Webinar: Reducing hepatitis C transmission

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Jessica Helwig: Okay, I think everyone's been let in, so we'll get started. Hello and welcome. My name is Jessica Helwig and I am the senior policy analyst with the public health agency of Canada in our knowledge mobilization and stakeholder engagement team. 

Thank you for joining the communicable disease and infection control webinar series. We are pleased to have you join us for today's webinar. While we meet today on a virtual platform, I want to begin by acknowledging that from coast to coast to coast, we each find ourselves on the unsurrendered and unceded territory of Inuit, Métis, and First Nations people.  

For myself, I am calling in from Ottawa, which is built on unsurrendered and unceded Anishinabe Algonquin territory 

I also want to recognize that viral hepatitis, like many Sexually transmitted and bloodborne infections, disproportionately impacts Indigenous communities and addressing this public health issue, both, here in our conversations today, and in our ongoing work, requires us to recognize the historical and ongoing impacts of colonization, systemic racism, and the social exclusion that have contributed to these health disparities. 

A few notes for today’s webinar. Today’s webinar includes content from those external to the Agency, which may not reflect the views of the Public Health Agency of Canada.  

Following today’s event, a copy of the presentation decks and recording, as well as a feedback form will be sent to you.  

This webinar will be conducted in English. Simultaneous interpretation in French can be accessed through selecting the Interpretation button in the menu at the bottom of your screen. Your audio has been muted to reduce noise, and video is disabled for this webinar. If you are having technical problems and need help, you can reach us through the chat function. Please feel free to communicate in either English or French. 

At the end of the presentations, we will open the floor for audience Q&A and panel discussion. At that time, if you have a question for one of our presenters, please submit it using the Q&A function. Note: you may check “send anonymously” if you do not want your name attached to your questions in the Q&A.   

I will now introduce our speakers for today’s webinar. 

Jennifer van Gennip is the Executive Director of Action Hepatitis Canada, a pan-Canadian coalition of 84 community-based organizations. Jennifer specializes in developing messaging and communications materials to support campaigns for policy or social change, and helping stakeholders discover the collective power they hold when they organize together. In addition to her work in hepatitis, she is an active advocate in the affordable housing and homelessness sector and the co-chair of the Ontario Alliance to End Homelessness.  

Jo Parker is the Program Manager at Mainline Needle Exchange in Halifax, Nova Scotia. Jo has a background in health promotion and research management. She has worked on numerous initiatives in Nova Scotia and British Columbia, with a focus on health equity, substance use and harm reduction. 

And lastly, we have Dr. Nadine Kronfli and Dr. Olivia Price. 

Today, presenting on behalf of Dr. Kronfli is Dr. Olivia Price  

Dr. Olivia Price is a post-doctoral research fellow based at the Research Institute of the McGill University Health Centre. Her research focuses on prevention on infectious diseases among key populations, including people who inject drugs and people in prison. 

With that I will turn it over to Jennifer to begin her presentation.  

Jennifer van Gennip: thank you very much. 

It's great to be here with you today on a, it's a little bit rainy here where I am, but probably a lovely July afternoon for a lot of you. So, thank you for making the time. we're very pleased to be able to speak to you about rethinking prevention and this is based on a report that Action Hepatitis Canada put out in May. 

So, Jessica already said this, so I'll keep moving, but we are all about holding governments accountable to their commitment to eliminate viral hepatitis as a public health threat by 2030. And we have already had a really nice land acknowledgement. I'm joining you today from I'm near Pictou, Nova Scotia. 

Actually, I'm usually in Ontario, but we're on our maritime tour. And so, I'm in Pictou, which is the territory of the Mi'kmaq people. So, as I said, this report came out in May and we called it rethinking viral hepatitis prevention, confronting systems that create risk. 

And this can be found on our website to understand where this report came from. it came directly out of our 2025 progress report. So, Action Hepatitis Canada writes a progress report every other year. 

This was our third one in 2025. And we just sort of report on six metrics on how all the provinces and territories and then also collectively nationally and federally how we're doing on these metrics to reach the 2030 elimination targets. One of our key takeaways in that report was that hepatitis C reducing new infections in hepatitis C remains Canada's weakest viral hepatitis elimination metric. 

So out of all of them, we're doing pretty well. We've removed a lot of barriers to treatment. but an area where we are struggling is that it's really time for provinces and actually also prisons to get serious about prevention. 

So while many provinces and the federal prison system have made great progress in removing barriers to hep C treatment, their prevention policies are often directly undermining these treatment efforts. And viral hepatitis prevention is an area where some jurisdictions are actually making policy choices that directly conf conflict with the abundance of evidence that is available to them. We like to say that curing hepatitis C is great, but not getting it in the first place is even better. 

Feels really obvious, but it apparently needs to be said. When we look at the where we are and where we're trying to go, we can see that there's a bit of a gaps. Well, there's a big gap. 

So, this chart shows newly diagnosed hep C cases per 100,000 population. So, the target for us that we're all working towards the World Health Organization target for 2030 is no more than five new cases per 100,000 population. In Canada, the the most recent national data we have is 2023. 

And so that's 19 is where we were at in 2023. But then several provinces are higher than that. Of course, Manitoba is one. 

In 2025, there were 32. And then sometimes when we dig even deeper and we look at specific public health units or public health areas we can get as high as 139. That's the highest one I've seen but up to 139. 

So we see that hep C is not distributed evenly across the country. It's definitely concentrated in specific communities. And so that hints that it's not just about people. 

It suggests that there's definitely something happening in environments that are making it easier or harder to prevent risk. So this is where we kind of got into the idea of reframing how hepatitis C risk is understood. So hep C and STBBI transmission, they certainly follow patterns in access or the lack of access to safer drug use equipment, testing, treatment, stable living environments, and culturally safe supportive care. 

And when infections con concentrate in particular communities, this is more of a reflection on how those prevention systems are working than they are about the personal choices of people. And we have a nice framework for this. the concept of risk set setting is pretty well established in the harm reduction community and it comes from a book by Dr. 

Norman Zinberg called drug set and setting from 1984. So often we get very focused on the risk part of this which is the drug or the activity itself and its potential for harm or transmission. But the set and the setting are also important. 

And so in in this the set would be the personal circumstances someone brings into a situation including their health status, their trauma history, their income stability and their own emotional well-being. And then that setting it could be the physical setting or also the social or the policy environment that an activity is in in in which that activity is taking place. So together these factors shape whether exposure becomes likely or avoidable. 

Just to put a finer point on it, when people have access to safer drug use equipment, testing, treatment, and stable places to live, transmission drops. And when they are navigating criminalization, stigma, housing instability, or fragmented services, the likelihood of exposure increases. When that focus stays on the populations that are most affected rather the env than the environments that they are being affected in the conditions that shape the hep C transmission risk can remain invisible. 

So in our report we introduced six different environments risk environments and these are not intended to be exhaustive and just like when we talk about priority populations when we talk about risk environments there's a lot of overlap. So the ones that we wanted to introduce to just get people thinking along these ideas, colonial policy environments, criminalization policy environments. so colonial policy environments would include things like mass incarceration of Indigenous People, but also trauma and the various colonial choices that have caused created trauma for people. 

Criminalization policy environments. Whenever we make something illegal and we drive it underground, it becomes inherently more dangerous. Carceral settings. 

This is the idea of abstinence based prisons and jails where maybe people can't access harm reduction equipment or perhaps opioid prescribing is not available or has the policies have changed and made it made it less available less choices available for people. health care settings that can be quite fragmented. Shelter systems again often based on abstinence can make can make it quite dangerous for people who are dependent on substances. 

And then gendered relationship environments. This gets at the idea of the gender dynamic in injection drug use where women often aren't in full control of how things are going with their drug use and are often we call it second on the needle but more likely to be injected by and after their male partner. So policy environments shape where risk concentrates. 

Institutional settings can shape how transmission occurs and those social environments shape who is most affected even within those same physical or policy spaces. Some people are more vulnerable even in those same policy or same spaces. So if we want to close the elimination gap, it will require strengthening prevention, testing, treatment and care in the environments where transmission is occurring, not just identifying the populations most affected. 

We also included a section in the report about how harm reduction is a radical act of love, compassion and justice when we spoke to people about how to talk about harm reduction in sometimes a political environment that isn't very harm reduction friendly. There was there was some advice to kind of try to water it down a little bit and make it more just talk about it as health care and a person with lived experience just stood up and said, "You know what? I don't want to water it down. 

I don't want to talk about it that way. Harm reduction is a radical act of love and we've been taking care of each other since before the government got involved and we'll be taking care of each other even if this government is no longer involved. And I thought, yeah, like that's the movement that I want to be part of. That's so much more attractive to me. 

And that is really the sentiment of the harm reduction workers that that we that we work with. And so we wanted to make sure that was captured in this report. We gave six recommendations. 

I'll just go through them quickly. The first is to strengthen and protect the community-led prevention infrastructure through sustained federal partnerships. This is mostly about multi-year funding that allows the community- based organizations to continue to have sustained relationships with people so that they can connect them with care. 

Specifically I'm going to name the community action fund and the harm reduction fund because our sector is really advocating hard right now to try to protect those funds to make sure that we're able to continue to provide these critical services. the second one is for the provincial and territorial governments making sure that harm reduction supplies and prevention services across the provincial territorial systems are consistent. So, not it's not just about being able to distribute equipment, it's also about if it's a provincially funded program for shelter or housing or community- based program, you can put minimum standards in place. 

You can require harm reduction principles to be to be in place in those programs and that is what we would love to see. Third one is about making sure that testing and treatment is in those same spaces where the prevention infrastructure is. So we're on a tour right now. 

We're in New Brunswick and Nova Scotia and just kind of see how things are going. And we're finding that here, like in some other provinces that we've definitely been in, community based groups are doing the education and the prevention and clinical groups are doing the testing and the treatment. And there is not a super clear path in between. 

And so we'd love to see those services co-located as much as possible. Drug policies can produce preventable hep C risk. So this is federal, provincial, territorial, municipal. 

We're talking about laws, bylaws, enforcement practices, and funding conditions that increase rushed or hidden drug use, restrict harm reduction, harm reduction access, interrupt care, or criminalize survival strategies. The fifth one is specific to carceral settings. We've already kind of talked about that. 

But I do actually want to highlight discharge planning as part of that because it's also about that transition back to the community. We find a lot of times the risk is actually in the transition between institutions or different settings as well. And then the sixth one is just our regular ask all the time for a hep B vaccination through universal birth dose programs and adult catch-up access. 

Most of this report is focused on hep C because for hep B we have a vaccine. So the ask it's not a whole report. It's just please vaccinate please offer the vaccine to everyone in a timely way and that way we'll be able to prevent and eliminate hep. 

So the report is out now and it's on our website and thank you very much.  

Jo Parker: Hey everybody. this is Jo Parker from Mainline Needle Exchange in Halifax. 

I'm here today to talk about one of our kind of practical solutions that we have implemented to help with prevention of hep C as well as other infections here in Nova Scotia. Next slide. So mainline we're a harm reduction program based in Halifax, Nova Scotia. 

We were founded in 1992 and we are a program of the Mi’kmaq Native Friendship Center here which is a pretty big center in Nova Scotia with over 200 employees. our core funding comes from Nova Scotia Health and Wellness and we're pretty small agency. We've have 11 staff currently. 

Almost all of our staff are people with lived experience of substance use. Most are in substance use recovery. and we also have many opportunities beyond our staff positions for peers. 

So that would be current and former clients, many of whom are still using drugs, others who are, you know, in recovery but not ready for a staff role. We have a lot of opportunities for them to be involved in outreach, in needle cleanup, in helping with different projects.  

Next slide. 

So our main functions are supporting safer drug use. So we distribute supplies for safer injecting, safer smoking, and safer sex. we distribute this directly to clients on outreach and at our office. 

As well as through distribution partners like shelters and housing programs.  

Next slide.  

And then the flip side of that of course is supporting safe disposal of used needles which is a big task. 

So last year we distributed about 2.2 million needles and syringes and we collected about 2 million returns for safe disposal. So we maintain a number of mailboxes and smaller mounted bins out in the community. we collect used needles from clients on outreach and from the shelters and from the housing programs as well as having many peers and staff engaged in cleaning up needles that are found out in community. 

So we do proactive searches 7 days a week in all of the known hotspots and then we respond to calls from the public when needles are found on the ground or you know in public washrooms, things like that.  

Next slide.  

We also try to kind of care about our people and wrap around and do as much to help them with other needs as we can. 

We support people to access housing. we help people get on income assistance, help them with financial advocacy. For example, we file income taxes here. 

Last year, we filed just over a thousand people's income taxes, which I'm sure many people know is a real important step for people accessing benefits like income assistance, housing subsidies, and things like that. we help people to access health care. We partner with the local street nurses and we do a lot of advocacy in in the hospital as well as in community. 

We also do legal system navigation. we help we do courthouse support and we have a free phone line from the provincial and federal institutions so people can call us from jail. we do a lot in the space of trying to help people navigate the legal system. 

And we also offer training to other organizations on harm reduction on the toxic drug supply. We do peer support training. a lot of topics we cover. 

All right, next slide.  

So, we try to get around. people find us here. 

Our office is open 365 days a year, holidays, snowstorms, we're always open. we do central outreach 6 days a week in Halifax and just across the harbor in Dartmouth. And we do provincial outreach one day a week to southwestern Nova Scotia. 

We also have a peer walkabout which is like an outreach program where two current clients go with a backpack full of supplies and connect with people out around the city. We do a weekly outreach with the street nurses that are through MOSH and as I mentioned the courthouse outreach and then finally the brown bag program which is what I'm here to talk to you about today.  

Next slide. 

So the brown bag program came about really as a result of the area that we serve. So in Nova Scotia, there are four health management zones and we are tasked with covering two of them. So looking at the map, mainline covers central zone and western zone. 

It's a pretty big area to cover and there are a lot of small towns and communities along the way. So, I just added this line as one example that from Halifax to Yarmouth is 300 km. of course, we're not driving straight there because we're stopping in every small town along the way to see clients and to see distribution partners. 

So it's a huge area to cover and really impossible to go more than once every few weeks to each community. which means that access to our supplies is limited in most of those small towns. as well as access outside of our hours. 

So in the western zone, we might only see people every 3 or four weeks. but even in Halifax, our office is closed at night and that's of course people are still using drugs and still needing clean supplies in the evenings. and a final kind of challenge we were dealing with is that pharmacies were really not seen as safe and supportive spaces. 

So we heard repeatedly from clients they faced a lot of stigma in buying syringes at pharmacies or asking for support there. and were seen as maybe not being like good customers. So, they felt quite unwelcome. 

They would try to dress their best or pretend that they had diabetes or do kind of strategies like that to access a pharmacy, but it was certainly not a comfortable environment. Next slide. So the brown bag program started very organically but basically it is a partnership with pharmacies around the province to increase access to clean injection supplies. 

So we deliver brown bags with the sterile supplies in them to participating and they distribute them to clients. So this is an opt-in program for pharmacies. They're not required to, but many pharmacies do choose to take part. 

And of course, we only work with the ones in central zone and western zone.  

Next slide.  

So, here's what's in a bag. 

There's a picture of one of the brown bags opened up. So, it's got 10 needles. We make up boxes of short tips and long tips, 10 filters, 10 alcohol swabs, two cookers, which is like a single use disposable spoon, four pods of sterile water and one tourniquet.  

Next slide. 

So the program is pretty simple in terms of the mechanics of it. We here at the office mainline staff assemble the bags. They put all the items in the bags and they box them up into boxes of 20 bags per box. 

We deliver the boxes to pharmacies. Anyone can go into the pharmacy and ask for a brown bag at the counter. So, it's free and it's meant to be no questions asked. 

So, if people just say, "Can I have a bag of short or can I have a bag of long and the pharmacist will give them a bag and then the idea is they call us when they're running low." So, we're not constantly checking on inventory at all these pharmacies. Some, in particular, ones that are very remote, a box might last them months. Others we go twice a week to drop off more boxes. 

Next slide.  

So the program has grown you know it started probably in 2015 or 2016 was when we started working with pharmacies this way. initially this was driven as with all harm reduction by the people by the clients people who are using drugs. 

They saw the need for access to supplies after hours and in small communities. They talked about the challenges at the pharmacies. and we started having conversations with pharmacies and some of them wanted to help and so it started quite informally that we would bring some supplies to pharmacies and they would help by giving them out. 

Around 2017 it became a little more formal. We did have a endorsement from Nova Scotia Public Health. They sent a letter to the pharmacy association encouraging them to encourage this among their member pharmacies. 

And so PANS put out the word to pharmacies that kind of this was a good role for them to play in you know improving public health and improving access and it also spread by word of mouth. So clients do now go to pharmacies and ask for brown bags and sometimes if it's not a participating pharmacy they may tell them about it and then the pharmacy may call us to get on board.  

Next slide. 

So today we have over 120 participating sites across 45 communities. We maintain a list of where people can go on our website and we have really simple promotional materials we hand out to pharmacies. Some stores opt in and then later decide that it's not a good fit for their store which we're okay with because if they're not comfortable doing it then we don't want to send our clients there because it won't be comfortable for the clients either. 

So if they say they want out we say okay thanks and that's over. and we also think that it's really important for promoting the visible role for pharmacists in harm reduction and sending a message that they can be part of that community of care.  

Next slide. 

It is a simple program but not without its challenges. So the biggest one being the vole and workload. we have staff making bags and boxing them up every day, every day of the year. 

It's a huge role as you can imagine that we're putting together. So, it's a lot of workload, a lot of resources go into it. There is some product wastage because not every person would use every item in the bag and it's just standardized. 

So, some things we know get thrown out. and there's costs. We pay for the bags and we pay for the boxes. 

And there's a trade-off. We know that there is much better access especially in these small communities which is so important but we do find we miss the connection directly with clients. So in some communities people come to rely on the pharmacy they go to the pharmacy every week instead of seeing our outreach. 

So we kind of lose that you know frequent contact with people and then we miss out on the opportunity to help them with other things. I think that's the end. 

Thanks everyone. 

Olivia Price: Hi everyone. I'm Olivia based at the McGill University Health Center. and as Jessica mentioned, I'm speaking today on behalf of Dr. Nadine Kronfli. which are big shoes to fill, but I'll do my best. so today we're talking about safer environments to reduce hepatitis C transmission. 

So I want to start by highlighting why prisons are an important setting to consider. So injecting drug use is a key transmission pathway for hepatitis C. and due to the criminalization of drug use, there's an over representation of people who inject drugs in carceral settings. 

And this is estimated to be about 50 times higher among people in prison than in the general population. And although we know that entering prison is associated with a decrease in frequency of injecting drug use, the risk of hepatitis C transmission per injecting episode is much higher in prisons compared to the community due to limited or no access to sterile injecting equipment. and the importance of providing services in prison that reduce hepatitis C transmission is underpinned by the Nelson Mandela rules which state that people in prison should have access to the same standard of health care that's available to them in the community. 

So, the Canadian prison system is comprised of federal and provincial prisons. And federal prisons hold individuals serving sentences of at least 2 years. And that's what I'm going to be focusing on in today's presentation. 

And it's Correctional Service Canada that's responsible for health services in federal prisons. and here I just want to highlight the over representation of Indigenous people and people who inject drugs. and I also want to highlight that these disparities are particularly pronounced among women. 

So you'll see that about half of women who are incarcerated are Indigenous and about one-third have a history of injecting drug use. And so in the Canadian federal prisons, it's estimated that about one in five people have a history of exposure to the hepatitis C virus which is 20 times higher than in the general population. So it's quite a huge disparity. 

And again you'll see the disparity here by gender with women disproportionately affected with about one in three women with a history of hepatitis C exposure versus about one in five men likely reflecting the increase of the prevalence of injecting drug use among women who are incarcerated. And so there are three sort of key aspects to hepatitis C prevention in the Canadian federal prison system. And the first one is treatment as prevention which aims to reduce hepatitis C transmission by treating people with an active infection which thereby reduces the number of people who can transmit the virus to others. 

And this relies on active case finding through opt out treatment opt- out testing sorry upon admission which was introduced by CSC in 2025 and follows best practice guidelines and then linkage to treatment following diagnosis. but we know from modeling studies that treatment as prevention alone is insufficient to completely prevent hepatitis C transmission in prisons. And so the second pillar is the prison needle exchange program or PNEP. 

And Canada is one of only 10 countries in the world with a prison needle exchange program. they were introduced in 2018 to nine of the 43 federal prisons. and this was expanded to a further five over the last few years. 

And there's currently no planned no plans for further expansion. and the third pillar is opioid agonist treatment which is the most effective treatment for opioid dependence and is available in all federal prisons with people who enter on OAT already continued on treatment within 24 hours on admission. and I guess what I want to highlight here is that none of these interventions is sufficient on its own to prevent hepatitis C transmission, but Canada is quite uniquely positioned globally to eliminate hepatitis C in prisons with one of the most comprehensive harm reduction packages. 

And over the next few slides, I'm going to highlight some challenges in the current sort of status, but I want to emphasize that the infrastructure is there. It's just about making these programs work as effectively as possible. All right. 

So, where are we currently at with the prison needle exchange program? historically, there's been very low participation. It's estimated that less than 10% of people who inject drugs access the program. 

And participation in the program requires a threat risk assessment or TRA, which is a process unique to the Canadian system and not required in any other countries with prison needle exchange programs. And the TRA involves answering three questions that sort of speak to security risk and then requires there's a requirement for approval from multiple people in the prison. So correctional managers and assistant wardens and this can create a bit of a long turnaround time sometimes in the order of weeks which is problematic when someone is waiting to access sterile injecting equipment. 

We don't currently have clear metrics in place to measure the success of the program. So in community settings for NSPs will often measure reach. So how many people who inject drugs access the program and then coverage so how many syringes are distributed per person per year which are important measures of whether the program is actually meeting the need for sterile equipment. 

And we've done some work to understand what the barriers to participation to this program are, to understand why participation is so low and found that they exist sort of across like a spectrum of levels from individual and program level barriers up to institutional factors. and I guess I think across different stakeholder groups in different prisons, the most commonly cited barriers were was confidentiality. so which has been identified as a major issue internationally and in some settings this has contributed to the closure of prison needle exchange programs. 

But together these different barriers create an implementation gap. So we have a program that we know is effective in reducing hep C transmission but it's not effective or as effective as it could be if only 10% of people who inject drugs are using it. So, we received CIHR funding to do a five-year implementation trial, with the goal to reduce barriers and improve uptake of the prison needle exchange program. 

And this involves all of the nine original sites with the PNEP program with each study with each site, sorry, receiving the implementation intervention at different time points. So over two years we've had we over two years we have these monthly coaching calls with each prisons where they're coached to do a plan do study act or PDSA cycle which involves making a small process change each month and then they come back the next month and they look at objective data to evaluate how well that worked. and something I want to highlight here is that they are coached about what to do but not told what changes to make. 

And this is important because the teams that we work with, they know the prisons better than we do. They know the barriers. and for these changes to be sustainable going forward, they need to sort of own them and drive them. 

But the external coaching brings sort of a new lens to habits and systems that might be entrenched. And this is an effectiveness implementation trial. And what that means is the goal is to understand whether these tools can improve the effectiveness of the Peanut program which we define as participation in the program while also evaluating or describing how these different strategies work in in practice. 

And I know that all sounds very abstract. So I'm now going to give you some examples of what those process changes look like. So we're about halfway through the trial at the moment. 

And so I just want to highlight yeah some of the changes that the teams have made. So firstly to increase awareness of the prison needle exchange program teams have introduced touch points at key moments including at admission and OAT induction just to ensure that everyone has the opportunity to learn about the existence of the program and consider whether they want to apply for it. And then some teams have then gone sort of a step further and introduced more targeted approaches to reach people who may benefit from the program. 

So one prison is using chart reviews to identify people with a history of substance use disorder and then proactively going to them and asking them if they would like to enroll in the program. and the teams have also focused on reducing the time it takes to be approved to use the program. so one team found that the emails sort of on that ladder of the approval chain were getting lost and so they introduced quite a simple change where they changed the subject line of the email to say PNEP and then the person's name and they found that this just sped up the approval process along the way. 

And another team opted to stop using the internal mail system in the prison and physically walk the application along this sort of ladder of approvers to speed up the process. And you'll note that these are all like relatively simple changes to existing processes, but these changes once a month over 24 months really do have the potential to make a meaningful difference to the people being able to access the program. and so I want to briefly now talk about a recent policy change to OAT medicine availability in federal prisons. 

And previously people could act people could access sublingual so like a film under the tongue or long acting injectable buprenorphine with methadone available as a second line option. but since October of last year, long acting injectable bup has become the only firstline treatment. And CSC introduced this change with a goal of improving continuity of care after release, reducing overdose risk and reducing diversion of BUP in prisons. 

But the evidence that long- acting injectable buprenorphine improves retention is mixed and reducing choice in oat medicine may actually create barriers for people who don't find this formulation suitable. So, this is a relatively recent change and just something that we're following quite closely because lower retention on OAT does have implications for not only hep C transmission but also for overdose risk and reincarceration. And just more broadly speaking, ensuring that people have access to an OAT formulation that works for them is an important part of establishing retention in in treatment and engagement. 

And I also just want to quickly talk about another recent policy change which I think is quite a positive step forward. So CD585 was introduced in March this year and it recognizes substance use as a health issue and that drug related stigma creates barriers to accessing care. And so as part of this new guideline, people are screened for substance use disorder at intake and referred to health services if deemed necessary. 

And during incarceration, if a random urine tox screen is positive, they are now referred to health services rather than a disciplinary action. and although drug trafficking and diversion are still operational issues, this does represent a shift towards treating substance use as a health issue rather than a corrections issue. and I think that this this could also have a positive effect on people accessing the prison needle exchange program. 

So I'll just finish up now with some key lessons learned and future directions. so treatment as prevention, prison needle exchange program and OAT together represent a comprehensive package of interventions needed to support hep C elimination in prisons. And the introduction of this new CD585 does represent an important shift in how we treat substance use disorder in prisons and hopefully does signal a broader move towards a health focused approach to substance use. 

There are some opportunities for improvement here. We need to systematically be collecting data so that we can measure progress towards hep C elimination as well as syringe coverage and reach of the prison needle exchange program. And we also really need to be monitoring OAT retention given this policy change. 

There's a need to continue to expand access to PNEP through opening it at sort of expanding it to new prisons and ensuring that people in the prisons where they're available have the best access to them. and finally, there's a need to reconsider the recent OAT policy change and restore patient choice to maximize treatment retention. but as I said earlier, I think while there are some opportunities for improvement, there have been some promising developments that we can build on to move towards hep C elimination in Canadian federal prisons and be leaders in this space globally. 

And so I'll leave my presentation there.  

Thank you.  

Jessica: Thanks, Olivia. 

And thank you to all of our presenters. I found it so incredibly valuable to learn about the broader factors that are driving hepatitis C transmission and then the harm reduction efforts underway to confront the system at risk. I'm also pleased to say that Dr. Nadine Kronfli, associate professor in the division of infectious disease at McGill University has joined and will be participating with us for the rest of the webinar. I can see the questions already rolling in.  

So without further delay, let's move over to the Q&A portion of our webinar. 

A reminder to our audience members that you can submit your questions to our presenters using the Q&A function located at the bottom of your screen in the Zoom toolbar. To get us started off, I have a question for you, Jo. First, just a terminology question. 

Can you define what a what people mean when they say what is a short versus long?  

And I think that was in in regards to the bags.  

Jo: Yeah. Those are just the two most common sizes of insulin syringes. So the that we give out here at the office, the long tip is a half inch tip and the short tip is 5/16 of an inch. 

So they're not that different. It's really personal preference. Perfect. 

Jessica: And maybe since you're already that talking, I'll get you to keep going and I'll ask if you have any thoughts on what could be done to make pharmacies more welcoming if you are a pharmacist. what is something you can do to ensure that you are creating a safe space for people who are looking to access supplies?  

Jo: I think that kind of emulating what we do here in the office, we have a no questions asked approach. 

So when people come in for the first time or even the 20th time if it seems like the vibe, we don't ask their name. We don't ask, you know, too many we don't push too much help on them. We don't ask too many things. 

What do you need this for? Where do you stay? what do you we kind of just hi how are you and what can I get for you we hand it to them have a great day and I think that that is just a little less threatening when people are being asked all kinds of questions sometimes there's a lot of paranoia and people may feel uncomfortable so we like that the pharmacies are supposed to do this of course it's hard to police how they're actually interacting with clients but we just have to have some trust that if they want to take part in the program they are going to be cool and just not ask too many questions, not too pushy. 

And then I think, you know, we have made some posters and some pharmacies we've have asked for them and want to hang a poster that says we participate in Mainline's brown bag program. You know, please ask if you want injecting supplies. Others don't really want to advertise it. 

And again, we want pharmacies to do this who really are interested in participating and helping people. So if they don't want to hang a poster that's okay. I think we ask the pharmacies to please refer people to us for other supports. 

So of course there are some other things. Some pharmacies now are more involved in primary care. They may be able to do some kind of simple testing and things like that. 

We leave the medical piece to them but we only provide injecting supplies. So if people are asking for smoking supplies or asking for a large quantity, we ask the pharmacies please like tell them that mainline comes down this way every few weeks and you know they're really nice so give them a call. They deliver. 

So that's kind of the main thing is we try to connect through the link to us as obviously they must be not too bad if they want to take part in the brown bag program.  

Jessica: Thanks Jo. I I'm just wondering and I see a couple questions in the in the chat about this as well. Is there support provided to the pharmacists in order to kind of guide how they should respond whether it be a sort of training or recommendations any resources provided to them on how to be the best supporting actor? And then I guess to read the question more specifically what about non-pharmacist staff assistants, technicians, cash registers are they included in that as well?  

Jo: So we do try to keep it pretty simple and don't over complicate things. 

So when a new pharmacy signs up we will just explain to them that it's meant to be no questions asked free of charge and giving people you know one to two bags a day. We have certainly had to manage this in the last year in particular. Some pharmacies that say, "Oh, I've got a guy who comes every day and gets a whole box” and we're like, No, it took us half hour to make that box. 

Like, just we'll deliver. We'll bring him what he really needs. We can bring him 500 syringes if he wants. so just trying to kind of remind them that it's like a small quantity, quick interaction. 

It can be the text or the pharmacy. Anybody can give it out. it just it happens at the pharmacy counter. 

So I am assuming that if somebody asked the cashier they would say oh you got to go back to the counter. but we don't really do much training. I think if anyone has concerns we have had some pharmacies like I mentioned in the presentation that wanted to pull out you know saying things like they thought it was contributing to shoplifting or bringing the wrong kind of people into our store. 

And so we were happy to see those stores go.  

Jessica: Great. Thanks, Jo. 

I'll give you a bit of a break and I'll shift over to you, Jennifer. I think this is a conversation that you've probably had before, but do you see the shift from focusing on people who are at risk to environments at risk having an impact on how hepatitis C and stigma is perpetuated? 

Jennifer: Yes, and thank you for the question because I didn't really talk about this. 

So thank you. There were a few goals that we had with this and definitely one of them was just from a communications perspective. It's an opportunity to address stigma. 

When we talk about party populations or risk populations, it's really useful for targeted interventions, but as a as public messaging, it's kind of done maybe a little bit of harm to be honest because it can be quite stigmatizing. Jessica and I have talked about this before. our jobs are to educate people about the priority populations and reduce stigma and those two those two jobs collide quite a bit. 

So part of the idea is to reduce stigma and then part of it is to shift the responsibility more appropriately onto systems. Sometimes when we try to reduce stigma and shift the responsibility off of individuals, we talk about social determinants of health, but social determinants of health can feel like weather patterns, like they just happen and you can't do anything about it. But when we shift it onto systems, it makes it really quite a bit more obvious who's responsible or what systems are responsible. 

But even within that, it helps take some of the some of the responsibility off of the individuals into the in the systems like off of the frontline shelter providers or off of the nurses working in corrections and put it back onto the decision makers and the policy makers in those systems.  

Jessica: Thanks, Jennifer. Yes, I think that's such an important perspective to have on this. 

Jumping over to both Nadine and Olivia, I'd be curious to hear your thoughts on opportunities for connection to care throughout the various programs that you touched on and what are some of the most successful features that help bridge that gap that you've seen?  

Olivia: I guess I think within the prison system, so for people who are using drugs in prison, the prison needle exchange program when it's accessible can act as a really good link to other services. That's what we see in the community. 

and as can OAT and we actually try and use people, we kind of you try to use those touch points to increase engagement in in the opposing one. So we try and use people the OAT appointments for people who are accessing that program to increase access to the prison needle exchange program. and it also does sort of allow for conversations about bloodborne viruses and other STI and testing for those sort of ongoing. 

Everyone is tested on admission to federal prison. but it can hopefully lead to conversations about ongoing risk based testing. through those services. 

Nadine, anything else to add?  

Nadine Kronfli: No, I think you've covered it well. I would say that through our Nexus study, we've learned about additional touch points that we didn't realize existed, but do exist as gateways to care. 

And that's at the time of OAT induction daily dispensation of OAT followup with the ID nurses. All of these moments in time are great opportunities where individuals have one-on-one time with people in health care and allow for opportunities for further engagement in various services that can assist them with their with their drug use.  

Jessica: Great. 

Thanks, Nadine.  

Jo, I'm going to go back to you and I think there's clearly some program evaluation experts in our audience today because they're wondering how you evaluate the brown bag program. Obviously, you'll have number of bags given out, but if it's a no questions asked, you're not collecting metrics. 

How are you able to deem the program as a as a success? What do you use to quantify that?  

Jo: I would say we are not evaluating the brown bag program. 

It is I think the success obviously the uptake is the biggest indicator and the pharmacies that are participating like they're re-uping. So to us it's working people are accessing supplies through those locations and if the pharmacies are calling again then they feel like this role is acceptable to them. So I realize that's a not an evaluation answer, but we have we haven't done a formal like program evaluation of this. 

It is actually hard to tease out the numbers just the way that our database is set up because we have close to 300 distribution partners and so only like less than half of them are pharmacies, but we also work with all of these you know shelters and housing programs and outreach teams and all these other things. and it's just tough the way our software that we're required to use by the province doesn't differentiate between which ones are pharmacies and which ones aren't. So really we just kind of are keeping tabs on the vole we need weekly to you know in like the days the weeks that we go to the Annapolis Valley for example the van is packed to the roof with brown bags because the pharmacies there go through really high volume. 

Ones here in the city like there's one just a few blocks away. We go up there twice a week to drop off a few more boxes. So that's the success for us is obviously people are accessing it and that that access didn't exist prior to this program. 

So definitely great opportunity for any evaluators out there who want to reach out.  

Jessica: thanks Jo and I think that's a great reminder that you know program evaluation is one element but does not necessarily a sole indicator. I think communities know what work and they just they do what works for them. 

Jennifer I think we have time for one last question. so I'm going to go to you and say the report that you mentioned emphasizes that HCV transmission reflects system performance not individual choices. what frameworks do you use to quantify how much transmission is attributed to these structural factors versus individual behaviors? 

Jennifer: Yeah, that's a great question. so originally the report was designed kind of as a communications tool like a messaging. and very quickly we started getting questions like what would success metrics look like in reducing or in reducing risk or in changing the risk level in environments which hadn't even honestly occurred to us when we wrote it but is a fabulous next step. 

So that is certainly the another phase that we would love to explore. I mean, I don't know how you measure how much of it is an individual's choice to be that is outside of the scope of my expertise, but I'd love to be able to explore that conversation further for sure.  

Jessica: Thanks, Jennifer and thanks to everyone who joined us for today. We are at time. So I do want to say once again a special thank you to Jennifer, Jo, Nadine, and Olivia for their time and insights. 

As a reminder to our audience, you will receive an email following this session with a recording, a copy of the slides, and a short feedback form. We really value your input as it informs our future webinars. On behalf of the Public Health Agency of Canada, thank you again for participating. We look forward to seeing you at future sessions. So, take care and enjoy the rest of your day.