Hepatitis C virus (HCV) infects the liver. Once HCV becomes established in this organ it causes inflammation. Over a period of years, this leads to increasing dysfunction and liver injury. If left untreated, HCV-related liver damage leads to poor health and serious complications, including liver failure, liver cancer and in some cases death. The risk for developing such complications is greater among people who are co-infected with both HIV and HCV.
In high-income countries such as Canada, Australia, the United States and Western Europe, screening of the blood supply has virtually eliminated transmission of HCV via blood transfusions. In these countries, HCV is now usually transmitted in the following ways:
- sharing contaminated equipment for substance use (including needles, crack pipes, straws and rolled-up currency bills)
- exposure to unsterilized equipment used for tattooing and piercing
- among HIV-positive people, particularly men who have sex with men – having unprotected anal sex, sharing sex toys and not changing condoms and gloves between partners
The Public Health Agency of Canada estimates that HCV infections are several times more common among Aboriginal people compared to non-Aboriginal people. Young Aboriginal people are at particularly high risk for HCV. Most new HCV infections among Aboriginal people appear to be caused by sharing contaminated equipment for injecting street drugs.
British Columbia – a tale of two cities
Researchers in the cities of Vancouver and Prince George have been engaged in a study with young Aboriginal people called the Cedar Project. As part of this study, participants aged 14 to 30 years, most of whom live in the downtown areas of the two cities and all of whom smoke or inject street drugs are screened for eligibility. An Aboriginal study coordinator explains the purpose of the study and the procedures involved and after discussion, seeks informed consent.
Once enrolled, participants are interviewed extensively and have blood drawn for HIV and HCV testing. Nurses provide counselling both before and after testing and participants are encouraged to return to the study site for their test results. Every six months participants return to the study site for further interviews and blood tests.
The researchers found that among young people who were new to injecting street drugs, rates of HCV infection were very high. In its report, the Cedar Project team made recommendations, which, if implemented, have great potential to stop the spread of harm caused by substance use and HCV infection. Furthermore, their findings and recommendations are likely useful for community-based and public health workers who are struggling to help Aboriginal people in other parts of Canada deal with addiction and HCV infection.
The Cedar Project enrolled 605 participants. However, the HCV sub-study recruited 148 participants who were HCV negative when they entered the study and our report focusses on these people.
The average profile of the 148 participants at the start of the study was as follows:
- 47% men, 53% women
- age – 23 years
- 55% had at least one parent who had been in a residential school
- 68% had been taken from their biological parents and placed in the child welfare system
- 52% had been sexually abused
- 2% had been sexually assaulted in the past six months
- 38% had lived on the streets for more than three nights
The substance use of participants in the past six months was as follows:
- 14% had overdosed on street drugs
- 11% injected cocaine daily
- 3% injected crystal meth daily
- 18% injected opiates daily
- 13% shared syringes
- 9% reused their own syringes
- 10% found it difficult to obtain new syringes
- 26% needed help injecting street drugs
- 21% went to a drug or alcohol treatment program
- 3% were currently taking methadone
On average, participants were in the study for 2.5 years.
Among young people who were new to injecting drugs, 38% became HCV positive within the first year of the study. By the third year of the study this figure had risen to more than 50%.
Other factors linked to an increased risk for HCV infection were as follows:
- injecting drugs frequently
- sharing equipment for substance use
- having recently become involved in sex work
Unexpectedly, participants who had been injecting for many years had a relatively low risk for HCV. This may be because they survived and could enter the study while people with long-term HCV infection may have succumbed to the complications caused by this infection and were therefore unavailable to enter the study.
Bear in mind
The research team stated that they found it “shocking” that despite the presence of “established harm reduction programs,” a large proportion of young people became infected with HCV shortly after they began injecting drugs.
Recommendations - For the short-term
To stem the tide of new infections in the short-term, the Cedar Project team calls for more engagement with young Aboriginal people and the provision of these specific services for them:
- clean equipment for injecting drug users
- more addiction recovery programs
- more testing for HIV and HCV
Recommendations - For the long-term
The Cedar Project team also recognizes the need for programs to prevent people from using street drugs. To reduce the harms associated with substance use, they recommend that public health and harm reduction programs do the following:
- “Be mindful of how the past can shape the response to current and future [HCV] prevention initiatives.”
- “Nurture flexible, trust-based relationships that seek to build upon young Aboriginal people’s resiliency in the face of intergenerational and lifetime traumas.”
- Give young people “the opportunity to provide leadership in program design intended to reflect their needs.”
- Include the perspective of young people who have learnt “how to remain safe” and avoid viral infections from injecting drugs.
The Cedar Project researchers caution that many factors interact with each other to create the situations in Vancouver and Prince George that place young Aboriginal people at risk for injecting drugs and viral infections. They stressed that the following factors “must be acknowledged”:
- the impact of colonization and residential schools
- the impact of racialized care
- generations of mistrust of both provincial and federal authorities
Engaging in sex work was also significantly linked to an increased risk for acquiring HCV infection. The Cedar Project team notes that other studies in British Columbia have found that “impoverished Aboriginal women involved in sex work and [the use of street drugs] continue to be exposed to alarming levels of drug-related harm, infectious disease and violent predation.”
They call for intensifying services “aimed at reducing drug- or sex-related harm for young Aboriginal women, particularly in Northern and remote communities.”
The findings from the Cedar Project, while disturbing, are valuable. They provide the evidence for the urgently needed expansion of services for Aboriginal people who inject street drugs to first reduce harm and then to help them transition to a drug-free and healthier future. Such services should be culturally appropriate and include psychosocial support.
The Cedar Project’s findings and recommendations are likely applicable to other Aboriginal people, not only in other parts of Canada but perhaps Australia and other countries where Aboriginal people face similar issues.
- Sean R. Hosein
- Spittal PM, Pearce ME, Chavoshi N, et al. The Cedar Project: high incidence of HCV infections in a longitudinal study of young Aboriginal people who use drugs in two Canadian cities. BioMed Central Public Health. 2012; in press.
- Schmidt AJ, Rockstroh JK, Vogel M, et al. Trouble with bleeding: risk factors for acute hepatitis C among HIV-positive gay men from Germany - a case-control study. PLoS One. 2011 Mar 8;6(3):e17781.