HA-REACT Joint Action on HIV and co-infection
prevention and harm reduction
3rd EU Health Programme
Call: HP-JA-2014, Topic: JA-02-2014
9.4.2015 Mika Salminen/Outi Karvonen 1
A proposal for a Joint Action project under the EU Health Programme 2014 call
• Addresses Annual Work Programme, subheading 2.2.1.2. “Improvement of HIV and co-infection prevention and treatment in priority regions and priority groups in the European Union”
• Addresses all 4 priorities of the programme:
– promoting healthy lifestyles
– protection from cross border threats
– contributes to priorities 3 and 4, as several work packages of the proposal address the access to care in particularly vulnerable groups and settings
• Addresses the Communication from the Commission [COM(2009)569] on “Combating HIV/AIDS in the European Union and neighbouring countries, 2009 -2013” and its [SWD(2014)106] action plan extension 2014-2016
9.4.2015 Mika Salminen/Outi Karvonen 2
Persons who inject drugs (PWID) are at increased risk of infections
• HIV, TB and hepatitis B/C infection are still very relevant health problems in the EU for people who inject drugs.
• Poor access to safe injection equipment leads to sharing, creating high risk of blood-borne epidemics
• TB infection is highly associated with poverty and marginalisation, common to many PWID populations
3
Infections for which persons who inject
drugs may be at increased risk
HIV infection;
hepatitis A;
hepatitis B (HBV);
hepatitis C (HCV);
hepatitis D;
tuberculosis (TB)
skin and soft tissue infections caused by
Staphylococcus aureus (including methicillin-
resistant Staphylococcus aureus, MRSA) and
streptococcal infections (e.g. endocarditis,
necrotising fasciitis);
severe systemic sepsis (e.g. infections with
Clostridium novyi, Bacillus anthracis);
STIs other than HIV infection or hepatitis (e.g.
chlamydia infection, syphilis and gonorrhoea);
respiratory infections such as pneumonia,
diphtheria and influenza;
wound botulism;
tetanus;
human T-cell lymphotropic virus (HTLV)
infections.
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Rate /
100 000 population
20 to 49
10 to 19
5 to 9
< 5
≥ 50
> 5
3 to <5 1 to <3
< 1
Rate / 100 000
population
5 to 9.9%
1 to 4.9%
≥10%
< 1%
HIV
TB
HIV+TB
Geographic concentration of blood-borne infections and TB among PWID
Purpose of the action
• To stop (eradicate) transmission of blood-borne and poverty related infectious diseases among people who inject drugs (PWID) in the EU
• By implementing country-tailored preventive interventions, using well tried evidence based harm reduction approaches
• Creating sustained, improved capacity of all EU countries to respond to infection risks and vulnerabilities among (PWID)
• With a specific focus on Latvia, Lithuania and Hungary, but engaging all partner countries
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EU Priority groups
Comprehensive prevention
service package
Integrated, comprehensive public health service approach with an emphasis on capacity development
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Coordi-
nation
Dissemi
nation
Evalu-
ation
Selected
partner
countries for
capacity
development
Direct support
from the project
funds
Partners with
exiting
comprehensive
services
packages and/or
experience in
overcoming
structural
barriers and
issues of
sustainability
EU Priority
Regions
Direct
support
Training
and bench-
marking
ECDC & EMCDDA joint guidance
– Comprehensive Guidance document
• Based on evidence and fully referenced
– Two part evidence assessment
1. Needle and syringe programmes and other interventions for preventing hepatitis C, HIV and injecting risk behaviour
2. Drug treatment for preventing hepatitis C, HIV and injecting risk behaviour
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Seven interventions,
one aim: no
infections
Seven key recommended interventions
• INJECTION EQUIPMENT: Provision of and legal access to clean drug injection equipment, including sufficient supply of sterile needles and syringes, free of charge, as part of a combined multi-component approach, implemented through harm-reduction, counselling and treatment programmes
• VACCINATION: hepatitis A and B, tetanus, influenza vaccines, and, in particular for HIV-positive individuals, pneumococcal vaccine
• DRUG DEPENDENCE TREATMENT: Opioid substitution treatment and other effective forms of drug treatment
• TESTING: Voluntary diagnostic testing with informed consent for HIV, HCV, (HBV for unvaccinated) and other infections including TB should be routinely offered and linked to referral to treatment
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INFECTIOUS DISEASE TREATMENT: Antiviral treatment based on clinical indications for those who are HIV, HBV or HCV-infected. Anti-tuberculosis treatment for active TB cases. TB prophylactic therapy should be considered for latent TB cases.
HEALTH PROMOTION: health promotion focused on safer injecting behaviour; sexual health including condom use; and disease prevention, testing and treatment
TARGETED DELIVERY OF SERVICES: Services should be combined and organised and delivered according to user needs and local conditions; this includes the provision of services through fixed sites offering drug treatment, harm reduction, counselling and testing, and referrals to general primary health and specialist medical services.
COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION SYNERGY AND EFFECTIVENESS
• Ensure confidentiality.
• Promote service accessibility.
• Create a user-friendly atmosphere.
• Engage in dialogue with users and
promote peer involvement.
• Adopt a practical approach to the
provision of services.
• Refrain from ideological and moral
judgement.
• Maintain a realistic hierarchy of goals.
Core values of prevention of infections among people who inject drugs
A pragmatic approach to health promotion
The clients’ rights perspective
Public health objectives Guidance based on scientific evidence and expert experience
Principles of prevention
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Correlation of service increase and annually reported cases of HIV infection
0
1 000 000
2 000 000
3 000 000
4 000 000
0
20
40
60
80
100
Equipment exchanged
Annually rate
Focusing the action: use of ECDC and EMCDDA objective selection criteria
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AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LT LU MT NL NO PL PT RO SK SI ES SE UK
HIV trendHIV case reports and prevalence
(15% weight; no increase in case
reports or prevalence=0;
increase in one=1; increase in
both=2; high without an
increase=1)
0 0 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 1 0 0 0 0 0 0 2 0 0 0 0 0
Transmission riskprevalence of injecting drug use,
changes in injecting risk
behaviour (HCV prevalence and
trends) (10% weight; no
changes=0; moderate increase
in one criteria=1; increase in >1
criteria=2)
0 0 2 0 1 2 0 2 2 2 0 0 0 2 0 0 0 0
OST coverage% estimated problem opiate
user population receiving OST
(cut-off 30%) (25% weight; OST
coverage >30%=0; no data=1;
OST coverage <30%=2)
0 1 1 0 0 0 1 1 1 0 0 0 2 1 0 0 2 2 0 0 0 0 2 1 1 2 0 0 1 0
NSP coverageNumber of syringes given out
per PWID per year (cut-off 100
syringes) (25% weight; NSP
coverage >100=0; no data=1;
NSP coverage<100=2)
1 2 1 0 2 0 1 0 0 1 1 2 2 1 1 1 2 1 0 1 1 0 1 1 2 2 1 0 1 1
Taking part in the Joint Action x x x x x x x x x x x x x x x x x x x x
Scores (maximum 2)0,3 0,8 1 0 0,6 0 0,5 0,6 0,3 0,3 0,3 0,9 1,2 0,5 0,3 0,3 1,5 0,9 0 0,3 0,3 0 0,8 0,5 1,3 1 0,3 0 0,5 0,3
Ranking of those participating in
the JA (1=greatest
need/opportunity to improve
harm reduction situation) 6 3 8 5 2 1 4 6NO ALERT – no evidence for increase in case reports or HIV/HCV prevalence and/or transmission risk and/or low intervention coverage
CONCERN - Subnational increase in HIV/HCV prevalence and/or transmission risk or consistent but non-significant rise at national level.
ALERT – evidence for significant increase in case reports or HIV/HCV prevalence and/or increase in transmission risk and/or low intervention coverage.
Information unknown/not reported to EMCDDA/ECDC.
Table 1: Indicators of HIV trend, transmission risk and prevention coverage
Structure of the Joint Action
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HIV and co-infection prevention and treatment in priority regions
and priority groups in the European Union improved
Improved capacity of countries to respond
to HIV and co-infection risks and
vulnerabilities with specific focus on people
who inject drugs (PWID) in Latvia, Lithuania
and Hungary
0.
Management
of the Joint
action
1. Provision of
low threshold
services for
PWID
2. Harm
reduction and
continuity of care
for prisoners
3. Promotion of
quality of care
models for PWID
4. Programme
capacity of
countries
WP1
Coordination
WP2
Dissemination
WP3 Evaluation
WP4 Implement
early diagnosis
WP5 Scale up
harm reduction
WP6 Increase the
access to harm
reduction services
and continuity of
care for drug users
in prisons
WP7 Promotion
of quality of care
models to
increase access,
uptake and
quality of HIV,
HCV and TB
treatment.
WP8 Mapping
the barriers for
access and
quality delivery
of services
Support the
development of
sustainable
national HIV and
co-infection
programmes
Associated and affiliated partners: 24+2 from 19 countries
• Belgium (BE) Modus vivendi asbl
• Croatia (HR)
– Croatian institute of Public Health (HZJZ)
– Life Quality Improvement Organisation FLIGHT (LET)
• Czech Republic (CZ) National monitoring center for drugs and additions (NMS)
• Denmark (DK) Centre for Health and Infectious disease Research, Rigshospitalet University of Copenhafen (CHIP)
• Estonia (EE) National Institute for Health Development (NIHD)
• Finland (FI) National Institute for Health and Welfare (THL)
• Germany (DE)
– Zentrum fur interdisziplinare Suchtforschung der Universitat Hamburg (ZIS)
– Institut fur Suchtforschung (ISFF)
– Deutsche AIDS-Hilfe (DAH)
• Affiliated: Germany (DE) AIDS Action Europe (AAE)
• Greece (EL) Hellenic Center For Disease Control and Prevention (HCDCP)
9.4.2015 Mika Salminen/Outi Karvonen 13
• Hungary (HU)
– OEK (National Centre for Epidemiology) (Országos Epidemiológiai Központ)
– Office of the Chief Medical Officer (OCMO), (OTH, Országos Tisztifőorvosi Hivatal)
• Iceland (IS) Landspitali University Hospital
• Italy (IT) Istituto Nazionale Malattie Infettive (INMI)
• Latvia (LV) Center For Disease Prevention and Control of Latvia
• Lithuania (LT)
– Center For Communicable Diseases And Aids (ULAC)
– Vilnius Center For Addictive Disorder (VPLC)
• Luxembourg (LU) Directorate of Health (Ministry of Health) – Division of Health Inspection
• Malta (MT) Ministry for Energy and Health (MEH)
• Poland (PL) National AIDS Centre of the Ministry of Health (NAC Poland)
• Portugal (PT) Directorate-General of Health (DGS)
• Slovenia (SI) Association SKUC
• Spain (ES) Instituto de Salud Carlos III (ISCIII)
– Affiliated:Centro de Investigacion Biomedica end Red (CIBER)
Collaborating partners: 12 with an additional 4 countries and 2 EU agencies • Norway (NO) Norwegian Institute of
Public Health, Oslo
• Sweden (SE) Public Health Agency of Sweden, Stockholm
• United Kingdom (UK) Department of Health, London
• Cyprus (CY) Medical and Public Health Services of the Ministry of Health of the Republic of Cyprus
• Czech Republic (CZ):
– The Czech AIDS help Society (CSAP)
– The national institute of Public Health (SZU)
– Ministry of Health (MZ CR)
• Spain (ES) Coordinadora Estatal de VIH-SIDA (CESIDA)
• Belgium (BE) Free Clinic
• Lithuania (LT) Vilnius University
• EU Agencies
– European Centre for Disease Prevention and Control (ECDC)
– European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
9.4.2015 Mika Salminen/Outi Karvonen 14
Thank you for your attention!
9.4.2015 Mika Salminen/Outi Karvonen 15