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


Structural recommendations

The following recommendations detail structural approaches and mechanisms that foster integration and enable the development of responsive models of care that are accessible, relevant and effective in addressing hepatitis C.

Structural recommendation #1: Develop a national action plan for addressing hepatitis C with differentiated approaches designed by and for each priority population

A key structural factor to successfully address hepatitis C nationally is evidence-based public health policy. It is critical to have national and provincial strategies that include clear targets and financial commitments to address hepatitis C. To design effective and relevant strategies to address hepatitis C in priority populations, individuals from these populations must play a central role in designing, delivering and evaluating population-specific approaches. Priority populations, including people who use injection drugs, people who are in prison, Indigenous peoples, street-involved youth, immigrants and newcomers to Canada from high-prevalence countries, older adults and HIV-positive men who have sex with men, must be invited to develop and deliver national and local strategies to address hepatitis C. For example, Indigenous-led and Indigenous-specific interventions are essential in terms of reaching and offering effective care to Indigenous peoples.

Structural recommendation #2: Ensure that optimal testing, monitoring, and treatment options are available and accessible to everyone living with, affected by, and at-risk of hepatitis C

The best testing, monitoring and treatment options must be widely accessible to all individuals regardless of their geographic location, socio-economic status, or stage of liver damage or disease.

Treatment eligibility must be based upon clients’ readiness and desire for treatment, not ‘traditional’ clinical or financial eligibility requirements.

Investment in the development of more streamlined, low-cost and accessible diagnostic tools and disease-monitoring technologies should be prioritized. Rapid hepatitis C antibody tests are available, but access to rapid testing remains a major challenge. Point-of-care testing for hepatitis C is available in the United States but is not currently available in Canada. A Fibroscan is a non-invasive and quick disease monitoring technology, but its availability is extremely limited.

Structural recommendation #3: Enhance surveillance and the epidemiological evidence-base for priority populations

Enhanced surveillance and epidemiological evidence is critical to better understanding the impact of hepatitis C in priority populations, and to developing policies, programs, and interventions that are based on the best evidence available at the time.

Structural recommendation #4: Ensure integration of hepatitis C into broader strategies for sexually transmitted and blood-borne infections at local, provincial and national levels

A commitment to incorporate hepatitis C into broader strategies and funding structures for sexually transmitted and blood-borne infections is critical. Some provincial HIV strategies developed for people who use injection drugs have not included hepatitis C services in efforts to scale up testing and treatment. This omission represents a significant missed opportunity.

Structural recommendation #5: Facilitate the development and implementation of primary care and nurse-led approaches to hepatitis C

A key structural factor in providing quality care to under-served communities and populations is having care integrated into primary care settings and investing in nurse-led models. Building the capacity of primary care providers and nurses to provide hepatitis C services is key to delivering integrated services in low-density areas. Limited access to speciality care is an issue not only in low-density settings, but also in some cities. It is important to develop professional guidelines and educational opportunities for primary care providers to engage in hepatitis C testing, treatment and care. Facilitating and prioritizing hepatitis C training opportunities for nurses and investing in nurse-led models of treatment and care is also useful. An important on-reserve example is the model established in Ahtahkakoop, Saskatchewan. As part of this Indigenous-led and collaborative model, an Indigenous nurse manager from outside of the community comes to the health centre regularly and links clients with a physician through a technology called ‘Doc in a box,” where a specialist is immediately linked to a client through online technologies. The nurse manager also brings a Fibroscan to enable rapid testing.

Many Indigenous communities are leading the way in developing or adopting innovative ways to provide speciality care in low-density settings. One example is the use of the “Doc in the box” technology, which has allowed local family physicians to provide treatment support to patients on small Reserves in northern Saskatchewan. A nurse manager comes to the health centre in northern Saskatchewan regularly and immediately links clients to a specialist through online technologies. This online technology allows clients in northern Saskatchewan to be linked with a specialist in real-time during their appointment.

Structural recommendation #6: Develop national harm reduction policies including harm reduction in prisons and invest in hepatitis C programs inside prisons

Harm reduction must be central to the national hepatitis C strategy. A commitment to harm reduction is an evidence-based health-centred approach for people who inject drugs.

There is a huge gap in strategies and interventions for the prison population. It is essential for governments (all levels) and prison authorities to acknowledge that people use injection drugs in prison and for them to support harm reduction interventions, including distribution of safe drug-use and tattooing equipment.

Structural recommendation #7: Develop funding models that support salary-based compensation and promote provision of resources to non-traditional healthcare providers

Current funding models are not well-suited to developing integrated, client-centred and health equity oriented hepatitis C care. Fee-for-service models and limited resources for peers and non-traditional staff, including Indigenous healers and Elders, limit capacity to provide culturally safe, client-centred care. Providing funding for salary-based models and ensuring availability of resources for peers and non-traditional healthcare providers, including Indigenous healers and Elders, is critical.

Structural recommendation #8: Link funding eligibility and evaluation metrics to health equity outcomes

It is important to link funding eligibility and evaluation metrics to health equity outcomes. Developing targeted testing, treatment and health outcomes for priority populations, rather than targets for whole populations, will incentivize the development of services geared toward priority populations.

Structural recommendation #9: Invest in health system reforms geared toward health equity including mandating equity-oriented hiring practices, anti-racism and anti-oppression training and transfer of power to service users in shaping care

“Why aren’t people getting good care? Our system doesn’t demand that you provide good quality primary care and services to people who use drugs.” – Meeting participant

It is essential that, through health policy, health systems be restructured to be accessible and effective for people who are marginalized, oppressed, and excluded in society. It is important to develop policies that ensure diverse healthcare workforces with strong representation from marginalized populations. For example, development of policies that mandate the implementation of health advisory boards governed by people who are systematically underserved by health systems is one way to ensure that health institutions and professionals are held accountable to those who are systematically underserved.

Structural recommendation #11: Invest in strategies that address social determinants of health, including anti-poverty initiatives and develop policies to address racism, stigma and discrimination in society

Having a health system that properly serves those who are marginalized and excluded in society is an important step, but in and of itself is ultimately just a bandaid solution to the larger, more fundamental problems of social exclusion and marginalization.

It is essential to invest in policies and programs that improve the social and economic living conditions of oppressed and marginalized populations. Investing in housing, employment, education, harm reduction, and community-building initiatives creates safe and healthy communities. Investing in prisons, policing and other punishment-oriented institutions serves to re-traumatize individuals and reinforce social exclusion, marginalization, personal safety issues and poor health.

Historic and continued societal oppression in the form of racism, colonialism, homophobia and transphobia are roots of social exclusion and marginalization. It is important for governments at all levels, and for local authorities to partner with groups and individuals with lived experience of discrimination to invest in public education campaigns and to develop policies that require schools, healthcare centres and workplaces to adopt decolonized, anti-oppressive and anti-racist strategies. In addition to educational elements, strategies must include power-sharing and re-structuring initiatives that shift power to individuals and populations with lived experience of racialization and discrimination.

Structural recommendation #13: Invest in systems-strengthening initiatives, including advocacy and cross-movement building

There is an urgency to establish collaborative partnerships for effective advocacy and systems change efforts. Action Hepatitis Canada has begun to provide leadership in hepatitis C advocacy at the national level. There is also a need to revisit existing initiatives, including the Public Health Agency of Canada’s Hepatitis C Strategic Framework for Action (2009). Funding for access to treatment could become a ‘wedge’ issue, with various groups competing for preferential treatment, but it is important to unify and mobilize for access to treatment and care together.

It is also critical to invest in cross-movement building with non-hepatitis C specific groups. These cross-movement building and partnership initiatives require dedicated funding and resources.