Windows of Opportunity: Integrated Hepatitis C Programming Approaches for Priority Populations

The landscape in hepatitis C is changing. New hepatitis C treatments have dramatically increased cure rates, shortened treatment durations and have few side effects. The first national best practice recommendations for harm reduction have been produced, and there is a growing evidence base to inform the development of new age-cohort and risk-based national guidelines for hepatitis C screening and diagnosis. There is also updated epidemiological data on priority populations and new research findings on the sexual transmission of hepatitis C among men who have sex with men. Together, these changes have the potential to significantly transform and improve the national frontline response in hepatitis C prevention, testing, treatment and care for communities and individuals affected and at risk. There is now the possibility of eliminating hepatitis C as a public health threat.

For this goal to become a reality, not only must the new treatments be made accessible to all, but health programs, organizations and systems must be able to properly serve the populations most affected.  This includes diagnosing individuals with hepatitis C, providing treatment and care, and preventing further spread of the virus. The burden of hepatitis C is largely carried by populations underserved by the mainstream health system, including people who use injection drugs, people who are in prison, Indigenous populations, street-involved youth, and immigrants and newcomers¹ from endemic countries. Older adults have a higher prevalence of chronic hepatitis C than younger people, and they are often dealing with co-morbidities and issues related to aging. The challenge and the opportunity is to develop a health system that responds to the unique realities of populations affected by hepatitis C through a commitment to health equity.

CATIE hosted a National Deliberative Dialogue on Integrated Hepatitis C Programming and Services to explore frontline hepatitis C continuum of care models (prevention, testing, treatment and support) for priority populations and to identify promising directions in hepatitis C programming, policy and knowledge exchange.

The National Deliberative Dialogue highlighted the fact that programs are most relevant and responsive when those most affected shape and tailor programming. Across Canada, service providers and service users are responding to community needs by developing integrated hepatitis C models of care that incorporate a range of broader support services within specific cultural and community contexts. Organizations that promote and foster programs designed and delivered by those most affected are able to be responsive to community needs and provide effective hepatitis C programming. To address the root causes of the epidemic and eliminate hepatitis C as a public health threat, it will be important to maintain and expand the breadth and depth of community-led programs even as treatment times become shorter and easier to manage.

Many integrated hepatitis C models of care have been developed by motivated, driven individuals and organizations, largely working upstream within funding, political and social structures that are not necessarily conducive to the development of creative health equity models.  In order for there to be a broader and more effective national response, beyond these outlying and unique integrated hepatitis C models,  service providers and service users must mobilize for health sector reforms as well as broader socio-political reforms including the decriminalization of drug use, the development of a national hepatitis C strategy and the promotion of anti-oppression and anti-racism policies. Initiatives that strengthen community systems, including advocacy, cross-movement building and community development, are key factors for success. It is critical that the community mobilize to ensure that the best testing, treatment and care options are available to all, regardless of fibrosis level or social, political, economic, racial and cultural location.

The programming, organizational and structural recommendations within this document can begin to inform a collective response to the hepatitis C epidemic.  Each stakeholder has a unique role to play moving forward and the recommendations provide a starting place for more detailed strategizing and action planning which can take place within regions, organizations and communities.   As the national knowledge broker in hepatitis C prevention, testing, treatment and care, CATIE will use these recommendations to inform our knowledge exchange work over the next few years.  The deliberative dialogue discussions identified that CATIE can continue to play a role in convening these action planning discussions when and where useful, as well as undertake community systems strengthening initiatives and knowledge transfer and exchange activities as outlined in Knowledge exchange resources and tools to build capacity for change.   CATIE will continue to engage, consult and follow the guidance of those most affected by hepatitis C as well as a breadth of other stakeholders in defining CATIE’s role and responsibilities in the collective work to eliminatehepatitis C.  

At a glance:  Recommendations: Programming, organizational and structural recommendations.

Programming recommendations

1. Develop community-specific and culturally safe programming
2. Ensure opportunities for clients to engage in programming as soon as they are ready
3. Prioritize relationship building and develop trust and credibility with service users
4. Ensure a commitment to harm reduction approaches in all aspects of integrated programming
5. Develop trauma-informed and reconciliation-based approaches to crisis and conflict resolution
6. Despite shortened treatment durations, ensure programs incorporate the full continuum of care
7. Facilitate seamless access to services beyond the traditional continuum of hepatitis C services
8. Provide non-traditional incentives to service users
9. Enhance meaningful service-user engagement
10. Invest in peer programming
11. Enhance outreach and testing efforts with an emphasis on underserved and marginalized populations
12. Identify, document and research hepatitis C programming approaches in the new era of hepatitis C treatment

Organizational recommendations

1. Ground inter-agency and cross-sectoral partnerships for hepatitis C programming in a common visionand goals
2. Create organizational partnerships and structures to foster a client-centred multidisciplinary team-based approach for hepatitis C services
3. Develop structures of community governance and embed health equity into the organizational values
4. Invest in community system strengthening
5. Explore alternative funding that allows for internal resource distribution and incentive structures that promote integration and health equity
6. Strive for a salary-based compensation structure and invest resources in fairly compensating peers and other non-traditional healthcare providers
7. Engage a broad set of stakeholders in organizational changes
8. Address the social determinants of health through cross-sectoral partnerships
9. Address racism, stigma and discrimination through equity-oriented hiring, anti-oppression training, shifting internal power structures and public education

Structural recommendations

1. Develop a national framework for addressing hepatitis C with differentiated approaches designed by and for each priority population
2. Ensure that optimal hepatitis C testing, monitoring and treatment options are available and accessible
3. Enhance surveillance and the epidemiological evidence base for specific populations
4. Ensure hepatitis C integration into broader strategies for sexually transmitted and blood-borne infections at the local, provincial and national levels
5. Facilitate the development and implementation of primary care and nurse-led approaches to hepatitis C
6. Develop national harm reduction policies including harm reduction in prisons and investment in hepatitis programs inside prisons
7. Develop funding models that support salary-based compensation and promote provision of resources to non-traditional healthcare providers such as Indigenous healers, Elders and peers
8. Link funding eligibility and evaluation metrics to health equity outcomes
9. Invest in health system reforms geared toward health equity
10. Invest in strategies that address the social determinants of health including anti-poverty initiatives and develop policies to address racism, stigma and discrimination in society
11. Invest in systems-strengthening initiatives, including advocacy and cross-movement building

• 1. Refugees are an important sub-group to be considered within the newcomer population.