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Standing Committee on Health - 10/03/2015 - Hepatitis C in Australia

FARMER, Mr Frank, Executive Director, HepatitisWA Inc.

HATCH, Mr Rodney, Prisons Education Officer, HepatitisWA Inc.

ROWELL, Ms Sally, Community Services Manager, HepatitisWA Inc.

Committee met at 08:58.

CHAIR ( Mr Irons ): I declare this public hearing of the Standing Committee on Health open and would like to thank you all for your attendance today. Before we begin, may I ask one of the members of the committee to move the media be allowed to film the proceedings today in accordance with the rules set down for committees which include not interfering with committee proceedings and not taking footage or still images of members', committee staff or witnesses' papers or laptop screens. So moved, Ms Hall.

Welcome to everyone here. Welcome, particularly, to my two eastern states counterparts who have travelled all the way for this hearing. I also welcome the people who are here today to give evidence. I call representatives of HepatitisWA to come up and join us at the front here. Do you, as witnesses appearing before the committee, have any objection to being recorded by the media during your participation in this hearing? No.

These hearings are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. The evidence given today will be recorded by Hansard and also attracts parliamentary privilege. I invite you to make a brief opening statement to the committee.

Mr Farmer : Initially, HepatitisWA would like to express our gratitude for the establishment of this committee and the opportunity to contribute. We acknowledge the traditional owners of the land on which we meet, the Whadjuk people, and honour elders past, present and future. As already acknowledged, I am accompanied by my colleagues Ms Sally Rowe, the Community Services Manager, and Mr Rodney Hatch, who is an educator for our organisation and a man living with hepatitis C.

HepatitisWA is the peak community organisation in Western Australia responsible for: providing information and education to the broader community and targeted groups; prevention and education for prisoners in all metropolitan prisons and youth detention centres; assisting in providing the best possible care and support for people living with and affected by viral hepatitis; and HepatitisWA also operates a needle and syringe program. The aspects of the hepatitis C epidemic we will highlight today include: prevention; Aboriginal and Torres Strait Islander peoples; prisons; treatment; and stigma and discrimination. I will start with prevention.

Australia is acknowledged as a leader in the provision of a range of needle and syringe programs, or NSPs as they are commonly known. NSPs are proven, effective and legitimate health services. NSP coverage across the country and throughout Western Australia is to be commended. However, in order to halve the incidence of hepatitis C infections, the availability of needles and syringes needs to double. Additionally, if NSPs are to maximise their potential beyond the distribution of injecting hardware—for example, the inclusion of brief education interventions, limited clinical services and referral—the capacity of NSP staff needs to be increased. In Western Australia we have a tiered state-wide needle and syringe program. Primary needle and syringe programs have a full range of equipment and are exchanges. Secondary NSPs include but are not limited to regional hospital emergency departments, public health units, a range of community organisations, pharmacies and vending machines. Secondary NSPs usually only distribute fit packs. In many secondary needle and syringe programs the provision of the service is an add-on—that is, the responsibility for providing the service is added on to another service or position. This can lead to competing priorities which may limit service delivery and often breeds resentment in the staff involved as the provision of NSP equipment intrudes on a person's chosen professional work. This is often apparent in regional areas. Our recommendation is that needle and syringe programs need to continue to expand and be enhanced to build capacity and maximise service delivery beyond the supply of harm reduction hardware.

I will move on to Aboriginal and Torres Strait Islander peoples. In part, the Fourth National Hepatitis C Strategy 2014-17 states:

Aboriginal and Torres Strait Islander people are at particular risk of BBV transmission through injecting drug use. There is a significantly higher rate of diagnosis of hepatitis C among Aboriginal and Torres Strait Islander people who inject or have injected drugs. The rate of hepatitis C infection among Indigenous injecting drug users (IDU) is between three and 13 times higher than that of the non-Indigenous IDU population [28]. Furthermore, in 2012 a greater proportion of newly diagnosed HIV infections were attributable to injecting drug use in Aboriginal and Torres Strait Islander people compared to non-Indigenous people …

Aboriginal people are more likely than non-Aboriginal people to have a history of incarceration and being in prison is acknowledged as an independent risk factor for hepatitis C. Recent voluntary prison-entry testing in Western Australia revealed a greater proportion of Aboriginal people being diagnosed with hepatitis C and injecting drug use was the most common risk factor for Aboriginal people, as it was for non-Aboriginal people. In HepatitisWA's experience, through our own needle and syringe programs and through our engagement with some regional needle and syringe providers, injecting drug use among Aboriginal people is accelerating.

Aboriginal people account for 25 per cent of HepatitisWA's needle and syringe program clients, which is the highest representation of Aboriginal people accessing NSP services in the metropolitan area of Perth. On a recent trip to the well women's health centre in the Pilbara, which is the largest NSP provider, they advised us that 85 per cent of their clients are Aboriginal. While it is encouraging that Aboriginal people are accessing NSP services, the potential for increased hepatitis C and HIV infection and transmission is alarming. Our recommendation in relation to this is that Aboriginal peak bodies, health professionals, community leaders and decision makers must be encouraged to acknowledge the risk related to injecting drug use and blood-borne viruses, and they need to be supported in the promotion and implementation of appropriate harm reduction measures to reduce the impact on individuals, families and communities.

In relation to prisons it is conservatively estimated that a third of men, and two-thirds of women, entering prison are living with hepatitis C—although that is not necessarily true of prisons in remote areas of Western Australia. As mentioned previously, being in prison is an independent risk factor for hepatitis C. In Western Australia, prisoners have the benefit of prevention education in relation to sexual health and blood-borne viruses through the implementation of the Health in Prisons, Health Outta Prisons program, or HIP HOP as it is affectionately known. The HIP HOP program is intimated by HepatitisWA in the metropolitan area under contract to the Department of Corrective Services. The program is delivered to inmates within two weeks of entering prison, with a refresher session prior to exiting prison. The Western Australian government is to be commended for providing this important initiative, as well as providing safe-sex equipment in an attempt to enable persons to protect their health in prison.

In relation to the sharing of injecting drug-using equipment, prisoners have access to the knowledge of how to protect themselves; however, they do not have the means to do so if they choose to inject drugs whilst in prison. Apart from the fact that prisoners have the right to have access to health services equivalent to those in the community, the response to hepatitis C will never be successful until transmission in prisons is addressed. It will come as no surprise to this committee that HepatitisWA strongly advocates for the introduction of needle and syringe programs in Australian prisons.

The committee is aware that revolutionary drugs which have the potential to contribute to the elimination of hep C are available in some countries in the world. The fourth national strategy appears to be framed with the expectation that these drugs will be available in Australia within the life of the strategy. The strategy acknowledges that, in relation to services provided in the community, the availability of new drugs cannot be seen as a stand-alone solution to the elimination of hepatitis C. The strategy acknowledges that treatments must be seen as part of a suite of initiatives which includes, but is not limited to, needle and syringe programs and opiate replacement therapy programs. In relation to prisons, however, the strategy concludes that treatments alone will be sufficient to address hepatitis C. In part, the strategy states:

The prevalence of hepatitis C is disproportionately higher among people in custodial settings, due primarily to the high rate of imprisonment for drug-related offences and unsafe injecting drug use in prisons. New drug therapies which will cure the large majority of hepatitis cases should inform future approaches.

There was no mention of needle and syringe programs. Hepatitis WA finds it incomprehensible that advocacy for the introduction of needle and syringe programs in prison has been excluded from the current strategy when it has been present in previous strategies. Theoretically, being in a prison environment for an appropriate length of time should be an ideal place for people living with hepatitis C to undertake treatments. This will be particularly relevant when the new treatments become available. In the meantime, treatment uptake in WA prisons is low, as it is in the community. Clinical capacity and allied support services must be improved in prisons to accommodate hepatitis C treatments. Additionally, systemic operational barriers must be addressed and the needle and syringe programs must be implemented if hepatitis C is to be addressed in prison settings. Our recommendation is that all Australian governments work together to ensure that needle and syringe programs are implemented in Australian prisons.

In relation to treatments, it goes without saying that the new treatments for hepatitis C must be made available in Australia—as widely as possible, as soon as possible. We acknowledge the issues of cost, cost effectiveness and affordability; however, the Australian government must be proactive in negotiating the inclusion of the most effective available treatments onto PBS to ensure the best outcome for people living with hepatitis C. At the 9th Australasian viral hepatitis conference held in Alice Springs in 2014—

CHAIR interjecting—

Mr Farmer : I am just about to conclude.

CHAIR: No worries. Most opening statements are fairly brief. It gives us time to ask you a lot of questions. Keep going.

Mr Farmer : —it was constantly reiterated from the clinicians and researchers that, in the main, new treatments will be available to be administered in primary health care and community settings rather than almost exclusively in tertiary hospital settings, as is the case today. Tertiary settings are not always a preferred point of service for some clients, especially people who are currently injecting drugs, so they often are reluctant to access treatments through these facilities. In anticipation of the new treatments becoming available in the foreseeable future, we must start to build interest and capacity in the primary health and community sectors now. Our recommendations are, firstly, that the Australian government ensures the most effective drugs which can cure hepatitis C are listed on the PBS and are available to all people who require them. Secondly, that all Australian governments work together to build capacity in the primary health care and community sectors and with allied health services to deliver hep C treatment services, including community prescribing, dispensing and point of care testing.

Finally, going to stigma and discrimination: the national strategy acknowledges that stigma and discrimination are often directed at people because they are living with hepatitis C. However, more often it is moralising and judgement about the mode of transmission behaviours which lie behind the disease that are the root of the problem. People living with and-or who are affected by hepatitis C must be central to the development and implementation of any initiatives to counter stigma and discrimination, and they need to be seen and heard. This means that people living with hepatitis C need to be supported in coming to terms with their circumstances without feeling shamed or diminished by external influences or by their own internalised perceptions. This is not an easy task, because while drug taking and injecting remain illegal, it is a tough call to ask people to publicly admit to, or to associate themselves with, such behaviours. Nevertheless, these issues must be acknowledged and addressed. We will not make any significant inroads against stigma and discrimination until the legitimate and authentic voices of people affected by hepatitis C are heard, and they are seen and accepted as valued partners and deserving members of the community.

We call upon Australian governments to work with the community to create an enabling environment in which people living with hepatitis C can empower themselves and take their rightful place in the response to hepatitis , and to invest in appropriate awareness campaigns in partnership with people living with hepatitis C.

In conclusion, we believe that Australia is losing in the response to hepatitis C, with an estimated 230,000 people living with hepatitis C, new notifications running at approximately 10,000 per annum and less than two per cent of people accessing treatments annually, and people being warehoused while we await the availability of new treatments. Australia is failing. We have the strategy. We are to be commended for having successive strategies, but the current strategy must be implemented and must be funded to ensure that it is fully implemented. Thank you for the opportunity to make that prolonged opening statement.

CHAIR: Thank you, Mr Farmer. Would Ms Rowell or Mr Hatch like to add to that briefly?

Mr Hatch : Not at this point.

CHAIR: I thought you might like to advise us of your situation and whether you are currently living with hep C.

Mr Hatch : I am happy to do that. I have been living with hepatitis C for a number of decades now. Personally, I consider myself amongst the lucky percentage in that, so far—and I touch wood—I have been relatively okay. I consider living with hep C to be not just something that involves me personally on a physical level but also, for me, it is a disease of loved ones, family and friends. I have had spouses and close family members and a lot of friends who have lived with hepatitis C and have not been as lucky as me and have suffered severe consequences due to the fact that they had been infected. Some of those close family members were infected through a very brief flirtation with risky behaviour—the same as me, many decades ago. It may have been a weekend of indulgence in some behaviour that they probably thought they would get away with, and the repercussion is that it has caught up with them over the years.

When my sister was diagnosed she lost a partner, who decided to leave her at that time. My first wife died of an injury that was exacerbated to the point where she died because her liver was compromised through her hepatitis C. My second wife was put on a waiting list for a liver transplant but was told, pretty much in no uncertain terms, that her position on the list would not be secure if she continued to use illicit drugs. I have seen friends die of liver failure in quite squalid conditions, reluctant to access treatment.

I myself have always deferred treatment. I have maintained quite a regular monitoring of the state of my liver over the decades since I was first diagnosed, and I encourage other people to do that. I have always put off going on treatment for various personal reasons—partly because I thought I may not be eligible and party because I was afraid of the side effects. Also, I did not receive a lot of encouragement to go on treatment over the years. There was not a lot of encouragement from health professionals to go on treatment.

CHAIR: I appreciate your candour.

Ms HALL: Given the new range of drugs that are becoming available and the fact that there are fewer side effects, would you be looking to go onto those sorts of treatments whereas you have rejected treatments in the past?

Mr Hatch : I am very encouraged by the new regime of treatments that are coming on line now. Frank used the term 'warehousing'. The vast majority of people who are living with hepatitis C do not take up treatment. I see the practical limitations. Even though there are now new treatments, I see the possibilities being limited for quite a few people. I would take treatment if I could. I certainly cannot afford the prices of the treatments that have come on line if they come on line at those high prices. There are people who have been living with hepatitis C for a long time, and I see very young people still being infected. I would like to see them be able to receive immediate treatment so that they do not have to live with it over decades. I see that there will need to be some kind of system of prioritising, and I would not necessarily see myself very high in that order of prioritising.

CHAIR: Can I ask why you would not see yourself as a priority?

Mr Hatch : It is because I see other people who would need treatment more immediately than I do. As I said, I consider myself one of the lucky people, to have been living with the virus for many decades—as I said, touch wood. But I have seen a lot of other people who have suffered more serious consequences. The infection rate for young people is still relatively high in certain sectors of the community. I would not like to see them put in a position where they need to live with the virus for years and decades. I would like to see young people who have been recently infected go immediately on to treatment.

Ms HALL: So you have learned to structure your life around living with hep C. You mentioned limitations of the drugs, such as price. Are there any other limitations associated with the new drug treatments?

Mr Hatch : I am encouraged by the minimal side effects compared with previous treatments. The treatments that are available at the moment can still have quite severe side effects.

Ms HALL: Yes, they can be pretty horrendous.

Mr Hatch : It remains to be seen what happens in the future. The future looks encouraging, but I am not sure how it is going to pan out.

Ms HALL: So you the limitations mainly associated with the cost?

Mr Hatch : And uncertainty.

Ms Rowell : Can I just add to that?

Ms HALL: Yes.

Ms Rowell : Another limitation is the fact that we do not have the capacity to see the people that we need to see. The waiting lists are already huge in tertiary institutions and clinics. Being able to get into see somebody to have treatments is a huge limitation.

Ms HALL: I will push that later when I get the chance, but I know others would like to ask questions.

Mr WYATT: I have a couple of questions. There is currently no access point for care testing or rapid testing. What would you like to see?

Mr Farmer : If you do not mind, I would really like to defer this question to Sally. Is that all right?

Mr WYATT: That is fine.

Ms Rowell : We would like to see rapid testing at least to be seeing the effectiveness of it for hard to reach groups—for example, people who are currently injecting who not access any other health services but access, say, a needle syringe program and may not know their hep C status and will not access other services to find out. Having the ability to have them on the spot and able to be tested and get their results there and then could have a huge impact on, for one thing, their behaviour. They may actually alter the behaviour they are involved in, or they may also look at better health outcomes for themselves.

You would be looking at putting that in a service like ours, for example, that has an NSP, peer driven services or street doctors and places like that where there are people who are hard to reach, who will not go to services or, if they do go and get a test, they may not necessarily want to come back for the results. So they would get the tests there and then and be able to know their status.

Mr WYATT: I asked that in the light of the survey administered to 60 people with hep C, because if we take those figures and look at what is trending in that result then that creates a fairly scary image of people living with hep C and the fact that they do not seek treatment but are likely to be cross-infecting others.

Ms Rowell : Absolutely, and one of the things that we are most wanting to stress here is that we see it like a bath: the bath is overflowing at the moment, and people are bailing out water or trying to stop it, but you actually need to turn the tap off. To turn the tap off you need to start working with the people who are most likely to transmit the virus, and that is people who are currently injecting drugs.

Mr WYATT: The other question I want to ask is: given the proportion in each of the categories, among the homeless people, 33 per cent were found not to access services, and then there is the Indigenous element, where 28 per cent identified but 90 per cent had never had their liver monitored. So, we have some incredible challenges in how we deal with hep C within an urban community. Or would you see that prevailing across WA?

Ms Rowell : I would think it is across WA. I certainly think that injecting is probably, at this moment, more of an urban thing, particularly for Aboriginals, but the potential is really large. If we look at other Indigenous communities—for example, in Canada—we can see the progression that has occurred there, and we are no different here. So, I think there is a potential. But certainly in the urban area I think that is a risk.

Mr WYATT: Given your citation of the Canadian study, how comparative is that with the trending in Australia?

Ms Rowell : There has been a lot more work done in Canada than in Australia, but there are certainly some comparisons there.

Mr WYATT: Is there work being done around the effectiveness of Aboriginal Community Controlled Health Services in addressing hepatitis C?

Ms Rowell : Yes, there is work being done. I am not sure that enough work is being done. I think there is certainly a lot more that could be done. I think there is a reluctance within some Aboriginal health services to acknowledge injecting drug use in their communities, and I think there are a whole lot of reasons for that as well. But yes, of course some work is being done, and there is some good work being done, but there is not enough at the moment.

Mr WYATT: What would you change?

Ms Rowell : As Frank said, a big issue is around the stigma and discrimination that goes along with this virus. And it is not just about having hepatitis C; it is actually about the behaviours that lead to this, and I think there needs to be some acknowledgement and acceptance of people who inject drugs. I think we need to start looking at how we treat those people and how we see them. And I think we need to look at opening services up, taking them out of tertiary clinics. I think we need to go into more care based or community based organisations where we can allow those people who are really hard to reach to access. We need the new treatments; there is no doubt about that. We need people to have access to treatments that they are going to want to be on. They do not want to be on interferon at the moment, because all they hear is that it makes them sick, and they cannot afford to be sick. You cannot afford to be sick when you are living on the streets. So I think we need services that can actually let people access good treatments and access them in a place where they feel comfortable and that can accommodate them.

Mr WYATT: Are you finding that people are accessing the StreetDoctor program? You have one that operates in the Fremantle region and one in the northern metropolitan area. Are they effective in also reaching out to those who need treatments for hep C?

Ms Rowell : They would be referring for hep C treatments; they would not be doing them themselves.

Mr WYATT: Is that a standard practice with GPs—that they would refer?

Ms Rowell : Yes, because they cannot initiate treatments. That is the other area where we have a real issue with this—the fact that people have to see a specialist to have treatment initiated, and I think that probably needs to change as well; GPs need to start being able to initiate.

Mr WYATT: Given your comment that you need to see a specialist, that then creates a problem for a state that is geographically diverse and has key points such as Karratha, Broome, Port Hedland and maybe Kununurra and Fitzroy as areas where you may access a specialist. That then means that anywhere else, outside of the major hubs, would be problematic.

Ms Rowell : Not necessarily, because if you had telehealth, for example, that is a great service that is being used now for people to access specialists. If you have nurse-led practitioners who can do that as well, that could increase that.

Mr WYATT: We heard that in either Sydney or Melbourne—about nurse-led treatments. I will hand over to my colleague Mr Watts.

Mr WATTS: You would not be surprised to hear that we have heard a lot of evidence throughout the inquiry about needle and syringe programs in prisons. Given the particular position you are in, in delivering prevention programs within a prison context and also involvement with needle and syringe programs, could you talk in a bit more detail about your view of how that could work in practice, instead of conceptually whether or not they are a good thing? We have had plenty of evidence on that, but how would they work? And are you aware of any trials or existing programs that might provide a model there?

Mr Farmer : This is not my forte. I really have not done a study of successful NSP programs in prisons in other countries, except we know that they do exist and that they are successful. There are a range of models, I believe, that are being implemented in other countries. So, I do not have a particular model in mind that I would be wanting to recommend for Western Australian prisons. I know that in some prisons they furnish each cell with a clean syringe, but in others the needles and syringes are distributed by a medical officer in the clinical setting. If you bring back a used syringe, the medical officer will give you another one. So, there are a range of ways that it can be done, but obviously, and as you would be aware, there has been significant resistance from the prison workers union because of that unfortunate incident where somebody was infected with HIV. But really there needs to be a willingness from the hierarchy within corrections to get some movement on this area.

Mr WATTS: You also mentioned earlier that you viewed there being a need to double NSP program delivery in Australia in order to drive down current rates. What is the basis of that figure? And are you seeing significant unmet demand, or do you think that demand would increase if availability increased as well?

Mr Farmer : Do you mean demand for the equipment?

Mr WATTS: Yes.

Mr Farmer : The information I have received is that there is a demand, and if it was more accessible then people would access it. I think the metropolitan area in Western Australia is well serviced. The Western Australian AIDS Council runs a mobile service that circulates around the metropolitan area. It has been established almost from the outset of the recognition of the HIV epidemic. But in regional areas—and I am sure this will not come as a surprise to anybody here—when people are living in small communities, whether they are Aboriginal communities or non-Aboriginal communities, trying to access services where everybody knows everybody, and people want to be very discreet about their drug use, is problematic. I remember going down to Kojonup and talking to the medical staff down there in the hospitals specifically about running a workshop about NSP enhancement, and they were saying, 'No, none of our locals access the ED department to access equipment; they're all travellers who're passing through.' Well, of course they are. They are coming from the other towns, 30 kilometres away, while the injecting population in Kojonup is going to those other towns. People have to think very carefully about how they access their equipment. I think confidentiality in small communities is a really big problem. I think that is going to be a major problem if we try to work with Aboriginal communities around that. I think it will be very, very sensitive.

Mr WATTS: Are you aware of any innovative models designed to tackle that? Because, again, this is something we have heard repeatedly. At the Melbourne hearings we heard evidence about how one service in regional Victoria that was down the corridor, behind the forest—you have the ocean on one side and only forest on the other; they still could not get people into the street. Are you aware of different innovative trials around the way you might set this up to get around these issues?

Mr Farmer : What we have been involved with is we were invited by the sexual health and BBV program to negotiate with some regional hospitals about the installation of a vending machine. That involved me actually going and talking to hospital staff and working with them around where it might best be located within a hospital campus. It needs to be accessible by clients who want it, in a discreet way—but not so discreet that, if somebody chose to shoot up right there on the spot, they would not be observed. That has been an interesting process around where we may or may not locate a machine with a hospital campus.

But that is a double-edged sword. It does offer anonymity for clients accessing the service but they do not have the opportunity of the brief intervention that they may get—and I stress, may get—if they were accessing a public health unit or an ED, for example.

CHAIR: Ms Rowell, you mentioned rapid testing and how it might cause behavioural change if it was done with the NSP programs. Is there any evidence base to support that?

Ms Rowell : There have been a few studies around. I cannot quote any at the moment, I am sorry; but there are a few people in the audience who might be able to, down the track, for you.

CHAIR: Maybe when their time comes.

Ms Rowell : Yes. But when you talk to people as well you hear that, when people inject, they take calculated risks. If you know that you are hep C negative and you are going to share, you might inject first, rather than follow someone else. Knowing your status may change the way you actually make those choices.

CHAIR: The rapid testing, how long does it take?

Ms Rowell : Up to about 30 minutes, usually.

Ms HALL: We have heard a lot about the needle exchange program. I have two questions. First of all, is the needle exchange program the only answer as far as preventing the spread of hepatitis C? I would have thought there was a role for education as well; in everything that I have read in relation to this inquiry there was only one mention, in any of the information, about education. Education is one aspect that needs to be expanded. What sort of programs need to be put in place and how can that get out, not only to those people who are already hep C positive, but to those people who are not as yet hep C positive?

Mr Farmer : It is part of our remit to provide education to the community generally. Obviously youth is a priority group for us and, within that, youth at risk would be an even higher priority. Sally and I have a lot of experience in going into schools, for example, to provide education around safe sex and injecting drug use. Certainly, that is where I started my career in the blood-borne virus sector. When you walk into a classroom of 15-year-olds and you say you are going to talk about safe sex and you pull out a dildo and you are going to demonstrate to them how to put on a condom, they are riveted. You get their attention because it is on their radar and most of them are probably engaging in sexual behaviours. But when you walk in and you say you are going to have a session about hepatitis C and you are going to talk about injecting drug use, by and large it is not on the radar of young people at that age. There may be a small number of them who go on to experiment or become injecting drug users later on.

We have found it challenging to try and engage with young people in what I would call the mainstream—through schools, for example. The best opportunity for us is to work with youth at risk through particular youth services or youth sporting events that are implemented to capture young people who might be at risk of being on the streets, like Midnight Basketball, for example. We try and engage with those kinds of activities. We work closely with Outcare, which is a facility that engages with young Aboriginal people who have brushed up against the justice system or been through the justice system. We have had and have a very good relationship with them because we know that they are at risk, not only of injecting but also of unsafe tattooing—backyard tattooing, for example. We cannot look at mainstream stuff; we have to look at very targeted ways that we can engage with young people.

Ms HALL: Thank you very much. The other question I wanted to ask was around the needle exchange program. I agree that it is vitally important for tackling the issue of hep C, but my question and concern revolves around what backup support program is in place to go along with the needle exchange program. If we had a program in prisons, when a person is released, what about the follow-through and looking at the whole person, not just the one aspect of the treatment of hep C? Would you like to expand on that one for me, please?

Mr Farmer : We recognise that that time, that period when people get out of prison and transition back into the community, is a critical time. It is my understanding that people do fall through the net around a number of issues. That has certainly been acknowledged in our discussions with clinical staff in prisons. They recognise that people who may have been preparing for treatment or who in fact are on treatment, when they get out of prison, are lost when they get into the community. We recognise that an organisation like Outcare, for example, is a very valuable partner, because they do provide services to support the people in the 12 months after they are released from prison. We recognise that if we want people to remain aware of hepatitis C and risk factors, we need to access those people through Outcare and its outreach staff and support staff.

Ms HALL: And for the people who are not in prison—what extra support do they get?

Ms Rowell : An NSP is not just somewhere where someone comes and gets their equipment. There is a lot more that happens. Once a rapport been built with a client, that actually becomes one of the very few places where they can talk openly, they can be honest about who they are and what they are doing, and they start to ask questions. We are asking questions all the time. Suddenly this relationship happens where you are actually able to spend some time with that person. Maybe they need to be referred to a doctor because they have a gaping abscess that is just hideous and they are not doing anything about it; or they are being beaten by their partner and they do not know where to go or what to do. There are a whole range of things that NSPs do, but that is the hook to get them in. There are people that come that do not want to take drugs any more: 'I don't know what to do. All my friends take drugs; what do I do?' 'Okay, let's get you somewhere that is safe that you can go to.'

So when you are talking about an NSP, we look at the whole person. Whilst our remit is to stop the transition of blood-borne viruses, it is actually about the health and wellbeing of these hard-to-reach and really vulnerable people.

Ms HALL: What happens to the people who are on the waiting list?

Ms Rowell : Of hep C treatments? They keep waiting.

Ms HALL: What is their long-term prognosis?

Ms Rowell : Some might die.

Mr WYATT: If we go back to sexually transmitted diseases, as they were known in the 80s and 90s, if you thought you had an STD then, you would go to a sex clinic. In WA it was Moore Street; in other capital cities it was other locations. Then it was devolved to GPs, so the stigma then dissipated. Would that be a solution to dealing with the stigma for people with Hep C, instead of having to go to specialists, working through their GPs?

Mr Farmer : Potentially, it should be—if GPs are not judgemental. We do get anecdotal evidence consistently back that people are reluctant to access GPs because they feel that they are discriminated against. My personal experience is that, because I also live with a blood-borne virus, I have never had a GP that has discriminated against me on the basis of that. But I turn up and I am a responsible client or patient. So I think there are difficulties around dealing with people who are currently injecting drugs and their lifestyle; that is where it might impact on the way that they are perceived by medical services, including GPs. Does that make sense?

Mr WYATT: Yes, it does, thank you.

CHAIR: Okay, thank you for giving the evidence, unfortunately we have run out of time. We appreciate you coming along and making time, but if you have been asked to provide additional information could you please forward to the secretariat by Tuesday, 24 March. If the committee has any further questions, we will send them to you in writing through the secretariat. From some of the evidence you have given, we might have some more questions. Yes, we do appreciate your time and thank you for coming along today. And I am sorry for the drilling.