A new study on the patterns of hepatitis C virus (HCV) infection in Status First Nations people found gaps in testing, treatment and follow-up. Understanding these gaps can guide efforts to eliminate the disease. The study is published in CMAJ (Canadian Medical Association Journal).

Hepatitis C virus infection is a major public health issue in Canada, having been described as the most burdensome of infectious diseases in the country. Among Status First Nations peoples in Ontario, both testing and diagnosis have greatly increased between 2006 and 2014. Treatment with direct-acting antiviral (DAA) regimens offers a potential cure before patients develop advanced liver disease or even die from this disease. This progress has given the opportunity to eliminate HCV as a public health problem in Canada. However, planning elimination efforts will require data on how people progress from HCV testing, to diagnosis, to linkage to care and, ultimately, to treatment (the HCV cascade of care) to guide where to prioritize elimination efforts.

Diagnosis of HCV infection, which is often asymptomatic, relies on a 2-step testing approach to identify individuals with active infection. As the first step, detection of HCV antibodies indicates exposure to the virus. If positive, follow-up confirmatory testing for HCV RNA is done to test for active infection. In partnership with First Nations organizations, researchers looked at ICES data on Status First Nations people with a confirmed positive test result for HCV antibodies or RNA between Jan. 1, 1999, and Dec. 31, 2018, to understand HCV care and to identify gaps. The “cascade of care” was characterized as 6 stages, following the patient care journey from positive HCV test to treatment, to cure.

This research is part of an ongoing collaboration between the Ontario First Nations HIV/AIDS Education Circle, ICES and academic researchers.

By the end of the 20-year study period, 4962 First Nations people were alive in the province and had tested positive for the virus. Overall, 17% of people who tested positive for HCV antibodies did not receive follow-up testing for HCV RNA to confirm active infection, and almost 60% of those with a positive HCV RNA test did not start treatment. Among people treated, researchers were unable to confirm cure for 20%.

“Progress has been made with the availability of DAA treatments and testing, but substantial gaps remain in access to treatment, especially among those who reside within First Nations communities,” says first author Dr. Andrew Mendlowitz, postdoctoral fellow at the Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, and an ICES postdoctoral trainee.

The authors observed successful engagement in HCV RNA testing and shorter time to treatment for those who reside within First Nations communities versus outside, which they attribute to the resilience of Indigenous Peoples and the role that Indigenous culture and community play in health.

“Successes may speak to demonstrations of how community attachment, cultural continuity and social supports promote resilience and improve quality of life after HCV diagnosis,” say the authors.

These data will serve as a benchmark for Canada’s commitment to the World Health Organization’s goal to eliminate viral hepatitis by 2030 as a major public health threat. Within the Blueprint to Inform Hepatitis C Elimination Efforts in Canada, First Nations peoples have been identified as a priority focus, calling for representation in elimination efforts, tailored programming, and monitoring and surveillance. These data can assist researchers to partner with First Nations decision-makers and health leaders to codesign approaches to prioritize engaging individuals in testing and health care to support the elimination of HCV as a public health threat.

“Characterizing the cascade of care for hepatitis C virus infection among Status First Nations peoples in Ontario: a retrospective cohort study” is published Apr. 11, 2023.

Research: https://www.cmaj.ca/lookup/doi/10.1503/cmaj.220717