27 September 2012 

East Toronto program successfully helps some marginalized people recover from hepatitis C virus

In high-income countries such as Canada, Australia, the United States and Western Europe, screening of the blood supply has virtually eliminated transmission of hepatitis C virus (HCV) via blood transfusions. In these countries, HCV is now mostly transmitted in the following ways:

  • sharing contaminated equipment for substance use (including needles, crack pipes, straws and rolled-up currency notes)
  • exposure to unsterilized equipment used for tattooing and piercing
  • among HIV-positive people, particularly men who have sex with men – having unprotected anal sex, sharing sex toys and reusing condoms and gloves

Some people use street drugs in an attempt to relieve psychological distress and suffering. Unfortunately, this can lead to a downward spiral into addiction and psychosocial problems and it also exposes users to viruses and other germs. One commonly used street drug is a more potent and highly addictive form of cocaine called crack. Usually crack is smoked, though it can also be injected.

Although most programs to help substance users recover from addiction and HCV infection focus on people who inject heroin and other chemically related compounds in the context of a methadone program, few studies have documented successful recovery from HCV among crack users outside of addiction-based treatment models.

Three community health centres and two specialists from Toronto-based hospitals have been collaborating on a program funded by the Ontario Ministry of Health and Long-Term Care to help marginalized populations cope with multiple diagnoses and improve their access to HCV treatment and mental health and social services. The population under study in this community-based program had a high rate of crack cocaine use. The program provided services to support HCV treatment working from a harm reduction framework. The program has been successful and may be a useful model for other communities trying to help marginalized populations on the road to healthier living.

A broad program

The East Toronto Hepatitis C Program (ETHCP) has at its core a blend of health care providers and community support workers. In this program, treatment of HCV is centred on weekly educational support group meetings at community-based clinics that are facilitated by a case manager and program coordinator. Each meeting lasts for about two hours and each group, consisting of 20 people, gathers for four months. At each weekly meeting a different HCV-related topic is discussed.

Prior to, during and after each weekly meeting, a multidisciplinary team meets with individual participants. Team members include the following:

  • family physician
  • nurse
  • nurse practitioner
  • infectious disease specialist
  • psychiatrist

This team assesses participants and provides the necessary care and treatment on site. At the health centre clients are helped with gaining access to social and health-related services.

Study details

The ETHCP team reviewed health-related information that they collected between March 2007 and July 2010 for a study of the program.

The average profile of 129 HCV-positive participants when they enrolled was as follows:

  • 71% men, 29% women
  • age – 48 years
  • 96% were unemployed
  • 65% had stable housing
  • 6% were HIV positive
  • one participant was also infected with hepatitis B virus (HBV)

Risk factors for HCV infection included the following:

  • history of injecting street drugs – 87%
  • history of using crack cocaine – 85%
  • history of being imprisoned – 74%
  • history of being tattooed – 57%
  • having an HCV-positive sexual partner – 33%
  • having part of their body pierced – 19%
  • men having sex with other men – 5%

Mental health

Many participants also had mental and emotional health issues:

  • 30% of participants were taking medicines for mental health conditions
  • 25% had previously been hospitalized because of attempted suicide

Commonly used substances when participants entered the study were as follows:

  • crack – 45%
  • marijuana – 43%
  • alcohol – 34%
  • injection street drugs – 8%

HCV treatment

During the study period, the standard of care for HCV consisted of a combination of two drugs:

  • once-weekly injection of a long-lasting form of interferon-alpha called peginterferon
  • twice-daily doses of the nucleoside analogue ribavirin

The duration of treatment depended on a number of factors but could last for anywhere between 24 and 48 weeks.

Prior to the study, only 24 participants (19%) had been referred to and evaluated by a liver specialist. Of these 24, only seven were offered treatment and only four elected to initiate therapy. Of all of these participants, only one was able to complete his course of therapy.

However, once in the ETHCP, 95% (123 of 129 people) agreed to have further evaluation of their liver disease and overall health. Of these 123 people, 24 participants were able to meet the criteria set by the provincial Ministry of Health to receive subsidized HCV treatment. Only three of these 24 participants missed one or more doses of peginterferon. One of the 24 participants died because of an overdose of street drugs.

Eleven of the 24 participants had strains or sub-types of HCV called genotypes 2 and 3. These genotypes respond relatively well to treatment, and 10 of the 11 participants were cured.

Genotypes 1 and 4 tend to respond less well to therapy, and seven of the remaining 13 participants who had these genotypes and who received treatment were cured in the ETHCP study.

Factors affecting success

The study team found that having a support group integrated with “community-based, inter-professional care can improve access to health care for people with HCV who face barriers to traditional care including, poverty, unstable housing, substance use and mental health concerns.”

The research team notes that by minimizing barriers to care and services and providing ways to reduce the harms associated with substance use, they were, at least with some participants, ultimately able to “overcome the stigma of trimorbidity: HCV, illicit drug use and mental illness.”

Fear factor

A major barrier to treatment is fear of side effects—specifically the increased risk of anxiety and depression that can occur as a side effect of interferon. This is particularly the case among people who have pre-existing anxiety and/or depression. However, the combination of weekly support group meetings and ready access to a psychiatrist helped to smash this barrier.

Under one roof

That care and support services were available from one site helped to ease access to other services needed by participants. Also, participants did not need an appointment to see a nurse or family physician, which made access to care easier.

Skills and education

The program staff taught participants to help resolve competing priorities in their lives as part of the facilitated weekly group meetings. Moreover, all of the education and support provided by the care team helped to keep participants motivated and engaged in their care and treatment.

The importance of housing

Taking many factors into account, the study team found that having housing was significantly linked to initiating therapy for HCV.

Such a finding should not be surprising. A study funded by Health Canada and overseen by the Mental Health Commission of Canada also found that having housing plays a major role in the process of stabilizing mentally ill people. By giving them subsidized housing and access to addiction, mental health and social services, researchers with the Commission’s study were able to give hope to homeless and addicted people and to help them begin the journey to recovery.

In addition to the Commission’s study, the ETHCP stated that “a growing body of research [demonstrates] that both provision of housing and housing improvement [leads] to better health behaviours and outcomes.” They also noted: “Housing status may also be a surrogate marker for other factors such as social support or economic standing, each of which has been shown to improve access to health care.”

Having stated those points, the ETHCP team stressed that living in unstable housing should not be a reason to delay initiation of HCV therapy if “adequate supports [are] in place.” Indeed, the program “successfully treated” three participants who were homeless when they began it.

Gender issues

Although not statistically significant, the researchers noticed a trend: Women appeared less likely to initiate HCV treatment than men. A larger study would be needed to confirm or refute this trend. Possible reasons for this finding could include the following, as suggested by the research team:

  • The support groups had more men than women. This could have lead to an environment where women felt “less comfortable attending and participating actively.”
  • Women likely have responsibilities, such as caring for children and other family members and running the household. These responsibilities could cause women to “prioritize the needs of others over their own health.”
  • Another study has found that HCV-positive women are more likely than their male counterparts to report stigmatization by health care staff. This could result in women experiencing anxiety and depression and might make further contact with the health care system daunting. It is possible that some women in the study had previously experienced stigmatization which hindered their progress once in the ETHCP study.

Substance use

The researchers stated that in the past patients who were engaged in “active substance use” were discouraged from requesting HCV treatment. However, according to the ETHCP researchers, their study “contributes to a growing body of evidence that these patients can be treated when given adequate psycho-social supports and community-based, low-barrier health care.” Furthermore, they add, the rates of recovery from HCV in the present study are similar to those seen from clinical trials.

                                                                                                                        —Sean R. Hosein


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