From October 14-16, 1998, the Laboratory Centre for Disease Control, Health Canada, held a national consensus conference in Ottawa: Hepatitis C - Prevention and Control: A Public Health Consensus. The aim was to review progress in addressing the public health recommendations of a 1994 conference, examine the present state of public health knowledge and action on
hepatitis C virus (HCV) infection, and update the previous public health recommendations as necessary.

Participants were assigned to one of six working groups: surveillance; public health interventions; public health laboratory
issues; injection drug user issues; education; and blood supply issues. Several important recommendations were as follows.

. . .

Injection Drug User Issues

     Hepatitis C prevention programs should adhere to the harm reduction model as a health promotion strategy.

     A federal-provincial advisory committee should be created to ensure the implementation of a hepatitis C national action
     plan on injection drug user (IDU) issues; where there is significant overlap of issues, other bloodborne infectious diseases
     often found among drug users should also be addressed by the committee.

     Drug users themselves must be included at all levels of discussion and intervention. This involves the creation, provision
     of resources for and continuing support of drug user groups at federal/provincial/territorial and local levels.

     Since HCV infection is acquired very rapidly after initiation into injection drug use, prevention efforts should target above
     all (but not exclusively) new injection drug users and those who are contemplating injecting.

Recommendations

. . .

4.Injection Drug User Issues Working Group

HCV is more easily transmitted through the percutaneous/parenteral route than is HIV, and infection is acquired earlier after initiation of injection drug use. Prevention efforts should therefore target above all (but not exclusively) new IDUs and those who are contemplating injection. Minute amounts of blood may be sufficient to transmit hepatitis C, so the risk associated with sharing of drug equipment such as spoons, pipes and straws, or with tattooing and body piercing may be higher than that for HIV. On the other hand, many HIV prevention strategies (e.g. needle exchange programs) will also help to prevent hepatitis C.

At the social and legal level, improving the attitudes of the public towards IDUs and treating drug use as a health issue rather than a criminal issue may contribute to the prevention of both HCV and HIV infection. Some of the current legislation on drug use may have the effect of preventing access to services.

The harm reduction model should be used as the basis for hepatitis C prevention programs. The guiding principle of this model is to minimize harm. The model may include strategies to prevent initiation of injection drug use and to enhance safe injection among those who are injecting, and may emphasize detoxification and rehabilitation services. Abstinence could be one goal, but it is not necessary and should never be a condition of access to services. The harm reduction model is a humanistic and pragmatic approach that precludes repressive interventions.

A healthy public policy is necessary to support a strong national hepatitis C prevention strategy. Coordination between the main stakeholders - public health, police, mental health, drug user services - is necessary at the federal and provincial/territorial level and locally in order to ensure a coherent strategy. Issues related to drug use are better handled by the health care and social services system than by the criminal justice system, and, in line with this, reallocation of funding would provide the means for comprehensive programming.

The HIV, AIDS and Injection Drug Use National Action Plan⁽⁶⁾ is endorsed but, given the specific characteristics of hepatitis C, additional interventions are needed. Implementation of a comprehensive program, including multiple strategies for these measures, is not possible without adequate funding.

Recommendations

4.1 Hepatitis C prevention programs should adhere to the harm reduction model as a health promotion strategy.

4.2 A federal-provincial advisory committee should be created to ensure the implementation of a hepatitis C national action plan on IDU issues.

4.3 Where there is significant overlap of issues, other bloodborne infectious diseases often found among drug users should also be addressed by the committee.

4.4 Drug users themselves must be included at all levels of discussion and intervention. This involves the creation, provision of resources for and continuing support of drug user groups at federal/provincial/ territorial and local levels.

Preventing transmission - individual level

4.5 Awareness about hepatitis C should be increased through dissemination of information, education, and communication targeting drugs users and those at high risk of initiating injection.

4.6 Outreach services directed to recently initiated injectors (through peer educator groups or outreach workers) should be increased.

4.7 Drug users and those at risk of initiating injection should be educated about alternatives to injection and about safe injection practices.

4.8 There should be increased access to drug abuse treatment, including a wide range of substitution treatments and low threshold interventions (Interventions that are user friendly and accessible without any specific conditions attached, such as abstinence or the promise to be abstinent.).  Substitution can also be considered a means of preventing initiation of injection, but more research is needed.

4.9 Physicians, nurses, social workers, school educators, and other appropriate workers, including outreach workers, should be trained to identify and offer early intervention to youth contemplating injection drug use.

Preventing transmission - community level

4.10 Drug education programs should be updated to include accurate and complete information so that youth can make informed decisions.

4.11 Drug education and funding should primarily have a health focus. Cooperation between community policing, drug user groups, and the social agencies is vital to the success of the hepatitis C prevention and control program.

4.12 Community prevention programs need to be based on a comprehensive harm reduction model and should include needle exchange; safe injection sites; access to sterile drug use paraphernalia; greater access to detoxification and rehabilitation services, particularly for minors and young adults; well-coordinated and integrated health care and social services; user advocacy groups; lifeskills programs; and low threshold substitution therapy.

4.13 Measures, including regulatory measures, should be taken to ensure that personal services (e.g. tattooing, body piercing, acupuncture) are delivered safely.

4.14 Preventive measures available in the community should be available in the prison setting.

Preventing transmission - family/networks

4.15 Medical and social services should be available to support families in difficulty and parents of young drug users.

4.16 Interventions targeting drug user social networks should be implemented to promote modes of use other than injection.

Preventing transmission - social/legal

4.17 Since social isolation and exclusion can increase the risk of hepatitis C, interventions to increase the general public understanding about drug use and drug users should be developed and implemented.

4.18 In recognition that some current legislation may contribute to the spread of hepatitis C and other bloodborne pathogens and present barriers to health action, and in support of the HIV/AIDS National Action Plan recommendations, it is proposed that the Minister of Health establish a national committee to review current drug laws and develop a plan to implement necessary changes.

Keeping infected IDUs “healthy”

4.19 Screening IDUs for hepatitis C provides an opportunity for counselling, treatment and other medical interventions and should be part of a comprehensive program based in settings providing services adapted to drug users.

4.20 All HCV-infected people, including IDUs, should be considered eligible for assessment and treatment. Compliance issues should be addressed on an individual level as with other diseases or populations.

Research

4.21 Research should be carried out in the following areas:

• the determinants of initiation into injection drug use
• the determinants of drug use reduction and cessation
• the possibility of a link between nonmedical injected steroid use and hepatitis C
• the role of substitution therapy (e.g.methadone) in preventing initiation of injection
• the optimal methods of delivering health care services to IDUs with hepatitis C
• the value of counselling, testing and the consequences of positive or negative test results on IDU behaviours
• the determinants and practices associated with HCV infection
• monitoring of the evolution of the HCV epidemic with respect to prevention programs
• the role of intranasal or inhalation drug use in the spread of hepatitis C infection
• feasibility studies, and process and implementation evaluation studies on specific strategies such as needle exchange programs in correctional settings and community safe injection sites

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