The treatment was simple — three pills a day, best taken on a full stomach — and it cured Gabriel Serna of hepatitis C in eight weeks.
He just had to wait eight years to get it.
Revolutionary medications have made the blood-borne, sometimes fatal infection curable, so people with the disease need not endure the inexorable and irreversible damage it causes to their livers.
Unless they are in one of New Mexico’s prisons, like Serna was for much of his wait.
That’s because although the state’s inmates have the highest prevalence of hepatitis C of any group in New Mexico — more than 4 in 10 are infected — the prisons are not hardly treating any all of them. Out of some 3,000 prisoners diagnosed with the disease, just 46 received treatment for hepatitis C during the 2018 fiscal year.
State officials have been aware of their obligation to treat inmates with hepatitis C for years. In a television interview in 2016, the Corrections Department secretary at the time acknowledged New Mexico might be sued if it didn’t increase drug access in the state prisons.
And local civil rights lawyers are already considering ways to push for reform, including litigation.
Failed response
Like most people with hepatitis C, 55-year-old Serna of Albuquerque couldn’t pinpoint when he was infected. When he tested positive in 2001, he reasoned that he might have picked it up when he had a tattoo of an old girlfriend’s name inked over.
He also had injected drugs since he was 11.
The virus is insidious, causing progressive liver damage that results in scarring and then liver cancer or end-stage liver disease. At the point a patient begins to experience symptoms, the person might have just months to live.
More than 3.5 million Americans are thought to have hepatitis C, and it kills about 20,000 of them each year, triple the number killed by AIDS.
The prevalence in New Mexico is particularly high: Researchers estimated that as of 2010, nearly 1 in 40 of the state’s adult residents was infected, 60 percent higher than the national average. And nowhere is the concentration higher than in the state’s prisons, where as of January, 44 percent of people screened positive, according to corrections officials — the highest known share of any prison system in the country.
Beginning in 2009, all people locked up in New Mexico prisons have been offered screening.
Until a few years ago, however, the standard drug treatment for hepatitis C was barely tolerable: It took six months, induced side effects like depression and severe fatigue, and failed to cure the patient as much as half the time.
But in 2014, Gilead Science introduced the first of a series of game-changing drugs known as direct-acting antiretrovirals. Most patients could be cured, with few to no side effects, in as little as eight weeks.
Gilead launched its first, sofosbuvir, at $84,000 per course of treatment; since then, competing therapies have driven down prices, but they still run around $20,000. Private and public insurers have proven willing to pay.
But correctional health systems across the United States have balked.
Many have erected barriers to treatment, narrowing eligibility to inmates whose livers have already become irreparably scarred.
Serna was in the Penitentiary of New Mexico south of Santa Fe in 2010 when he began seeking treatment and was rebuffed.
A set of New Mexico Corrections Department guidelines from June indicated the agency restricts treatment to inmates free of major disciplinary infractions for at least 12 months. Even a history of multiple minor infractions, such as “abusive language or gestures,” can exclude a patient from treatment.
“They told me that the best thing to do — because they were not going to treat it, that was the bottom line — was for me to drink a lot of water and exercise,” Serna said.
When he neared release, corrections officials changed tactics. “The reason why we’re not giving you treatment,” he recalled them telling him, “is because you’re going home.”
He finally got treated through Medicaid after his release from prison.
David Selvage, health services administrator for the Corrections Department since October 2017, acknowledged that when it comes to hepatitis C, the department is failing to meet the needs of prisoners.
The eligibility criteria are a means of rationing scarce health care dollars, he said. “We simply don’t have enough funding to treat everybody who needs to be treated at the time of infection,” Selvage said.
For the coming fiscal year, Selvage said, his goal is to triple the number of people treated, at a cost of $2.5 million. But by his estimate, the department would need $50 million worth of medication to treat all infected people in its custody — a thirtyfold increase in spending over 2018 and more than its entire annual health care budget.
And that price tag doesn’t reflect the cost of additional hires needed to manage the treatment of thousands of new patients.
Whether or not the state is prepared, change could be coming from the courts.
Since 2015, prisoners in at least 16 states have introduced class-action lawsuits asserting a right to access the new therapies.
In the first major ruling in November 2017, a federal judge in Florida ordered the state to accelerate prisoners’ access to treatment, at a cost of hundreds of millions of dollars. Soon after, Colorado settled a lawsuit and agreed to allocate $41 million in new funding to treat all people with hepatitis C in custody, and Massachusetts and Pennsylvania quickly followed.
A handful of governors have pre-empted litigation by committing to provide universal treatment in their prisons as part of strategies for eliminating hepatitis C.
Civil rights advocates in New Mexico are aware of these trends.
Frances Carpenter, a private attorney who has represented incarcerated people, said she was struck by her clients’ descriptions of the Corrections Department’s narrow criteria for treatment access.
Recently, she met with the local chapter of the American Civil Liberties Union, which has filed public records requests seeking information about the state’s treatment practices, according to its legal director, Leon Howard. The team members say they are watching the actions of Democratic Gov. Michelle Lujan Grisham carefully. Should she fail to act, they say, litigation is a real possibility. Lujan Grisham’s staff has signaled she might be more proactive in addressing the problem than her Republican predecessor, former Gov. Susana Martinez.
“The numbers are jarring,” said Tripp Stelnicki, a spokesman for the governor.
He indicated the governor would lead rather than follow: “She has no interest in letting this play out in the courts, rather than addressing behavioral health needs in our prison system. And on top of that, it’s just responsible from a moral and fiscal perspective.”
Addiction treatment
While a court’s decision could expand treatment to the pool of sick inmates already in the state’s custody, the cures for hepatitis C do not confer immunity against reinfection, such as by injection drug use.
Advocates say that to effectively address the epidemic, policymakers need to allow prisoners with opiate addictions to receive medication-assisted treatment to help them reduce their drug use and slow the spread of the disease.
“I think for you to understand hep C, you have to understand the addiction, too,” said Fernando Trujillo, an Española native who became caught in a cycle of drug-possession charges and incarceration. “Why else do we have hep C, the majority of us? It’s because of our addiction.”
Trujillo said he was introduced to prescription drugs at 13 and tried heroin at 16. In 2011, he was diagnosed with hepatitis C.
“I felt like I had cancer or something,” he said, adding, “I never thought I would get rid of it.”
He accepts responsibility for his actions, Trujillo said, but in crucial ways the criminal justice system made it harder for him to quit using drugs. For one thing, he said, heroin is more freely available in prison than it is on the outside.
To stay sober, he depends on a daily dose of the opioid buprenorphine, better known as Suboxone. In combination with other behavioral therapies, this type of treatment has been shown to help people surmount their addictions and cut risk of a fatal overdose by as much as half. Yet New Mexico’s state prisons bar inmates from obtaining such medication while they are locked up.
Reforming the way New Mexico treats addiction could help it address hepatitis C, too. In a cohort of young adult injection drug users, those on medication-assisted treatments were 60 percent less likely to acquire the virus.
Trujillo said the infection felt like a shadow cast by his prior drug use that was still clinging to him; eliminating it gave him the sense he was finally freed from that phase of his life.
“When [the nurse] told me that I didn’t have hep C no more, I cried,” he said, his eyes welling up. “That gives me just another reason not to relapse, not to backtrack, not to mess up.”
Ted Alcorn is a writer whose work has appeared in the New York Times, the Atlantic, and the Lancet. He lives in New York City and was raised in New Mexico.
