- Researchers monitored engagement in care for 1,809 people coinfected with HIV and hepatitis C
- Most participants disengaged from care at least once, but most were able to reengage later
- A common reason for falling out of care was a change in residence
According to researchers who study hepatitis C virus (HCV), coinfection with HCV occurs in 20% to 30% of Canadians with HIV. Rates of coinfection are even higher among people who inject drugs—ranging from 50% to 90%. Many people who use drugs have a history of trauma, low income and unstable housing, have exchanged sex for drugs and are at high risk for incarceration.
Due to social determinants of health as well as historic and ongoing colonialism and racism, Indigenous people in Canada are at heightened risk for harms related to drug use. What’s more, research suggests that between 70% and 80% of new HCV infections in Canada occur among people who are Indigenous.
The intersection of injecting street drugs and being coinfected with HIV and HCV can influence the trajectory of both infections and make people more socially vulnerable.
Understanding engagement in care
Many analyses of data that focus on the path to care in people with HIV, HCV or both infections merely look at one direction—from testing to linkage to care to access to treatment to achievement of cure (in the case of HCV) or viral suppression (in the case of HIV). However, some people have more complex patterns; they go in and out of care and, in some cases, back into care for HIV and HCV. To try to capture dynamic patterns of engagement in viral care and treatment that accurately reflect people’s lived experience, a team of Canadian researchers used a comprehensive approach.
Study details
The researchers analyzed data from 1,809 people with both HIV and HCV that was collected between 2003 and 2022 (19 years). This group of people took part in a study called the Canadian Co-infection Cohort Study (CCC). Participants were from 18 clinics in the following provinces:
- British Columbia
- Alberta
- Saskatchewan
- Ontario
- Quebec
The average profile of participants at the start of the study was as follows:
- 71% male, 28% female, 1% transgender
- age – 45 years
- 82% reported a history of injecting drugs; 25% disclosed current injection drug use
- 24% of participants were Indigenous (data on other ethno-racial groups were not made available)
- 12% of participants had been incarcerated in the past six months
- CD4+ cell count – 457 cells/mm3
- undetectable HIV viral load – 65%
- HCV infection (presence of HCV’s genetic material in blood samples) – 66%
- HCV treatment status: not treated – 83%; missing results – 8%; cured – 7%; treatment failed – 2%
Results
Using an analysis called multistate modelling, the researchers found that 46% of participants fell out of care (the technical term for this is “disengaged”) once during the study. Such periods of disengagement lasted a minimum of 18 consecutive months. Some people fell out of care more frequently: 16% had two episodes of disengagement, 5% had three episodes of disengagement, and smaller proportions had a greater number of such episodes.
Most people (57%) who fell out of care were subsequently able to reengage with care.
According to the researchers, a common reason for falling out of care was change in residence.
Statistical analysis found that people who had one or more of the following factors were at high risk of falling out of care:
- a detectable HCV viral load
- no history of HCV treatment
- initiated HCV treatment but did not return to be tested for cure
- recent imprisonment
Survival
The researchers found that nearly one in five participants (383 people) died during the study. In general, the risk of death was twice as high among people who fell out of care vs. people who remained in care.
Causes of death were similar whether participants were engaged in care or fell out of care. They included drug poisoning, severe infections and complications arising from severe liver injury (caused by HCV coinfection).
Overall, Indigenous people were twice as likely to die as non-Indigenous people, regardless of whether they remained in care or transitioned in and out of care.
The harms faced by Indigenous people
The researchers were disturbed by their finding that Indigenous people were at heightened risk of dying even if they reentered care after falling out of care. They stated that this increased risk of death “suggests the possible role of structural racism and the deeply rooted inequities faced by Indigenous communities in Canada even after engaging in clinical care.”
The researchers added: “The entrenched historical and ongoing discrimination against Indigenous people of Canada functions as a pervasive barrier to sustained engagement in the HIV and HCV care cascades, ultimately leading to negative long-term health outcomes. Driven by historical and ongoing systems of oppression and White supremacy, systemic discrimination against Indigenous people is unfortunately embedded in the Canadian healthcare system. These barriers to care are pervasive within the Canadian healthcare system, including HIV and HCV care.”
Potential approaches
There is no simple remedy for repairing the damage to human lives and spirits caused by what the researchers called “the entrenched historical and ongoing discrimination against Indigenous peoples of Canada […].” This does not mean that such systems cannot be repaired. However, it is likely that multiple approaches are needed to make healthcare systems better and, indeed, safer for multiple populations, including Indigenous people.
The World Health Organization (WHO) is encouraging cities, regions and countries to help eliminate HCV as a public health issue by 2030. For Canada to achieve this goal and improve the health of people coinfected with HIV and HCV, it will be necessary to address the impact of what the researchers called the “historical, intergenerational and lifetime trauma—including the lasting effects of residential schools, forced assimilation, and poverty—on engagement in care and, consequently, the achievement of viral suppression [for HIV and cure for HCV].” This will require sustained interventions by all levels of governments in coordination with Indigenous people.
—Sean R. Hosein
Resources
CAAN Communities, Alliances and Networks
People who inject drugs report unique barriers to hepatitis C treatment – CATIE News
Alberta – improvements in survival but changing causes of death – CATIE News
Researchers encourage simultaneous testing for three viruses—HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) – CATIE News
Elimination of hepatitis by 2030 – World Health Organization
Hepatitis B in Canada: 2021 surveillance data update – PHAC
Read online | Download the infographic
Hepatitis C in Canada: 2021 surveillance data update – PHAC
Read online | Download the infographic
HIV in Canada: 2022 surveillance highlights – PHAC
Read online | Download the infographic
Trends in HIV pre-exposure prophylaxis [HIV-PrEP] use in nine Canadian provinces, 2019-2022 – PHAC
Read online | Download the infographic
Hepatitis C testing and diagnosis – CATIE
Blueprint to inform hepatitis C elimination efforts in Canada – Canadian Network on Hepatitis C
Harm Reduction Fundamentals: A toolkit for service providers – CATIE
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