A study from Toronto General Hospital Research Institute (TGHRI), in partnership with the Ontario First Nations HIV/AIDS Education Circle (OFNHAEC), has identified steps needed to help eliminate hepatitis C in First Nations peoples.
“Canada aims to eliminate viral hepatitis by 2030. We are working with Indigenous peoples, including First Nations communities, to make this a reality,” says Dr. Jordan Feld, a TGHRI Senior Scientist who helped guide the project and support the partnership between OFNHAEC and UHN researchers.
Hepatitis C is a viral infection that primarily affects the liver and is transmitted through blood-to-blood contact. It can lead to chronic liver disease, cirrhosis and an increased risk of liver cancer if left untreated. Current medications are highly effective, very well tolerated and can cure the infection before it progresses to severe liver disease in almost all those who are treated.
“Unfortunately, the historical and ongoing effects of colonialism have led to high rates of mental health problems and substance use among First Nations peoples,” explains Lyndia Jones, a member of OFNHAEC. “This has resulted in the disproportionate impact of hepatitis C among First Nations communities.”
“In order to focus our efforts on eliminating hepatitis C, we need to understand how First Nations peoples move through each step of the treatment process, which includes being tested, diagnosed and linked to care for treatment,” says Dr. Feld.
Researchers used provincial health administrative data to study hepatitis C testing records among Status First Nations peoples in Ontario between 1999 and 2018. They examined each step of the care process, known as the "cascade of care", to identify areas that need improvement.
“We found that out of 4,962 people who tested positive for the hepatitis C antibody, 83% went on to be tested for hepatitis C RNA, which is the next step in the care cascade. Of the people who tested positive for the RNA, only 42.2% went on to initiate treatment,” says Dr. Andrew Mendlowitz, a postdoctoral fellow working with Dr. Feld and the first author of the study.
The findings reveal significant improvements in testing and diagnosis over time, particularly for people living in First Nations communities. However, substantial gaps in treatment initiation remain due to barriers such as limited access to health care services, as well as the presence of stigma and systemic oppression that may discourage treatment initiation.
The study highlights the need for new tailored approaches to deliver care to First Nations communities. Increasing access to health care providers who can prescribe treatments and utilizing peer and community supports may help treatment initiation efforts.
Additionally, implementing anti-racism and cultural safety training for health care providers may improve trust between Indigenous peoples and the healthcare system. Integration of harm reduction and substance use services may also help to overcome barriers to care.
“Only through partnering with First Nations decision-makers, health leaders, care providers and patients can we make real in-roads to eliminating this virus. Through this partnership, we have gained key insights that will help us to address gaps across the entire care spectrum” concludes Ms. Jones.
This study was funded by the Canadian Institutes of Health Research (CIHR), the Government of Ontario, the UHN Foundation and the Canadian Network on Hepatitis C (CanHepC). CanHepC is an initiative that is jointly funded by the CIHR and the Public Health Agency of Canada. Dr. Jordan Feld is a Professor of Medicine at the University of Toronto. Dr. Andrew Mendlowitz received postdoctoral fellowship funding from CanHepC and CIHR. Dr. Beate Sander holds a Tier 2 Canada Research Chair in Economics of Infections Disease and Dr. Jennifer Walker holds a Tier 2 Canada Research Chair in Indigenous Health Data and Aging. *Dr. Murray Krahn passed away during the preparation of this manuscript for publication and held a Tier 1 Canada Research Chair in Health Technology Assessment.
William Wong and Murray Krahn received research support from the Canadian Liver Foundation. Beate Sander reports travel support from the Canadian Network on Hepatitis. Jordan Feld received research support or consulting fees from AbbVie and Gilead Sciences, and is past president of the Canadian Association for the Study of the Liver.
Mendlowitz AB, Bremner KE, Krahn M, Walker JD, Wong WWL, Sander B, Jones L, Isaranuwatchai W, Feld JJ. Characterizing the cascade of care for hepatitis C virus infection among Status First Nations peoples in Ontario: a retrospective cohort study. CMAJ. 2023 Apr 11;195(14):E499-E512. doi: 10.1503/cmaj.220717.
OFNHAEC aims to enhance the awareness, prevention and education of HIV/AIDS and other blood-borne pathogens such as hepatitis C among First Nation communities (image from the ofnhaec website).