In Canada, recent estimates show that people who inject drugs continue to be disproportionately affected by high rates of hepatitis C and HIV. They are also less likely to be tested, connected to care or receive treatment. To prevent hepatitis C and HIV, as well as improve outcomes for people who inject drugs, it is important to gain a better understanding of how changes in the drug supply and related trends impact vulnerability to these infections and how we can improve supports.
To identify where these additional supports are most needed, the following three important points can help us to understand the hepatitis C and HIV epidemics among people who inject drugs.
Hepatitis C and HIV disproportionately affect people who inject drugs in Canada
Injecting drugs is the most common risk factor for new hepatitis C infections in Canada. It is estimated that 45% of people who inject drugs have ever had hepatitis C and that one in four people who inject drugs was living with a current hepatitis C infection in 2019.
A pan-Canadian study found that approximately one in 10 people who inject drugs is living with HIV (2017-2019). In addition, 19.8% of the estimated 1520 new HIV infections in Canada during 2020 were among people who inject drugs. While national-level data are instructive, they do not give an accurate picture of what is happening in different regions of the country. Certain provinces have a much higher rate of HIV among people who inject drugs compared to other provinces where the epidemic is concentrated in gay, bisexual and other men who have sex with men. For example, an estimated 63% of new infections in Saskatchewan and 60% of new infections in Manitoba were among people who inject drugs in 2020. Unfortunately, national-level data broken down by region for people who inject drugs are not available for hepatitis C.
The cascade of care shows us where people who inject drugs are being left behind
The cascade of care is a concept that helps to show how people progress from being diagnosed with hepatitis C or HIV, to engaging in care and then successfully taking treatment. The cascade looks slightly different for hepatitis C and HIV; however, for both we have data to show that people who use drugs are being left behind when it comes to diagnosis and engagement in care and treatment.
Although there are limited pan-Canadian data for hepatitis C, a study of people who inject drugs found that only 50% of participants with a current hepatitis C infection were aware of their status and only 49% of those who knew their status had been linked to care. Among those linked to care, only 11% had ever taken treatment and only 4% were currently taking treatment. These data demonstrate very large gaps in care among people who inject drugs, from testing all the way to accessing curative hepatitis C treatment.
The most recent estimates show that 90% of all people living with HIV in Canada are diagnosed, 87% of people who are diagnosed are on treatment and 95% of people on treatment have a suppressed viral load. In comparison, among people living with HIV who inject drugs, it is estimated that only 83% are diagnosed, 88% of those who are diagnosed are on treatment and only 63% of those on treatment have a suppressed viral load. This means that people who inject drugs are less likely to be aware of their status and much less likely to have a supressed viral load compared to all people living with HIV in Canada.
It’s important to understand evolving drug use trends and patterns
We know that many different factors can impact vulnerability to hepatitis C and HIV for people who inject drugs. Structural factors such as the criminalization of drug use make it more likely for people to experience stigma, discrimination, incarceration and other forms of marginalization. These factors can intersect to increase the risk of hepatitis C and HIV, and create barriers to engaging in care.
Another factor that can impact risk is changes in the unregulated drug supply, which can impact drug use trends and increase the risks of hepatitis C and HIV for people who inject drugs. Understanding these changes in how people use drugs and what drugs are available can help to identify possible points of intervention.
First, evidence suggests that the number of people injecting drugs in Canada may be increasing, which means a larger community at risk for hepatitis C and HIV. Between 2003 and 2019, a pan-Canadian study identified large increases in the injection of certain drugs, including fentanyl, methamphetamine, cocaine and hydromorphone. These drugs are all typically associated with a high frequency of injecting, resulting in more opportunities for equipment sharing and an increased risk for hepatitis C and HIV transmission.
While it is important to acknowledge that sharing of needles and syringes has decreased over time, possibly reflecting increased knowledge of the risks, the same study found that the sharing of other injection equipment is on the rise . Sharing injecting supplies, such as cookers, filters and water appears to have increased significantly, which is problematic because sharing these supplies also carries a risk for hepatitis C and HIV transmission.
All the above trends point to a need to address factors that increase vulnerability to hepatitis C and HIV for people who inject drugs. They also indicate the need for more education about the transmission risks associated with sharing injecting supplies and a need for greater accessibility to the full range of harm reduction equipment.
Where do we go from here?
It is clear that people who inject drugs are disproportionately affected by hepatitis C and HIV, but the data also help shed light on the supports that people who inject drugs need to help prevent transmission and improve hepatitis C and HIV outcomes. Data suggest we need to scale up harm reduction services and education to help prevent new infections. For example, there are many innovative programs working to address the holistic health needs of people who use drugs. Discrepancies in the cascade of care point to the need to increase accessibility of hepatitis C and HIV testing to increase diagnosis, as well as support linkage to care. We also need to facilitate access to hepatitis C treatment and cure, as well as support long-term retention in care for people with HIV, including helping people to be able to take their HIV medications consistently and suppress their viral load.
Given the known regional discrepancies across the country, it is also important to be aware of what’s happening in our own communities to inform the work locally. It is critical to involve people who use drugs in designing, implementing and evaluating services in order to help tailor programs to community needs, reach intended community members and build community trust.
The data also suggest an urgent need to address factors that increase hepatitis C and HIV risk and create barriers to care for people who inject drugs. The loss of life in Canadian communities due to the toxic drug supply is unrelenting. Simply keeping people alive has become a huge priority in harm reduction work. Service providers need support in terms of policy changes that improve the lives of people who use drugs (e.g., decriminalization, affordable housing) and increased funding for harm reduction to continue their lifesaving work while also maintaining a focus on prevention, testing and treatment for hepatitis C and HIV.
Camille Arkell is manager of HIV and harm reduction at CATIE. She has a master of public health degree in health promotion and has been working in harm reduction and HIV-related education and research since 2010.