HCV in injecting drug users: developing indicators of prevalence and responses

HCV in injecting drug users: developing indicators of

prevalence and responses

VHPB WHO Consultation Meeting

Geneva, 13 May 2002

Lucas Wiessing

European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal, [email protected]

EMCDDA activities on HCV, HBV and HIV in IDUs

1. Collect existing data on prevalence rates in IDUs (HIV, hepatitis B/C) using standardised data collection form (‘standard table’)

2. Stimulate seroprevalence studies and screening in routine settings using comparable methods / questionnaire (EU Network established)

Data collection system for aggregated existing data

• Standard reporting tables for aggregated data on

epidemiology and prevention

• Data from expert networks and national drug focal

points to EMCDDA –> annual report

(http://annualreport.emcdda.org/)

• Yearly EU expert meeting, national meetings

• Definition and mapping of potential data sources

Existing Data : sources / settings

Drug treatment

Low-threshold /needle exchanges

Prisons (arrests)

• Overdose deaths

• Public Health Labs

• STD clinics

• Pregnant women

• Hospitals

---

Community studies

Notifications

Data collected in standard table

• Methodological items such as type of data source, def. IDU, serological markers

• Total sample size, nr valid tests, number positive tests, % HIV positive in IDUs

• Same data, broken down for age (<25, 25-34, >34), gender, years injected (<2, >=2), opiate use or not

1 Definition of injectors (Note: if possible data for current injectors only)

1a How long have they injected

Both

2 Gender Males only Females only Both

3 Age range from to years

4 Recruitment area (Geographical Coverage) [Indicate only one ]

Other (e.g. rural)

4a

Yes No

5 Data source(s) [Tick all that apply ]

Other

6 Method of data collection

6a Describe the sampling method:

Exhaustive (all eligible individuals) Sampling

(Public Health) Laboratories Arrests

Specify Not Know

Needle Exchanges Hospitals

Low threshold services Prisons

If the geographical coverage is the whole country or two or more regions / cities, can the data be provided for each individual region / city

Overdose deaths and/or non-fatal emergencies STD clinics

Drug Treatment Centres Pregnant women

The whole country Two or more regions / cities

Only one region / city Not known

<2 years Not known

Not known

Not known

2 or more years

Ever Current (i.e. injected in last 12 months)

For guidance go to Notes worksheet

Country Date

among recent injecting drug users in EU Countries (Version 18.09.01)EMCDDA standard reporting table: Prevalence of hepatitis B/C and HIV infection

Indicate the geographical area described in question 3. If data for sub-areas are available - in particular for capital cities or major urban areas,

complete a separate copy of this page for each region/city or other area

If data for more than one test is available use a separate copy of this page for each set of results

In Row 1: Indicate the total sample size of injectors. In Row 2: Indicate the number of injectors who tested positive only.

In Row 3: Indicate the total number of injectors who tested positive or negative for the test indicated above.

In Row 4: Indicate the percentage who tested positive (row 2 divided by row 3).

Row 1992 1993 1994 1995 1996 19971234

In Rows 5–13: Indicate the percentage of the sub-groups that are infected, then the number who were positive

Row 1992 1993 1994 1995 1996 19975

5a

66a

7

7a

88a

99a

1010a

1111a

1212a

For guidance go to Notes worksheet

Results for geographical area

What virus was reported (from 8a) What marker was tested for (from 8b)

YearTotal sample size of injectors (IDUs)No. of IDUs with a positive test resultTotal no. of IDUs tested

IF AVAILABLE

Percentage infected

and the total number tested for each of the sub-groups described.

Year

Number Positive ¦ Number Tested








MALES percent infected

FEMALES percent infected

IDUS AGE < 25 percent infected

OPIATE USING IDU percent infected

IDUS AGE 25 - 34 percent infected

IDUS AGE > 34 percent infected

RECENT ONSET IDU (see note) percent

LONGER TERM IDU (see note) percent

Problems / limitations

• Data from many ad hoc sources (comparability)• Non-injectors not always excluded• Self reported test results • Some small sample sizes (esp. breakdowns)• Sampling/selection procedures not always clear • Much drug treatment data available, other sources

much less• Few studies that are repeated (follow trends)

HCV prevalence in IDUs, from different settings

0%

25%

50%

75%

100%

1996 1997 1998 1999 2000 2001

Austria low threshold

Austria treatment

Belgium, Flemish Community, treatment treatment

Belgium, Antw erp, low threshold

Belgium, French Community, treatment

Funen, Denmark, prison/treatment

Greece, northern region, methadone

Greece, Athens, public health lab

Greece, prisons

Greece, central region, treatment

Greece, treatment

Ireland, Dublin, treatment

Ireland, prisons, saliva


Luxembourg, prisons, saliva

the Netherlands, Heerlen/Maastricht, community w ide study

the Netherlands, Den Haag, community w ide study

Coimbra, Portugal treatment

Porto, Portugal

Lisbon, Portugal, study

Finland, Helsinki, needle exchange, saliva

Finland, overdose deaths

Finland, prisons saliva

Engl/Wales excl London, treatment, saliva

Engl/Wales excl London, comm. surveys, saliva

England, prisons, saliva

London, treatment, saliva

London, comm.surveys, saliva

HCV prevalence in IDUs, prisons

0%

25%

50%

75%

100%

1996 1997 1998 1999 2000 2001

Funen, Denmark,prison/treatment

Greece, prisons



Luxembourg, prisons,saliva

Finland, prisons saliva

England, prisons, saliva

HCV prevalence in IDUs, drug treatment

0%

25%

50%

75%

100%

1996 1997 1998 1999 2000 2001

Austria treatment

Belgium, Flemish Community, treatment

Belgium, French Community, treatment

Greece, northern region, methadone

Greece, central region, treatment

Greece, treatment

Ireland, Dublin, treatment

Coimbra, Portugal treatment

Engl/Wales excl London, treatment, saliva

London, treatment, saliva

HCV prevalence in IDUs aged <25, from different settings

0%

25%

50%

75%

100%

1996 1997 1998 1999 2000

Flemish Belgium, treatment, n=65

Greece, treatment, n=115; 248

Greece, Athens, publ hlth lab, n=324

Ireland, Dublin, treatment, n=535

Austria, Vienna, low threshold, n=50; 51

Coimbra, Portugal treatment, n=70

Helsinki, Finland, needle exchanges,n=97

England and Wales, excl London,community w ide surveys, n=210

Italy, treatment, n=226

England and Wales, excl London,treatment, saliva, n=784; 843

England, London, treatment, saliva,n=51; 95

HCV prevalence in recent onset injectors (< 2 years injecting)

n=121

n=84 n=43n=216

n=137

0%

25%

50%

75%

100%

1996 1997 1998 1999 2000

England and Wales, community widestudy (J udd et al. AIDS 2000)

Coimbra, Portugal, diagnostictesting in drug treatment

Ireland treatment, injected 1-12months, selfreported (Smyth et al. JEpidemiol Comm Health 1999)

Ireland treatment, injected 13-24months, selfreported (Smyth et al. JEpidemiol Comm Health 1999)

Italy: Surveillance data from Public Drug Addiction Treating Centres

centres=518 in 1999;patients=142,651

- aggregated information annually collected - gender, age, type of client - type of substance - type of treatment - HIV, HBV, HCV test results

Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction

Piedmont Region - Turin - Italy

HCV prevalence among injecting drug users.518 Italian Public Drug Addiction Treating Centres

0

10

20

30

40

50

60

70

80

90

100

1992 1993 1994 1995 1996 1997 1998 1999 2000

%

0

10000

20000

30000

40000

50000

60000

70000

80000N

Total no. of IDUs tested

MALES

FEMALES

.



HCV prevalence by type of patient and gender: 518 italian drug treatment centres

0

10

20

30

40

50

60

70

80

90

100

1991 1992 1993 1994 1995 1996 1997 1998 1999

%

Old FemalesOld MalesNew FemalesNew Males



HCV in Italian IDUs in treatment, by region

0%

25%

50%

75%

100%

1997 1998 1999 2000

ITALYPiemonte Lombardia

Trentino Veneto FriuliLiguriaEmilia Romagna

Toscana Umbria Marche Lazio

Abruzzo Molise Campania PugliaBasilicata

Calabria Sicilia Sardegna

Source: Min. Health

HCV prevalence among injecting drug users by region. 518 italian drug treatment centres. 1999



VEdeTTE Study (V alutazione dell’E fficacia dei T rattamenti per le T ossicodipendenze da Eroina)

Design of the study Cohort prospective Follow up

At 36 months after enrollment (random sample of 1,500 patients) Update

- 112/518 Public Drug Treatment Centres (12/20 regions)

- 11,818 patients enrolled - preliminary analysis ongoing Giuseppe Salamina

Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

HCV test result from clinical records

pos neg pos 4770 66

92.1 neg 410 2322

97.2

HCV reported by the patient

total 5180 2388



HCV prevalence in routine treatment data vs. Vedette treatment study - regions in Italy, 1998

0%

25%

50%

75%

100%

Friuli

Ligu

ria

Emilia

Rom

agna

Tosca

na

Mar

che

Lazio

Campa

nia

Sicilia

Sarde

gna

routine

study

HCV prevalence Belgium, Flanderssource: De Sleutel, 2000

0

20

40

60

80

100

1997 1998 1999

total

male

female

<25

25-34

>34

HCV among needle exchangers in Helsinki, 2000 (n=157)

source: National Institute of Public Health

0

20

40

60

80

100

total males females <25 25-34 >34

Selfreported HCV prevalence in IDUs attending specialist treatment centers, France

(source: national focal point; DREES)

0

20

4060

80

100

1994 1995 1996 1997 1998 1999

total

male

females

<25

25-34

>34

HCV prevalence among Needle exchange attenders in France, 1998

(Valenciano et al. Addiction 2001)

0%10%20%30%40%50%60%70%

HCV prevalence among IDUs in treatment, Coimbra, Portugal 1999-2000

source: national focal point IPDT

0%20%40%

60%80%

100%

1999

2000

HCV prevalence among IDUs in England and Wales, community surveys 1998

(J udd et al. AIDS 2000)

01020304050

London

Elsewhere

Potential indicators of HCV prevalence in IDUs

• Prevalence in all IDUs in drug treatment

• Prevalence in IDUs getting first treatment

• Prevalence in IDUs in prisons

• Prevalence in IDUs under age 25

• Prevalence in new IDUs (< 2yrs injecting)

Prevention / responses to HIV and HCV in IDUs

Start-up year of SEP’s in Spain, France and Italy (PESESUD, CEESCAT 1998)

1988 89 90 91 92 93 94 95 1996

0

10

20

30

40

50

60

70

n

Spain France Italy Total

IFS

T

Effectiveness needle exchangesMacDonald M et al. preliminary results,

for similar paper on HIV see: Hurley SF et al. Lancet 1997; 349: 1797-1800.

• Ecological study: HCV prevalence/ incidence in cities with and without NSP

• 190 calendar years of data from 101 cities (41 cities without, 9 cities implemented between two studies, 51 already had NSP)

• Median prevalence: 75% without, 60% with NSP• Little change before introduction, followed by decline of

1.5-2% /yr after introduction NSP• Median prevalence in new injectors much lower in cities

with NSP (25% vs 66%)• HCV incidence /100 pyo: 16 (with NSP), vs. 25

“Stéricup” - hepatitis prevention (E. Imbert et al: http://www.steribox.tm.fr/

Syringe exchange programs/points: rate per million population

(absolute number in country)

(420)

(2) (2)(8)(6)(6)(>100)(355)(64)

(1007)

05

10152025303540

Pharmacies: rate per million population

0

200

400

600

800

1000

Estimated rate of IDUs per 1000 population of all ages

0.0

1.0

2.0

3.0

4.0

5.0

low estimate

high estimate

Estimated provision of syringe exchange programs/points per 1000

IDUs

0.0

5.0

10.0

15.0

20.0

25.0

high est.

low est.

Estimated coverage of syringe exchange programs (syringes per IDU

per year)

0100200300400500600

high est.

low est.

Availability of pharmacies per 1000 estimated IDUs

0200400600800

1000

low estimate

high estimate

SEPs and pharmacies developing as complementary services?

Syringes / IDU / year Pharmac./ 1000 IDUsUK (+pharm) 360 Greece 675Luxembourg 102 Belgium 248Czech Rep 68 France 181Slovak Rep 30 Czech Rep 150France 18 Finland 147Belgium 15 UK (E+W) 140Sweden 15 Sweden 58Greece 4 Luxembourg 46

Incidence of problem opiate use by back-cal-culation from drug treatment data (Amsterdam)

EMCDDA 2000; Rossi C, Ravà L et al. submitted

Incidence of problem opiate use by back-calculation from drug treatments (Italy)

EMCDDA 2000; Rossi C, Ravà L et al. submitted

Health care costs of HCV (red), HBV (yellow) and HIV (green) in millions of Euros for ten

EU-countries Postma M, Wiessing L, Jager J. Bull Narc. in press

0 200 400 600 800

UK

Spain

Portugal

Netherlands

Italy

Greece

Germany

France

Denmark

Belgium

Conclusions

• Indicators of HCV (and HIV, HBV) prevalence among IDUs in Europe are being developed

• Quality and comparability need to be improved (EMCDDA working groups)

• Differences in prevalence observed (UK low), effect of prevention?

• Preliminary data on coverage of specialized needle exchange services suggests it may be low in most countries (but pharmacies…)

Acknowledgements

• Giuseppe Salamina, Italy• Margaret MacDonald and Greg Dore, Australia• Anna Rodes, Spain• Carla Rossi and Lucilla Rava, Italy• Maarten Postma and Hans Jager, the Netherlands• Elliot Imbert and Julien Emmanuelli, France• National Focal Points of the EMCDDA• EMCDDA National EU Representatives on drug

related infectious diseases

Modelled rate of progression to cirrhosis. Individual dot points (and 95% confidence intervals)

correspond to cirrhosis prevalence at estimated mean duration of infection for each individual study

Freeman AJ et al. Hepatology 2001; 34:809-16

Modelled rate of progression to cirrhosis. Individual dot points (and 95% confidence intervals)

correspond to cirrhosis prevalence at estimated mean duration of infection for each individual study

Freeman AJ et al. Hepatology 2001; 34:809-16

Documents

HCV in injecting drug users: developing indicators of prevalence and responses