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— 59 — There are a number of problems in specialised medical care for the prison population, which were highlighted in the prison healthcare quality report (CAPRI, 2002). These included excessive delays in specialised consultations, defective communication between specialists in referral hospitals and prison doctor, missed appointments and difficulties with logistics, security and privacy for inmates when being transferred to hospital1. Telemedicine offers a unique opportunity to remove the difficulties inherent in hospital use and geographical barriers, it improves the chances for equal access to specialised healthcare, guarantees treatment continuity between medical environments, improves organisational problem (such as appointment times), avoids the need for the security measures required in transfers and ensures inmates’ privacy. It also improves communications and links between hospitals (specialised healthcare) and prisons (primary healthcare), facilitates ongoing training and its use in geographical areas far away from specialists has shown it to be a cost effective option2. One of the most prevalent health problems in prisons is that of chronic hepatitis from the hepatitis C virus (HCV)3-5, although prevalence of the disease has decreased considerably in recent years. Even so, the prison population is still a major reservoir of infection and a key population in the fight to eliminate it6. Indeed, the strategic plan of the Ministry of Health, Consumer Affairs and Social Welfare to control hepatitis C considers intervention in prisons to be a priority issue in this regard7. The strategy of micro-elimination was recently proposed as a pragmatic approach to enable faster and more efficient treatment and prevention of infections and re-infections8. Strategic micro-elimination populations would be the prison population, people who inject drugs (IDUs), the immigrant population from areas with a high prevalence of HCV (by convention, equal to or more than 3%) and men who have sex with men (MSM). The last of these groups has greater prevalence if they have a prison background9. The appearance and approval of modern direct acting antiviral (DAA) therapies fulfils the criteria of disruptive technology proposed by professor Christensen10, and it has been demonstrated that they are cost effective in Spain11. Such a scenario opens up opportunities to eliminate HCV from prisons and makes the WHO’s health objective of getting rid of the infection by 2030 an achievable one12. In our geographical area we have used telemedicine for treating hepatitis C in the prison population. There are other experiences along the same lines. An example is the teleconsultation program to monitor 66 patients already treated with DAA in Dueso prison, in northern Spain13, which has had very good results, along with other experiences where the same integration and links with specialised care of the prison population was achieved, or where it was used as a tool to complement monitoring13-15. A randomisation of telemedicine should evidently have been carried out to compare it with habitual practice and to gain a notion of the intrinsic value of telemedicine and its contribution towards eliminating hepatitis C, along with a comparison of the results in different prisons (open randomised study). This would be difficult at the very least and at this late stage is frankly impossible. What we can offer however is the elimination data from a prison (Madrid IV) that uses telemedicine and that, as far as we know, is eliminating HCV at a faster rate than that in the vast majority of similar prisons in Spain. The conclusion could well be drawn that there is a link between the use of this tool and elimination of the disease, and even if this does not mean that there is Editorial

Telemedicine and specialised consultations in prisons. The example of HCV chronic hepatitis