RECAP-PING Volume 1, September 2020


Welcome to RECAP-PING the first quarterly RECAP newsletter! In September, December, March and June each year this newsletter will update you on what has been going on with RECAP, introduce interesting local, national and international research and news on harm reduction and hepatitis C, and highlight how we are working toward achieving our vision of a 'Health equitable world without hepatitis C'.

In this Issue

  • A bit of history on RECAP
  • Who are our patients?
  • The COVID-19 effect on harm reduction and hepatitis C elimination
  • Adding to the knowledge: recently published research on harm reduction and hepatitis C


In the spring of 2014, our little not-for-profit hepatitis C focused clinic for at-risk populations quietly opened thanks to the generous donation of space from Prince Edward Guardian on Prince Edward Street - right in the heart of Waterloo Village in Saint John New Brunswick.

At the time, a tiny two room clinic - no advertisements and no fanfare - but by the end of 2014, 73 patients, by the end of 2015, 258 patients served and fast-forwarding to September 2020 - almost 1,200 patients served.

It's mission? To bring interdisciplinary, stigma-free holistic care for hepatitis C and all of its associated issues to the people most at risk - people who use substances.

“Fairness does not mean everyone gets the same. Fairness means everyone gets what they need.” - Rick Riordan

We aim to care for their physical health, mental health, and be advocates and guides to help them in access community programs to support them and their families to:

  • address and assist with food insecurity
  • secure and improve stable and safe housing
  • open up education and employment opportunities

Who do we serve?

Our patients are diverse and come from all backgrounds, with varying level of needs and engagement. What is common to all of them? They will receive the care at RECAP that is best for them based on their individual circumstances. This may mean treating their hepatitis C, providing opiate agonist therapy, offering counselling, assisting in managing individual and family social support needs, providing primary care, giving wound care, training to use Naloxone, educating on harm reduction practices that may help them stay safer and healthier - or some or all of the above.

Some quick stats on visits:

  • In 5 1/2 months (Mar. 31-Sept. 18, 2020): 1109 attended appointments (65% in clinic, 29% by phone, 6% outreach)
  • 265 difference health issues management/addressed in appointments - average of 2 issues per appointment.
  • Average of 12-14 visits per day (non-COVID times)
"I am not treated like a worthless junkie, or a number. I am listened to. It is not a one-size-fits-all clinic. They have made accommodation for me as the dosing schedule was leaving gaps in my pain relief. They were empathetic and did all they could to help me....If it wasn't for RECAP I don't know where I would be....I firmly believe RECAP and the ladies who give it life, saved mine. Mine and hundreds of others who are not "worthless junkies". My story could just have easily been yours, your mom's, your sister's or your children." - 40-year old RECAP patient.

Some demographics of our patients (derived from a cohort of 42% of our patients in our research database taken at or near their initial visit):

  • Average 40 years-old overall (36 years for women, 42 years for men)
  • 65 % male
  • 26% live in rural areas
  • 29% have no primary care provider
  • 58% have children, 26% have custody of one or more of their children, 22% report having Child Protective Services involvement in the past year
  • 13% have unstable housing or no housing
  • 59% report income < $25,000 per year
  • 32% do not have easy access to reliable transportation
  • 28% report experiencing regular food insecurity
  • 36% do not have a high school diploma/GED
  • 32% report a history of one or more types of abuse
  • 39% report injection drug use in the past 12 months
  • 20% have a family history of hepatitis C infection
  • 66% have a family history of addiction
  • 69% are hepatitis C positive
  • 41% report a 'Fair' or 'Poor' quality of life
  • 27% report that their life is somewhat or much worse than a year ago
“I have been on methadone since 2004 but was never able to stop using drugs. I have never gotten the care I got from RECAP. They go above and beyond to help people regardless of their past or present. They don’t just give medical care, they give a family feel. They saved my life and my kids’ lives. I’ve been clean for two years.” - M. 33 years old, Saint John

The COVID-19 effect on harm reduction and hepatitis C elimination

"The COVID-19 pandemic has had an impact on all stages of the hepatitis C cascade of care and has resulted in reduced access to critical medical services. While controlling the transmission of SARS-CoV-2 is a necessary public-health priority, it is crucial to consider the direct and indirect harms to affected populations in our communities. Not only does the reduction in care directly hamper progress toward the elimination of hepatitis C, but the increased isolation experienced by priority populations may exacerbate the already substantial harms they face, including stigma and discrimination, overdose risk, co-morbidities, precarious housing, poverty and domestic violence." ~ Evan Cunningham and Charlotte Laniece Delaunay

The Impact of COVID-19 on hepatitis elimination (The Lancet Gastroenterology and Hepatology, Volume 5, Issue 9)

Survey sent out to members of the World Hepatitis Alliance - a group of over 300 members across 99 countries in March 30-April 4, 2020.

Responses from 132 civil society organizations and frontline hepatitis providers - 94% reported interruption of services due to COVID-19.

Only 36% reported that people have continued access to testing for viral hepatitis.

Travel restrictions/lockdowns, avoidance of healthcare facilities, closure of organizations, and redeployment of staff were all reported as common reasons that treatment for viral hepatitis was limited.

Overwhelmingly, civil society organizations - experts in the communities they serve - had little to no role in community response to COVID-19.

The impact of COVID-19 on global hepatitis C elimination (Journal of Hepatology, August 6, 2020)

Looked at the impact of a "1-year delay" scenario - a pause in screening, diagnosis and treatment efforts toward the United Nations Sustainable Development Goal of hepatitis elimination by 2030. In this scenario, between 2020 and 2030 it is expected that:

  • 906,000 new diagnoses will be missed in this decade
  • 746,000 fewer hepatitis C treatments will be initiated
  • 121,000 new infections
  • 44,800 excess hepatocellular carcinoma (a form of liver cancer) cases
  • 72,300 excess liver-related deaths predicted

Impacts of the COVID-19 Pandemic on People Who Use Substances: What We Heard (Canadian Centre for Substance Use and Addiction)

Small Canadian qualitative study of people with lived experience on the impact of COVID-19 on their mental and physical well-being. The most noted issues included:

  • Lifestyle, working and living situation not conducive to being able to follow public health recommendations leading to increased fear and emotional distress.
  • Closure of so many community organizations and other places of gathering (restaurants, cafes, libraries, etc.) leading to increased social isolation and a greater amount of time to reflect on their lives and past traumatic events.
  • For those street-involved, their ability to survive has been challenged by loss of income from the informal economy (collecting spare change or recycling, sex work) lack of access to public spaces, and increased security/police presence to enforce physical distancing rules.
  • Conflicting messaging on drug use from a strong emphasis on not using alone to a now strong emphasis on meeting physical distancing requirements that can only be met by using alone.
  • Changes in the drug supply due to interrupted supply lines affecting quality, degree of contamination, and cost.
  • The move to telephone or online health services is not sufficient to serve a large portion of this at-risk population and a drastic reduction in outreach support and walk-in services.
A sample of news headlines from around the world related to COVID's impact on substance use

Adding to the knowledge: recently published research on harm reduction and hepatitis C

Canadian Publications

A cohort study of evaluating the association between concurrent mental disorders, mortality, morbidity, and continuous treatment retention for patients on opioid agonist treatment (OAT) across Ontario, Canada, using administrative health data

55,924 individuals enrolled in opioid agonist treatment - 87% with concurrent mental disorders

Concurrent mental disorders related to:

  • 1.4 times higher all-cause mortality
  • 2.25 times higher rate of emergency department visits
  • no association found with OAT treatment retention at 1-year

Long-term pre-treatment opioid use trajectories in relation to opioid agonist therapy outcomes among people who use drugs in a Canadian setting

464 individuals in Vancouver, BC at OAT initiation between 2005 and 2018

Two substance use trajectories in the 3 years before OAT initiation found:

  • gradually increasing frequency (47.0%)
  • high frequency user (53.0%)

High frequency users were noted to have a significantly higher OAT engagement and lower ongoing opioid use. The same association was not found in those with gradually increasing frequency.

Unstable housing, stimulant use, experiencing violence, sex work involvement and incarceration were independently associated with ongoing opioid use.

International Research

HaRePo (harm reduction by post): an innovative and effective harm reduction programme for people who use drugs using e-mail, telephone, and post service

Program founded in 2011 in France targeted at people who use drugs (PWUD) who have difficulty accessing harm reduction resources. The most common reasons for using HaRePo are:

  • Distance issues
  • Issues with local harm reduction centers
  • Anonymity/stigma issues

The program can be accessed 24/7 by telephone or e-mail with harm reduction professionals available provide harm reduction counselling, help individuals access other services they may need and identify the type and quantity of supplies they need shipped to them

Harm reduction supplies are safely and confidentially packaged and shipped by post to the individual - average of 48 hours to receive the supplies. Package also contains harm reduction education materials specific to the individual's needs

HaReBo has served over 2,000 PWUD and shipped over 10,000 harm reduction supply parcels containing 1.7-million syringes and more than 6-million harm reduction-related items.

Decreased tool re-use and sharing of all types of drug paraphernalia reported by users.

44-80% of HaRePo users consider their drug-related practices safer

39-53% reported an improvement in their physical state (venous condition, point of injection, swelling of extremities)

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