In corroboration with the views of Akiyama and colleagues,1 affordable test-and-treat strategies might benefit prisons in low-income and middle-income countries (LMICs), and these settings might be part of the countdown to hepatitis C (HCV) elimination, provided political will and financing are granted.1 However, these strategies might not be enough. Policies are still likely to be defeated by planning challenges and inconsistencies in high-income countries and LMICs alike.
For example, in France, the focus is on “informing” health-care professionals and prisoners “of the merits of HCV screening and treatment”.2 But, in practice, France does not yet recommend HCV self-testing in prison, contrary to guidance from WHO.3
Beyond preventing deaths in custody, little incentives exist for the French prison health system to meet its objectives related to HCV or more broadly. Minimum staffing standards for French prison health units were abolished in 2012 and the health-care workers operating in the prison system are stretched thin. Prison health is managed by local hospitals, which can share staff with other government-led units or departments. Faced with cost containment policies, there is little room to deviate from traditional spending patterns and invest in performance-based financing initiatives, such as those that would reward the delivery of primary care services, health promotion, and comprehensive addiction services in prisons.4
Drug law offenses represent about 20% of incarceration cases in France (the second most frequent reason), but because of the dominant rhetoric on the war on drugs, there are few opportunities for harm reduction programmes. Although HCV is most frequently spread through sharing needles and other drug injection equipment, the implementation of the French needle and syringe programme has been stalled in prisons since 2016, creating further polarisation among prison staff regarding local health initiatives.4
In recognition that HCV elimination targets and global health objectives more broadly cannot be reached unless health promotion without discrimination becomes a policy priority at all levels, prisoner health must be revalued.5, 6 If this is achieved, the global countdown to HCV elimination will be easier to attain.
We declare no competing interests. Both authors contributed equally.