Spotlight Series on Hepatitis C

East Toronto Program Successfully Helps Some Marginalized People Recover From Hepatitis C Virus

September 27, 2012

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In high-income countries such as Canada, Australia, the United States and Western Europe, screening of the blood supply has virtually eliminated transmission of hepatitis C virus (HCV) via blood transfusions. In these countries, HCV is now mostly transmitted in the following ways:

  • sharing contaminated equipment for substance use (including needles, crack pipes, straws and rolled-up currency notes)
  • 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 reusing condoms and gloves

Some people use street drugs in an attempt to relieve psychological distress and suffering. Unfortunately, this can lead to a downward spiral into addiction and psychosocial problems and it also exposes users to viruses and other germs. One commonly used street drug is a more potent and highly addictive form of cocaine called crack. Usually crack is smoked, though it can also be injected.

Although most programs to help substance users recover from addiction and HCV infection focus on people who inject heroin and other chemically related compounds, few studies have documented successful recovery from HCV among crack users.

Researchers and community-based workers have been collaborating in a program funded by the Ontario Ministry of Health and Long-Term Care to help marginalized crack users cope with multiple diagnoses and improve their access to HCV treatment and mental health and social services. They hoped that making these services accessible would help crack users stabilize their health and begin to recover from addiction. The program has been successful and may be a useful model for other communities trying to help crack users on the road to healthier living.

A Broad Program


The East Toronto Hepatitis C Program (ETHCP) has at its core a blend of health care providers and community support workers. In this program, treatment of HCV is centred on weekly educational support group meetings at community-based clinics that are facilitated by a case manager and program coordinator. Each meeting lasts for about two hours and each group, consisting of 20 people, gathers for four months. At each weekly meeting a different HCV-related topic is discussed.

Prior to, during and after each weekly meeting, a multidisciplinary team meets with individual participants. Team members include the following:

  • family physician
  • nurse
  • nurse practitioner
  • infectious disease specialist
  • psychiatrist

This team assesses participants and provides the necessary care and treatment on site. At the health centre clients are helped with gaining access to social and health-related services.

Study Details

The ETHCP team reviewed health-related information that they collected between March 2007 and July 2010 for a study of the program.

The average profile of 129 HCV-positive participants when they enrolled was as follows:

  • 71% men, 29% women
  • age: 48 years
  • 96% were unemployed
  • 65% had stable housing
  • 6% were HIV positive
  • one participant was also infected with hepatitis B virus (HBV)

Risk factors for HCV infection included the following:

  • history of injecting street drugs: 87%
  • history of using crack cocaine: 85%
  • history of being imprisoned: 74%
  • history of being tattooed: 57%
  • having an HCV-positive sexual partner: 33%
  • having part of their body pierced: 19%
  • having unprotected sex with other men: 5%

Mental Health

Many participants also had mental and emotional health issues, such as these:

  • 30% of participants were taking medicines for anxiety, depression or schizophrenia
  • 25% had previously been hospitalized because of attempted suicide

Commonly used substances when participants entered the study were as follows:

  • crack: 45%
  • marijuana: 43%
  • alcohol: 34%
  • injection street drugs: 8%

HCV Treatment

During the study period, the standard of care for HCV consisted of a combination of two drugs:

  • once-weekly injection of a long-lasting form of interferon-alpha called peginterferon
  • twice-daily doses of the nucleoside analogue ribavirin

The duration of treatment depended on a number of factors but could last for anywhere between 24 and 48 weeks.

Prior to the study, only 24 participants (19%) had been referred to and evaluated by a liver specialist. Of these 24, only seven were offered treatment and only four elected to initiate therapy. Of all of these participants, only one was able to complete his course of therapy.

However, once in the ETHCP, 95% (123 of 129 people) agreed to have further evaluation of their liver disease and overall health. Of these 123 people, 24 participants were able to meet the criteria set by the provincial Ministry of Health to receive subsidized HCV treatment. Only three of these 24 participants missed one or more doses of peginterferon. One of the 24 participants died because of an overdose of street drugs.

Eleven of the 24 participants had strains or sub-types of HCV called genotypes 2 and 3. These genotypes respond relatively well to treatment, and 10 of the 11 participants were cured.

Genotypes 1 and 4 tend to respond less well to therapy, and seven of the remaining 13 participants who had these genotypes and who received treatment were cured in the ETHCP study.

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This article was provided by Canadian AIDS Treatment Information Exchange. Visit CATIE's Web site to find out more about their activities, publications and services.

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