The Ontario Hepatitis C Elimination Roadmap

Eliminating hepatitis C as a public health threat in Ontario is within our grasp.
Read on to learn how we can put Ontario on the road to hepatitis C elimination.

Download the full English Roadmap Télécharger la version intégrale de La Feuille de route


Hepatitis C virus (HCV) is the first curable chronic viral infection.1 With widespread testing, an effective cure and proven prevention strategies, eliminating HCV as a public health threat is within our grasp.

More than 110,000 Ontarians are living with HCV,2 which is one of the leading causes of death and illness from an infectious disease in Canada.3 4 5 Cure prevents liver injury and advanced liver disease, and it reduces the risk of liver failure and liver cancer even for those with advanced disease. Cure for HCV can also improve a person’s overall health and quality of life.6

The World Health Organization (WHO) has set global targets to eliminate HCV as a public health threat by 2030 and Canada has committed to meeting this goal.7

What is the Ontario Hepatitis C Elimination Roadmap?

Building on a national HCV elimination strategy, the Roadmap brings together advice and insights from more than 130 individuals collected over dozens of consultation sessions to generate specific recommendations to achieve HCV elimination in Ontario. These include clinicians, service providers, researchers, public health professionals and individuals with lived and living experience.

See who was involved in the development of the Roadmap

The recommendations are separated into three parts:

  • Part 1: Enabling Policy and Health System Change outlines how Ontario can set the stage to implement the recommendations from this Roadmap
  • Part 2: Seven priorities to put Ontario on the road to elimination includes high-impact strategies that Ontario must adopt to achieve elimination
  • Part 3: Population-Specific Recommendations outlines specific recommendations based on the needs of the priority populations who experience the greatest burden of HCV in the province

Part 1:
Enabling policy and health system change

HCV elimination is within reach and would be a historic public health achievement. Ontario is one of the few Canadian provinces not on track to eliminate HCV by 2030. Accelerating elimination efforts to meet this target would save up to $114.5 million in healthcare costs by preventing long-term liver disease, including cirrhosis and liver cancer.8

Implementing the recommendations from the Roadmap requires collective action, but the provincial health system has a central role in supporting policy and system changes to prioritize investment and resourcing to help people connect to care.

To reach elimination at the provincial level, we must commit to:

  • elevating HCV as a provincial priority
  • building and maintaining an implementation coalition
  • improving capacity for data and monitoring

Elevating HCV as a provincial priority

To reach elimination, the province’s health system must take a coordinated approach to HCV elimination. This includes buy-in and action from provincial health agencies, and leadership from key government actors.

Summary of recommendations

Government and health system leaders need to prioritize HCV elimination, including public endorsement. This includes inclusion of HCV as part of a provincial cancer prevention strategy, funding agreements for healthcare organizations and buy-in from public health units and Ontario Health Teams.

To see the full list of recommendations in this section, read the full report.

Ontario elimination steering committee: Building a coalition to eliminate HCV

The recommendations outlined in this Roadmap span multiple systems and touch every sector of healthcare. Reaching elimination by the year 2030 will require long-term commitment and coordination from many partners.

An HCV Elimination Steering Committee is proposed to lead implementation and coordination of HCV elimination activities in Ontario. The committee will be supported by a core project team, but will also include participation from government, clinicians, service providers, people with lived/living experience, researchers and public health professionals who are committed to spearheading change

Summary of recommendations

Establish a steering committee to advance elimination goals and provide overall oversight for implementation of recommendations and monitoring progress toward HCV elimination goals.

To see the full list of recommendations in this section, read the full report.

Improving capacity for data and monitoring

Available Ontario data for HCV are currently housed across several provincial bodies. A centralized source for information would be a valuable step forward to help inform health policy, program planning and research.

To achieve HCV elimination, Ontario needs a comprehensive, integrated surveillance and data framework that achieves two objectives:

  1. To support health system planning and the delivery of programs and services
  2. To help monitor our progress toward 2030 elimination goals

This would require a concerted effort to link existing databases, share data and measure new indicators that can help inform our progress toward HCV elimination. On the basis of available data, baseline metrics need to be set, including for specific populations.

Summary of recommendations

Provincial data partners (including Public Health Ontario, ICES and the Ontario Ministry of Health) should collaborate to develop evidence-based indicators, identify baseline measures and make updated data available through a centralized dashboard.

To see the full list of recommendations in this section, read the full report.

Part 2:
Seven priorities to put Ontario on the road to hepatitis C elimination

The following seven priorities outline key areas for action on HCV elimination in Ontario. These were developed through extensive consultation representing diverse voices in the HCV sector and the health system and build upon recommendations from the Blueprint to Inform Hepatitis C Elimination Efforts in Canada (2019) to put us on the path to elimination.

  1. 1 Use new testing approaches to eliminate delays in HCV diagnosis
  2. 2 Expand HCV testing beyond risk-based screening
  3. 3 Streamline HCV testing and treatment for new care settings
  4. 4 Bolster harm reduction services to reduce new HCV cases
  5. 5 Increase the role of primary care in HCV elimination
  6. 6 Provide universal HCV testing and linkage to care in prisons
  7. 7 Raise awareness and link people and providers to HCV information

1 Use new testing approaches to eliminate delays in HCV diagnosis

To achieve HCV elimination goals, Ontario needs to make screening and diagnosis quick and easy for people who are not aware of their status. Ramping up testing and taking advantage of advances in testing methods can help link people to care faster, prevent long-term health impacts and prevent transmission of new cases in the community. This includes providing reflex RNA testing at provincial laboratories and funding point-of-care and dried blood spot testing to expand access to testing in the community.

Data suggest that HCV testing rates have not yet recovered from their decrease during the COVID-19 pandemic,9 further highlighting the need to both simplify testing and increase access.

Summary of recommendations

Finalize implementation of routine reflex RNA testing in provincial laboratories. Loosen restrictions and begin funding point-of-care and dried blood spot testing, including providing training and tools for providers. These tests can be brought into high-prevalence settings where traditional blood draws are a barrier.

To see the full list of recommendations in this section, read the full report.

2 Expand HCV testing beyond risk-based screening

Ontario cannot achieve elimination without a dramatic increase in diagnosis rates. Ontario has historically relied on risk-based screening and testing, resulting in low rates of diagnosis particularly among older age cohorts and among immigrants and newcomers who may have contracted HCV outside of Canada.10 People may be reluctant to talk about past risk factors because of stigma and may face systemic barriers to healthcare. Providers may also lack knowledge on risk factors for HCV.

Offering universal or birth cohort testing is increasingly being considered in many jurisdictions. One-time screening offers the best option to reach the 1945–1975 birth cohort and immigrants and newcomers, who make up the vast majority of people living with HCV.11 12 13 In addition to being cost-effective, universal screening can normalize HCV testing, simplify the approach to screening for healthcare providers and remove stigma — a key barrier to people engaging in HCV care.

Summary of recommendations

Explore one-time HCV screening for all adults, including training and guidance for service providers, as well as increasing routine screening in care settings that serve people at highest risk of HCV. Awareness campaigns and public testing events can help to reach more community members.

To see the full list of recommendations in this section, read the full report.

3 Streamline HCV testing and treatment for new care settings

The increased simplification of HCV testing and treatment has opened the door for participation of more types of providers in both clinical and non-clinical settings. From sexual health clinics, addiction treatment centres and hospital emergency departments to shelters and harm reduction sites, more organizations can play a role in preventing, testing and curing HCV infection.

Integrating HCV care into non-traditional health and social services can reduce stigma and make HCV care part of people’s routine interactions with familiar, trusted providers. But to take on these roles, organizations need support at multiple levels, including staff training, funding and tools to implement HCV services.

There is a growing number of successful examples of community-based multidisciplinary HCV models. 15 16 Task shifting can be implemented to enable non-specialist service providers, including pharmacists, nurses, outreach workers and workers with lived and living experience, to deliver HCV care. These providers are often in the best position to offer low-barrier, integrated and stigma-free care to those who may otherwise not have access to health services.

Summary of recommendations

Expand funding for low-barrier, community-based HCV programs, including alternative outreach or mobile models of care, and integration of HCV care into existing services that are already accessed by HCV priority populations. Expand task shifting of HCV care, including expanded roles for people with lived or living experience.

To see the full list of recommendations in this section, read the full report.

4 Bolster harm reduction services to reduce new HCV cases

HCV among people who use drugs must be understood in the context of the growing drug poisoning and overdose crisis. The unregulated drug market is increasingly exposing people to toxic substances and leading to more overdose deaths. Drugs like fentanyl have shorter lasting effects, leading people to inject more frequently.17 This increases the likelihood of sharing or reusing equipment, thereby increasing the risk of HCV transmission.18 19 The use of methamphetamines and other stimulants is also growing in Ontario, which is linked to increased risk of HCV transmission.20 21 The COVID-19 pandemic limited access to harm reduction services, increasing the likelihood that people shared or reused drug use equipment and potentially contributing to an increase in new HCV infections.22

To reduce new infections, Ontario needs to continue expanding low-barrier harm reduction services including wider access to new drug use equipment.

Summary of recommendations

Expand harm reduction programs in Ontario, including in community and prison settings. This includes exploring alternative program models, longer hours, improved access in rural communities and tailored programs for youth, 2SLGTBQ+, gender-diverse and racialized communities.

To see the full list of recommendations in this section, read the full report.

5 Increase the role of primary care in HCV elimination

It is estimated that fewer than 10% of people treated for HCV in Ontario receive their prescription from a primary care provider.24

Primary care is key to expanding the number of providers offering HCV testing and treatment. Barriers include a lack of knowledge about risk factors or new treatment options, a lack of appropriate treatment settings, stigma or reluctance to treat those with current or past drug use.

Priority should be placed on increasing the number of primary care providers delivering high-quality HCV care. This includes ensuring they have the information and support they need to begin offering testing and treatment as part of their routine practice. Additional focus should be placed on providers who are working in high-prevalence settings or with priority populations.

Summary of recommendations

Encourage primary care providers to take up HCV care, including through delivery of awareness campaigns and incentives (e.g., performance metrics, billing codes). Provide adequate tools to support their practice, including accredited trainings, clinical consult services and program implementation tools, all available on a centralized website.

To see the full list of recommendations in this section, read the full report.

6 Provide universal HCV testing and linkage to care in prisons

HCV elimination cannot be achieved without changes in Ontario’s provincial and federal correctional institutions. Delivery of appropriate HCV care in correctional facilities is complex, particularly in provincial institutions where length of stay is often very short, with many people either awaiting a trial or in remand. Adding to the complexity, health services in provincial corrections is a separate system from public healthcare, creating challenges in navigating and administering care.

Ontario is well positioned to advance HCV elimination strategies in provincial prisons. Ontario is increasing HCV training among prison healthcare staff, strengthening linkages with community providers and expanding access to healthcare providers. However, many barriers remain, and work is needed to increase HCV testing rates and standardize practices among institutions.4

Summary of recommendations

Standardize HCV care across provincial prisons, including routine testing and immediate treatment starts or linkage to a community provider. Increase awareness and reduce stigma through education for both people who are incarcerated and all prison staff.

To see the full list of recommendations in this section, read the full report.

7 Raise awareness and link people and providers to HCV information

A centralized source for HCV information can help to create accessible, reliable information with resources for both the public and healthcare providers. Stigma and misinformation about HCV compromise access to testing and treatment and hinder prevention efforts. Stigma makes people less likely to disclose their HCV status or take steps to reduce risks and makes them more likely to avoid healthcare interactions, including testing or treatment. Because direct-acting antiviral treatment for HCV is relatively new, even those working in health and social services may not have up-to-date information about HCV treatment, let alone risk factors and prevention.

In addition, policy and health service interventions to eliminate HCV need to be complemented by widespread, public-focused information campaigns to change the narrative on HCV, including targeted messages for priority populations. They must be developed with input from the communities they are trying to reach and communicated through trusted channels where people already go for information.

Summary of recommendations

Raise awareness through public campaigns, including working with other sectors and community members to tailor messages to their audiences. A website can be built as a single source for HCV resources, with information and referrals for the public and training resources and clinical tools for providers.

To see the full list of recommendations in this section, read the full report.

Part 3:
Population-specific recommendations

A priority populations approach to HCV elimination

The elimination of HCV in Ontario can only be realized through a priority populations and health equity approach.27 The national Blueprint identified five priority populations that experience a disproportionate burden of HCV in Canada. These groups are marginalized by social and structural factors, including discrimination, criminalization and stigma, that increase their risk for acquiring HCV infection and create barriers to accessing care. Although we discuss each priority population individually in this section, we recognize that people may have multiple, intersecting identities that impact their experience with HCV.

HCV among priority populations in Canada

First Nations, Inuit and Métis peoples


As a coalition for HCV elimination, we begin this work in the spirit of truth and reconciliation, recognizing the critical importance of cultural safety and acknowledging the harms of colonialism, including from within Ontario’s health system. Indigenous-specific recommendations were developed with guidance and wisdom from an Ontario working group, consisting of an Indigenous Elder, Indigenous healthcare providers and Indigenous community members, as well as a pan-Canadian, Indigenous-led initiative for HCV elimination being led by Waniska, an Indigenous research centre on HCV, HIV and other sexually transmitted and blood-borne infections.

The strength and wisdom of Indigenous peoples are key to the elimination of HCV in Ontario. Historical and present-day colonialism and trauma have resulted in significant health and social inequities including substance use and HCV among First Nations, Inuit and Métis people in Canada. Today, ongoing discrimination, stigma and racism create significant barriers for people to access life-saving health services. Despite this, Indigenous culture, community and self-determination are creating resilience and strength in enabling Indigenous peoples to address HCV.

Provincial HCV strategies need to meet the calls to action from Canada’s Truth and Reconciliation Commission, including funding and supporting programs that are Indigenous led and informed by Indigenous knowledge, as well as increasing cultural competency for non-Indigenous providers.

Wholistic well-being is important in First Nation, Inuit and Métis understandings of health, including physical, mental, emotional and spiritual elements.28 Indigenous healing and well-being strategies can aim to reconnect people to culture and incorporate Indigenous knowledge and practices that extend beyond Western concepts of disease.

Summary of recommendations

Support Indigenous-led, whole-person care that prioritizes involvement of Indigenous Elders, healers and community members, particularly in rural Indigenous communities. Ensure trauma-informed, culturally safe care can be delivered in mainstream health settings, including hiring of Indigenous staff and adequate training for non-Indigenous providers.

To see the full list of recommendations in this section, read the full report.

People who use drugs

People who use drugs have the highest rates of new HCV infections but are often overlooked and underserved by the healthcare system.29 Treatment is highly effective at curing HCV for all people, including people who use drugs. Treatment should be offered regardless of drug use and without stigma, including for reinfections.25

Care providers often lack the knowledge or resources to support people who use drugs or are reluctant to treat them in their practice. However, low-barrier models, like the Ontario Hepatitis C Teams, have been successful in providing wraparound supports for HCV care, integrating harm reduction, mental health, housing services and social support.

People with lived and living experience of substance use are also important providers, bringing unique expertise and community connections to HCV programs for people who use drugs.

Flexible, low-barrier programs can help to meet people where they are. This includes flexible appointment scheduling, meeting in the community instead of a clinic, and options for how medication is dispensed

Summary of recommendations

Integrate HCV care into other services that are already being accessed by people who use drugs, with programs being designed and delivered by people with lived or living experience. Explore new ways to deliver care that meet people where they are, including through outreach or mobile models, and wraparound supports for housing, primary care and more.

To see the full list of recommendations in this section, read the full report.

People with prison experience

People who are incarcerated have among the most complex health and social service needs in the province. Studies have consistently shown that this population has higher rates of infectious disease and is is more likely to have issues with substance use and other healthcare and mental health needs.30 Criminalization means people who use drugs are over-represented in prisons, leading to high rates of HCV with little or no access to harm reduction inside. This leads to increased risk of transmission inside prisons as well as from other practices including tattooing or piercing.

Prison sentences offer an opportunity for marginalized individuals to be engaged in healthcare, including HCV treatment. There are a growing number of programs across the province to strengthen prison healthcare services. This includes an investment in primary care nurse practitioners who can play a key role in HCV care, as well as increased training about HCV for corrections healthcare staff.

Summary of recommendations

Standardize HCV care for people in prisons, so that they have options for routine testing and access to immediate treatment options, whether during the sentence or in the community upon release. Scale up prevention in prisons, including access to harm reduction services and education on HCV.

To see the full list of recommendations in this section, read the full report.

Immigrants and newcomers

In Canada, 2% of all immigrants and newcomers have had a current or past HCV infection.31 Most acquired HCV in their country of origin, primarily through inadequately sterilized medical equipment or unscreened blood products.32

Common barriers to HCV care include difficulty accessing healthcare, systemic racism, stigma and misinformation around infectious diseases in some communities. People born outside of Canada are not diagnosed until, on average, 10 years after arriving.33 Compared with those born in Canada, immigrants with HCV are also more likely to be hospitalized with complications and more likely to die of HCV-related causes.34

Newcomers and immigrants have not traditionally been prioritized for HCV screening, and many providers are not aware of the risk for this group. Primary care providers, including community health centres and walk-in clinics, are important stakeholders to expand care.

Summary of recommendations

Engage health services that are already serving immigrants and newcomers to prioritize and deliver HCV care, particularly those that can offer in-language services. Create culturally relevant awareness campaigns within communities and with local partners to destigmatize HCV and encourage testing.

To see the full list of recommendations in this section, read the full report.

Gay, bisexual and other men who have sex with men (gbMSM)

While gay, bisexual and other men who have sex with men (gbMSM) represent a relatively small percentage of people with HCV, rates of infection are on the rise.37 Transmission can occur through sexual transmission, particularly among people living with HIV, as well as through shared drug equipment.

To address this emerging need, HCV efforts need to be integrated with HIV and sexual health services (including HIV pre-exposure prophylaxis or PrEP). This includes new strategies that promote risk reduction for HCV transmission in the context of sex, as “chemsex” or “party n' play” (using drugs to facilitate or enhance sexual encounters) grows.

Agencies serving gbMSM, including HIV services, sexual health clinics and PrEP/PEP (post-exposure prophylaxis) clinics have a long-standing role in HIV and sexual health. As trusted providers, they can offer confidential, easy-to-access and stigma-free community health promotion for a population that continues to face barriers because of homophobia and discrimination.

Summary of recommendations

Raise awareness of HCV as an issue among gbMSM, through tailored campaigns in partnership with other agencies. Engage providers and community organizations working with gbMSM to offer HCV services, including in sexual health and PrEP clinics.

To see the full list of recommendations in this section, read the full report.


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