Abstract
Hepatitis C virus (HCV) infection is highly prevalent in U.S. jails, yet access to curative direct-acting HCV therapy remains limited because of the inmate Medicaid exclusion rule. However, an innovative expansion of the AIDS Drug Assistance Program in California now supports HCV treatment for individuals experiencing incarceration who are living with HIV. We describe the implementation of this pilot program in the Los Angeles County Jail, including the formation of a multidisciplinary task force designed to rapidly identify, evaluate, and initiate treatment despite the unpredictable length of stay and other barriers. Enabling treatment delivery within jail constraints has been possible with program adaptations such as provision of remaining HCV medications at release, shortened regimens and use of early sustained virologic response. Although challenges remain—including lack of universal screening, no funding for treatment of HCV monoinfection, and limited post-release linkage to care—this pilot demonstrates that targeted policy innovation combined with an effective implementation team can expand access to lifesaving HCV care in carceral settings in a group at very high risk.
Background
Hepatitis C virus (HCV) infection, which is highly prevalent in jails and prisons, progresses in many of those infected to cirrhosis or liver cancer. Globally, most people experiencing incarceration still do not have reliable access to HCV testing and treatment, despite the fact that HCV has become, over the last 15 years, highly curable using an 8–12-week, direct-acting antiviral (DAA) regimen (Santo et al., 2026). In the United States, one reason that the DAA breakthrough, as revolutionary as it has been, remains out of reach to the ∼8% of imprisoned people with active HCV is a decades-old federal policy known as the “inmate Medicaid exclusion policy” (Qureshi et al., 2021; Spaulding et al., 2023). Importantly, in California, a new program for people with HCV who are also also living with HIV is beginning to change this. For individuals living with both HCV and HIV, the state has piloted a project to allow an existing program funding medicines for underinsured people with HIV—the California AIDS Drug Assistance Program (ADAP)—to begin also paying for HCV treatment in jail.
This workaround has been necessary because Medicaid, the health insurance program in the United States for the poor and near-poor, has, since its inception, contained within it an important coverage gap, which is the longstanding exclusion of people in prisons and jails (Wurcel et al., 2024). For example, for those in jail who would otherwise qualify, the Medicaid exclusion policy affects not only those convicted but also those who are incarcerated pretrial because of inability to pay bail. In very concrete ways, the Medicaid exclusion policy has undermined basic health care by preventing doctors from addressing some of the most common and serious medical conditions in the jails if the cost of treatment is too high, including HCV. In contrast to Medicaid, ADAP is not subject to the Medicaid inmate exclusion policy because it is funded through the Ryan White HIV/AIDS Program and state resources. ADAP operates as a payer of last resort and can provide medication access during incarceration, which in California has now been leveraged to fill the HCV/HIV treatment gap.
One reason the ADAP expansion to include HCV treatment in jail is critical is because the cure for HCV in persons with HIV is a matter of considerable clinical urgency. Although people living with HCV and HIV represent only a minority of those with HCV, the progression of HCV in those with HIV to cirrhosis and its complications is both more rapid—by up to a decade—and more likely (Sulkowski et al., 2007). Treating HCV has additional benefits; it reduces future risk of kidney disease, neurocognitive disorders, and cardiovascular disease, major causes of morbidity in people with HIV (Jeong et al., 2025). Although individuals with both HCV and HIV were once thought to be a “difficult to cure” group, recent clinical trials show that HCV cure rates in those with HIV using DAAs are ∼95% (Naggie et al., 2015; Wyles et al., 2017). Importantly, jail also offers a unique opportunity for the treatment of HCV in those otherwise not well-positioned to access care in the community owing to inadequate housing, mental illness, substance use disorders, or a combination of these factors. In jail, stabilization of some or all of these barriers can provide a window during which the 8 to12-week HCV treatment course can be effectively delivered (Chan et al., 2020). Additionally, the resolution of HCV infection while in jail has implications not only for the individual cured but also for the community, including both needle-sharing and sexual partners, whose risk of acquiring HCV is diminished by effective jail HCV treatment programs.
Macrolevel Implementation of the ADAP HCV/HIV Pilot
This ADAP pilot program was implemented through administrative collaboration and programmatic approval rather than new legislation. The decision-making authority involved state ADAP leadership in collaboration with county correctional health administration, which jointly approved the framework and rollout of the program. Planning for the program involved stakeholder discussions to develop operational workflows, define eligibility, and coordinate medication delivery. Of note, it was designed to focus on individuals housed in county jails (not prisons), but eligibility is not dependent on sentencing status and may include individuals who are pretrial or post-sentencing. Following the planning phase, the program moved to local implementation in several jails. The implementation phase involved additional stakeholders, crucially, jail-level pharmacy and clinical teams, as outlined below. The development outside of the legislative pathway and meaningful collaboration of stakeholders allowed this California expansion of ADAP to proceed rapidly from concept to realization.
Local Implementation of the ADAP Pilot: The Los Angeles County Jail Experience
Currently, the ADAP jail program is being piloted in several California jails, including the LA County Jail, the largest such system in the United States. Lessons learned in the LA County Jail may be relevant for other jails as they seek to build an HCV/HIV treatment program around this new funding source. A first critical step was the formation of a Task Force with a focus on rapidly bringing incarcerated coinfected individuals into treatment. The Task Force consists of an epidemiologist (to quickly identify coinfected persons in the jail), two physician champions (to expedite evaluation and treatment), and a pharmacist (to oversee ADAP enrollment, process clinician requests for DAAs, and review drug–drug interactions). The Task Force meets weekly to review potential candidates, identify clinic slots with trained HCV providers for treatment initiation, and problem-solve complex cases that may benefit from multidisciplinary brainstorming. The Task Force also directly supports nonspecialist providers in the jail (internal and family medicine-trained) with complexities such as distinguishing HCV reinfection from relapse, staging liver disease, and managing adherence challenges. Input to the Task Force from jail custody (deputies and custody assistants) has been important to estimate release dates to determine if there is a realistic window to deliver DAA therapy, minimally 8 weeks for the shortest pangenotypic DAA regimen, glecaprevir/pibrentasvir (Mavyret). Even with custody support, the unpredictable timing of release from the jail creates an ongoing challenge to the completion of an entire HCV treatment course before release, and as a result, our local protocol has had to quickly evolve. For example, if jail release occurs with less than 1 month of DAA therapy remaining, the remaining tablets are provided (in hand) as release medication for completion outside of jail. Additionally, instead of measuring success by measuring HCV RNA viral load 12 weeks after completion, we use—based on more recent evidence—week 4 sustained virologic response (SVR) as a proxy for successful treatment outcome, a metric that can be obtained at an earlier time point (McDonell et al., 2026). These adjustments have had a major impact on delivery of HCV treatment in the jail and assessment of outcomes.
Nonetheless, several important challenges remain. First, as in most carceral institutions in the United States, there is no systematic HCV screening of people entering the LA County Jail, resulting in ongoing missed diagnostic and treatment opportunities (Maner et al., 2022). This is important considering that 30% in the United States with HCV cycle through a correctional facility on a yearly basis (Hammett et al., 2002). However, developing a system for opt-out screening—the most optimal strategy—in the jail’s inmate reception center daily has remained, because of volume, a daunting challenge (Farrell & Pino, 2025; Sheehan et al., 2025). A second challenge is that there is currently no broadly accessible funding mechanism to support treatment of HCV in those not also infected with HIV; individuals with HCV “monoinfection” make up the majority with active HCV in the jail and currently do not benefit from the curative program. However, in the interim, the work that has been done in implementing this smaller initiative is likely to help deliver on the goal of universal jail access to DAAs (Sheehan et al., 2025). Potentially filling this funding gap in the next year is California Advancing and Innovating Medi-Cal, a state expansion of Medi-Cal, which will include coverage of health costs, including HCV testing and treatment, for incarcerated people 90 days before release as well as enhanced care coordination. Third, it has not been uncommon for patients with HCV and HIV to initiate DAA therapy but be released before treatment completion, leaving—despite the provision of remaining tablets as release medicines—the clinical outcome uncertain. This is a key gap because prior research indicates the likelihood of a cure is lower (Chan et al., 2020). That said, studies of HCV treatment with DAAs in community (nonincarcerated) contexts, indicate that loss to follow-up is also a problem outside the jail context in outpatient HCV programs (Eckardt et al., 2019; HepNed study group, 2020). To reduce loss to follow-up, both for those who initiated HCV treatment in jail and for those diagnosed but not initiated in jail, innovative initiatives with proven efficacy—such as transitional care coordination and navigation—as well as tighter linkage to community health care partners for ongoing HCV care are needed (Akiyama et al., 2019). Currently, such connections are weak for several reasons, including institutional factors, prominent among them siloed workflows, and challenges for outside entities accessing the jail. Such partners ideally would initiate patient contact before jail release to help improve the likelihood of post-jail linkage. To address this, both internal quality improvement work, and enhanced data sharing between jail health services, public health agencies, community clinics, and HCV/opioid agonist therapy-focused nonprofits will be explored in the months ahead.
Conclusions
The experience in the LA County Jail with utilizing the California ADAP jail pilot to cure HCV in people living with HIV is new but has already resulted in the cure of people in jail with HCV/HIV coinfection, with the Task Force at the center of the implementation. The Task Force has been an important tool for an efficient and flexible workflow that has been sufficiently nimble to respond in real-time to the diverse challenges that have arisen. Additional steps remain in the jail to improve HCV screening, initiate DAAs earlier in the jail stay, to establish a curative program for people living with HCV monoinfection and avoid to HCV treatment courses interrupted by jail release potentially through stronger community collaborations. As the program matures, we will report HCV outcomes, including treatment completion, SVR at 4 weeks post-treatment, and important process indicators, including time from HCV diagnosis in the jail to treatment initiation. At this fiscally difficult time, when ADAP programs around the United States have been targeted with formulary and service reductions, in California eligibility criteria and drug coverage have remained stable (Dawson & Kates, 2026). As a result, the LA County Jail, although not yet positioned to treat all patients with HCV, has been able to begin to cure people living with HCV and HIV who represent a subgroup with a particularly high risk for rapid progression with this innovative state program.