia Mental Health and Substance Use Services, n.d.). This
health authority is not only responsible for the management of all medical needs of a person
while they are held in provincial custody, but also for transitions to community services when an
individual is released from custody (British Columbia Mental Health and Substance Use
Services, n.d.). Within each of BC’s 10 provincial centers, there is a primary healthcare team
comprised of multiple care providers, including physicians (MDs) and nurse practitioners (NPs)
(British Columbia Mental Health and Substance Use Services, n.d.).
According to the WHO (2018) report, 26% of PIC worldwide are infected with HCV, and
64% have a history of injection drug use. In Canada, approximately 25% of all PIC have been
exposed to the HCV (Kronfli et al., 2019a). The WHO has identified PIC as a population of
priority for HCV screening and treatment due to the high-risk behaviours prevalent in this
population, such as sharing of injection and tattooing needles (see Table 1). The criminalization
of drug use has meant that one in every five PIC is in detention for a drug-related offence (WHO,
2018).
Challenges in Treating Hepatitis C in Custody
PIC experience a much higher burden of HCV infection compared to the general
population, making correctional facilities an important setting for screening and treatment.
Although PIC are entitled to receive a level of health care that is equivalent to that provided in

8

the community, delivering consistent and effective HC in a correctional setting remains
challenging. Some of these challenges include limited healthcare and correctional officer
staffing, incomplete medical records, frequent transfers between facilities, short or unpredictable
length of stays, and security policies that can delay, restrict, or interrupt treatment (Kronfli et al.,
2019a). In addition, stigma surrounding both incarceration and HC may discourage individuals
from seeking care or completing prescribed treatment (Spaulding & Thomas, 2012). As a result
of these challenges, not all PIC who could benefit from treatment will actually receive it.
In Canada, PIC often face delayed or missed opportunities for care, despite having high
rates of HC (Kronfli et al., 2021). Provincial correctional settings in particular face logistical
challenges, and continuity of care can break down during transitions in and out of custody.
Interruptions in care, whether due to short stays, transfers, or lack of infrastructure, can result in
missed chances to detect and treat the disease effectively (Kronfli et al., 2019b).
In addition to variability in the length of stay, access to testing and treatment inside provincial
prisons is inconsistent, posing an additional barrier to HC treatment; however, the federal prison
system has worked towards bridging this gap (Kronfli et al., 2019b).
This inconsistency in care provision for PIC is concerning because correctional facilities
offer a unique chance to diagnose and treat HC among this at-risk population. Yet many PCPs
working in these settings may not be initiating treatment, even when it is clinically appropriate.
This integrative review explores potential reasons why HCV treatment may not be initiated in the
carceral setting. Identifying the barriers that prevent PCPs from prescribing DAAs in Canadian
prisons could help address treatment gaps, improve care for people living with HC while
incarcerated, and support broader public health goals, including the 2030 HCV elimination target
set by the WHO (2019).

9

Chapter Two
Methods
This integrative review follows the five-step framework outlined by Whittemore and
Knafl (2005), which provides a structured approach to synthesizing research from diverse
methodologies. These steps are: identifying a problem, conducting a systematic literature search,
applying eligibility criteria, critically appraising the quality of selected studies, and analyzing
findings through thematic synthesis. This method allows for comprehensive understanding of
barriers in HC treatment delivery within Canadian correctional settings.
Step 1: Problem Identification
This integrative review employs the PICO framework to examine the barriers faced by PCPs
in delivering HC treatment to people incarcerated in Canadian correctional facilities. The PICO
elements are defined as:
•

P (Population/Problem): People incarcerated in Canadian correctional facilities, who
have a high prevalence of HCV infection.

•

I (Intervention): HC treatment.

•

C (Comparison): Current standard of care.

•

O (Outcome): Improved access to, and delivery of, HC treatment by PCPs, leading to
higher treatment initiation and completion rates.

This review focuses on studies published between 2015 and 2025, a period marked by
significant advancements in HC treatment, notably the introduction of DAAs in 2014. These
medications have transformed HC management by offering high cure rates, shortened treatment
durations, and improved tolerability (Walker et al., 2015). The timing is also significant due to
the adoption of the Mandela Rules in 2015, which emphasize the right of prisoners to receive

10

healthcare equivalent to that available in the community (United Nations General Assembly,
2015). This review examines how these developments intersect with the experiences of PCPs in
Canadian correctional facilities.
Step 2: Literature Search Strategy
A systematic search was conducted across several electronic databases selected for their
relevance to health sciences and correctional healthcare research, using the University of
Northern British Columbia (UNBC) online library system in October and November of 2024.
The writer received assistance from the UNBC librarian in developing the search terms and
navigating the databases, as well as how to best utilize the databases. The EBSCOhost interface
facilitated searches across four academic databases: CINAHL, PubMed, MEDLINE with Full
text, and SocINDEX. Initially, broad search parameters yielded an overwhelming number of
results; therefore, refined search strategies were employed, incorporating Boolean operators and
specific keywords related to the research question. In addition to database searches, Google
Scholar was utilized to identify relevant studies that had not been indexed in the formal
databases searched. Heavily cited authors in this research area, such as Nadine Kronfli and Sofia
Bartlett, were also searched in Google Scholar by name. Reference lists of found articles were
also hand searched for articles that were relevant to the review question. Hand searching resulted
in one article that focused on patients coming through an emergency room (Lam &
Dimaculangan, 2023), not solely the target population (people who had experienced or were
experiencing incarceration). This study was included as it demonstrated how augmenting a
multidisciplinary team with additional expertise impacted the care of people with HC. Moreover,
it is possible that people who had experienced incarceration were included in their study. Only
peer reviewed, published studies (i.e. no grey literature) were included to ensure methodological

11

rigor (Kutcher & LeBaron, 2022). Given the environment and population being studied, and the
significant marginalization of PIC (Bartlett et al., 2021, Kronfli et al., 2021, Lafferty et al., 2018,
Overton et al., 2019), it was decided that grey literature held too much risk of contributing to that
marginalization since it is not peer reviewed. Kutcher and LeBaron (2022) assert that excluding
grey literature can be a method for quality control. This process of refining the located articles
into the final studies included in this integrative review is represented in the PRISMA flow
diagram shown in Table 2.

12

Table 2
PRISMA Flow Diagram

13

The results of creating searches in each database using relevant search terms and Boolean
operators are presented in Appendices A and B. Searches were conducted focusing on peer
reviewed articles published between 2015 and 2024. These searches and search terms were
selected to reflect the intersection of HC treatment, correctional healthcare, and PCP experiences
in the Canadian context.
Step 3: Eligibility Criteria
Studies were included in this review if they met the following criteria:
•

published in English (because the author of this integrative review is fluent in English
only and there were no translation services available);

•

had undergone a peer review process;

•

were published between 2015 and 2024; and

•

included people that had experienced, or were experiencing, incarceration;

•

were primary research studies; only one systematic review was included in the integrative
review because it directly addressed the research question and provided relevant insight
into structural and systemic barriers to HCV care in correctional settings. Kamarulzaman
et al. (2016) was selected for its focus on global prison-based interventions and alignment
with the review’s thematic priorities. Other systematic reviews were excluded if they
focused primarily on clinical outcomes or populations outside of correctional contexts.
This review met all inclusion criteria and was rated as moderate-to-high quality using the
AMSTAR 2 tool (Shea et al., 2017).

Studies were excluded if they:
•

were not published in English;

•

had not undergone a peer review process;

14

•

were published outside the specified date range;

•

were focused on people that had not experienced incarceration;

•

Systematic reviews, save one.

Keywords used in the searches were the following: ***one list of all the words used***
HCV, prison, primary care providers, as well as synonyms and abbreviations such as Hepatitis C,
HCV, prison, incarceration, nurse practitioner, and primary care provider. Two tables presenting
the search terms, limiters/expanders, Boolean operators used in each search, and the search
outcomes from each database can be found in Appendices A and B.
Step 4: Critical Appraisal
Each of the nine articles selected for inclusion in this integrative review was critically
appraised to assess its methodological quality. The appraisal process involved evaluating the
study’s design, sample size, data collection methods, and relevance to the research question.
Initially, the Mixed Methods Appraisal Tool (MMAT) was applied to all included studies to
assess methodological quality. However, it became evident that the MMAT is specifically
designed for mixed methods research and did not adequately address the unique requirements of
purely qualitative, purely quantitative, or systematic review studies included in this review. In
response to this limitation and following feedback, the critical appraisal process was revised to
utilize design-specific tools that more appropriately evaluate the methodological rigor of each
study type. The AMSTAR 2 tool was used for the systematic review, the CASP Qualitative
checklist for qualitative studies, and the Joanna Briggs Institute (JBI checklists for quantitative
cross-sectional and cohort studies. This revision provided a more precise assessment of studyquality based on methodological design. The results of this updated appraisal are summarized in
Table 3.

15

For transparency and comparison, the original MMAT appraisal results are included as
Appendix D. Incorporating this approach strengthens the overall reliability of the review findings
by ensuring quality assessment aligns with the methodological diversity of the included
literature.
Table 3
Critical Appraisal Summary Using Appropriate Tools
Author(s),
Year

Study Design

Appraisal Tool

Overall Quality
Rating

Notes
Variation in included
studies; overall well
conducted
Clear methodology
and appropriate
sampling
Large sample size,
clear data collection

Kamarulzaman
et al. (2016)

Systematic
Review

AMSTAR 2

Moderate to
High

Lafferty et al.
(2018)

Qualitative

CASP
Qualitative

High

Poulin et al.
(2018)

Quantitative
CrossSectional
Quantitative
CrossSectional
Quantitative
Cohort
Quantitative
Cohort
Quantitative
CrossSectional
Qualitative

JBI Crosssectional

High

JBI Crosssectional

Moderate to
High

JBI Cohort

High

JBI Cohort

High

JBI Crosssectional

High

Silbernagl et
al. (2018)
Overton et al.
(2018)
Kronfli et al.
(2019)
Kronfli et al.
2021

Appropriate
methodology and
analysis
Some loss to followup; otherwise sound
Robust data analysis
and clear reporting
Clear survey methods,
good response rate

Ruiz et al.
CASP
High
Strong thematic
(2022)
Qualitative
analysis and reflexivity
JBI Cohort
High
Clear intervention and
Quantitative
Lam &
outcome reporting
Cohort
Dimaculangan
(2023)
Note. Quality ratings are based on criteria from the appraisal tools appropriate to each study
design: AMSTAR 2 for systematic reviews (Kamarulzaman et al., 2016), CASP Qualitative
Checklist for qualitative studies (Lafferty et al., 2019; Ruiz et al., 2022), and Joanna Briggs
Institute checklists for quantitative cross-sectional and cohort studies (Poulin et al., 2018;
Silbernagl et al., 2018; Overton et al., 2019; Kronfli et al., 2019; Kronfli et al., 2021; Lam &
Dimaculangan, 2023). Overall quality ratings reflect the methodological rigor assessed by each
tool.

16

Interpretation of Appraisal Outcomes
All nine studies included in this review were rated as high quality, using the appraisal tool
most appropriate for their specific study design. A “high” rating reflects strong alignment
between a study’s objectives and its overall execution, including clear and systematic data
collection, ethical integrity, and conclusions that are well supported by the data.
Each tool used in this appraisal process focused on different aspects of study quality.
AMSTAR 2, applied to the systematic review, evaluates elements such as clarity of the research
question, comprehensiveness of the literature search, assessment of bias, and the appropriateness
of synthesis methods (Shea et al., 2017). The CASP checklist, used for qualitative studies,
emphasizes clarity of aims, rigor in data collection and analysis, and consideration of researcher
reflexivity (Critical Appraisal Skills Programme, 2018). JBI checklists, used for both crosssectional and cohort studies, assess sampling methods, the reliability and validity of
measurement tools, and how well confounding variables were accounted for (Joanna Briggs
Institute, 2017). The notes provided in Table 3 offer concise, study-specific insights that
contextualize the quality ratings, for example, highlighting strengths such as strong thematic
analysis, comprehensive data reporting, or rigorous sampling methods. These comments help
clarify how each study met the standards of its appraisal tool. The consistent “high” ratings
across all nine studies contribute to the overall credibility of the review and provide a solid
foundation for the thematic synthesis that follows.
Step 5: Data Analysis
Key data were extracted from each study and incorporated into a data extraction table; a
portion of this large spreadsheet is attached as Appendix C. This extraction table included
information on study characteristics, population, setting, reported barriers to HC treatment

17

delivery, and any identified systematic or institutional factors. This structured approach ensured
comprehensive data collection, facilitating subsequent analysis.
Thematic analysis was employed, using the Thematic Networks (Attride-Stirling, 2001)
discussed in the next section, to synthesize the findings from the included studies. The purpose
for using this framework was to provide a structured and transparent method for identifying,
organizing, and interpreting patterns across diverse literature. By breaking down complex data
into basic, organizing, and global themes, it enables nuanced thematic mapping that captures
both surface-level observations and deeper conceptual relationships. This approach supports
clarity in analysis and ensures interpretations remain closely grounded in the data, allowing for
meaningful conclusions about the barriers PCPs face when delivering HC care to PIC.
Analysis Framework
Thematic Networks was used as the theoretical framework to gather and organize themes
from each selected study. Developed by Attride-Stirling (2001), this framework offers a
structured and transparent approach for interpreting complex qualitative data by mapping
emerging themes into hierarchical categories. The process begins by identifying “basic themes”
within each study’s findings, which are then grouped into broader “organizing themes.” These
organizing themes represent more abstract concepts that summarize the basic themes and are
further refined into overarching “global themes.”
To identify the basic themes for this review, the findings sections of each included study
were carefully read and manually coded for recurring or significant barriers mentioned in
relation to HC care in correctional settings. Codes were created for any concept or barrier that
appeared frequently or carried conceptual weight, such as limited provider training, gaps in
continuity of care, or policy restrictions. These codes were then grouped based on similarity and

18

meaning to form basic themes. The basic themes were then clustered into organizing themes,
which served to capture broader conceptual categories, such as institutional barriers or systemlevel fragmentation. Finally, these organizing themes were synthesized into a smaller set of
global themes that reflected the most significant and recurrent domains of challenge. This
structured process helped ensure the analysis was both systematic and grounded in the data,
while remaining flexible enough to capture complexity across studies.
The analysis of these themes aimed to provide a nuanced understanding of these barriers,
considering factors such as institutional policies, resource limitations, and stigma associated with
both incarceration and HC. The findings were interpreted through a Canadian correctional
system lens, emphasizing implications for practice, research, and education. An example of this
thematic refinement process is illustrated in Figure 1, with a detailed discussion of the themes
presented in the Findings chapter.

19

Figure 1
Example of a Thematic Network
Sufficient time in
custody to allow
for screening and
treatment

Telehealth helped
patients stick to
meds and stay in
touch with
providers

Linkage to
treatment for all
PIC, regardless of
length of sentence

Provider
ava
in the
community

High degree of
mobility for PIC
between prison and
community

Sufficient time in
custody to allow for
screening and
treatment

Incarceration
length

Linkage to care,
post-release

Organizing
Theme

Global
Theme

Note. Example of Thematic Networks (Attride-Stirling, 2001), refining basic information into
global themes. This example demonstrates how the theme of “Linkage to Care, Post-Release”
was established.
The 3 coloured boxes in the bottom row are the legend for interpreting the groupings.
Search Limitations
The method used to select articles for inclusion in this integrative review may have
exposed the study to pre-existing biases. It is possible that relevant studies were not encountered
during either the database searches or the hand selection process, and there may have been
subconscious preference extended by the author for certain researchers and the work they had
already published in the field. However, this bias was likely reduced by the inclusion of
assistance from the UNBC librarian in developing the search terms and navigating the databases.
Kutcher and LeBaron (2022) advise that there is a decreased risk of bias influencing search
strategies and choices when a professional librarian facilitates those steps in the search process.

20

The reproducibility of this integrative review was also compromised due to the loss of
certain search data midway through the process. All preliminary search steps and search results
had been saved in the author’s UNBC library profile and much was inadvertently erased.
Fortunately, the search data that had been included in key assignment milestones was retrievable.
The author re-performed those original searches, including the steps of hand-searching reference
lists and searching heavily cited authors by name, and the results are shown in Appendices A and
B. This more recent set of searches also evolved to include qualitative studies that were
applicable to the research question.

21

Chapter Three
Findings
This integrative review included nine-peer-reviewed studies investigating barriers to
hepatitis C treatment in correctional settings. The research designs varied, including crosssectional studies (e.g., Kronfli et al., 2021; Silbernagl et al., 2018), retrospective cohort studies
(e.g., Kronfli et al., 2019b; Lam & Dimaculangan, 2023; Overton et al., 2019), qualitative
inquiries (e.g., Lafferty et al., 2018; Ruiz et al., 2022), and one systematic review
(Kamarulzaman et al., 2016). Together, these studies provided a broad and nuanced view of how
HC care is delivered, or interrupted, for PIC.
Study Characteristics and Populations
The included studies were conducted in Canada (n=4) (Kronfli et al., 2019; Kronfli et al.,
2021; Poulin et al., 2018; Ruiz et al., 2022), Australia (n=2) (Lafferty et al., 2018; Overton et al.,
2019), Austria (n=1) (Silbernagl et al., 2018), and the United States (n=1) (Lam &
Dimaculangan, 2023), with the single systematic review drawing from multiple international
contexts (Kamarulzaman et al., 2016). Five of the studies involved PIC as participants (Kronfli et
al., 2019; Lafferty et al., 2018; Overton et al., 2019; Poulin et al., 2018; Silbernagl et al., 2018)
two focused on the perspectives of healthcare or correctional staff (Kronfli et al., 2021; Ruiz et
al., 2022), and one examined patient care linkage to a modified interdisciplinary patient care
model for HC treatment in a hospital-based setting not limited to incarcerated individuals (Lam
& Dimaculangan, 2023). Although the research by Lam and Dimaculangan (2023) was not
specifically working with PIC, it was chosen for this integrative review because it was focused
on the treatment outcomes for people with HC, and how their care would be impacted, by adding
a pharmacist to their multidisciplinary team.

22

Although the overall focus of these studies was consistent, addressing HC among
incarcerated or justice-involved populations, each had a distinct emphasis. For instance, Kronfli
et al. (2021) surveyed provincial prison healthcare teams in Canada to assess HCV screening
protocols, treatment restrictions, and availability of harm reduction services. Silbernagl et al.
(2018) explored HC prevalence and treatment access among adults receiving opioid agonist
therapy (OAT), and among incarcerated youth in Austria. Ruiz et al. (2022) used semi-structured
interviews with staff in Quebec prisons to identify institutional enablers and barriers to the
implementation of opt-out HCV screening among PIC.
Other studies used retrospective cohort data to trace patient experiences and treatment
outcomes. Overton et al. (2019) followed a large cohort of Australian prisoners, identifying those
screened and treated for HCV and tracking their serological outcomes. Similarly, Kronfli et al.
(2019b) analyzed prison laboratory data to map the progression of inmates through the HC care
cascade. The retrospective cohort study by Lam and Dimaculangan (2023) was the only study
included in this review that did not explicitly focus on incarcerated individuals. Instead, the study
examined patients who were screened and diagnosed with HC while receiving care at Jersey City
Medical Centre. The setting included both the emergency department and inpatient units. Their
inclusion criteria comprised individuals who tested positive for HCV at the medical center and
were subsequently linked to care through the facility’s Comprehensive Care Centre, where
follow-up treatment and monitoring were provided.
Qualitative studies added depth to the findings. Lafferty et al. (2018) interviewed HCV
RNA-positive prisoners in New South Wales, uncovering both knowledge gaps in HCV
transmission, and the clandestine practices related to sharing injection equipment. Poulin et al.

23

(2018) conducted a large cross-sectional study in Quebec’s provincial prisons, linking both
sociodemographic data and self-reported risk behaviours with HCV prevalence.
A summary of each study’s methodology, participant characteristics, and key findings is
presented in Table 4.
Table 4
Summary of Research Studies on Hepatitis C in Correctional Settings
Setting/Location

Key Findings/Relevance

Author(s),
Year
Kamarulza
man et al.
(2016)

Sample Size &
Population
N=12 articles

Study
Design/Methods
Systematic review

International

Lafferty et
al. (2018)

N=32 HCV
RNA+ inmates
(male & female)

Qualitative
interviews

New South
Wales, Australia

Poulin et al.
(2018)

N=1579 male and
female inmates

Cross-sectional
using anonymous
oral fluid samples

Quebec
provincial prisons

Silbernagl
et al. (2018)

N-133 imprisoned
adults on OAT,
N=71 imprisoned
adolescents and
young adults
N=698 inmates
across 36
correctional
centres
N=4931
sentenced inmates
(N=1972 with
sentence 1
month
59/65 Canadian
provincial prison
healthcare teams

Cross-sectional
study

Austria

Retrospective
cohort

New South
Wales, Australia

57% SVR cure rate; treatment
often incomplete due to release or
lack of follow-up.

Retrospective lab
data analysis

Quebec, Canada

Web-based survey

Canadian
provincial prisons

Described HCV care cascade: low
screening rates (7%), high dropoff across stages; screening
improved to 17% among those
with longer incarceration.
Identified availability and
limitations of HCV screening,
treatment, restrictions, and harmreduction services.

Overton et
al. (2019)
Kronfli et
al. (2019)

Kronfli et
al. (2021)

Reviewed WHO-recommended
HIV/HCV/TB interventions in
prisons; Highlighted variation and
implementation gaps.
Investigated knowledge on HCV
prevention and treatment;
highlighted reinfection risk and
IVDU equipment sharing
practices.
Measured HCV antibody
prevalence and risk behaviours;
provided epidemiological insight
into inmate population.
Evaluated HCV prevalence,
testing, knowledge of status, and
psychiatric comorbidity.

24

Author(s),
Year
Ruiz et al.
(2022)

Sample Size &
Population
N=16
stakeholders (8
healthcare, 8
corrections)
N=83 (46 preintervention, 37
post-intervention

Study
Design/Methods
Semi-structured
interviews

Setting/Location

Key Findings/Relevance

Quebec, Canada

Explored barriers/enablers to optout HCV screening; emphasized
systematic and operational
challenges.
Lam &
New Jersey, USA Post-intervention group (with
Retrospective
Dimaculancohort
pharmacy team) had improved
gan (2023)
HCV care linkage compared to
pre-intervention group.
Note. This table summarizes the characteristics and key findings of the nine studies included in
the integrative review. It outlines the sample size and population, study design and methods,
correctional setting and geographic location, and highlights each study’s relevance to hepatitis C
care in correctional settings. For an example of the full data extraction spreadsheet from one of
the included studies, see Appendix C.
Introduction to Data Appraisal
To ensure transparency and evaluate the methodological rigor of the included studies,
each article was critically appraised using design-specific tools appropriate to its methodology.
While the Mixed Methods Appraisal Tool (MMAT) was initially considered, it became clear that
MMAT is primarily intended for mixed methods studies and does not adequately assess purely
qualitative, quantitative, or systematic review designs. In response, the appraisal process was
revised to use more targeted tools: AMSTAR 2 for the systematic review (Shea et al., 2017), the
CASP Qualitative Checklist for qualitative studies (Critical Appraisal Skills Programme, 2018),
and the Joanna Briggs Institute checklists for quantitative cross-sectional and cohort studies
(Joanna Briggs Institute, 2017).
A summary of the quality ratings for each study is presented in Table 3, providing context for
interpreting the strength and reliability of the evidence included in the thematic synthesis. This
table complements the descriptive overview in Table 4, and together, these appraisals support the
credibility of the findings presented in this integrative review.

25

Participant Samples and Data Scope
The studies included in this review varied widely in sample size and scope, reflecting the
range of research approaches used. Larger quantitative studies, such as Poulin et al. (2018),
surveyed over 1,500 PIC, while smaller-scale qualitative work, such as Ruiz et al. (2022), offered
in-depth insights from 16 stakeholders. Both approaches contributed valuable perspectives to this
integrative review: large datasets helped to quantify trends in testing and treatment uptake, while
the smaller studies provided important context on the systemic and interpersonal barriers
influencing those outcomes.
Retrospective cohort studies (e.g., Kronfli et al., 2019b; Overton et al., 2019) followed
individuals through different points in the HC care continuum. Kronfli et al. (2019b) began with
a sample of nearly 5,000 sentenced PIC, of whom only 344 were screened for HCV, and only
three initiated treatment. These findings illustrate the steep drop-offs that can occur even in
systems where screening and treatment infrastructure exist.
While most studies focused on PIC, Lam and Dimaculangan (2023) examined HC
treatment linkage in a hospital setting without identifying incarceration status. Although not
correctional in focus, the study’s emphasis on care continuity still offers relevant insights for
correctional health setting, particularly around post-screening follow-up and interdisciplinary
coordination.
Taken together, the range in sample types and sizes adds breadth and depth to the review.
Larger studies identify system-level patterns and gaps, while smaller or qualitative studies
highlight the lived experience of those navigating the system, offering a fuller picture of the
barriers that PCPs and PIC face.

26

Broader Context and Timeline
The timeline of the studies (from 2015 to 2024) aligns with two major public health
shifts: the introduction of DAAs for the treatment of HCV and the onset of the COVID-19
pandemic. DAAs, which became widely available around 2014, significantly improved cure rates
and shortened treatment duration (Walker et al., 2015). This timeline also intersects with the two
ongoing public health crises that emerged as important contextual factors across studies: the
opioid epidemic and COVID-19.
The COVID-19 pandemic was mentioned in three studies (Kronfli et al., 2021; Ruiz et
al., 2022; Lam & Dimaculangan, 2023), where it was found to have impacted HCV screening
rates, service delivery, and follow-up care due to facility lockdowns and shifting priorities. While
all of the included studies touched on opioid-related risks or interventions to some degree,
detailed analysis of opioid-specific harm reduction strategies is beyond the scope of this review.
Those elements are instead considered in relation to broader barriers to HCV treatment when
applicable.
Thematic Synthesis
Thematic synthesis was guided by Attride-Stirling’s (2001) framework for thematic
networks. Through this process, five global themes emerged from the dataset:
1. Standardization of Systems: Inconsistencies in HCV screening, treatment access, and
care protocols across institutions.
2. OAT and Harm Reduction: The availability (or lack) of OAT and harm reduction
services, and how these impact treatment uptake and engagement.
3. Opt-Out Screening: The challenges and benefits of shifting towards routine opt-out
HCV testing in correctional settings.

27

4. Linkage to Care Post-Release: The structural and systemic barriers that disrupt
treatment continuity once individuals are released from custody.
5. Education for Providers and Patients: Knowledge gaps among both correctional PCPs
and PIC, which influence screening rates, engagement, and adherence.
These themes will be discussed in depth in the following section, along with their
implications for practice, policy, and future research in healthcare settings.
Standardization of Systems
A common finding in the reviewed studies was that systems of care need to be
standardized (Kamarulzaman et al., 2016; Kronfli et al., 2019b; Kronfli et al., 2021; Ruiz et al.,
2022; Silbernagl et al., 2018). Silbernagl et al. (2018) emphasized coordination and provision of
healthcare for PIC must be provided by the governmental group responsible for healthcare, rather
than the group responsible for justice and corrections. Three researchers (Kamarulzaman et al.,
2016; Kronfli et al., 2019b; Ruiz et al., 2022) also recommended the provision of healthcare
services should be separated from the role of corrections, and that doing so will allow these two
systems to align priorities and strategies regarding screening, treating, educating, and providing
harm reduction initiatives to PIC. Kronfli et al. (2021) reported such cooperation between
systems should be standardized across Canadian provincial prisons. This standardization and
prioritization of responsibilities could prevent a situation, such as that reported by Silbernagl et
al. (2018), in which the public safety priorities of some prisons did not match the public health
needs and priorities of PIC. Kamarulzaman et al. (2016) emphasized this issue, finding that the
high prevalence of infections among PIC is a public health concern due to the high degree of
movement between prison and their own communities. Addressing the prevalence of HC and
improving treatment outcomes among PIC would require both systematic and organizational

28

changes in healthcare systems and a level of cooperation between healthcare and correctional
leaders and policymakers for operationalizing care (Kamarulzaman et al., 2016.; Kronfli et al.,
2019b; Ruiz et al., 2022).
The WHO (2021) recommends that healthcare for prisoners should be provided by a
dedicated healthcare system, not by the same institution responsible for separating PIC from
many of their rights. The psychological impact on a prisoner of receiving healthcare services
from the same body responsible for maintaining their imprisonment is one reason why PIC often
hesitate to access healthcare services to which they are entitled while in custody (Jack, 2021).
Jack (2021) also identified other barriers discouraging PIC from accessing healthcare services,
such as the timing of offering services and feeling forced to accept that care. Offering those
services at a time when a someone is newly in custody, and is still acclimating to the prison
environment and the psychological impact of feeling forced to receive care within the coercive
cultural context of a prison, may affect their decision-making process (Jack, 2021). The view of
PIC that they are receiving care services from their jailers was identified by Ruiz et al. (2022) in
terms of the stigma associated with receiving sexually transmitted blood borne infections
(STBBI) testing in prison. Since other PIC may perceive such testing as a sign of active
infection, accepting such healthcare services can be detrimental to a person’s safety while in
custody (Ruiz et al., 2022).
Ruiz et al. (2022) found that healthcare and correctional systems exist and operate
without a clear direction about who has authority over care provision. Ruiz et al. (2022)
summarized this need for streamlined and dedicated provision of healthcare. For HC care
cascades to be successful for PIC, the responsibility for care must be transferred to the health
ministry, as prison systems that had made this transition were experiencing higher levels of HCV

29

screening and treatment and harm reduction practices (Ruiz et al., 2022). However, ensuring
each of the two systems (healthcare and corrections) hold independent and appropriate
responsibilities and accountabilities does not replace ongoing and effective cooperation between
those two systems. Responsibility of care must be considered when those systems update HCVrelated policies and operational guidelines to include harm-reduction and OAT, opt-out HCV
screening, transitional care from custody to community, and education for PCPs and patients.
OAT and Harm-Reduction Supplies
Adequate provision and dosing of OAT was found to be an integral part of the HC
treatment cascade (Silbernagl et al., 2018). Silbernagl et al. (2018) found that suboptimal doses
of OAT lead to PIC seeking alternative substances to abate their cravings and withdrawal
symptoms. This could be surmised as either inadequate training and knowledge of OAT
prescribers to properly assess and provide OAT (Kronfli et al., 2021; Silbernagl et al., 2018) or it
may be due to restrictions regarding who can access HC and OAT treatment that is placed on
providers by leadership and organizational policies (Kamarulzaman et al., 2016; Kronfli et al.,
2021). This potential lack of training and OAT education could have implications for the practice
of PCPs regarding the provision of quality HCV care to PIC. If PCPs can obtain appropriate
education and training regarding proper prescribing practices for PIC who require OAT, it can
lead to improved STBBI prevention by minimizing the desire to seek unsafe opiate alternatives
while in custody (Kronfli et al., 2021; Silbernagl et al., 2018). This fact was evidenced during
interviews with PIC, who confirmed that the provision of OAT only led to a significant reduction
in opiate use and risky behaviours if adequate doses of OAT were prescribed (Silbernagl et al.,
2018).

30

Needle and Syringe Replacement Programs
Harm-reduction based policies need to include needle and syringe replacement programs
(Kamarulzaman et al., 2016; Kronfli et al., 2021; Silbernagl et al., 2018) and must ensure access
to sterile tattooing equipment to prevent transmission and infection during this common practice
of carceral environments (Kronfli et al., 2021; Poulin et al., 2018). Poulin et al. (2018) surveyed
PIC and found that one-third of male participants had been tattooed while in prison and that reuse of unsterile equipment was a prevalent practice. The absence of these harm-reduction
programs in provincial prisons was found to be a barrier to HC prevention and led to
transmission and infection (Poulin et al., 2018). This can be compared to the Canadian federal
prison system, which employs needle and syringe exchange programs (Kronfli et al., 2021;
Lafferty et al., 2018; Poulin et al., 2018) and is on track to achieve HC elimination by 2030
(Kronfli et al., 2021). This target is likely to be achieved because of the accompanying robust
OAT programs, opt-out HCV screening, and education programs aimed at PIC for longer
periods than is seen within provincial institutions (Kronfli et al., 2021). Kronfli et al. (2021)
found that there are no provincial correctional facilities in Canada that utilize needle and syringe
exchange programs.
The argument for sterile tattooing and injection materials as harm-reduction tools to
achieve population HC elimination was made by Kronfli et al. (2021). Kronfli et al. (2021) stated
that provincial prisons would not be able to eliminate HC from PIC without the provision of
needle/syringe exchange and safer tattooing programs. If healthcare leaders and providers
ensured access to clean equipment, the practice of sharing needles would be reduced or
eliminated, meaning less exposure to STBBIs. PIC surveyed by Lafferty et al. (2018) indicated
they felt it was inevitable that they would be exposed to HCV during the common practice of

31

sharing intravenous drug-use (IVDU) equipment. That exposure was further illustrated when
Lafferty et al. (2018) described the hierarchy established for small, close-knit groups of PIC who
choose to share equipment and substances within their circle. This hierarchy and forced risktaking means that almost everyone involved in the re-use of IVDU equipment will be at risk of
contracting an STBBI.
Opt-Out Screening
Opt-out screening was prioritized in five of the nine studies reviewed (Kamarulzaman et
al., 2016; Kronfli et al., 2019b; Kronfli et al., 2021; Ruiz et al., 2022; Silbernagl et al., 2018). It
was recommended by Ruiz et al. (2022) as the crucial first step in a cascade of care aimed at HC
elimination and it is recognized by HC experts across the globe as a gold standard screening
strategy (Kronfli et al., 2021). Kamarulzaman et al. (2016) and Ruiz et al. (2022) identified optout screening as an additional opportunity for PIC to be tested for HCV and other STBBIs, but
also to encourage additional discussion and education. The opt-out process requires providers to
meet with PIC and discuss STBBI screening, harm-reduction, and education about safe practices
while in custody and in their community (Kamarulzaman et al., 2016; Ruiz et al., 2022).
Kamarulzaman et al. (2016) described reasonable uptake with opt-in STBBI testing
practices, but screening was markedly higher with opt-out. Kamarulzaman et al. (2016) also
found that there are limitations and difficulties experienced by the opt-out process which also
need to be considered in its creation and implementation. Ruiz et al. (2022) further noted that
opt-out HCV screening should not be viewed as a standalone intervention, but rather as one
element of a more comprehensive approach to HCV care in provincial prisons. Jack (2021)
found in their study of HCV opt-out programs in the United Kingdom, that the comparison of
opt-in and opt-out approaches has mixed impact on PIC, especially when compared to people

32

accessing care from a hospital or another healthcare facility they are choosing to attend versus a
forced custodial setting. As previously mentioned, the prison-based context of healthcare
delivery has impact on an individual’s acceptance of that healthcare and the response to a test
being offered in custody will typically differ from those in hospitals or community settings.
The Jack (2021) study saw greater uptake in opt-out programs offered to antenatal
patients compared with antenatal PIC, with the difference being the option of choice. PIC are
already losing many of their freedoms and ability to make choices by virtue of being in custody,
and being forced to undergo testing is not perceived in the same light when compared with an inpatient attending a healthcare facility by choice. This limitation regarding perception of choice
does not negate the findings of the five studies that recommended opt-out screening
(Kamarulzaman et al., 2016; Kronfli et al., 2019; Kronfli et al., 2021; Ruiz et al., 2022;
Silbernagl et al., 2018), as they were able to show that opt-out screening is an effective tool in
the cascade of HC care. Meaning, policymakers need to be mindful of the impact that loss-ofchoice has on PIC when designing interventions to enable the elimination of HC in a vulnerable
population (Jack, 2021). Opt-out screening also places the onus on healthcare system leadership
and policy-making stakeholders to design a system that has the capacity for implementation and
operation of opt-out screening. It is critical to ensure that all stakeholders, including those with
lived experience, can provide perspectives on the design of said systems (Ruiz et al., 2022).
Once instituted, opt-out screening would be the first step in the cascade of care for PCPs to
become involved in the provision of quality HC care, as more PIC would be tested, and
subsequently, more people with HC would become engaged in the cascade of care.

33

Linkage to Care Post-Release from Custody
PIC who are released to the community need to be linked to another provider or program
that is capable of continuing the HC care cascade without interrupting, or repeating, the existing
state of treatment, especially considering that PIC being treated for HC have comparable, or
better, outcomes when treatment was initiated while in custody (Aspinall et al., 2016; Overton et
al., 2019; Poulin et al., 2018). This final step in the cascade takes into consideration potential
HCV exposure to a larger community once someone is released from custody. Aspinall et al.
(2016) found that most people with HC who use intravenous drugs will enter the prison system at
some time, and during their period of study, 40% of that same population was also released from
custody or transferred to a different facility. Ruiz et al. (2022) and Overton et al. (2019) found
that PIC are more likely to access healthcare in a prison than in the community, so taking
advantage of that opportunity to engage and link them to care when released could yield positive
outcomes.
Kronfli et al. (2021) felt that the efficacy of linkage to care would require more study to
determine if better outcomes were being attained, but maintained that linkage to care was a
crucial step in HC care treatment, especially for PIC with shorter sentences. This linkage can
take many forms, although the most effective form was not distinguished in this review and
could be an area for future study; such future research may include community PCPs, addictions
services, infectious disease specialist, peer-support workers, pharmacists, or STBBI specialty
care nurses and providers (Aspinall et al., 2016; Kronfli et al., 2021; Lam & Dimaculangan,
2023).

34

Education for Providers and Patients
HCV education in this review followed two pathways for preventing transmission and
infection: (1) for PCPs and staff; and (2) for PIC with HC. The respondents in the cross-sectional
study by Kronfli et al. (2021) found that providers and patients identified a lack of HCV
knowledge as a common barrier to screening and overall HC care. More than half of the
physicians surveyed in Kronfli et al. (2021) failed to initiate HC treatment, citing a lack of
training as a systemic barrier to care provision.
Lam and Dimaculangan (2023) compared the introduction of a clinical pharmacist into
the HC care team as an intervention and included patient education regarding HC in their preand post-exposure groups, although this writer found their outcomes to be less than persuasive as
only 11 (23.9%) of the pre-intervention patients achieved SVR, and 12 (32.4%) in the postintervention group achieved SVR.
Kamarulzaman et al. (2016) recommended that education programs for PIC should be
tailored to educate about prevention of infection and transmission of HCV. Programs should be
offered in a way that is easy to digest and comprehend, with consideration for utilizing peerbased educator sessions that incorporate other priorities for PIC, such as housing and
employment (Kamarulzaman et al., 2016). Biondi and Feld (2020) also supported this
recommendation and noted that their research found peer-based educator programs reduced and
changed risky behaviours by supporting individuals, leading to increased screening and linkage
to care.
The consideration for including peers as educators showed some efficacy when networks
of PIC were found to be secretly sharing needles and IVDU equipment (Lafferty et al., 2018).
These networks operate in secrecy and rely on the trusted relationships built between PIC to

35

function in their desired way. Introducing an outsider, especially one who is not in custody
would result in continued secrecy and a disinclination to listen or participate in discussion about
risky behaviours or HCV status (Lafferty et al., 2018). The youth in custody who were studied in
Silbernagl et al. (2018) showed vulnerability for potential exposure to a substance use disorder
and STBBIs, with a recommendation for preventative steps and education about the risks of
STBBIs and how they are transmitted, especially as it related to IVDU.
A lack of HCV knowledge and training was found to one of the reasons why many PCPs
were not providing HC care to PIC (Kronfli et al., 2021). Kronfli et al. (2021) also posited that a
nurse-led model of care that included prison-based HC education programs could be an avenue
for those systems to enhance and improve the HC care cascade, without necessarily changing the
way PCPs practice. Improving prescribers’ knowledge and comfort in initiating HC treatment
would also have additional positive impact. This was evidenced when the Kronfli et al. (2021)
study found a low percentage of PCPs providing HC care but also found the lack of HC-related
knowledge to be a significant barrier to providing HC care, both for providers and recipients.
Increased PCP knowledge can be applied to OAT prescribing practices, as Silbernagl et al.
(2018) found inadequate OAT dosing to be a factor in increasing the risk-taking behaviours in
PIC, as previously discussed.

36

Chapter Four
Discussion
This integrative review examined the multifaceted barriers to HC treatment for PIC and
revealed a consistent call across the literature for systemic reform in correctional healthcare. A
central theme emerging from the findings is the urgent need for structural realignment between
correctional and healthcare systems. Fragmented service delivery, inadequate harm-reduction
infrastructure, inconsistent provider training and a lack of post-release continuity have all
contributed to suboptimal outcomes for PIC living with, or at risk of, HCV infection. These
findings have significant implications for PCPs, and particularly for NPs, who are uniquely
positioned to address many of these barriers within their expanding scope of practice.
System Standardization
Multiple studies emphasized the critical importance of decoupling healthcare provision
from correctional oversight (Kamarulzaman et al., 2016; Kronfli et al., 2019b; Ruiz et al., 2022).
Healthcare systems operating= under correctional bodies often prioritize institutional security
over patient health, creating a misalignment of goals that undermines efforts to address
communicable diseases like HC. Standardization of healthcare governance, where responsibility
for prisoner health is transferred to public health bodies, was found to improve screening,
treatment initiation, and access to HR services (Ruiz et al., 2022; Silbernagl et al., 2018). The
psychological burden imposed by receiving care from the same system responsible for
incarceration contributes to distrust and reluctance to engage in care (Jack, 2021). With a
purposeful division in responsibilities, the health service providers could enhance their
autonomy, improve care continuity, and foster trust-based therapeutic relationships.

37

Harm Reduction and OAT
Adequate access to harm-reduction services, including OAT, needle and syringe
programs, and safer tattooing equipment, is essential for interrupting HCV transmission within
correctional settings. Data from multiple studies (Kronfli et al., 2021; Poulin et al., 2018;
Silbernagl et al., 2018) demonstrates that inadequate OAT dosing and a lack of sterile equipment
drive risky behaviours among PIC, including injection substance use and equipment sharing.
These behaviours are not only hazardous to the individual but also pose a public health concern
due to the oft-times unpredictable movement between prisons and the community. NPs with
training in addiction medicine are within scope to assess and prescribe adequate doses of OAT,
yet some institutional policies and limited prescriber education continue to impede effective
practice (Kronfli et al., 2021). Expanding NP training and authority in correctional settings,
alongside structural support for harm-reduction programs, would enhance the effectiveness of the
HC care cascade.
Opt-Out Screening and Choice in Care
Opt-out screening is widely recognized as a best practice for increasing HCV testing rates
for PIC (Kamarulzaman et al., 2016; Kronfli et al., 2021; Ruiz et al., 2022). However, concerns
around perceived coercion and the loss of autonomy and choice experienced by PIC must be
considered (Jack, 2021). The implementation of opt-out strategies should be carefully designed
to respect individual agency, ideally facilitated by healthcare providers who are not beholden to
priorities of the correctional system. NPs can play a role in balancing public health objectives
with ethical and trauma-informed care by ensuring screening processes are accompanied by
informed consent, education, and timely communication. Properly executed, opt-out screening

38

represents the critical entry point into the HC care cascade, enabling PCPs to engage with
patients early and consistently.
Linkage to Care and Transitional Support
Continuity of care post-release is essential to achieving SVR and preventing reinfection.
Yet, linkage to care upon re-entry to the community remains inconsistent and poorly coordinated
(Aspinall et al., 2016; Kronfli et al., 2021). This represents a major gap in the HC care cascade.
While prisons present an opportunity to initiate treatment, failure to transition individuals to
community-based providers results in missed opportunities for long term disease management
and increased risk of transmission. NPs can serve as central actors in the development and
implementation of transitional care models, including discharge planning, referral pathways, and
integration with harm-reduction and housing services. Given the potential for recidivism,
transitional care also serves as an upstream public health intervention that could reduce future
healthcare costs.
Education for Providers and Patients
A lack of provider and patient education related to HCV emerged as a recurrent barrier to
HC treatment uptake. Kronfli et al. (2021) identified a potential deficit in PCP knowledge about
HC management, which directly impacts both the availability and quality of care for PIC.
Likewise, patients often lack adequate understanding of HCV transmission, treatment efficacy,
funding streams that can avoid associated costs, and prevention strategies (Kamarulzaman et al.,
2016). Nurse-led education models, especially those incorporating peer educators, were
identified as promising strategies to improve patient engagement and reduce stigma (Biondi &
Feld, 2020). This is particularly relevant in prison environments, where trusted peer networks
often have more influence on behaviour than formal education efforts led by external providers

39

(Lafferty et al., 2018). Expanding HC training for NPs and all involved PCPs, and involving PIC
in the design and delivery of peer-based programs, could improve both the reach and impact of
educational interventions.
Synthesis and Implications for Nurse Practitioners
The findings of this integrative review indicate that NPs, as PCPs, have the ability to
address multiple points of failure in the current HC care cascade for PIC. Whether through
delivering OAT, initiating treatment following opt-out screening, providing patient education, or
coordinating transitional care, NPs can contribute to the success of prison-based HCV
elimination strategies. However, the realization of this potential is contingent on system-wide
reforms that enhance NP autonomy, improve intersystem cooperation, and prioritize health
equity within correctional institutions. PCPs in positions of leadership, or with input into strategy
and policy and procedure, can influence the systems in which they work to better position the
provision of healthcare, with improved modes of delivery and recognition of the barriers that
exist in providing the UN-mandated standards of care for PIC (United Nations General
Assembly, 2015).
A model of care that empowers NPs as primary coordinators of HC management in
correctional settings could mitigate many of the existing barriers identified in this review. Such a
model would require investment in provider training, policy changes to support NP-led care, and
the institutional separation of healthcare from correctional operations.
Areas for Future Study
Future study should prioritize evaluating the efficacy and feasibility of harm reduction
interventions within prison setting, such as needle and syringe programs, safer tattooing
initiatives, and accelerated, or interrupted, HCV DAA provision schedules. Despite some

40

promising pilot projects, such as the in-prison tattoo programs aimed at reducing bloodborne
virus transmission, these programs were discontinued. They could be reinstituted, with an aim to
be evaluated for their long-term impact or cost-effectiveness. Further studies are needed to assess
the implementation and outcomes of such initiatives, including the unique social dynamics of
correctional facilities that influence PIC healthcare uptake and sustainability. Additionally,
exploring how injection-based substance use operates as a social practice within the prison
environment could yield important insights for tailoring prevention education and improving
risk-reduction strategies. Investigating the prevalence and context of contraband activities,
including illicit substance use, tattooing, and sex-for-drugs exchanges, would also help develop
more responsive and realistic health interventions for PIC.
Evaluating the acceptability and efficacy of point-of-care HCV testing, particularly in the
context of short-term incarceration, could support strategies to close gaps in the HC care cascade.
A stakeholder prioritization process, including voices of people with lived experience of
incarceration, would be critical in guiding all these efforts and ensuring that interventions
address the most pressing barriers to HCV elimination in Canadian prisons.
Kronfli et al. (2021) suggested that more study was required to determine if better
outcomes were being attained by linking HC positive prisoners who are being released to care in
the community after release, and that examination into the most appropriate structure of that
connection was an area for future study.
There remains a pressing need for research that examines how HCV and other STBBIs
affect Indigenous individuals who are incarcerated, a group that continues to be
disproportionately represented in Canadian prisons. This review did not address those specific
impacts, and future studies must give priority to Indigenous perspectives and lived experiences.

41

Any research in this area should be carried out in accordance with the OCAP principles of
Ownership, Control, Access, and Possession, outlined by The First Nations Information
Governance Centre (2025), which emphasizes Indigenous authority over their data.
Meaningful collaboration with Indigenous scholars, communities, and knowledge keepers
is essential to ensure research is respectful, culturally relevant, and attuned to the specific health
challenges and priorities facing Indigenous PIC. This review was written from the perspective of
a white settler and therefore it cannot claim to represent Indigenous voices or interpret their
experiences beyond what was presented in the sources examined. Looking ahead, work in this
field should be guided and shaped by Indigenous leadership. A decolonized research approach,
one that actively challenges colonial structures in healthcare and correctional systems, is
necessary to address long-standing health inequities. Supporting Indigenous data sovereignty and
prioritizing reconciliation in public health research are not just ethical imperatives, they are vital
steps towards more just and effective healthcare for all.

42

Chapter Five
Conclusion
This integrative review brings attention to the deep-rooted and structural barriers that
continue to obstruct effective HC treatment for PIC in Canadian provincial correctional centres.
The findings suggest that, without intentional reforms and improved collaboration between
sectors, efforts to meet national and global HCV elimination targets are likely to fall short.
Common themes across the literature point to a range of challenges, including disjointed
healthcare systems within prisons, limited access to harm-reduction measures, gaps in training
for PCPs, and inconsistent continuity of care following release from custody. These barriers are
compounded by the inherently coercive nature of carceral environments, which can undermine
the trust required for a therapeutic patient-provider relationship, restrict autonomy, and affect a
prisoners’ willingness to engage in care, especially when it comes to screening or treatment of
communicable diseases.
This review was able to highlight a number of concrete strategies for improvement. One
widely supported recommendation is shifting the responsibility for provision of healthcare for
PIC away from correctional bodies and placing it within the purview of health authorities. This
model, endorsed by the WHO (2021), helps ensure that health systems and correctional
institutions can each focus on their distinct roles: delivering health promotion and care services
versus maintaining safety and security. Standardizing this division of responsibilities in
correctional facilities across Canadian prisons would help create consistency in how HCV
screening, treatment and harm-reduction practices are provided to PIC.
The implementation of specific practices, such as opt-out screening, adequately dosed
OAT, needle and syringe programs, and peer-led education, was consistently recommended.

43

When combined with proper training for PCPs, these interventions could significantly reduce
transmission risk and potentially lead to improved treatment uptake among PIC. NP roles are
expanding in correctional and primary care, and NPs are well positioned to lean into this work.
With adequate support and improved training, NPs can initiate treatment, provide HCV-related
education, manage OAT, and facilitate transitions to community care upon release.
Ensuring continuity of care after incarceration remains an important final step in the HC
care cascade. Given the high rate of turnover and shorter sentences in provincial facilities,
establishing strong post-release pathways to community-based care is essential. This requires
system level coordination, timely referrals, and providers who are aware of the health challenges
and exposure to health inequities that PIC face, during, and after incarceration.
Indigenous-specific considerations also warrant attention. Indigenous peoples are
significantly overrepresented in the prison populations in Canada and experience a
disproportionate burden of HCV and related health concerns. While this review did not focus on
Indigenous health, it would be remiss of the author to not position the essential requirement for
all future reforms to incorporate culturally safe practices and community-led solutions.
Correctional health strategies should align with federal guidelines, such as the Correctional
Service Canada’s Indigenous Continuum of Care and recognize the importance of integrating
Indigenous voices into program design and evaluation (Government of Canada, 2024).
Ultimately, this review calls for a shift toward a more coordinated, public-health oriented
correctional healthcare model. Eliminating HC among PIC requires systemwide policy reform,
expanded harm-reduction infrastructure, interprofessional collaboration, and a greater role for
NPs as frontline PCPs. These changes are not only vital for the health of incarcerated individuals

44

but are also applicable in protecting broader community health and upholding the principles of
equitable healthcare access.

45

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Wanamaker, K., Filoso, D., Mahboob, W., & Johnson, S. (2024). Infectious diseases, risk
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Appendix A: Search Terms and Results from October 3, 2024

51

52

Appendix B: Search Terms and Results from October 12, 2024

53

54

Appendix C: Data Extraction Table
Article

Disparities in hepatitis C care across Canadian provincial prisons: Implications for
hepatitis C micro-elimination. Kronfli et al. (2021)

Article Details

Original Research. Published in the Canadian Liver Journal. An invitation to fill out a
web-based survey was sent to a representative at each of the provincial prison health care
teams (excluding Ontario) to gather their respective positioning on HCV screening,
treatment, treatment restrictions, and harm reduction. The provision of healthcare services
was determined (Health Authority vs Correctional body). Results showed tremendous
variability in HCV screening and care practices across Canadian prisons.

Study Purpose/

To compare the state of HCV screening and treatment variability across Canadian

Aim

provincial prisons. To compare what successes were found, to compare treatment
outcomes, to study if some approaches were more successful than others. I think the
ultimate goal of this study was to champion opt-out screening

Methodology

A cross-sectional study of Canadian provincial prisons, was sent to each adult provincial

and Methods

prison in Canada, excluding Ontario. One member of the healthcare team from each
prison was invited to participate. They filled out an online survey-type questionnaire of 41
response guided: yes and no, multiple choice and short answer questions. Survey tool was
pilot tested with a small group of respondents (n=4) and feedback incorporated before the
survey was distributed. Overall and stratified (provincial, ministry) descriptive statistical
analyses were used to summarize current HCV practices and barriers to care. Cross
tabulation analysis was also used to report the number and proportion of correctional
facilities for each step along the HCV care cascade.

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Key Findings

Linkage to care lacks standardization across Canadas provincial prisons, likely due in part
to limited resources. Little research has been dedicated to this field. The most effective,
acceptable and sustainable interventions to maximize linkage to care after release from
prison have yet to be determined. Linkage to care is a crucial step along the HCV care
cascade for those incarcerated in provincial prisons. Linkage to care is unlikely to be
prioritized if systemic screening is not yet in place. Linkage to care is unlikely to be
prioritized until more data accumulate regarding predictors of linkage to HCV care after
incarceration. Until prison-based needle and syringe programs and safer tattooing
programs become routinely available, HCV elimination at the provincial prison level is
unlikely to occur. A key barrier to the provision and receipt of HCV care for providers and
patients is a lack of HCV knowledge. More than half of all on-site physicians fail to
provide HCV care to people incarcerated. De-centralized nurse-led models of HCV care
could replace the current physician-centric models of care to accelerate engagement in
care. Systems-level eligibility restrictions may be contributing to the lack of expansion to
access to treatment such as fibrosis restriction still existing in several provincial prisons,
despite their requirement being removed in all Canadian provinces by min-2018. Some
initiatives have recommended linkage to treatment for and initiation of treatment to all
incarcerated individuals, regardless of incarceration length, given the high rates of SVR
(sustained virological response) despite suboptimal adherence, and the potential impact on
community level HCV prevalence, incidence and transmission.

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Strengths and

Limitation: Exclusion of Ontario (d/t approval from their ministry because of their

Limitations

cessation of research r/t covid). Only one informant per prison, the informant was selected
by the research team to ensure those w the greatest knowledge of the HCV Tx services
were captured, but this step was not internally validated, so they cannot rule out invalid
responses or social desirability bias. The study was cross-sectional, meaning changes in
HCV care practices over time were not captured (but because changes take a lot of time in
prison, the captured info may be relevant for several years). Researchers did not account
for prison size or HCV prevalence, financial budget for HCV Tx, on on-site logistical
considerations in the interpretation of the results. Which may have influenced the
availability of HCV services at the provincial prison level. Strengths: Good return of
participants (59/65). (strength and limitation: a broad swath of prison staff submitted
responses)

Relevance to

The findings that 50 % of physicians aren’t providing HCV care, and that including nurses

the Integration

(I will expand this to include NPs) in the models of care could accelerate engagement in

of the Study

care support an answer to the question of "What barriers exist to PCP's providing HCV
care to people in custody in provincial prisons". The linkage to HCV care as a crucial step
in the treatment cascade. Another barrier found is the disconnect between health authority
(Ministry of health) provision of care and public safety/corrections (Ministry of justice
and public security) provision of care (better OAT programs, higher opt-out screening
requirements, higher offering of direct acting antiretrovirals, and fewer restrictions for the
initiation of treatment. Systemic screening of all people in custody needs to be streamlined
and implemented. Ultimately, the adoption of opt-out screening practices should be

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considered as a starting point. To advance HCV care, adopting opt-out screening and
removing eligibility restrictions may be important initial strategies.
Implications

Train nurses and all PCPs in prison-based HCV education programs, aimed at both

for education

educating patients regarding all aspects of HCV risk and care/treatment, and training all
providers to be able to screen and treat everyone they see.

Implications for

Correctional health policies need to be evaluated at the individual correctional centre level

future research

to provide an accurate assessment of their HCV policies and practices. Additional studies
are needed to better understand the multilevel barriers that exist in expanding access to
treatment at the provincial level. Study the efficacy of prison-based needle and syringe
programs. Study the efficacy of safer tattooing programs. Cost-effective analysis of
various screening strategies and larger studies assessing the acceptability of point-of-care
testing among people in prison.

Implications for

Train nurses to provide venipuncture so that in the moment capture of willing/interested

practice

patients can be captured. Review and address system and individual prison policies about
opt-out testing as a model of care.
thematic analysis framework is designed to organize and interpret qualitative data by
systematically identifying basic, organizing, and global themes. Its purpose is to bring
structure and clarity to complex data, enabling transparent analysis and deeper insight into
the underlying patterns and meanings.
organizes complex qualitative data into basic, organizing, and global themes to facilitate
structured, transparent, and meaningful interpretation.

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Appendix D: Mixed Methods Appraisal Tool
Critical Appraisal of Included Studies Using the Mixed Methods Appraisal Tool (MMAT)

Study

Study
Design

Clear
Appropriate
Research Methodology
Question

Relevant
Sampling
Strategy

Appropriate Findings Overall
Data
Address Quality
Collection Research Rating
Question

Kronfli et al.
(2021)
Poulin et al.
(2018)
Silbernagl et
al. (2018)
Lam &
Dimaculangan
(2023)
Overton et al.
(2019)
Kronfli et al.
(2019)
Lafferty et al.
(2018)
Ruiz et al.
(2022)
Kamarulzaman
et al. (2016)

CrossSectional
CrossSectional
CrossSectional
Retrospective
Cohort

Yes

Yes

Yes

Yes

Yes

High

Yes

Yes

Yes

Yes

Yes

High

Yes

Yes

Yes

Yes

Yes

High

Yes

Yes

Yes

Yes

Yes

High

Retrospective
Cohort
Retrospective
Cohort
Qualitative

Yes

Yes

Yes

Yes

Yes

High

Yes

Yes

Yes

Yes

Yes

High

Yes

Yes

Yes

Yes

Yes

High

Qualitative

Yes

Yes

Yes

Yes

Yes

High

Systematic
Review

Yes

Yes

Yes

Yes

Yes

High

Note. This table is included only for review purposes, as this appraisal tool was not the
appropriate tool for critical appraisal in this integrative review.

59