At the last Canadian Liver Meeting in 2020, there was a palpable sense of optimism about the prospect of eliminating hepatitis C in Canada. Researchers, service providers and community members launched a blueprint outlining our collective goals and possible strategies, and we shared evidence from research and practice to guide policy and programs.
Then the COVID-19 pandemic happened. It had an enormous impact on our sector, with services scaled back, researchers and clinicians shifted to the COVID-19 response, and the communities most affected by hepatitis C also facing increased risks from COVID-19 and a growing overdose crisis.
It was in this context that we met again at the 2021 Canadian Liver Meeting, from May 2 to 5, but held virtually for the first time. This meeting was co-organized by the Canadian Association for the Study of the Liver, the Canadian Network on Hepatitis C (CanHepC) and the Canadian Association of Hepatology Nurses, and included a two-day North American Viral Hepatitis Elimination Summit focused on hepatitis C elimination efforts and produced in partnership with the American Association for the Study of Liver Diseases.
In the midst of the COVID-19 pandemic, leading scientists and advocates discussed its impact on hepatitis C elimination efforts, the continued and growing burden of viral hepatitis around the world, and opportunities for changing the course of the hepatitis C epidemic in Canada.
The burden of viral hepatitis continues to grow
One of the frustrating themes underlying multiple presentations at the conference was that, despite the existence of vaccines for hepatitis A and B, and curative treatments for hepatitis C, the global burden of viral hepatitis continues to grow. While the dominant type of viral hepatitis can vary depending on where you live, this burden of hepatitis and resulting liver disease is shared around the world.
In Canada, the number of chronic hepatitis C cases tells an interesting story. According to a presentation from Dr. Howard Njoo at the Public Health Agency of Canada, the incidence of cases across the country does not appear to be decreasing. This trend is taking place regardless of major efforts to scale up both testing and treatment, indicating the underutilization of services and barriers to accessing them for people who are disproportionately affected.
No elimination without equity
Viral hepatitis, including hepatitis C, is rooted in social inequities. Tackling these illnesses requires an understanding of the vulnerabilities that increase the likelihood that individuals and communities will be exposed to hepatitis C and other infectious diseases, as well as a commitment to tailored approaches that will disrupt these vulnerabilities.
It’s with this health equity frame in mind that Dr. Stuart Skinner urged meeting participants to consider hepatitis C elimination not as a disease-specific approach, but one that needs to be broadened to reflect the needs of individuals and communities. Each community is unique and different, and therefore requires tailored interventions in order to have an impact. Amid the COVID-19 pandemic, healthcare and social service providers made increased efforts to simplify the model of care for hepatitis C. Throughout the meeting, we saw examples of low-threshold program models grounded in local realities and embedded in communities, increasing partnerships and integrating hepatitis C care into essential community services (such as housing and shelters), improving task-shifting and the optimization of nurses to deliver care, as well as the prioritizing peers to co-design and deliver programs.
In the Canadian context, the Blueprint to Inform Hepatitis C Elimination Efforts in Canada describes several priority populations that are disproportionately affected by hepatitis C. These communities (Indigenous people; people who use drugs; people with experience in the prison system; immigrants and newcomers from countries where hepatitis C is common; gay, bisexual and other men who have sex with men; and adults born between 1945 to 1975) are overrepresented in chronic hepatitis C, but have less access to the care they need to address it.
These vulnerabilities don’t just increase the risk of exposure to viruses. These populations are also at increased risk of liver disease and related complications. A presentation from Dr. Nicole Rich demonstrated that these disparities have been reflected in the incidence of liver cancer, access to treatment and mortality.
Syndemics exacerbate challenges, complicate care
Vulnerabilities to and consequences of hepatitis C infection are often not independent of other factors. Drs. Judith Feinberg and Chris Fraser asked the question: “What other epidemics are people with hepatitis C and other illnesses experiencing that could be impacting their health?” The term syndemic describes the accumulation of two or more epidemics or diseases that, when combined, intensify the burden of disease and the prognosis of those affected. Many populations living in Canada are experiencing intersecting challenges, such as a high burden of hepatitis C and HIV, outbreaks of other sexually transmitted and blood-borne infections like syphilis, the overdose epidemic, an affordable housing crisis, structural racism and discriminatory policies and practices.
These challenges have all been exacerbated by the emergence of COVID-19, which has disrupted how hepatitis C and related services are delivered. This disruption in services, combined with the unintended consequences of physical distancing on overdose risk, have disproportionately affected key populations at risk for hepatitis C.
Testing approaches need to expand to find the undiagnosed
There are many people living with chronic hepatitis C who remain undiagnosed. When diagnosis is delayed or never achieved, opportunities to reduce forward transmission and prevent the progression of liver disease with treatment or ongoing monitoring are greatly diminished.
Dr. Jordan Feld explored the merits of current approaches to hepatitis C screening in Canada. The main approach to hepatitis C testing in Canada is risk-based, which involves conducting tests for people who have an increased chance of being exposed to the virus. Evidence from a Canadian context has demonstrated that while risk-based testing is helpful for some populations (such as people who use drugs), this approach has proved inadequate for others. Current screening recommendations, in combination with a lack of public awareness about hepatitis C, have resulted in late diagnosis for populations such as older adults and individuals with little interaction with the healthcare system.
Dr. Feld offered strategies to address this gap and increase the diagnosis of hepatitis C in Canada, including screening beyond risk, increasing uptake of low-barrier testing and improving public awareness about hepatitis C testing.
Data drive decision-making
The elimination of viral hepatitis requires coordinated and tailored interventions that are informed by evidence and responsive to the needs of given populations and contexts. Improvements to how population-specific data is collected, when it is made available, and to whom it is made available, can be leveraged to improve the delivery of prevention and testing services.
One example, described by Dr. Mel Krajden as the ‘proof of concept’ of what can be achieved with data integration, is the British Columbia Hepatitis Testers Cohort (BC-HTC). The BC-HTC draws data from a variety of clinical, case, testing and administrative sources in order to “monitor disease burden related to hepatitis and associated infections and social conditions, evaluate impact of interventions, and monitor hepatitis program progress to inform policy and programming in British Columbia and Canada.” The BC-HTC has been a valuable tool to track disease trends, monitor programs and the cascade of care, and consider the impact of viral hepatitis as part of a larger overlap in syndemics.
Integrating data to this scale and from a wide collection of systems is difficult and not without its challenges. A drawback of this and other hepatitis C data banks across the country is that the updates have never been made in real time. This limits the ability of decision-makers to respond to current challenges, as they are often using data that is years old.
The emergence of COVID-19 as a health crisis in Canada has pushed forward the urgency of real-time data integration into policy and practice. Information is being shared, combined and applied in unprecedented ways.
Looking ahead: The promises of COVID-19 and where to build from here
The impact of the COVID-19 pandemic on populations living with or vulnerable to hepatitis C exposure has been significant. Many of the populations most affected by COVID-19 are also disproportionately affected by overlapping syndemics including viral hepatitis, HIV and the overdose crisis. Public health measures in place to slow the spread of COVID-19 have had unintended consequences on these other health concerns, and have disrupted many stages of the hepatitis C cascade of care. Disruptions to hepatitis C prevention, testing and treatment services will certainly have an impact globally, resulting in new infections, re-infections and liver disease. Dr. Naveed Janjua presented modelling data that predict disruptions to the hepatitis C cascade of care will result in increased incidence of hepatitis C in low-income countries and excess cases of liver cancer and liver-related deaths in high-income countries.
In a presentation discussing lessons learned from COVID-19 that could enhance viral hepatitis elimination, Dr. Betsy Verna noted that the parallels between COVID-19 and viral hepatitis are substantial. Both are highly transmissible among social networks, and both highlight disparities in the healthcare system. Although the pandemic and its associated public health measures will likely delay the achievement of World Health Organization hepatitis elimination goals by 2030, there have been many advancements made during the pandemic that could be leveraged for the hepatitis C response:
- Public awareness of infections has never been higher. The COVID-19 pandemic has been a fixture of daily news and media for over a year. In her presentation, Dr. Verna noted that only the world wars have had comparable news coverage. Public engagement has been high and has emphasized harm reduction approaches to preventing infection. This high level of public engagement can be harnessed and continued beyond the COVID-19 pandemic.
- Healthcare disparities are increasingly acknowledged and incorporated. The COVID-19 pandemic has further highlighted the healthcare disparities experienced by marginalized populations. Increasingly, monitoring, testing and vaccination efforts have been scaled up among vulnerable and institutionalized populations. Further population health efforts can be made to build on this infrastructure, as well as increased resources to provide testing and treatment to these groups.
- Digital health and telemedicine. Digital health platforms, including mobile health apps and online education, and the provision of virtual care via telemedicine, have rapidly expanded over the past year. Dr. Hemant Shah reflected on the expansion of telemedicine and provision of virtual care in his own practice and encouraged others to think about how this technology can be integrated across their practices. Dr. Mayur Brahmania cautioned about the use of digital health interventions without working to address factors that may limit access, as some populations haven’t been able to benefit from digital health solutions as well as others. Such factors include: poverty, homelessness, poor digital health literacy, services being under resourced and a lack of understanding how clients would interact with the technology. Digital health interventions intentionally implemented to address these factors have proven to be successful and have shown improved health outcomes in marginalized populations.
- Clinical advancements in testing, diagnosis and vaccination. The virus that causes COVID-19 is the most sequenced virus in the world. The global attention to the pandemic has resulted in remarkable investment and advances in testing and vaccine technologies. Whereas the polio vaccine was developed over the course of 60 years, there have been multiple vaccines developed for the SARS-CoV-2 virus over the course of 12 to 18 months. Hepatitis C is another virus with a novel timeline – progressing from discovery to cure in 30 years. Drs. Michael Houghton and Harvey Alter (Nobel Laureates for their roles in the discovery of the hepatitis C virus) attended the meeting and presented their current focus on vaccine research. The increased investment in testing, vaccine technology and infrastructure for COVID-19 can be a benefit as we continue to make steps towards viral hepatitis elimination.
The COVID-19 pandemic has pushed those working in viral hepatitis to be reflective and reflexive about public health approaches to viral illnesses.
Looking forward, a COVID-19 recovery plan must include recognition of the impact of the pandemic on viral hepatitis and other infections. Modelling suggests a delay in achieving elimination goals and an uptick in new cases, re-infections and liver disease can be expected. The COVID-19 pandemic has also highlighted the healthcare disparities experienced by marginalized populations.
We must consider how an equity approach can be further integrated into elimination strategies to ensure that the most vulnerable are not left behind. Despite the challenges presented by the pandemic, Action Hepatitis Canada has launched a progress report to sustain the moment and keep provincial and territorial governments accountable to our federal commitment to viral hepatitis elimination.
Shannon Elliot is CATIE’s knowledge specialist in hepatitis C.