Why Shift From Risk Populations to Risk Environments?
While science has opened the door to eliminating viral hepatitis, infrastructure determines who gets to walk through it.
In Canada, hepatitis C continues to disproportionately affect people who use drugs, particularly those navigating unstable housing, criminalization, and other systemic barriers to care. These patterns are not solely indicative of individual behaviour; they are a direct reflection of environments that either offer or deny access to prevention, treatment, support, and care.
When the focus stays on populations rather than environments, the conditions that shape HCV transmission risk can remain invisible.
Closing the elimination gap will require strengthening prevention, testing, treatment, and care in the environments where transmission is occurring, not just identifying the populations most affected.
While science has opened the door to eliminating viral hepatitis, infrastructure determines who gets to walk through it.
In Canada, hepatitis C continues to disproportionately affect people who use drugs, particularly those navigating unstable housing, criminalization, and other systemic barriers to care. These patterns are not solely indicative of individual behaviour; they are a direct reflection of environments that either offer or deny access to prevention, treatment, support, and care.
When the focus stays on populations rather than environments, the conditions that shape HCV transmission risk can remain invisible.
Closing the elimination gap will require strengthening prevention, testing, treatment, and care in the environments where transmission is occurring, not just identifying the populations most affected.
The HCV Elimination Gap
- Canada has made meaningful progress on several elimination targets through expanded access to curative HCV treatment and improved testing, reflecting our collective efforts toward elimination.
- However, a key metric for ending viral hepatitis as a public health threat — new cases — remains off track.
- While many provinces and the federal prison system have made great progress in removing barriers to HCV treatment, several have recently repealed prevention policies, undermining these efforts.
Importantly, rates of hepatitis C transmission are not evenly distributed across Canada.
Where HCV Risk Is Produced
- In Canada, approximately 85% of new HCV infections occur through sharing or reuse of drug-use equipment.
- This statistic is often used to describe who is at risk, but it is more useful for understanding where prevention systems are failing people.
- Research increasingly shows that HCV risk is shaped not only by individual behaviours but by broader economic, social, and policy environments that influence access to safer drug use equipment, healthcare, and stable living conditions.
- Reinfection is part of this same picture. When HCV continues to circulate within a community environment, people can be exposed again even after successful treatment.
- HCV transmission does not occur randomly. It follows predictable patterns based on the infrastructure of prevention tools, healthcare access or lack thereof, and social supports.
- Sociologist Dr. Tim Rhodes expanded on Dr. Zinberg's idea about how risk, set, and setting affect health. He showed that the risk of getting HCV is influenced by various social, physical, economic, and policy factors, which impact how easily people can access prevention and treatment options.
- Across Canada, several policy, institutional, and social environments consistently shape whether exposure is more likely or less likely, and where prevention, testing, and treatment can have the greatest impact.
- The six environments described in the report are not intended to be an exhaustive list of settings in which HCV transmission risk can emerge. Instead, they identify several key settings where prevention systems shape access to safer equipment, testing, and treatment. In practice, these environments frequently overlap, and broader structural forces, including racism and poverty, influence how risk is produced across multiple settings at once.
- Importantly, across these environments, the highest-risk moments are often points of transition: arrest, release, hospital discharge, shelter entry or exit, treatment intake or discharge, housing loss, or movement between communities. Prevention infrastructure must therefore be designed around continuity, not just program availability.
Recommendations
We are making 6 policy recommendations:
- Strengthen and protect community-led prevention infrastructure through sustained federal partnerships. Targeted, multi-year investments through Indigenous Services Canada and the Public Health Agency of Canada are needed to support Indigenous-led and community-based HCV (and other STBBI) prevention initiatives in regions with the highest transmission rates. Protecting the Community Action Fund and Harm Reduction Fund will sustain trusted outreach relationships, improve early testing and treatment connections, and reduce pressure on acute care and crisis-response systems.
- Ensure consistent access to harm reduction supplies and prevention services across provincial and territorial systems. Provincial and territorial governments play a central role in shaping the environments where HCV transmission occurs. Funding agreements for shelters, supportive housing, health services, and community programs should include harm reduction principles and minimum service standards, including access to safer-use supplies, testing pathways, and treatment connections. Consistent access to evidence-based prevention tools is essential to reducing HCV and other STBBI transmission.
- Align testing and treatment scale-up with prevention infrastructure in high-transmission environments. Public investments in testing and treatment should be routinely paired with prevention supports where transmission continues to circulate through social or service networks. Program models should combine testing access, rapid treatment linkage, safer-use supplies, and ongoing care connections to reduce reinfection risk and transmission.
- Reform drug policies that produce preventable HCV risk. Federal, provincial, territorial, and municipal governments should review and reform laws, bylaws, enforcement practices, and funding conditions that increase rushed or hidden drug use, restrict harm reduction access, interrupt care, or criminalize survival strategies. Drug policy reform should be treated as viral hepatitis prevention, not a separate issue.
- Strengthen viral hepatitis prevention and care within carceral settings and during transition back to community. Federal, provincial, and territorial correctional systems should implement minimum standards for evidence-based opioid agonist therapy, safer-use supply access, testing, treatment, and vaccination coverage. Discharge planning should include confirmed linkage to community health care, medication continuity, and prevention supports. Public reporting on access and outcomes would accelerate progress and accountability.
- Expand HBV vaccination through universal birth-dose programs and adult catch-up access. Provincial and territorial governments should implement universal birth-dose or infant vaccination schedules where not already in place, and expand catch-up access for adolescents and adults who missed earlier immunization. Integrating vaccination into prenatal care, primary care, pharmacy programs, newcomer health services, and corrections intake would accelerate gains and reduce the risk of future transmission.
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