The research brief prepared by DoHA for this study (p B9) describes the background context in the following words:
Studies have indicated that Indigenous people who inject drugs in both urban and regional areas have a higher prevalence of hepatitis C than non-Indigenous drug injectors. The Australian NSP Survey, National Data Report 2000-2004, commissioned by the National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, reports the prevalence of hepatitis C among Indigenous IDU has risen from 52% (compared to 54% non-Indigenous) in 2000 to 68% (compared to 59%) in 2004. This indicates that hepatitis C prevalence in Indigenous IDU is 9% higher than in non-Indigenous populations3.
Given that reliable figures on the extent of Indigenous drug injecting are not available, and that NSP data do not give a clear or straightforward picture of the representation of Indigenous IDUs among NSP clientele, it is not possible to say with certainty that Indigenous use of NSP services is disproportionately low. It should be noted, for example, that around 10% of the respondents to the Australian NSP Survey over recent years have been Indigenous. Nevertheless the high and increasing rates of hepatitis C infection among Indigenous Australians are clear cause for concern. Among other things DoHA has noted that the long-term health impact of HCV infection among Indigenous Australians may be particularly severe given high Indigenous morbidity and mortality rates and Indigenous disadvantage in terms of access to health services, housing, education and the like4.
A fact sheet issued by Hepatitis Australia in mid-2007 further highlights some of the key concerns that underlie the commissioning of this study. For example the fact sheet states that:
- In Australia some 264,000 people had been exposed to the hepatitis C virus, including a disproportionately large percentage of Aboriginal and Torres Strait Islander people.
- While Aboriginal and Torres Strait Islander people make up 2.4% of the total Australian population, it is estimated that they constitute 8.3% of the Australian population living with hepatitis C. This indicates that (by contrast with the HIV epidemic, where Aboriginal and Torres Strait Islander people have had much the same exposure rates per capita as the general population) Aboriginal and Torres Strait Islander people are considerably more likely to be exposed to the hepatitis C virus than are non-Indigenous Australians.
- Given that some two-thirds of hepatitis C notifications are reported without Indigenous status being recorded, it is possible the true rate of hepatitis C among Indigenous Australians is even higher; accurate data from Western Australia and the Northern Territory indicate that Aboriginal and Torres Strait Islander people account for around 10% of all new hepatitis C notifications5.
- Currently it is estimated that some 22,000 Aboriginal and Torres Strait Islanders people are living with hepatitis C antibodies among whom 16,000 are living with chronic hepatitis C6. Although rates of hepatitis C infection in the non-Indigenous population have improved, rates of infection within the Aboriginal and Torres Strait Islander population continue to rise.
- The National Hepatitis C Strategy 2005-2008 identifies three main priority populations for which action is urgently needed – Aboriginal and Torres Strait Islander people who engage in risk behaviour, people in custodial settings, and people who inject drugs. In addition to being identified as a priority population in their own right, Aboriginal and Torres Strait Islander people are also significantly represented within these two other at risk populations. In particular Aboriginal and Torres Strait Islander people are several times more likely to be imprisoned than non-Indigenous Australians, and they make up some 27% of the total prison population. Additionally, since Aboriginal and Torres Strait Islander inmates often serve shorter sentences than non-Indigenous Australians7, the rate of hepatitis C in custodial settings has greater potential to translate into increased infection rates within the general Aboriginal and Torres Strait Islander population.
- It is estimated that some 90% of all new hepatitis C transmissions are attributable to sharing of injecting equipment. Regular NSP surveys suggest an increase in participation in injecting drug use by Aboriginal and Torres Strait Islander people (who currently represent some 10% of the survey respondents) and also reveal an increasing prevalence of hepatitis C among Aboriginal and Torres Strait Islander participants8.
- The National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-2008 recognises the need for a whole of primary health care sector approach to addressing blood borne viruses in Aboriginal and Torres Strait Islander communities. A key priority of this strategy is access to Needle and Syringe Programs and the increased capacity of the health and community workforce to address all aspects of Aboriginal and Torres Strait Islander HIV/AIDS, sexually transmitted infections and blood borne viruses.
Although the overall rates of HIV diagnosis are similar for Indigenous and non-Indigenous Australians, the patterns of HIV transmission are somewhat different; with transmission related to injecting drug use having become considerably more significant in the Indigenous population:
Among Aboriginal and Torres Strait Islander people, the percentage of HIV infections attributed to injecting drug use increased from 5% in 1992-1998 to 18% in 2002-2006. In the non- Indigenous population, the percentage of HIV infections attributable to injecting drug use has remained constant at 3% during these periods10.
A research project carried out in 2003-04 by the Aboriginal Health and Medical Research Council of New South Wales (AH&MRC), in conjunction with Mandala Consulting, found – in the words of the present study brief (p B9) – that:
- among Indigenous Australians diagnosed with HIV, there is a higher proportion of IDUs diagnosed with HIV than non-Indigenous people;
- in NSW there is a greater proportion of Indigenous people with hepatitis C, attributable to injecting drug use;
- Indigenous people are diagnosed with hepatitis C at a younger age compared to non-Indigenous people; and
- there needs to be a fuller understanding of the risk of blood borne infections to Indigenous communities, which includes better understanding and support for the harm minimisation role of NSPs.
The brief for the present study suggests that some of the factors adversely affecting Indigenous communities and Indigenous IDUs include:
- limited knowledge about the risks of contracting blood borne viruses such as hepatitis C from unsafe injecting;
- reluctance among some community leaders to acknowledge the fact of drug injecting among members of their communities;
- tension between abstention and harm reduction models for addressing drug use problems.
- a higher proportion of young people in the Indigenous compared with the broader population
- significantly higher levels of incarceration compared with the non Aboriginal population
- the mobility of Aboriginal populations
- inadequate access to health services in general
- a low level of knowledge of hepatitis C within the Aboriginal community
- an increase in injecting drug use and its associated risks and harms.
Given the higher rates of hep C, a key issue for Aboriginal communities in addressing the condition is access to services such as harm reduction and other prevention, care, treatment and support services and an adequately prepared workforce.
Ward and Cairnduff have also argued that Indigenous Australians are at increased risk of exposure to hepatitis C because of their marginalised status, and possibly higher rates of sharing of injecting equipment. Echoing DoHA observations referred to above, they note that hepatitis C infection is also potentially more serious for people in the Indigenous community because of other health risks such as high rates of smoking, obesity and Type II diabetes. As noted above, within the prison population Indigenous Australians are at particular risk because of their young average age and the fact that they are more likely than other groups to be serving relatively short sentences, relatively frequently, for relatively minor offences. Young Indigenous Australians (especially young women) are again heavily over-represented in juvenile justice institutions.
At a conference on hepatitis C held in Melbourne in June, 2007, the CEO of Hepatitis Australia stated that although there are an estimated 22,000 Indigenous Australians infected with hepatitis C, it remains difficult to get this issue onto the Indigenous health agenda. Changing this situation, she argued, will require sustained leadership both from governments and from Indigenous communities12.
Some further statistical information relating to Indigenous drug injecting and BBV infection is set out in Appendix C to this report.
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3 The national NSP survey has subsequently shown a further rise in Hepatitis C infection to 71% of Indigenous NSP clients.
4 See Department of Health and Ageing, Hepatitis C Virus Projections Working Group, 'Estimates and Projections of the Hepatitis C Virus Epidemic in Australia 2006'.
5 National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-2008
6 Hepatitis C Virus Projections Working Group: Estimates and Projections of the Hepatitis C Virus Epidemic in Australia 2006
7 Quoting Australian Bureau of Statistics; 1301.0 – Year Book Australia, 2004
8 Australian NSP Survey; National Data Report 2001-2005, National Centre in HIV Epidemiology and Clinical Research
9 For information about BBV epidemiology in WA see sexual health and blood-borne virus webpage on the WA Department of Health - Public Health website (www.public.health.wa.gov.au).
10 Australian NSP Survey; National Data Report 2003-2007, National Centre in HIV Epidemiology and Clinical Research
11 James Ward and Sallie Cairnduff, 'Hepatitis C services and access for Aboriginal people', The Hep C Review 56, March 2007, pp27 and 35.
12 Presentation to the National Hepatitis C and Aboriginal and Torres Strait Islander Communities Workshop: Engaging Communities, Melbourne, 7 June 2007.