It takes a village - and more
When Middlesex London Health Unit (MLHU) officials recently sounded the alarm about staggering increases in HIV and hepatitis C in the city, they were responding to concerns brought to light by infectious disease specialists at St. Joseph's and London Health Sciences Centre (LHSC).
The citywide infectious diseases team including Dr. Kaveri Gupta and Dr. Michael Silverman (pictured) noticed the disturbing trend. At the same time palliative care specialist Dr. Sharon Koivu pointed out an increase in infective endocarditis (infection of the heart valves.) The group began to review why this was happening, how the hospitals could respond, and alerted the MLHU.
The MLHU began compiling data in February 2016 and consulted provincial and national experts as part of its investigation. Provincially, HIV rates went from 7.4 cases to 5.5 cases per 100,000 in the last 10 years while local rates have gone from 5.9 cases per 100,000 in 2005 to 9.0 per 100,000 last year, the MLHU found. For hepatitis C, the local rates have climbed from 32.2 cases per 100,000 in 2005 to 53.7 cases per 100,000 in 2015. The figures for infective endocarditis suggest a fourfold rise, and the incidence of invasive Group A streptococcal disease are also cause for concern.
Calling it a local public health emergency, the MLHU has recommended a reallocation of health unit resources to address this issue, a new outreach approach, and a field epidemiologist be assigned by Public Health Agency of Canada to assist in finding solutions.
"There appears to be four simultaneous infectious problems that are occurring in our local injection drug user population, which is a very vulnerable group that suffers from poverty, unstable housing and drug addiction," says Dr. Silverman, Chair/Chief, Infectious Diseases and Medical Director of the Infectious Diseases Care Program at St. Joseph’s Hospital. "It's a community outbreak that is a huge burden to the hospitals."
Working collaboratively with partner organizations, Dr. Silverman's team has several initiatives in place to address the problem:
- St. Joseph's provides outreach services in partnership with the London InterCommunity Health Centre (LIHC), where Dr. Silverman and Dr. Gupta, along with the LIHC nursing and social work staff, see HIV and hepatitis C patients who may otherwise have difficulty accessing care.
- In a novel collaboration, Dr. Silverman and Dr. Gupta provide consult services to an LIHC-staffed street outreach team of nurses, a nurse practitioner and community outreach workers. The physicians review cases and advise on medical care for those with HIV and hepatitis C.
- St. Joseph's has a peer mentor program to provide support to individuals living with or at risk of HIV infection. The plan is to expand the number of peer mentors and collaborate with other HIV peer mentor programs in the city.
- Research is underway in the lab to better understand how drug using techniques are contributing to infective endocarditis.
- At LHSC, Dr. Koivu is looking at improved opioid replacement therapy approaches for people who are admitted to hospital so that they avoid withdrawal and can complete hospital treatment. Helping patients work on their long term addiction issues is also a major focus of her work.
- A new infectious disease specialist, Dr. Lise Bondy, has joined the team at St. Joseph’s Hospital to help with increased volumes of HIV and hepatitis C.
The rising rates of infection "is a very serious concern," says Dr. Silverman. "There is high morbidity and mortality associated with what's going on. More than one quarter of people with injection drug-associated endocarditis will die in the short term."
For those with HIV, "treatment allows people to live long, healthy lives but it's very difficult to treat HIV when the individual is also battling addiction and dealing with homelessness and poverty," adds Dr. Silverman. "Untreated, HIV is infectious and it's lethal."
Hepatitis C treatment also transforms lives. “It's curative but it's extremely expensive and it's important that people are stable so that they can complete the treatment,” says Dr. Silverman.
Injection drug addiction leads to a lifetime of suffering and it takes more than a village to address the issues, says Dr. Silverman.
"People tend to blame those who get into this situation but there are many reasons for it. These people are suffering. It's not for us to judge. It's for us to have compassion and to help find solutions."
By the numbers
- 600 – the number of individuals with HIV that the St. Joseph’s Infectious Diseases Care Program team is currently providing care to, either through partnership outreach initiatives or at St. Joseph’s Hospital. Of those, nearly 200 are injection drug users.
- 350 – the number of people with hepatitis C the team provides care to through outreach or at the hospital.