Respondents included eight women and 11 men, ranging in age from 28 to 72 years and relevant professional experience from 5 to 32 years (with an average of just over 19 years). The majority of participants were based in NSW (n = 13), the location of the four STOP-C prisons; the remainder were based in other states and territories (n = 6). Seven respondents were employed in community-based organizations providing support and advocacy for people affected by hepatitis C, people who use illicit drugs, or people who have been (or are) incarcerated and their families. The remaining twelve were employed across a range of state health and correctional health departments, clinical settings and research institutes. Our sample included five CEOs, six Directors, one Deputy-Director, three Professors/Clinical Program Heads, two Senior Policy Analysts, one Senior Project Officer and one Program Coordinator.
Enabling strategic environment
Respondents identified a supportive strategic environment as one of the keys to a successful scale-up. In the Australian context, ensuring policy and political support is complicated by a federated polity comprising six states and two territories, each with its own legislative powers for the administration of criminal justice. Australia’s current national HCV strategy  designates prisoners as a priority population, with the cost of pharmaceuticals covered by the Federal Government’s universal access program, enabling in-prison prescribing through its specialist ‘S100′ scheme. Nonetheless, such support is not necessarily reflected within state and territorial jurisdictions. Crucially, it is state and territory government departments that remain financially responsible for any of the administrative, logistical and structural changes required for scale-up. Consequently, as respondents noted, the issue has to be ‘pushed at the state and territory level’ (P19), where the big challenge is the relevant departments ‘having sufficient resourcing and appetite to say that prison is a worthwhile recipient for investment if we’re to scale it up.’ (P7).
Respondents were acutely aware of the challenging politics surrounding prison budgets, especially when it concerns prisoner health rather than prison security: ‘Prisoners, they’re the lowest of the low. Governments hate spending money on prisoners unless they have to.’ (P3) Here, federation creates particular challenges, with heterogenous models of prison administration operating across the different jurisdictions:
I think places like Victoria and NSW are better suited to do it [treatment scale-up]. [In Queensland] each hospital and health service operate independently, and they control prison health, so there’s no central direction. (P16)
Reflecting this need for action at a state and territory level, documents such as South Australia’s ‘Prisoner Blood-Borne Virus Action Plan’ were cited as exemplars of enabling legislation: there is ‘ministerial commitment from Corrections and Health [in South Australia] to address hepatitis C and blood borne viruses generally’ (P5). Similarly, NSW was identified as a state with ‘a specific strategy in terms of elimination going prison to prison’ (P12). Here, HCV elimination targets have been introduced as part of prison governance, as a measurable (and thus ‘actionable’) key performance index. Respondents argued that what is possible within prison necessarily reflects broader levels of strategic prioritization and support:
[M]aintaining the [NSW] statewide focus on the broader goals of eliminating hep C will be important. If that falls away, our ability to support […] Justice Health in their practical attempts to address it are diminished as well. (P16)
We turn now from matters concerning the broader external environment to those internal to the prison system itself. While respondents highlighted prison-related differences across states and territories, they also emphasized heterogeneity within jurisdictions. As these two respondents explained: ‘what people don’t understand about working in prisons is how different each prison is and how each prison’s its own fiefdom almost: its own little kingdom.’ (P2); ‘There’ll be some individual issues within a prison, but there’s greater inequity I imagine from prison to prison.’ (P12). As respondents argued, given each prison is ‘like a world unto itself, managed quite separately’ (P17), then gaining the support of the governor and the management team becomes central to any scale-up effort:
The attitude of the management team within the prison [is crucial]: if you haven’t got a management team that’s engaged, they can sink your project before it starts. So, you’ve gotta have the understanding and the buy-in. (P7).
Custodial staff acceptance
While the imprimatur of governors and their management teams was identified as crucial, so too, respondents argued, was a level of basic acceptance for scale-up among correctional staff. Prison officers have the power to influence the effectiveness of a health intervention, either ensuring or obstructing prisoner-patients have access to clinical support. Regarding the SToP-C intervention, one respondent referred to a culture of ‘resentment’ (P14) that existed among officers, with others noting that this ‘culture’ had the potential to manifest as a reluctance among officers to support the use of ‘expensive therapies’ (P12) on (undeserving) inmates whose infections were deemed ‘self-inflicted’ (P12).
Despite these concerns, it is important to note that such fears were largely not borne out in practice. Considerable efforts were made to promote to correctional staff the benefits for everyone in reducing HCV prevalence within the prison environment. Respondents noted the decision of study prisons to recruit a prison officer as a dedicated SToP-C ‘champion’ to promote the intervention, not only to inmates but to their colleagues too. Perhaps as a reflection of such efforts, the stigma associated with injecting drug use ultimately appeared not to translate into opposition to HCV treatment:
[I]f prisoners are viewed as getting Fincol … to clean injecting equipment, then you’re gonna be a target for getting yourself searched or being watched. Whereas I don’t get the same impression about [HCV] treatment generally and most of the corrective services [officers] tend to be, once we explain [treatment-as-prevention], fairly positive. They can see the benefits both to the patients, the community and, of course, for themselves. (P1)
Indeed, the argument regarding the reduction of viral prevalence has proven ‘a definite winner’ (P5) with prison staff:
So, on the custodial side … they’re very worried not only about their own personal risk but the risk that they would carry home to the missus [sic] or the kids. So, [reducing prevalence] is a very compelling tool that we use to engage with the custodial staff. (P5)
Or, as this respondent puts it: ‘surely, from an occupational health and safety perspective, it just makes sense. You’ve got a cure that the Commonwealth [government] is paying for […] It’s not gonna cost Corrections [state-government department responsible for prisons] anything and it just makes things potentially a bit safer.’ (P9).
Security as priority
The matter of acceptance among custodial staff sits within a broader institutional culture of security-first. In prison, security trumps all. There can be a ‘cancellation of appointments because of lockdowns or other security reasons’ (P8), with minimal notice and without recourse. Here, the rollout of a health intervention is not a ready fit: it threatens a potential fault line of cultures, values and priorities. Without providing explicit examples from the trial itself, the issue of prison workplace culture was nonetheless raised by a number of respondents: it formed the institutional bedrock upon which the health intervention was played out. In this context, the imperative to ensure the support and goodwill of governors, management teams and the custodial officers who effectively oversee the daily running of prison, is clear.
Despite respondents’ unanimous, in-principle support for the universal rollout of new HCV therapies in Australian prisons, many were troubled by the lack of effective primary prevention. The absence of PNSP, for example—described by one respondent as the ‘gold standard’ (P1) of prevention—was consistently noted. The subtext of such concern, particularly in the context of treatment-as-prevention, was the risk of reinfection. As this respondent put it:
The prison is, in my opinion, the key priority to achieving elimination more broadly across the state and in the community […] [But] can we achieve elimination using a treatment-as-prevention approach alone or do we require access to other prevention tools? (P11)
Despite such concerns, responses to the issue of reinfection ranged considerably. For some respondents, while comprehensive primary prevention remained a desirable aspiration, reinfection was nevertheless a problem readily overcome with effective treatments and a pragmatic policy of retreatment:
[E]ven though it’s not optimum that we don’t have the harm reduction access that we do in the community, reinfection is easy to retreat and there is access to retreatment for reinfection. (P12)
As much as everyone would like needle and syringe programs in Australian prisons, that’s just not gonna happen anytime soon. But you can eradicate the virus from the prison just by treating everyone […] It’s like treating a strep sore throat. You’re given five to 10 days of penicillin and it’s gone. (P3)
For a minority of respondents, however, the issue of reinfection was a touchstone for their opposition to treatment-as-prevention more broadly. Arguing that such an approach prioritizes treatment over prevention, they advocated instead for prevention-as-prevention:
[T]o have [treatment] as the stand-alone role is wrong. […] [Prisoners] don’t have the means to prevent themselves from reinfection once they have cured their hep C through the DAA-treatment. So, you’ve only got half the picture. (P8)
[I]t feels a little bit like a second-best option […] Treatment-as-prevention seems to be an incredibly expensive and resource-heavy way of going about something that could probably be a bit simpler if they just actually implemented proper prevention strategies in prisons. (P2)
Prisoner time and movement
Time and movement were also considered key to scale-up efforts: ‘Time is a premium in prison… I mean it sounds a bit ridiculous when you think, Well, how hard can it be in prison [to find time for treatment]. Actually, it can be incredibly hard.’ (P7). Prisoners’ time is tightly regimented, with strict limits placed on periods spent outside of cells. As the respondent continues: ‘The constraints of the core day … you’ve got programs that you need to attend, work that you need to attend, phone calls that you need to make to your nearest and dearest’ (P7). While new DAAs have significantly shortened the duration of treatment, respondents noted the imperative of not only finding sufficient time for treatment itself but also for building relationships with potential patients.
Prisoner movement was another feature of prison life that similarly challenged treatment scale-up:
If there’s one thing we’ve learnt from SToP-C it’s how dynamic the movement is, even in the context of maximum-security prisons […] People saw SToP-C as working with, in inverted commas, a captive population, and that would [make it] really easy. Go in there and treat all these people and stop transmission. But that is absolutely not the case. (P12)
While respondents acknowledged transience was also a challenge for treatment rollout in the community, the issue was amplified in prison. And as one respondent pointed out, this is a growing concern: ‘The actual movement of patients in and out of different prisons [happens] much more quickly now. Even in the last two years …’ (P1). Respondents argued for the need to ‘minimize any harm that might come from high turnover or high movement rates within the prisons’ (P16), insisting that ‘there needs to be an absolute commitment that people who commence on treatment, unless released of course, are able to be retained in the center in which treatment can be provided.’ (P7).
Alongside prisoner time and movement, physical space was another practical yet fundamental consideration for effective scale-up. As this respondent explained: ‘logistics like space: have you got enough space to accommodate a big hep C treatment program when they’ve got other competing demands around primary care and mental health, and broader drug and alcohol issues?’ (P12). Indeed, for one of the SToP-C prisons, the shortage of clinical space was an ongoing issue: ‘there’s been other challenges like clinic space […] despite all their [prison name] efforts, they’ve really not been able to get that one solved.’ (P1). With only so many rooms available within each clinic, and a number of competing health programs (dental, population and primary health, for example) vying for limited space, dedicating one room solely to HCV care may mean compromising another program. As this respondent put it: ‘Space is generally a premium, particularly in NSW jails which are old and small, and not purpose-built […] So, having access to space can be a real nightmare.’ (P7).
Resourcing scale-up from trial to implementation conditions
Transposing the conditions, and by implication, the cost, of the SToP-C trial to broad-based scale-up was a point of contention among some respondents. Several questioned its reproducibility: ‘I don’t think it’s a great model […] very expensive’ (P1); ‘there was too much time and effort put in and too much money […] it’s not replicable.’(P3). Singled out as examples of trial innovations too costly to be part of a broader roll-out was the employment of dedicated SToP-C nurses and corrections officers, the hosting of BBQs for prisoners, and the provision of study visit payments: ‘those sort of things, ongoing, I think are a possible challenge without a significant amount of money’ (P1). For as this respondent pointed out, one of the critical challenges facing scale-up is ‘a clearly limited capacity through an existing number of resources and the number of nurses.’ (P8).
Nonetheless, while some SToP-C innovations may prove too costly for broader implementation, other innovations have already been adopted in NSW prisons beyond the trial. Initially, prisoners receiving DAAs were required to attend the prison clinic for daily supervised dosing; now, due to SToP-C, the majority are taking their medications in their cells: ‘a huge change [it] really opens up the overall capacity in terms of treatment.’ (P12). Ultimately, as another respondent pointed out: ‘It depends. It’s resource related. I think as long as it’s well-resourced, scalability is not an issue […] [I]f you scale-up with insufficient resources and then it falls over then that’s a really compromising factor.’ (P7).