Recommendations for decision makers regarding hepatitis C

Table of content INTRODUCTION ........................................................................................................................ 2 COMMITTEE MEMBERS ............................................................................................................. 4 PURPOSE OF THE COMMITTEE .................................................................................................. 5 PHILOSOPHY AND APPROACH .................................................................................................. 5 OBJECTIVES ............................................................................................................................ 5 CONTEXT ................................................................................................................................. 6 MAIN FINDINGS ........................................................................................................................ 7 RECOMMENDATIONS ................................................................................................................ 8 1. 2. 3. 4. 5. 6.

CONTINUED DEVELOPMENT AND SUPPORT OF INTERVENTIONS ........................................................... 9 RAISING AWARENESS OF HCV ................................................................................................... 10 HCV TRANSMISSION PREVENTION .............................................................................................. 11 HCV SCREENING AND TREATMENT ............................................................................................. 12 POLICY ................................................................................................................................. 13 RESEARCH AND DEVELOPMENT .................................................................................................. 14

GLOSSARY ............................................................................................................................. 15

_______________________________________________________________________________ Recommendations for decision makers regarding hepatitis C ‐ 2012

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Introduction

This document is the result of work completed by several organizations to help decision makers recognize important issues related to hepatitis C. This work began in 2004, and the organizations have since refined their recommendations. Additions, modifications and demands have been included over time. Discovered in 1989, the hepatitis C virus (HCV) acquired greater importance in following years when it was discovered that 160,0001 Canadians had contracted HCV through blood transfusions. Since then, this viral infection continues to be a major public health issue because of its prevalence (estimated to be five times that of HIV), the high cost of treatment and the great demand for resources and support to assist patients suffering from side effects. Symptoms appear slowly and often go unnoticed, leading to years of misdiagnosis. As well, thousands of new infections occur each year, many which lead to complications, cancers and cases of cirrhosis. It is predicted that the number of people whose condition will worsen will increase over time. Indeed, the number of deaths related to HCV is now higher than those caused by HIV2. In Canada, 242,521 people3 live with the hepatitis C virus. This figure underestimates the true extent of HCV infection because many people have not yet been diagnosed. It has been estimated that 21% of people infected with HCV are unaware of their serostatus with regard to this virus4. The World Health Organization (WHO) recognized the importance of HCV during the 63rd World Health Assembly that took place in May, 2010. Resolutions were adopted in support of a coordinated worldwide effort to address viral hepatitis and provide support for a national and international hepatitis awareness day5.


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Introduction (continued)

Advances and setbacks have succeeded each other through the years; it has been a case of one step forward, two steps back. Treatment breakthroughs have been clouded by setbacks in terms of accessibility. The Comité provincial de concertation en hépatite C encourages the development of prevention, support, research and treatment projects, as well as an improved follow-up of infected patients. The time for reflection is over. Action is now needed to mobilize our energies for the fight against hepatitis C. The federal and provincial governments can prepare themselves for an increase in HCV-related complications by coordinating concrete actions and following the recommendations set out in this document. Finally, we believe it's imperative that strategies reflecting all of the elements mentioned above be considered and put forth and that a responsible fiscal effort be considered as well.

1 Health Canada, Hepatitis C Prevention, Support and Research Program. Available at: http://www.phac-aspc.gc.ca/hepc/pubs/psrpmideval-ppsrevalinter/i_problem-eng.php 2

Article by Dr. Thierry Grivel in the Journal international du médecin - 15/02/2012

Public Health Agency of Canada. Hepatitis C in Canada: Surveillance report for 2005-2010. Available at: http://www.catie.ca/sites/default/files/1109-0139-Hep%20C%20Report-EN%20FINAL.pdf 3-4

5 World Health Organization (WHO). Resolutions from the 63rd world health assembly, 2010. Available at: http://www.who.int/mediacentre/factsheets/fs164/en/index.html

Introduction inspired by Responding to the Epidemic Recommendations for a Canadian Hepatitis C Strategy. Available at: http://www.hemophilia.ca/en/hcv-hiv/recommendations-for-a-canadian-hepatitis-c-strategy--2005


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Committee Members

The Comité provincial de concertation en hépatite C (Joint Provincial Committee on Hepatitis C), author of these recommendations, is composed of several organizations and groups working in the area of hepatitis C.

                  

Aids Community Care Montreal (ACCM) L'Association Québécoise pour la promotion de la santé des personnes utilisatrices de drogues (AQPSUD) Bureau Régional d'Action Sida (BRAS Outaouais) Cactus Montréal Centre Associatif Polyvalent d'Aide Hépatite C (CAPAHC) Centre d'Intervention et de Prévention en Toxicomanie de l'Outaouais (CIPTO) Dopamine Émiss-ère Hépatites Ressource Mouvement d'Aide et d'Information Sida (MAINS Bas-Saint-Laurent) Plein Milieu Programme National De Mentorat sur le VIH-sida (PNMVS) Point de Repères Société canadienne de l'hémophilie Sidaction Spectre de rue Stella Toxic-Actions L'Unité d'intervention mobile l'Anonyme


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Purpose of the Committee To ensure the collaboration of community organizations to make the recommendations of the Comité provincial de concertation en hépatite C known and acknowledged, in order to increase knowledge and harmonious policies and to support the actions of its members.

Philosophy and Approach To place people living with hepatitis C or at risk, at the heart of our concerns in a context of empowerment and harm reduction.

Objectives 1.

Support the development and implementation of actions designed to raise awareness and educate the population about hepatitis C and to prevent it.

2.

Promote the rights and responsibilities of people infected with hepatitis C and strengthen opposition to all forms of discrimination experienced by these people and those close to them.

3.

Encourage people living with the hepatitis C virus to participate in claiming their rights and support community actions in this regard.

4.

Promote the expertise of community organizations working with people infected and affected by hepatitis C.

5.

Serve as key contact for the various bodies responsible for influencing policy, as well as its implementation and follow-up.


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Context What is HCV? Hepatitis C is an inflammation and infection of liver cells that is caused by the hepatitis C virus (HCV). This virus is only transmitted by blood to blood contact. It is 10 to 15 times easier to transmit that HIV. HCV also survives much longer outside of the human body than HIV. As soon as it enters the bloodstream, the virus attaches itself to liver cells and begins to reproduce in huge numbers in order to infect other healthy liver cells. It causes damage or scarring of the liver that prevent it from functioning normally. Liver damage can cause cirrhosis or even cancer. HCV is constantly mutating, which allows it to outsmart the human body's immune system. Because the virus is difficult to reproduce in the laboratory, there is currently no vaccine for HCV. Hepatitis C infection is the main cause of liver transplants in Canada.

How is HCV transmitted? HCV is transmitted when the blood of one person comes into contact with the infected blood of another, in one of the following ways: 

Sharing any object contaminated with blood, including accessories for injecting, snorting or smoking drugs and instruments used for piercings, tattoos, nail care, electrolysis, shaving or acupuncture.



Blood transfusions or other medical procedures during which inadequate measures allow contaminated material to be used.



Certain sexual activities (e.g., unprotected sex during menstruation, unprotected anal intercourse and rough sexual activities that cause injury).



Accidental needle-stick injuries.



Vertical transmission (during delivery or breastfeeding if lesions are present).


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Main findings 

Hepatitis C virus infection is a public health problem in Quebec and Canada due to the rising number of cases; the most recent estimate puts the number of infected Canadians at 242,521.



In 2011, 2,700 new cases occurred in Quebec, according to the report entitled "Portrait des infections transmissibles sexuellement et par le sang (ITSS) au Québec, année 2010 (et projections 2011)." The number of declared cases of hepatitis C in the acute infection category is well below the real figure.

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The co-infections HCV/HIV and HCV/HBV complicate both the screening and treatment of infected people.



Costs associated with damage caused by hepatitis C progression are very high and could be avoided with early screening and timely treatment, usually early in the course of the infection. Often asymptomatic, HCV infection can progress to chronic hepatitis and later to cirrhosis (liver fibrosis with scarring) and liver cancer.



The hepatitis C virus affects men disproportionately, but the gap between the sexes is shrinking.



Most people living with hepatitis C in Canada are 30 years of age or older.


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Recommendations This document contains updated recommendations taken from the report "Portrait de l’état de la situation de l’hépatite C au Québec" from April, 2006. Following the collaboration of the community groups at the heart of this initiative and in light of the results and observations stemming from this exploratory study, the working committee is proposing the following recommendations for the six areas mentioned:

1. Continued development and support of interventions 2. HCV awareness raising 3. HCV transmission prevention 4. HCV screening and treatment 5. Policy 6. Research and development


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1. Continued development and support of interventions

1.1. Develop and maintain actions based on the harm reduction approach; 1.2. Develop and maintain actions in order to reduce barriers to HCV information, prevention and treatment; 1.3. Develop and offer a formal training framework to caregivers and community workers in order to develop relational and communication strategies targeting drug users, the main population affected by HCV; 1.4. Develop and offer a formal information and support framework for HCV infected and HCV/HIV co-infected people and their loved ones before, during and after treatment; 1.5. Develop housing, support and direct assistance services for people undergoing treatment who are dealing with homelessness; 1.6. Develop housing, support and direct assistance services for people undergoing treatment who are in need of respite.


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2.

Raising awareness of HCV

2.1 Raise awareness and inform the public about HCV; 2.2 Make information accessible and understandable to HCV and HIV infected, coinfected and affected populations; 2.3 Raise awareness, train and inform health-care professionals and social service workers about HCV.


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3.

HCV transmission prevention

3.1 Develop and implement actions based on adaptive strategies that reflect a harm reduction approach; 3.2 Develop and facilitate the involvement of vulnerable or at risk populations in all areas relating to HCV (education, information, awareness raising, screening, support, treatment, research, mobilization, services); 3.3 Develop capacity building actions targeted to individuals to increase their uptake of safer drug use, tattooing and piercing practices, and to prevent all other activities considered to carry a risk of HCV transmission for the public and prison populations; 3.4 Develop tools for prevention, awareness raising and education concerning the risks of transmission for users of injected hormones; 3.5 Develop and implement policies and regulations concerning infection prevention for health-care providers, beauty and body art practitioners and correctional institutes.


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4. HCV screening and treatment

4.1 Promote early screening and prevent infection progression; 4.2 Propose treatment during the acute phase as soon as a person with a history of negative serology learns of his or her HCV positive result; 4.3 Implement a collaborative organization of services to ensure access, continuity and treatment adherence; 4.4 Offer HAV and HBV vaccines to people at risk or infected; 4.5 Limit barriers by working to reduce prejudice against those most affected by HCV and taking action to revise regulations concerning access to care and treatment; 4.6 Promote screening and treatment access in provincial detention centres; 4.7 Promote access to the HCV screening test throughout Quebec.


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5.

Policy

5.1 Ensure the continued existence of the Comité provincial de concertation hépatite C; 5.2 Make the Comité provincial de concertation en hépatite C and its recommendations known and acknowledged among government bodies; 5.3 Promote community intervention capacity; 5.4 Promote the continuity and renewal of projects to ensure sustained interventions over time.


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6.

Research and development

6.1 Increase the documentation of different multidisciplinary approaches, both clinical and psychosocial; 6.2 Document treatment success among active drug users; 6.3 Promote the development of new information, intervention and training strategies; 6.4 Promote epidemiological research concerning treatment success and the relativity of current demands concerning treatment access; 6.5 Promote clinical research about HIV/HCV co-infection; 6.6 Promote research into treatment effectiveness when the infection has not yet reached the chronic stage; 6.7 Promote community participation in research (community-based research); 6.8 Promote epidemiological research among ethnocultural and immigrant communities; 6.9 Promote the implementation of corridors of service as well as the linking of services targeted to people living with HCV and those co-infected with HIV/HCV; 6.10 Promote liver transplants for people with HIV/HCV co-infection.


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Glossary HAV : Hepatitis A virus HBV : Hepatitis B virus HCV : Hepatitis C virus HIV : Human immunodeficiency virus STBBI : Sexually transmitted and blood-borne infections Empowerment An approach that aims to support the efforts of individuals and communities so they may develop or regain power over their lives and increase their capacity for autonomous action. Harm reduction A social approach designed to reduce the negative consequences of given behaviours. This method seeks first and foremost to achieve objectives that are realistic, prioritized and adapted to the individual, in order to eliminate the risks associated with the behaviours in question. Vulnerable populations       

Injection and inhalation drug users (IIDU) Men who have sex with men (MSM) Women At-risk youth People from endemic countries Aboriginals Prisoners


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ACKNOWLEDGEMENTS The CAPAHC wishes to thank all of its partners who contributed to the production of this document.


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