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Certain communities are more at risk of exposure to hepatitis C. This is due to certain practices within these communities but also the result of socio-economic factors, discrimination, stigmatization and barriers to services (notably prevention and healthcare). According to a study in British Columbia, new HCV infections are particularly prevalent among people co-infected with HIV and HBV, socio-economically marginalized communities, and people living with mental health problems and addictions.1
People who use drugs
PWUD (People who use drugs, injectable and non-injectable) have the highest prevalence rate for HCV. Worldwide, 39.2% of people who used drugs this year are living with HCV and 8.5% of all people with HCV are people who inject drugs (PWID).2
In Canada, PWID represents 80% of people living with HCV. The prevalence rate of HCV among PWID is 70% and 82.4% among PWID living with HIV.
According to simulation exercises, 70-80% of new HCV infections are among PWID.3
Indigenous peoples (First Nations, Inuit and Métis)
Despite data limitations, available data indicate that the prevalence of HCV is five times higher among indigenous people than the rest of the Canadian population.4
This overrepresentation is due to numerous factors including racism, colonialism, intergenerational trauma and systemic abuse that increase the risk of exposure to HCV for indigenous people. This problem is compounded by other issues of governance and access to healthcare and harm-reduction services.
Gay and bisexual men who have sex with men (GBMSM)
Gay and bisexual men who have sex with men (GBMSM) are an emerging priority because HCV, which is generally not contracted through sexual contact, is becoming more prevalent in this population. It is estimated that 5% of GBMSM are or have been infected with HCV.
The probable risk factors of transmission are sexual contact and drug use, especially in the context of chemsex.
Since 2000, an increase in the rate of HCV among GBMSM living with HIV has been observed, likely due in large part to exposure to infected blood during sexual relations.5
It should also be noted that new cases are appearing among GBMSM who are on PrEP. The emergence of HIV-prevention strategies such as PrEP and Undetectable = Untransmittable [u=u] as well as a lack of knowledge and understanding about HCV may contribute to this increase among GBMSM.6
GBMSM, particularly those living with HIV, are increasingly experiencing reinfection with HCV after being rid of the virus.7–8
People who are/were incarcerated
Incarcerated people are 40 times more at risk of exposure to HCV than the general Canadian population. More than 50% of the Canadian prison population have previously used drugs. Further, more than 75% of PWID in Canada have had previous experiences of incarceration, which puts this population at the highest prevalence for HCV of all detained people. The lack of access to safe materials for tattooing, piercing or drug injection forces many people to reuse non-sterile material.
Continuing anti-HCV care after liberation from prison is a major problem faced by correctional systems worldwide.9 In Quebec, for example, incarcerated people lose their drug insurance when their incarceration begins, which can create an immense barrier for treatment after their incarceration is finished.
Immigrants and newcomers from countries where HCV is endemic
Immigrants and newcomers from countries where HCV is endemic represent approximately 35% of the total number of cases of current or previous hepatitis C infections in Canada. In the countries where HCV is endemic, it is primarily transmitted via unsafe medical or dental practices (transfusions or reusing non-sterile instruments). HCV screening is not part of the health checkup requirements for Immigration Canada. It is recommended depending on country of origin, but there is no information currently available on the practical application of this recommendation. Though voluntary screening after arriving in Canada is among the national recommendations, access to healthcare services for immigrants and newcomers can be very complicated. Racism, stigmatization, and language or cultural barriers can be major obstacles in access to healthcare, and even more so for people whose immigration status is precarious.10
One study surveying data collected from 1990 to 2018 indicates that for immigrants in Quebec, the median amount of time to get a hepatitis C diagnosis was 7.1 years after arrival, 12.4 for a decompensated cirrhosis diagnosis and 14.8 years for a hepatocellular carcinoma diagnosis. After arriving in Canada, 17.8 years is the median life expectancy of immigrants who die of a hepatic related disease.
People born between 1945 and 1975
The highest prevalence of HCV affects the cohort of people born between 1945 and 1975. They constitute between 66-75% of the total number of people living with HCV in Canada. These people living with HCV are five times more at risk of developing complications (cirrhosis, cancer, premature death) than the general population of Canada. Many people born between 1945 and 1975 have not been tested for HCV. 98% of liver transplants are for people aged 40 years and older. Most cases of HCV among people in this cohort are related to medical/hospital procedures before 1992 or to past drug-use involving injection.11
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