Prevention in Focus

Fall 2019 

Blueprint to Inform Hepatitis C Elimination Efforts in Canada: What do service providers need to know?

By Christopher Hoy

How can we eliminate hepatitis C in Canada? With a global push for elimination and a cure widely available in Canada, we’re closer than ever. CanHepC, a Canadian network of hepatitis C experts, has developed a blueprint for how we can get there. The Blueprint to inform hepatitis C elimination efforts in Canada is a document to guide action by policy-makers and measure their progress. However, what’s the role for Canada’s frontline service providers and communities? This article explores the new blueprint document and what it means for frontline service providers.

What is the Blueprint?

The Blueprint to inform hepatitis C elimination efforts in Canada is a document developed for policy-makers, program planners and service providers. The Blueprint compiles expert recommendations to inform actions and strategies for eliminating hepatitis C. The Blueprint also outlines key targets that Canada can strive towards to track our progress.

The Blueprint has set targets for Canada to reach by 2030, such as the following:

  • 80% decrease in new infections
  • 90% of people living with hepatitis C will be diagnosed
  • 80% of people living with hepatitis C will have initiated hepatitis C treatment

So, how do we get there? The Blueprint provides a menu of evidence-informed actions and recommendations to which policy-makers and program planners can direct attention and resources. These actions range in scope from the national to community level. They include changing health policies, expanding health services and programs and introducing new approaches to address prevention, testing and treatment.

The Blueprint also provides recommendations for creating a robust, national surveillance system to track health data and an exhaustive list of performance indicators. This will help Canada to create tangible, measurable steps in addressing hepatitis C and track our progress.

The document follows two recent developments from both the international and national stages. In 2016, Canada endorsed the World Health Organization’s Global Health Sector Strategy on Viral Hepatitis, 2016–2021 to eliminate viral hepatitis as a public health threat by 2030. In 2018, the Public Health Agency of Canada launched Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030: A pan-Canadian STBBI framework for action, which aligns with the global strategy. The Blueprint complements these two documents by providing a hepatitis C-specific plan tailored to the context in Canada.

The current state of hepatitis C in Canada

Hepatitis C causes more years of life lost than any other infectious disease in Canada.1 Certain priority populations are at a higher risk of new hepatitis C infections, while people who have been living with hepatitis C for many years suffer from complications related to long-term liver damage. Approximately one out of every 100 Canadians have had hepatitis C in their lifetime.2 Half of these cases remain undiagnosed.

A highly effective cure for hepatitis C using direct-acting antivirals (DAAs) is now publicly covered with few restrictions for most Canadians. If treatment is supported with concrete actions in prevention and testing, hepatitis C elimination is possible in Canada for the first time.

A priority populations approach

To achieve elimination, efforts must focus on priority populations that are disproportionally affected by hepatitis C in Canada. This follows a health equity approach that recognizes that social, economic and environmental factors create inequities in health and that some populations require additional support and services outside of the mainstream health system.

Many individuals who face inequities are already marginalized in society and may be excluded from health services because of stigma and discrimination. This may be further exacerbated by the stigma that is associated with hepatitis C. Each of the priority populations below is not distinct or exclusive; an individual may belong to one or more groups, thus multiplying their risk for hepatitis C.

The Blueprint makes relevant recommendations for service providers for five main priority populations:

  • People who inject drugs/people who use drugs
  • Indigenous peoples (First Nation, Inuit, Métis)
  • Immigrants and newcomers from countries where hepatitis C is common
  • Gay, bisexual and other men who have sex with men (gbMSM)
  • People with experience in the prison system

Blueprint recommendations for service providers and healthcare workers

Many of the recommendations in the Blueprint are focused at the community or patient level. These recommendations are ones that can be implemented by service providers in their day-to-day work and incorporated into program planning in their community. This section summarizes some of the recommendations that are most relevant to frontline workers.

People who inject drugs/people who use drugs (PWID/PWUD)

The highest incidence and prevalence of hepatitis C in Canada are found among PWID.2,3 Criminalization, unstable housing, poverty and discrimination create barriers to services for PWID/PWUD, and incarceration increases their risk for hepatitis C.

Recommendations most relevant to service providers:

  • Ensure the meaningful involvement of PWID in program design, delivery and evaluation.
  • Move care and treatment to low-threshold environments, including places where PWID are already accessing services (harm reduction programs, community-based primary care).
  • Incorporate harm reduction and overdose prevention measures across the continuum of hepatitis C services.
  • Support community-based approaches that offer wraparound care that is focused on client needs, trauma-informed and responsive to social determinants of health.
  • Needle and syringe programs (NSP) can prevent hepatitis C transmission. Make them more accessible in terms of proximity, opening hours and access points. Consider operating specialized fixed sites and mobile outreach units and expanding traditional service points, such as pharmacies and clinics.
  • Increase access to opioid agonist therapy such as methadone and Suboxone. This includes making opioid agonist therapy available through pharmacists and nurse practitioners, and in various settings, such as at primary care clinics, in the community, at NSP sites in hospitals and at other emergency care sites.

Indigenous peoples (First Nation, Inuit, Métis)

Hepatitis C rates are higher among Indigenous peoples than among Canada’s general population.3,4,5 Complex, intersecting factors have an impact on this population. Racism, colonialism, intergenerational trauma and systematic abuse increase vulnerability to hepatitis C among Indigenous peoples. The same conditions make Indigenous people less likely to trust or access hepatitis C services.

Recommendations most relevant to service providers:

  • Ensure that approaches for addressing hepatitis C are Indigenous-led, multidisciplinary (including shared-care models that bring together Indigenous and Western approaches to health) and rooted in addressing Indigenous determinants of health (such as colonialism, racism and social exclusion).
  • Provide access to wholistic Indigenous healthcare services on-reserve and off-reserve through clinics with links to teams with shared-care models.
  • Build community awareness and readiness for hepatitis C programming, including harm reduction, with Indigenous leaders and their communities.
  • Be prepared to address broader community needs beyond hepatitis C and destigmatize drug use and hepatitis C.

Immigrants and newcomers from countries where hepatitis C is common

Hepatitis C rates are higher among immigrants and newcomers from countries where hepatitis C is common than among the Canadian general population.2 In their home countries, hepatitis C is commonly transmitted through unsafe medical and dental practices.

Recommendations most relevant to service providers:

  • Integrate screening and treatment into multidisciplinary, community-based models of primary care for newcomers, such as community health centres.
  • Educate healthcare practitioners about the increased risk for hepatitis C among immigrants and newcomers from countries where it is common and about the importance of testing them.
  • Train healthcare providers who treat large numbers of people from countries where hepatitis C is common to diagnose and treat hepatitis C.
  • Offer culturally sensitive services in the languages of immigrants and newcomers.

Gay, bisexual and other men who have sex with men (gbMSM)

gbMSM are an emerging priority population with an increasing number of hepatitis C infections.6 Among gbMSM, hepatitis C is most likely to be transmitted through sexual contact or drug use, especially through rough sex and group sex that involves drug use7.

Key recommendations and implications for service providers:

  • Integrate hepatitis C into existing sexual health and HIV strategies and programming for gbMSM, including providing hepatitis C testing and prevention services in sexual health clinics and offering hepatitis C testing to all individuals receiving pre-exposure prophylaxis (PrEP).
  • gbMSM do not always use traditional NSP. Harm reduction services should be integrated into other services and programs for gbMSM to facilitate access.
  • Provide regular monitoring for re-infection, along with testing for sexually transmitted blood-borne infections (STBBIs), among gbMSM who have cleared hepatitis C infection spontaneously or with treatment.

People with experience in the prison system

In federal correctional facilities, 30% of prisoners have evidence of a past or current hepatitis C infection.8 People who use/inject drugs, Indigenous peoples and other racialized populations are more likely to have experience in prison systems.9 Being in prison further increases this risk, because injecting drugs and tattooing with shared equipment are common practice.

Recommendations of note for service providers:

  • Implement harm reduction programs in consultation with prisoners and correctional health staff. This can include NSP, opioid agonist therapy programs, other harm reduction services, and mandatory training on overdose prevention.
  • Routinely offer voluntary, confidential hepatitis C testing, education and counselling to prisoners at prison entry and during prison stay. Where possible, this can be facilitated by community-based organizations.
  • Provide hepatitis C treatment for all prisoners and/or linkage to care upon release for those with short sentences, irrespective of eligibility for provincial drug benefit programs. Create mechanisms for linkage with community care upon release from prison. This includes seamless transfer of medical records and access to hepatitis C treatment.
  • Upon release, provide rapid linkage to harm reduction, social and other hepatitis C care services.

Implications for service providers

Service providers have an essential part to play in the elimination of hepatitis C. Although many of these recommendations from the Blueprint must begin with policy-makers and system planning, they require frontline service providers to implement them.

The Blueprint’s recommendations are all evidence informed and have been reviewed by Canada’s foremost hepatitis C experts. Service providers have strong voices in their communities, and the Blueprint can help service providers to advocate to policy-makers and funders.

 

References

  1. Bolotin S, Feld JJ, Garber G et al. Population-based estimate of C virus prevalence in Ontario, Canada. PLoS One. 2018 Jan 23;13(1):e0191184. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191184
  2. Trubnikov M, Yan P, Archibald C. Estimated prevalence of hepatitis C virus infection in Canada, 2011. Canada Communicable Disease Report. 2014 Dec 18; 40-19. Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-19/surveillance-b-eng.php
  3. Krajden M, Cook D, Janjua N. Contextualizing Canada’s hepatitis C virus epidemic. Canadian Liver Journal. 2018;1(4);218-30. Available from: https://canlivj.utpjournals.press/doi/10.3138/canlivj.2018-0011
  4. Gordon J, Bocking N, Pouteau K et al. First Nations hepatitis C virus infections. Six-year retrospective study of on-reserve rates of newly reported infections in northwestern Ontario. Canadian Family Physician. 2017 Nov;63:e488-e494. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685465/
  5. Spittal PM, Pearce ME, Chavoshi N et al. The Cedar Project: high incidence of HCV infections in a longitudinal study of young Aboriginal people who use drugs in two Canadian cities. BMC Public Health. 2012;12:632. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-632
  6. Public Health Agency of Canada. M-Track: Enhanced Surveillance of HIV, Sexually Transmitted and Blood-Borne Infections, and Associated Risk Behaviours among Men Who Have Sex with Men in Canada. Phase 1 report. Ottawa, ON: Centre for Communicable Diseases and Infection Control, Infectious Disease and Prevention and Control Branch, Public Health Agency of Canada; 2011.
  7. Jin F, Matthews GV, Grulich AE. Sexual transmission of hepatitis C virus among gay and bisexual men: a systematic review. Sexual Health. 2017;14:28-41.
  8. Correctional Service of Canada. Infectious Disease Surveillance in Canadian Federal Penitentiaries 2007–2008: Pre-release Report. Ottawa, ON: Correctional Service of Canada; 2012. Available from: https://www.csc-scc.gc.ca/text/pblct/infdscfp-2007-08/index-eng.shtml
  9. Kouyoumdjian F, Schuler A, Matheson F. Health status of prisoners in Canada. Canadian Family Physician. 2016 Mar;62(3):215-22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984599/

About the author(s)

Christopher Hoy is CATIE’s knowledge specialist, hepatitis C community health programming and works to build hepatitis C programming capacity for frontline service providers. Christopher has previously worked in public health communications and policy roles and has a Master’s of Public Health.