By Rivka Kushner
Canada is one of 194 countries that endorsed the World Health Organization’s Global Health Sector Strategy on Viral Hepatitis in 2016, committing to – among other things – the elimination of viral hepatitis as a major public health threat by 2030.
But what does eliminating viral hepatitis mean in practice? The recent Global Hepatitis Summit in Toronto from June 14 to 17, 2018, brought together researchers, healthcare providers, and public health practitioners from around the world to try to answer this question. Presenters shared the latest research findings, marked which countries are on track to meet the targets, and discussed what is needed in the rest of the world to get to elimination.
The elimination of hepatitis C as a major public health threat has been defined by the World Health Organization through targets that amount to diagnosing 90% of people living with hepatitis C, treating 80% of people with hepatitis C who are eligible for treatment, and reducing new transmissions by 90%. This has been lauded as an ambitious but achievable goal.
Jorge Mera, a physician with the Cherokee Nation in the United States, remarked during his presentation that if we aim for elimination targets of 90%, we already know who will make up the 10% who are not reached. It will be the most marginalized in our communities. With this in mind, let’s explore some broad themes that emerged from the Summit.
For hepatitis C specifically, curing people is the backbone of the strategy, since there is no vaccine available. We have had dramatic advances in treatment in the last few years. Direct-acting antiviral (DAA) treatments cure almost everyone. Real-world clinical trials have also found that people who use drugs have similarly high cure rates, and people who are co-infected with HIV, hepatitis B, or who have chronic kidney disease have excellent options for treatment and cure.
Beyond treatment, what else can be done to eliminate hepatitis C as a public health threat in Canada by 2030?
Simplify, simplify, simplify
The simplicity of treatment is a great opportunity to expand access to testing and treatment services. For many people, getting a positive test result for hepatitis C infection means two blood tests with three separate healthcare appointments. There can be delays for a person to get connected to care and treatment, move through the treatment coverage approval process, and have a complete diagnostic examination before treatment begins.
These testing and treatment processes can be made shorter and simpler with point-of-care testing and simple treatment guidelines. Implementing this will reduce loss to follow-up, and help keep people engaged in care and, ultimately, cured.
However, there is a counterpoint to a very simple and stripped-down treatment process for everyone. Some people will benefit more from having wrap-around care, including access to outreach and community workers, social workers, harm reduction services, group support meetings, and regular check-ins. There is tension between the simplification model and still providing wrap-around services to those who would benefit from them.
For people who experience barriers to receiving appropriate, supportive, and judgment-free care, hepatitis C treatment can be a positive catalyst in their life. It can be an opportunity to create more stability (for example, getting on social assistance or finding more stable housing), build trust with a healthcare provider, and have a positive interaction with the healthcare system.
Decentralize and integrate
Testing efforts need to be expanded. Task-shifting in testing means a broader range of service providers offering tests. For example, one researcher found high acceptability with community workers doing point-of-care testing. To reach as many people as possible, testing also needs to be integrated into services that people already access.
Treatment delivery needs to expand beyond the domain of specialists, too. This decentralization is already happening in parts of Canada with Project ECHO, an education program that trains non-specialist nurses and doctors to treat hepatitis C. Research is demonstrating that specialist and non-specialist hepatitis C care result in similarly high cure rates. Task-shifting in general can support more nurse practitioners and nurses taking the lead on treatment. Just like for testing, integrating treatment into services that people already access and use (for example, services that offer opioid substitution therapy, harm reduction services and sexual health services) will help to reach people more effectively.
Expand treatment access for all
Barriers to treatment access were seen globally. In Canada, specifically, there are still defined populations who do not have consistent access to treatment. People who use drugs are most affected by hepatitis C in Canada, yet they also experience barriers to accessing treatment because of stigma, discrimination, and a lack of adequate and appropriate services.
One out of every four people in prison in Canada has hepatitis C, which is 25 times higher than the general population. Yet people in provincial prisons face institutional barriers to accessing treatment. Correctional Service Canada has made strong commitments to offer treatment for hepatitis C in federal prisons, but getting treatment in provincial prisons is challenging, inconsistent and often comes with many barriers and delays.
Some countries such as Australia are focusing on prisons as an opportunity for micro-elimination, which is eliminating hepatitis C in smaller populations, settings, or regions as a way to get to national elimination. Providing treatment in all prisons in Canada could have a huge impact on hepatitis C elimination.
Indigenous people in Canada also have higher rates of hepatitis C, and there are immense inequities when you look at data on who has received treatment. Improving access to culturally appropriate testing and treatment, and having Indigenous-led initiatives to get this done, are key.
People who use drugs, people who have been in prison, and Indigenous people should not be viewed in isolation. People can share more than one of these identities or experiences, and each of these communities experiences institutional and systemic barriers that increase their likelihood of having hepatitis C, and can further increase barriers to accessing care.
Scale up harm reduction and other prevention efforts
A lot of the conversation around elimination focuses on testing, linkage to care, and treatment. But we can’t achieve elimination through testing and treatment alone. We also need an expansion and scale-up of harm reduction and other prevention efforts.
We need more services and resources for needle and syringe programs, supervised consumption sites, and drug user health more broadly. We also need to make sure these services meet people where they are at (which includes our prisons).
People who use drugs are currently more likely to die from overdose than hepatitis C. Efforts to eliminate hepatitis C should become an opportunity to expand support services for people who use drugs and drug user healthcare, including overdose prevention. Shifting drug use from the criminal justice system to the healthcare system can also help to address the underlying drivers of hepatitis C transmission.
There have also been some questions about sexual transmission of hepatitis C. This has emerged with gay, bisexual and other men who have sex with men, especially in the context of people who might be taking PrEP, having condomless sex or engaging in chemsex (sexualized drug use). We aren’t sure how this will affect hepatitis C transmission in these communities, but modelling studies presented at the Summit about PrEP use among men who have sex with men suggest that – without programming, education and regular testing – we could likely see much higher rates of hepatitis C in these communities.
Next steps for Canada
The Canadian Network on Hepatitis C (CanHepC) is leading efforts to create a blueprint for a hepatitis C national action plan – a framework that provinces and territories can use to set realistic elimination targets and offer a menu of evidence-based interventions to get us there. Where we currently sit in Canada is not acceptable.
With the momentum and energy that has been created by this international elimination effort, we must not forget about the increased resources that are needed to reach some populations, and about the opportunities to incorporate the social determinants of health into our elimination efforts – thinking broadly about drug user health, the health of people in prison, Indigenous health, and the health of other communities who are disproportionately affected by hepatitis C. This is an opportunity to rally together, push boundaries, and carve out better hepatitis outcomes – and health and well-being – for people around the world.
So, let’s not stop at 90% elimination. As Jorge Mera said, let’s aim for 100%, to make sure that we are trying to reach everyone, including the most marginalized in our communities.
Rivka Kushner is CATIE’s knowledge specialist in hepatitis C.