Priority directions to address hepatitis C amongst people who use injection drugs

Injection drug use[fn]There were 2 break-out groups discussing priority directions for people who use drugs at the deliberative dialogue.  This section summarizes and integrates the findings from both of these groups.[/fn] occurs across ages, genders, races, cultures, socio-economic classes and rural and urban settings. People who use injection drugs are diverse, and models for hepatitis C will need to adapt to the particular community they serve. Harm reduction services vary across provincial, territorial and federal jurisdictions and models will need to adapt to services, programs and infrastructures specific to each location.

Vision for a hepatitis C model of care for people who use injection drugs

Local and cultural contextualization of any model is critical, but the following elements support a common vision for an effective and relevant hepatitis C model of care for people who use injection drugs. Community-based primary care models are central to the vision.  Community-based primary care models should address the whole person and should include the following elements:

  • Models of care should be ongoing so that patients can remain in care indefinitely (i.e., it’s not just about hepatitis C treatment, but, about all aspects of care for an individual who is using injection drugs). One of the goals is for people who use injection drugs to develop an ongoing relationship with primary care, which might include engaging in after-treatment, engaging in support groups, leading support groups and becoming a staff member, and participating in ongoing testing.
  • Community-based organizations are part of the model and directly connected with the clinic.
  • Alternative funding allows for salary-based models of compensation as opposed to fee-for-service compensation.
  • The model should be driven by peers and people with lived experience. It might include:
    • peer-designed and peer-led programs;
    • patient/client advisory boards;
    • peer-led research and evaluation;
    • partnerships with peer-led organizations;
    • peer health navigators;
    • ongoing learning and training about best practices in peer work;
    • a strong knowledge-building component (it might serve as a hub to provide curricula and training);
    • a team-based approach to knowledge building and sharing; and
    • knowledge and training that addresses the misconceptions that healthcare providers have regarding people who use injection drugs.
  • The model should provide client-driven care in which clients lead and guide the service team.
  • Community/street outreach is embedded in the model:
    • Peer/community workers guide outreach services.
    • The catchment area can be broadened, including rural and remote areas.
    • Outreach can be used to expand testing.
    • There must be sufficient capacity in the primary care model to accept referrals from the outreach team for people who test positive.
    • Strong relationships must be built between outreach workers and clinical care providers, with an emphasis on consistent messaging, continuous communication and a smooth referral process.
    • Outreach can be conducted within prisons, and partnerships can be established with peer groups both within and outside of prison environments.
  • The model should explicitly follow principles of harm reduction:
    • The environment should be free of stigma and judgement. People who are using injection drugs are welcome to be in the space; they are designing and delivering programs; they are part of the staff team.
    • Safe equipment is available on-site with education around using safely.
    • Safe equipment and a harm reduction approach are used when working in prisons.
  • A multidisciplinary team approach is employed:
    • Key roles include addiction specialists, mental health counsellors, community and outreach workers, family physicians, and hepatitis C treatment specialists.
  • Nurse-led hepatitis C treatment models and nurse leadership is central:
    • Nurses should be enabled and supported to take lead roles in coordinating various kinds of care and supports required by individuals with hepatitis C. This makes it possible to centre care outside of specialty clinics, which can be inaccessible and more rigid in structure.
  • Community systems strengthening initiatives are important parts of the model:
    • Investments should be made in building the skills, partnerships and abilities of clients and staff to analyze root causes of health inequity and to mobilize for systems-level changes.
    • People with lived experience should lead the response.
    • Action Hepatitis Canada is a key organization, along with Indigenous organizations and organizations run by and for people who use injection drugs.

Recommendations to address hepatitis C amongst people who use injection drugs

  • Ensure that hepatitis C treatment is free and accessible for everyone who expresses readiness.
  • Invest in peer-based programming along with harm reduction programming in all settings.
  • Invest heavily in prevention through drug equipment distribution, education, testing and treatment with high-risk individuals.
  • Create a specific section within the national hepatitis C strategy designed by and for people who use injection drugs.

Tools, resources and supports

  • Training opportunities and resources on peer-led models should be developed (consider existing models, including the peer leadership development model in HIV by Ontario AIDS Network and Pacific AIDS Network).
  • People who use injection drugs should be supported to develop anti-stigma and good practice resources for use by people who work closely with people who use injection drugs.
  • Resources should be developed to build community systems strengthening capacity and leadership, especially by and for people living with hepatitis C.
  • Epidemiological data related to this priority population should be collected.
  • Bold and meaningful partnerships should be pursued with provincial/territorial and federal correctional services as well as peer health organizations operated by people who are incarcerated. Existing models of hepatitis C care within prisons can be used for guidance.[fn]Betteridge G, Dias G. Hard times: HIV and hepatitis C prevention programming for prisoners in Canada. Canadian HIV/AIDS Legal Network and Prisoners’ HIV/AIDS Support Action Network (PASAN.) 2007. Available from:[/fn]
  • Partnerships should be developed with researchers to leverage ability to pilot innovative and potentially controversial programming.