Hepatitis C virus infection in Saskatchewan First Nations communities : Challenges and innovations

Hepatitis C virus (HCV) infection has become a major public health issue in Canada, and especially in Saskatchewan First Nations (FNs) communities. One of the challenges in eliminating hepatitis C in Canada is accessing hard-to-reach populations, such as FNs people living on reserves. In Canada, HCV is a notifiable disease but complete and timely surveillance of HCV data is not always possible in remote communities. In addition, national surveillance data are insufficient for determining the number of cases of hepatitis C among FNs populations, because many provinces do not collect information according to ethnicity. Statistics for FN communities are available federally through the First Nations and Inuit Health Branch (FNIHB) in partnership with the communities and the province. There are multiple factors associated with the high rates of HCV in FNs communities, including barriers in accessing preventive services, early diagnosis and treatment. These access issues are largely attributable to issues with geographical remoteness, transportation, education and awareness, and a health care system designed around urban health. New and innovative ways of delivering information and services, such as the mobile hepatitis C clinic (Liver Health Days) and the community-driven Sexually Transmitted Bloodborne Infections (STBBI) Know Your Status program, are proving invaluable in remote FNs communities. Extending these in-community and community-driven programs to other FNs communities and to the prison population could be invaluable in working towards the World Health Organization elimination goals of hepatitis C virus for all. Affiliations 1 Regina Infectious Disease Clinic, Department of Medicine, University of Saskatchewan, Saskatoon, SK 2 Chief of Cote First Nation, SK 3 First Nation Inuit Health Branch Regina Office, Department of Indigenous Services Canada, Saskatchewan Region, Regina, SK *Correspondence: ibrahim.khan@ canada.ca


Introduction
Approximately 170 million people worldwide are chronically infected with hepatitis C virus (HCV) (1)(2)(3)(4)(5)(6).In Canada, 250,000 to 275,000 are chronically infected with HCV and an upward trend of both infection and HCV-associated liver diseases was reported nationally (1)(2)(3)(7)(8)(9)(10)(11)(12).Until recently an estimated 15,800 persons were living with cirrhosis and 5,500 with liver failure in 2017.It has been estimated that from 2007 to 2027, the number of prevalent cases of cirrhosis will increase from 15,814 to 17,570 and carcinoma will increase from 338 to 379 cases (13).The impact of HCV and the sequelae of hepatitis C infection on the health of Canadians are considerable in terms of the impact of chronic liver failure, liver transplant and early death (13).
There are significant limitations in HCV surveillance; and despite this, a continuous and rising burden of HCV has been documented in Saskatchewan FNs communities as well as correctional facilities where FNs people are over represented (1)(2)(3)(4)(5)11,12).Furthermore, 21%-44% of those chronically-infected are not aware of their HCV status (2,24,25).
In recent years, new curative Direct Acting Agents (DAA) have revolutionized HCV treatment and have brought hope of possible elimination of HCV and associated liver diseases.But to deliver these promising treatments, individuals with HCV have to be accessed, identified, educated and properly treated.This paper highlights the burden of HCV in Saskatchewan, identifies challenges and barriers to care, and outlines ways Saskatchewan has been working to improve access to prevention and treatment services to promote liver health among FNs living on reserves.

HCV and Saskatchewan First Nations people
Saskatchewan is a rapidly-growing province of over a million people.There are 70 distinct FNs in Saskatchewan and a total of 156,828 registered FNs people living in 84 geographically-isolated and geographically-dispersed communities.The community sizes range from 113 to 10,000 people.More than 50% of FNs people living on reserves in Saskatchewan, and 14% of these reserve communities are geographically isolated.Based on the population projection of Statistics Canada, one in every five people in Saskatchewan could be aboriginal by 2036 (7)(8)(9)(10).
In addition to geographical isolation, FNs people in Canada also suffer from a high incarceration rate; estimated to be 1,024 per 100,000 or almost nine times higher for FNs people than for non-FNs people (14).While FNs people made up only 15% of the general population in Manitoba and Saskatchewan, they accounted for 64% of the provincial jail admissions in Manitoba and 76% in Saskatchewan in 2000-2001 (14).At the same time, data suggests that FNs people are at increased risk for human immunodeficiency virus (HIV) and HCV infection and are infected at a younger age than non-FNs people.The high degree of mobility of FNs people between inner cities and rural areas may bring the risk of HIV and HCV to even the most remote communities (3,14,(18)(19)(20)24).
In addition, FNs people are over-represented in groups at high risk for HIV infection, in particular among injection drug users (IDUs).In Saskatchewan, a 2005 cross-sectional survey by Hennink et al. found that HCV is acquired relatively soon after IDUs begin injecting drugs (11).Within five years of beginning to inject, 50%-80% of IDUs were infected with HCV.As a result, many IDUs who become infected with HIV are already infected with HCV.Similarly Klein et al. found that HIV-HCV co-infected persons remained at markedly increased risk for death, despite treatment with antiretroviral therapy (15).A Canadian cohort study found that Aboriginal ethnicity and the female sex were associated with increased rates of HCV clearance, while HIV co-infection and illicit drug use were associated with decreased clearance rates (3).To further complicate identification and treatment of HCV-infected individuals, approximately 50%-85% of those who remain infected will progress to chronic infection but may be asymptomatic for decades.

The challenges HCV surveillance
In Canada, HCV is a notifiable disease.Complete and timely surveillance of HCV data is essential for early identification and response to HCV outbreaks to minimize transmission and to implement evidenced-based prevention strategies.But in FNs communities, complete and timely surveillance is not always possible.In addition, national surveillance data are insufficient for determining the number of cases of hepatitis C among FNs populations, largely because many provinces do not collect information according to ethnicity (1)(2)(3)(4)(5)(7)(8)(9)(10)(11)(12)(13)(14)(15).As a result, information regarding ethnicity has been confined to population groups already at high risk for acquisition of blood borne pathogens (such as prison inmates and IDU) (3).Although FNs peoples are considered to bear the highest burden, there is a paucity of data.Some statistics for FN communities are available federally through the First Nations and Inuit Health Branch (FNIHB) in partnership with the communities and the province.According to FNIHB-Health Canada, Saskatchewan Region, in 2015 the reported HCV new seropositive rates for FNs on-reserve communities were 372.0, 186.7, and 129.0 cases per 100,000 population in southern, central and northern FNs communities respectively.In 2015, these rates were six times, three times and two times higher than the provincial HCV rate (62.7 cases per 100,000), respectively.
In 2016, reported rates continued to increase, with the HCV new seropositivity rates of 401.2 cases per 100,000, 211.6 cases per 100,000 and 130.0 cases per 100,000 for the southern, central and northern communities, respectively (see Figure 1).HCV rates also increased markedly in the southern Saskatchewan FNs communities in the past years.
In 2016, the majority of the HCV cases in Saskatchewan FNs communities were males (66%) and many (33%) of the HCV cases diagnosed were 30-39 years of age (7)(8)(9)(10).This is in contrast to Canadian data where the age range of HCV cases is older (3,25).

Access to HCV treatment and prevention programs
Access to testing is not available in the some of FN communities in Saskatchewan and many do not have access to primary care (7)(8)(9)(10)(13)(14)(15)(16)(17)26).Furthermore for FNs on reserves, if the diagnosis is made off reserve where a local address is used, then the burden on reserves will be under represented.Mobility also leads to significant difficulty in locating patients and hence many are lost to follow up.Indeed, many do not get a confirmatory viral load diagnosis and many are not even aware of their infection.
Non-Insured Health Benefits (NIHB) program in Health Canada was one of the first plans to cover direct acting antiviral treatment for HCV for FNs and Inuit patients.Significant barriers related to poverty, communication and remoteness for FNs on reserves have impeded access to any curative therapy.Treatment requires access to fibroscan or staging of liver disease typically available in tertiary care centres only, as well as an HCV treatment provider, who is available predominantly in major urban centres.Further, untreated viremia, combined with limited access to harm reduction services, only continues to exacerbate the rates through on-going active transmission.
Liver transplantation is problematic, as access to specialized hepatitis clinics and treatment is limited in Saskatchewan and a growing number of patients are referred to the Edmonton liver transplant program (20,22,23,(27)(28)(29).In Saskatchewan only 28 patients have received liver transplants since 2008 and 225 are currently on the waiting list for a transplant (22,23,26).

The innovations Preventive services
The FNs communities are at various stages in terms of capacities and their response to the increasing HCV (and HIV) rates.

Mobile hepatitis C clinics
There has been a change in approach to address hepatitis C in FN communities in Saskatchewan over the past two years.A partnership has been established between public health, FNs communities, FNs leaders, labs and clinical providers to bring testing and care directly to remote FNs communities through the use of mobile hepatitis C clinics, which brings testing, education, fibroscans and DAA treatment directly to the Saskatchewan FNs communities.
These mobile clinics are multidisciplinary in nature.These clinics are advertised in advance and invite community members with HCV or those who engage in risk behaviours to attend.They provide one-on-one educational and in depth counselling sessions.Testing and assessment of patient's health/liver conditions are also undertaken and, where indicated, plans are made for integrated care and referral for community-based treatment the same day.Moreover, awareness and expertise developed locally has allowed communities to take ownership of this comprehensive approach to HCV infection, its underlying risk factors and the health of their members by providing culturally-sensitive and accessible care in a team-based model.
These mobile in-community HCV clinics have been named "Liver Health Days".They have not only attracted the interest of FNs people affected with HCV but have also improved treatment uptake, health outcomes and adherence rates.
The number of these mobile clinics is increasing as more FNs communities take ownership and leadership in the prevention programs.Community leadership, staff (e.g., community health nurses, registered nurses and nurse practitioners) trained in liver health and cultural safety in the provision of HCV care are the key ingredients of success in this regard.Culturally safe or appropriate care means that all members of the health care system are aware of the history and impact of intergenerational trauma and the current challenges (such as racism) that FNs people experience when trying to access health care, and that they do everything possible to ensure that the care they provide is respectful, comprehensive and holistic.

Injection drug use (IDU) and addressing determinants of health
As IDU is a primary risk factor for acquiring and for the transmission of HCV, addressing drug addiction and associated mental health issues are critical to the HCV response.Monitoring drug and addiction trends at the community level is an effective tool.While offering community-based services for HCV infection, awareness of factors that promote resilience and addressing determinants of health such as intergenerational trauma from a history of colonization and residential schools, racism, overcrowding, education and literacy, social exclusion and gender inequality, could help FNs people access to health care services (16,17).

Discussion
The HCV has become a major global public health issue that is reflected in the rising burden of HCV in Saskatchewan FNs people on reserves.Until recently, FNs people living on reserves in Saskatchewan have not been accessing treatment.Recent community-based programs innovations, such as the mobile hepatitis C clinic and the community-driven HIV/HCV Know Your Status program, which offer onsite testing/counselling, harm reduction services, diagnostics and treatment, are becoming invaluable in addressing the HCV situation on FN reserves (7)(8)(9)(10)21,26,30,32).
In 2016, Canada, along with member states of the World Health Organization, adopted the first global strategy on viral hepatitis with a goal to eliminate viral hepatitis as a major public health threat by 2030 and that everyone living with viral hepatitis has access to safe, affordable and effective treatment (33).The strategy identified underdiagnosis as a key barrier to eliminating HCV (2,6,34).Adopting best practices and innovative models that engage clients in prevention, early diagnosis and treatment of HCV is critical to stopping the transmission in all settings, whether it is on or off reserve.Given the high level of HCV in IDU, attention has focussed on this subgroup of the population.
A recent meta-analysis of strategies effective at reducing HCV sero-conversion found that employing a combination of interventions was most effective at reducing HCV transmission among IDU (24,25,32,(35)(36)(37)(38)(39)(40)(41) before the onset of cirrhosis (fibrosis stage F0-F3) have fewer long term HCV-related complications than those who achieve sustained virologic response (SVR) after the onset of cirrhosis (fibrosis stage F4) (2,4).Early intervention has been found to be effective not only in preventing progression of liver disease but also in stopping the spread of infection in communities.

Next steps
Based on the success of Saskatchewan's STBBI Know Your Status approach, expansion of similar community-designed and culturally appropriate programs to other FNs reserves across Saskatchewan will help to improve treatment and stop transmission of HCV.This could have the added benefit of improving surveillance information and providing good outcome data.
Partnerships between on and off reserve programs are needed to optimize care and provide outreach support and awareness campaigns across various national and provincial jurisdictions.It will be important to address attitudes that may interfere with the prevention, treatment and care activities, and to reduce HCVand HIV-related stigma and discrimination across the spectrum of services.
Due to the alarmingly high levels of HCV in prison inmates, particularly in the FNs inmates, targeted HCV initiatives by and for FNs inmates are needed in Saskatchewan.The FNs HCV programs already present at the community level could be linked to care in prisons.Interventions targeting modifiable risk factors, such as substance use, smoking, proper adherence to antiretroviral therapy and timely provision of HCV therapy could substantially reduce complications and lower death rates.
Further research is needed to evaluate the extent and the determinants associated with HCV infection, obtain population-based estimates of HCV prevalence and incidence in the Saskatchewan FNs population, develop FN community-led programs to prevent new infection, better understand HCV infection, and implement more effective methods of addiction management in HCV-positive patients.

Conclusion
There are multiple factors associated with the high rates of HCV in FNs communities, including barriers to access preventive services, early diagnosis and treatment.These access issues predominantly relate to remoteness, transportation, education and awareness and a health care system designed around urban health.Instigation of new and innovative ways of delivering information and services, such as the mobile hepatitis C clinic and the community-driven STBBI Know Your Status model of care, are proving invaluable in remote FNs communities.Extending these programs to other FNs communities and to the prison population, which often has a disproportionately high population of both FNs individuals and HCV-infected individuals, could prove to be invaluable in addressing HCV infection and helping Canada meet the global goal of HCV elimination.

Figure 1 :Abbreviation
Figure 1: Saskatchewan hepatitis C rates in First Nations on reserves, by region, 2012 to 2016