28 July 2022
The third World Indigenous Peoples’ Conference on Viral Hepatitis (WIPCVH) was held online from June 22-23, 2022. Chaired by Dr. Alexandra King (Nipissing First Nation, Ontario, Canada), the conference featured keynote speeches by Cree Senator Mary Jane McCallum on the impacts of Indian Residential Schools on contemporary Indigenous health and Prof. Bev Lawton on Māori health inequities in the context of viral hepatitis.
Over the two-day program, Indigenous people, including those with lived and living experience of viral hepatitis, Elders, Knowledge Holders, clinicians, researchers and policymakers gathered online to discuss the impact of viral hepatitis on Indigenous peoples throughout the world, to highlight issues and effect change. The conference showcased innovative and highly impactful research and provided an opportunity to come together to share, learn and address the disproportionate effect of viral hepatitis on Indigenous peoples. Here are some of our favourite sessions and key takeaways from the event.
Reducing structural disparities and barriers to care
Prof. Bev Lawton from Aotearoa (New Zealand), presented the Keynote Lecture, ‘Eliminating Hepatitis? Chasing Equity’, along with Dr. Lisa Edmonds and Elders Charlie Lambert and Matthew Bennett. The goal of the keynote presentation, as described by Matthew Bennett was to look at the issue of hepatitis from two perspectives, one from the clinical viewpoint and then to look at how this issue could be addressed from an Indigenous viewpoint within the tribal collectives of the Indigenous people of Aotearoa.
Prof. Lawton discussed the WHO Elimination goals in the context of the opportunities it presents for the elimination of viral hepatitis. In Aotearoa a hepatitis C (HCV) action plan was developed in 2021; however, there are marked disparities for Māori, the Indigenous people of Aotearoa. There are an estimated 45,000 people living with HCV, 40% being unaware of living with the virus; there are also an estimated 93,000 living with chronic hepatitis B (HBV)- the rate of infection 10 times greater for Māori than for European peoples. Māori people are over-represented in advanced liver cancer due to HBV or HCV, making up 45% and 23% respectively.
Intervention points along the continuum provide opportunities to approach and reduce disparities. Both personal and systemic barriers were discussed as needing to be addressed in order to do so, as was the need for greater recognition of the important role a person’s environment plays. Places of care and education for children, sporting activities at different levels as places for health promotion and knowledge transfer, and viral hepatitis champions within tribal groups were all noted as opportunities to reduce health disparities.
Linkage to care
Addressing linkage to care within a cultural context from an early point was highlighted as of key importance. The Te Tiriti settlement was provided as an opportunity in the context of more direct contact with the health system and the health authorities.
Whānau Ora, a culturally based approach to well-being puts whānau (family) at the core of decision-making. Having the family as the centre of treatment as opposed to the hospital, the equipment or the specialist was described as an opportunity to support and increase culturally safe linkage to care- meeting people where they are at along the care continuum.
Human papillomavirus (HPV) was provided as a good practice example of health promotion within Aotearoa, as opportunities for self-testing as well as outreach campaigns empower the community to engage with testing where they are at, of particular advantage in regional or remote areas where access to metropolitical hospitals is difficult. Empowering the community with information and involving Māori people from the beginning of policy development to enable ownership, were highlighted as key principles to reduce disparities and structural barriers and increase linkage to care.
The conference included a series of Breakout Sessions to enable a deeper dive into certain topics related to viral hepatitis and Indigenous peoples. These breakout sessions can be found here; and below are some of our key takeaways.
Unique care models are required to address gaps in OAT and HCV/HIV service provision in on-reserve and rural communities
In Breakout Session B, Jolene Blocka from Indigenous Services Canada and Big River First Nation in Saskatchewan, Canada, and Dr. Stuart Skinner from Wellness Wheel and the University of Saskatchewan presented on the topic of ‘Community Delivered HCV Treatment through the Expansion of a Suboxone Program in Big River First Nation, Saskatchewan, Canada’. A variety of barriers to accessing drug treatment and HCV/HIV services were outlined, including transportation challenges, time spent and lack of culturally responsive care.
To address these challenges, the Know Your Status Program, established in 2011, grew to include expanded phlebotomy, mental health support, harm reduction and clinics in the community. The program was further expanded in 2016 to include an addiction specialist to start a suboxone program. The program is a nurse-led model delivered from the community health centre with support from specialists, addresses food security and provides daily observed therapy from Monday to Friday. HCV treatment initiation at Big River First Nation began in 2016. From 2016-2020, 47 clients were prescribed HCV treatment with approximately 70% of those who initiated treatment being on Opioid Substitution Therapy at one point.
The team concluded that trusting relationships with a nursing staff built over time, as well as text messaging services, helped to improve treatment adherence and yielded a high proportion of clients who completed treatment.
ECHO programs can effectively integrate evidence-based HCV treatment with holistic culturally appropriate care
In Breakout Session C, Dr. Ashley Worth from Northwest Portland Area Indian Health Board and Oregon Health and Science University presented an evaluation of ‘Treatment Recommendation Characteristics of HCV ECHO Telemedicine Services Serving American Indian/Alaska Native Patients’. In this study, Dr Worth demonstrated how in the US, rates of new chronic HCV infections are increasing, with American Indian and Alaskan Native (AIAN) persons disproportionately affected. Barriers to HCV treatment for AIAN persons include the cost of treatment, lack of access to specialists, distance from referral facilities and access to transportation.
To address these barriers, in 2017, the Northwest Portland Area Indian Health Board established its first Extensions for Community Healthcare Outcomes (ECHO) program to treat HCV, under the name Indian Country ECHO. The ECHO model connects academic medical centre specialists with primary care clinicians over a video conferencing network. The Indian Country ECHO trains clinicians to provide high-quality care and connects them to a learning community of peers and experts. The results of the analysis undertaken through a categorization of treatment recommendations indicate that from 853 new case forms (776 new and 77 re-presented), 93% of cases received treatment recommendations to treat HCV. Most patients presented were able to be treated by their referring clinician with only 3% receiving recommendations for referral to a specialist.
The analysis found the ECHO provided holistic and comprehensive recommendations, with 56% of cases receiving prevention-based treatment recommendations.
Overall, the study found that ECHO treatment recommendations were multidisciplinary, and most patients were able to be treated by their primary health care provider.
Care should be offered in a culturally connected environment where wellness is not only considered in the physical sense but on spiritual, emotional and cultural aspects as well
On the second day of the Conference, in Breakout Session D, INHSU was thrilled to be given the opportunity to present our film Ahtahkakoop as part of our Connecting with Care film series. The Connecting with Care films are an advocacy campaign developed by INHSU in collaboration with local organisations. The short films use powerful storytelling to profile innovative models of care for HCV elimination among people who use drugs.
The film, produced by storyteller Conor Ashleigh, is set in Ahtahkakoop Cree Nation, an Indigenous community located in the northern Canadian province of Saskatchewan and profiles the ‘Know Your Status’ project, pioneered by the Ahtahkakoop Health Centre. The film includes perspectives from different groups engaged with the project, ensuring that the experience of the affected community is central. The program offers care in a culturally connected environment where community-based knowledge is respected, and an understanding that wellness is not just physical, but based on spiritual, emotional and cultural aspects as well. From 2016 until late 2019, Know Your Status has successfully treated 488 people for HCV by bringing treatment and care as close to home as possible.
Throughout both days of this powerful and moving conference, we learned how viral hepatitis impacts Indigenous peoples throughout the world at much higher-than-average rates, harming their physical, spiritual, emotional, social and economic health. The result of the lasting impacts of colonialism, inadequate access to immunization and treatment, and lethargy on the part of governments, we see the effects of disproportionate health outcomes and the enduring challenges to accessing culturally safe care. Through personal stories from those with lived and living experience, the latest evidence-based research as well as dance, song, music and movement, the conference provided an important forum to reduce disparities and enhance health outcomes for Indigenous peoples globally.