"It's just unbelievable how creative they can be," said Michele Deitch, a prisons expert at the University of Texas at Austin's LBJ School of Public Affairs. "They can jerry-rig pens to become needles. They use the dyes in paper products."
But the practice carries with it more than the risk of punishment -- it can also spread hepatitis C.
The prison population is particularly prone to this viral disease, which is transmitted largely through infected blood and can lead to liver cirrhosis and cancer.
Not only do inmates have a penchant for illicit tattoos, but they are also likelier than the general population to have engaged in high-risk behavior like intravenous drug use outside of prison.
Prison health officials estimate that as many as 50,000 of the state's more than 150,000 inmates could be infected with hepatitis C. The cost to treat Texas inmates with hepatitis C is expected to soar by as much as 380 percent next year, a result of the growing prevalence of the disease among inmates and a more effective, but more expensive, treatment protocol. Legislators, already facing a strained budget, will have to find millions more dollars to pay for this care.
Not all inmates are tested for hepatitis C when they enter the prison system. They are tested if they have other clinical indicators, like HIV or a history of intravenous drug use. In a 2007 report, health providers for the Texas Department of Criminal Justice said they had identified and were managing care for about 20,000 inmates with hepatitis C.
Dr. Stephanie Zepeda, the director of pharmacy services for University of Texas Medical Branch Correctional Managed Care, which oversees treatment of inmates, said she provided medication therapy for about 400 hepatitis C patients per month, at a cost to the state of about $2.8 million per year. Not all patients with the disease receive the medication, and the therapy can last from three months to a year.
The current protocol is composed of two drugs, and its cure rate is about 40 percent, Zepeda said. But new medical guidelines call for the use of a third medication, which can be one of two different drugs. One of them would increase the cost of hepatitis C treatment in prisons to more than $8 million a year, the other to more than $13 million, Zepeda said.
Zepeda said that adding a third drug raised the cure rate to 70 percent. But the drugs are not only expensive, they are also complicated to administer.
"It's great from a humanistic standpoint," Zepeda said. "But it's, practically, a challenge for the correctional system."
The new drugs must be administered precisely every eight hours. They must be taken with food, and patients risk developing a resistance to the therapy if they miss doses. In prison, where even small diversions from the regimented schedule require additional work for guards, and where inmates frequently move between units, ensuring that the expensive medications are given correctly could be problematic, Zepeda said.
"It just takes a tremendous amount of coordination to do it right and to do it well," she said.
Another complicating factor, Zepeda said, is that new, potentially more effective drugs with simpler procedures are expected to be available as early as 2014.
In addition to these changes, the Centers for Disease Control and Prevention issued a new recommendation in August calling for all people born between 1945 and 1965 to be tested for hepatitis C. The CDC estimates that this age group accounts for nearly three-quarters of all hepatitis C cases nationally.
More than a quarter of Texas prison inmates were born during that period, according to The Texas Tribune's prisoner database. More testing, Zepeda said, is likely to result in diagnoses of more cases and an increased need for treatment.
For Texas lawmakers, this means high costs now and potentially exorbitant ones in the future as inmates age and the disease progresses, causing liver disease and failure. Additionally, failing to control the disease in prisoners presents serious health risks to the general population. Inmates who are not cured of hepatitis C and are released could spread the disease, which the CDC reports is now the leading reason for liver transplants nationally.
"It is going to be a struggle as the disease continues to wreak havoc in the offender population," said Dr. Owen Murray, the vice president of UTMB's Correctional Managed Care program.
Murray said policy makers should consider ways to control other costs in the prison health care system in order to mitigate the expense of treating hepatitis C. Perhaps, he said, offenders with expensive health needs whose crimes are less severe could be paroled earlier, or state agencies could work with pharmaceutical companies to secure lower rates for drugs. It would be ideal, he said, if the state teamed up with a nursing home to provide care to the growing population of elderly inmates.
Until then, Murray said, prison health officials will have to consider which patients immediately need hepatitis C treatment, and which ones can wait.
"Ultimately, it's going to be much like HIV," Murray said. "You're just going to have to acknowledge you have this disease in prison and that it costs a lot to treat."
Deitch, the prisons expert, said preventing the use of dirty, homemade needles in prison by providing sterile ones for tattooing could be an inexpensive way to limit the spread of hepatitis C.
"Would you rather make those tools available or deal with the long-term cost consequences of the spread of the disease?" she asked.
Jason Clark, a spokesman for the criminal justice department, said the agency was not considering that, largely because of safety concerns. He said the agency already had rules in place to prevent the spread of diseases, including banning tattoos and sexual contact among inmates, along with the sharing of items like toothbrushes and razors.
In 1998, Clark said, the department began an education program focused on disease prevention.
In the program, which is available in 99 of the state's 111 prison facilities, 1,300 inmates teach other inmates about risk factors for infection and how to avoid them.
"They're more likely to have firsthand knowledge about the risk factors among offenders, which gives them credibility," Clark said.
State Sen. John Whitmire, D-Houston, chairman of the Senate Criminal Justice Committee, dismissed the notion of allowing sterile needles in prisons. But he said lawmakers should consider solutions beyond financing medication for inmates.
"This is not just about inmates and their cellmates," Whitmire said. "It's about our communities where these inmates are being released."
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