Beyond prescriptions: Equitable hepatitis C care for people who inject drugs

In Canada, people who inject drugs have led long, hard-fought, and ongoing campaigns for human rights-based drug policies and health services. Unfortunately, this community activism has often been met with varying degrees of government and healthcare system inaction.

For example, people who inject drugs have historically had limited access to essential harm reduction services like supervised consumption sites and needle and syringe distribution programs. The substandard availability and accessibility of services such as these persists in many settings today. As such, people who inject drugs have inequitably high rates of hepatitis C and HIV – bloodborne viruses that often are passed on by sharing contaminated injection drug equipment, such as needles, syringes and cookers.

Medications to treat these bloodborne viruses are available. In recent years, direct-acting antivirals have taken over as the first-line treatment for hepatitis C. Direct-acting antivirals represent a “game changer” in hepatitis C care, as these well-tolerated and highly effective medications cure most people of hepatitis C in eight to 12 weeks. As efforts to scale up access to direct-acting antiviral medications across Canada are underway, however, it is critical that hepatitis C care providers do not simply adopt a stance of “if we build it, they will come.”

Barriers to hepatitis C treatment persist

Figuring out where and how to access direct-acting antivirals can be challenging, particularly as the healthcare system adapts and “catches up” to these new treatments. To make matters worse, hepatitis C care in Canada has been criticized for existing in poorly linked siloes. This means that people who inject drugs and people with hepatitis C often are often referred elsewhere for testing and treatment, such as from one’s primary care provider to a specialist physician. Inadequate support throughout these referral processes can cause people to “fall through the cracks” and not make it through to hepatitis C treatment.

At the same time, it is well known that people who inject drugs face stigma and mistreatment when seeking out hepatitis C treatment. Some healthcare providers worry that people who inject drugs will just become re-infected after being cured of hepatitis C. Meanwhile, others withhold treatment from those who “actively” use substances, due to a perceived lack of motivation and stability to follow through with treatment.

When people who inject drugs are met with this sort of “gate keeping” and negative attitudes, it can (understandably) deter them from accessing care in the future. For those living with hepatitis C, this could result in their chronic disease being left untreated.

Despite concerns, new hepatitis C treatments can work

People who inject drugs are eager and fully capable of completing hepatitis C treatment. In one British Columbia study from 2018, 90% of people who inject drugs who were treated with direct-acting antivirals were cured of their hepatitis C.

In light of promising research such as this, all provinces and territories across Canada have expanded access to hepatitis C treatments. From 2017 to 2018, British Columbia and several other provinces across Canada removed restrictions on prescribing direct-acting antivirals to people who use drugs or have advanced liver disease. Direct-acting antivirals are now openly available to all people living with hepatitis C.

While this recent policy development is call for celebration, there is still a long way to go before these medications will be truly accessible to all people who inject drugs.

Bridging service delivery gaps: Decentralized, integrated and peer-led care

Decentralized health care can facilitate opportunities to engage in hepatitis C care, including direct-acting antiviral treatment. Given recent improvements in the tolerability of hepatitis C medications and their expanded eligibility criteria, it is time to expand hepatitis C care beyond specialist providers.

Hepatologists, infectious disease physicians and other specialist care providers have a central role to play in treating people with clinically complex hepatitis C, such as when an individual has significant co-morbidities or is experiencing end-stage liver disease. However, the vast majority of people who inject drugs and others living with hepatitis C ought to be treated in primary care settings.

It has been demonstrated that family physicians and nurse practitioners can feasibly and safely provide comprehensive hepatitis C treatment. Similarly, recent research shows that integrating hepatitis C treatment into other services related to substance use, such as opioid agonist therapy and HIV care, can and does work.

Peers also have significant potential for engaging and supporting people who inject drugs through hepatitis C care. Peers with lived experience are well positioned to connect people to hepatitis C treatments, including through outreach and in-reach services that are tailored to community needs and preferences. And because many people have had negative experiences with hepatitis C treatments, such as medication side effects or being denied treatment, knowledgeable and trusted sources of health information are greatly needed.

Toward an equity-oriented understanding of hepatitis C care

 Equity-oriented health care can improve hepatitis C treatment experiences and outcomes for people who inject drugs. This requires that healthcare providers pay careful attention to supporting those at greatest risk of poor health and healthcare access, like people who have been previously and unfairly denied hepatitis C treatment on the basis of their substance use. Given that people who inject drugs report experiences of being mistreated within healthcare settings, equity-oriented health care also means that healthcare providers commit to reducing power imbalances and to offering trauma- and violence-informed care.

To address the root causes of inequities for people who inject drugs and who are living with hepatitis C, there is also a need to address the broader structural issues affecting this group. This includes much needed efforts to end stigma, criminalization and structural violence.

Taken as a whole, promising advances in hepatitis C care and treatments are poised to greatly benefit people who inject drugs. Nevertheless, much work remains to ensure the accessibility of equitable hepatitis C care and other health services for people who inject drugs.

Trevor Goodyear is a registered nurse and graduate student in the master of science in nursing/master of public health program at the University of British Columbia. Building on his graduate research assistant work with the B.C. Centre on Substance Use, Trevor’s thesis research explores the implementation and uptake of hepatitis C treatments among people who inject drugs in British Columbia, Canada.