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Priority directions to address hepatitis C amongst Indigenous peoples

It is critical to appreciate the tremendous cultural, linguistic, and socio-economic diversity across and within Indigenous communities, with over half of the Indigenous population located in urban centres, and with much migration between urban and non-urban locations. There is immense variation in Indigenous models of integrated programming because of complex jurisdictional landscape issues and inconsistencies in terms of policies and self-government agreements across the country. There are on- and off-Reserve programs; programs in urban, rural and remote locations; programs under federal and provincial/territorial jurisdictions; multiple health providers; multiple health standards; and multiple funders.

Vision for a hepatitis C model of care for Indigenous peoples

Local and cultural contextualization of any model is critical, but the following elements support a common vision for an effective and relevant hepatitis C model of care for Indigenous peoples.

Structures must be developed and led by First Nations, Inuit and Métis peoples to eliminate the disproportionate burden of hepatitis C within Indigenous populations by establishing health targets for this population that surpass those for the overall Canadian population. Such a specific focus on and investment in health outcomes for priority populations is known as equity-plus1 in the provision of prevention, testing, care, treatment and support services to achieve zero.2

  • Indigenous-led and multidisciplinary approaches:
    • are rooted in Indigenous determinants of health (including colonial racism and social exclusion);
    • entail diverse and shared care models with primary, mobile, community-based, eHealth, and appropriate specialist support; and
    • prioritize Indigenous workforces, including health brokers and navigators (who are Indigenous but not necessarily from the community in question).
  • Multifaceted and equitable approaches:
    • involve the provision of integrated care and are structured to enable practitioners to spend the time needed to appropriately address particularly complex needs of many Indigenous clients;
    • involve integrated prevention, testing, treatment and care for sexually transmitted and blood-borne infections, provided either through service integration or program collaboration;
    • include appropriate post-test education and linkage to care; and
    • facilitate and make available access to hepatitis C treatment based on client readiness rather than clinical eligibility criteria markers (degree of fibrosis, number of courses of therapy) or financial criteria.
  • Wholistic and culturally safe approaches:
    • involve wholistic and culturally safe programming, with culture broadly defined to include gender, lived experience, and traditional cultural beliefs;
    • incorporate Indigenous processes and Indigenous ways of knowing and healing; and
    • provide trauma-informed care that addresses historic, collective and inter-generational trauma.
  • Geographically flexible and adaptable approaches:
    •  respond to and make connections between highly mobile rural and urban populations.
  • Cross-sectoral collaborative approaches:
    • involve formal ties and connections with other sectors (e.g., connections with correctional services are needed given overrepresentation of Indigenous peoples among incarcerated populations).

 Recommendations for addressing hepatitis C within Indigenous communities

  • Establish a national Indigenous mapping exercise to gather data on Indigenous models, including rural, remote, on- and off-Reserve, urban and mobile models. These models must be shared and used as guides for creating responsive programs.
  • Create a national Indigenous hepatitis C strategy to provide a framework for action for Indigenous leadership and communities, as well as healthcare providers and governments.
  • Invest in programs and services that are wholistic and culturally safe at both individual and organizational levels.
  • Invest in programs that are founded in Indigenous processes and Indigenous ways of knowing and healing.

Tools, resources and supports

  • A tool will be needed to map services across the country.
  • Mobile testing or pop-up clinics will be needed to increase uptake of testing. Appropriate post-testing education and linkage to care should be made available.
  • Formal ties and connections with provincial/territorial and federal correctional services should be established.
  • Models for peer support programs should be shared.
  • National and international health authorities will need to collect and interpret Indigenous-specific data and pursue an equity plus approach that includes establishing target numbers of Indigenous people being tested, treated and accessing services, instead of simply setting overall target numbers for the general population, which may miss population-specific differences.
  • Health education resources should be made available in multiple Indigenous languages.

Notes

  1. Equity plus is a term used to describe the goal of having target health outcomes for priority populations that not only equal those for the overall population but surpass them. This would require a focus on and specific investment in the health outcomes of priority populations.
  2. Achieving zero is a term referring to the aim of eliminating the overrepresentation of Indigenous peoples and other underserved populations in all health disparity data.