Doug Sider of Public Health Ontario presented on the epidemiology of hepatitis C (HCV) in Northern Ontario, drawing on data from 2014. He noted that the North is distinct when it comes to HCV, since HCV rates are going up in the North, while they are falling in the rest of the province. Hospitalization rates for HCV are also two to three times higher in the North. However, Northern populations are younger, so there tend to be fewer age-related complications, such as liver cancer.
“Hepatitis C is the most important infectious disease in Ontario when you look at mortality, impacts, and disability.”
Although HCV rates are higher in Northern Ontario, we don’t have enough data on how people are contracting the disease. Doug Sider noted that the large number of HCV cases could be due to injection drug use, but that, since we don’t have full data on transmission routes, we don’t know if this is the full explanation. It could also be that people are contracting HCV through sexual practises, inhalation drug use, or tattooing. While it’s important to focus on interventions around injection drug use, Sider argued that what’s really needed is better data on how HCV is transmitted in the North. Only then will we have a clearer picture of how to respond to it.
Alexandra King of the Vancouver Infectious Diseases Centre noted some of the barriers that have confronted HCV-positive individuals in remote communities:
- The first generation of treatment for HCV was extremely hard to tolerate, with severe mental and physical side effects. Geography itself became a barrier, since it was hard to prescribe medication with severe side effects to someone far from medical care.
- The latest generation of HCV treatment is far more effective and more easily tolerated, but, until recently, the use of these drugs was restricted to people with severe disease. Doctors needed to find evidence of liver fibrosis (or scarring) before the cost of the medication was covered.
Shariq Haider of McMaster Hospital noted that, not just in the North, but more generally, HCV remains undertreated; more people need to be engaged in care. He stressed the importance of health care providers and front line staff telling people living with or at risk of HCV that new treatments are much easier to tolerate.
Haider also stressed that treatment for HCV has advanced so much and so quickly that it’s comparable to the introduction of ART for HIV in the mid-1990s. HCV treatment that used to involve multiple needles over the course of a year, now consists (for most patients) of one pill, once a day for three months, with cure rates of over 90%.
“We’re talking at a time when this is very much a disease that we can cure, and it may even be reasonable to say we even have the potential to talk about eradication.”
A key priority for health care providers and agency staff is to get clients into care early, since it’s harder for people with advanced HCV to tolerate treatments; the risk of complications (such as liver cancer and cirrhosis) also rises as HCV progresses. Camille Lavoie of Réseau Access Network (RAN) and Trish Hancharuk of Sioux Lookout First Nations Health Authority both outlined steps being taken by their agencies to increase HCV testing and treatment in the North.
Camille Lavoie noted that trying to get people into treatment in small towns in the North is not straightforward, since there may not be established referral routes. More importantly, clients themselves might not see HCV treatment as critical; they might be more focused on immediate needs such as shelter, food, and income. For this reason, RAN helps clients with income supports, a food pantry, transportation money, psychiatric care, and opportunities for socializing.
“You need to give people as much stability as possible for them to even start thinking about their hepatitis C.”
Once clients do start treatment, the agency tries to bring medication to the client, as opposed to waiting for them to attend the clinic. RAN also runs a flexible clinic schedule: if someone misses an appointment with a specialist, they can see a clinic nurse and get rescheduled for the next clinic date. RAN’s goal is to promote 100% adherence, so that people taking medication clear HCV. Again, the focus is on providing support – through social work, primary care, nursing, and harm reduction — so that clients have the stability they need to take the medication as prescribed.
Trish Hancharuk of the Sioux Lookout First Nations Health Authority described outreach work being done in Sioux Lookout (a town of just 5,500 people) to bring HCV education, testing, and treatment to 33 Indigenous communities further north.
The Health Authority is focused on dealing with the rising rates of HCV and opioid addiction in these communities. However, rather than “bringing” expertise to the communities, the Health Authority works collaboratively with Chiefs and Councils to build capacity within communities and create community-driven responses to addiction and bloodborne infections. To this end, the Health Authority has created several programs including:
- A community wellness development team featuring a mental health specialist and an addictions specialist, who build up expertise already in communities. The program has already seen a lot of success, with 23 subloxone programs running with community support and involvement.
- A needle distribution service that helps communities build their own needle exchange and disposal programs. So far, 17 communities have begun actively running their own distribution programs, with all safer use kits being provided by the Health Authority.
- An initiative making a dedicated case manager available to increase access to HCV support and treatment. The case manager connects with everyone who tests positive for HCV or who might be at risk. The case manager makes sure everyone has the support they need, and facilitates referrals to housing, health, and substance use programs.
- An HCV treatment program in Sioux Lookout, in partnership with Elevate NWO and Toronto Western Hospital, to offer fly-in treatment and support for members of more remote communities.
The Health Authority also provides education, prevention, and testing materials for the region, though Hancharuk noted the need for more materials that specifically speak to Indigenous communities in Northern Ontario.
- OHTN Rapid Response: Hepatitis C reinfection after successful treatment
- I-Track study overview and reports (I-Track monitors STBBIs among people who inject drugs)
- Hepatitis C overview (CATIE)
- Hepatitis C in Canada and the importance of risk based screening
- Sioux Lookout First Nations Health Authority