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
Number Positive ¦ Number Tested
Number Positive ¦ Number Tested
Number Positive ¦ Number Tested
Number Positive ¦ Number Tested
Number Positive ¦ Number Tested
Number Positive ¦ Number Tested
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
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
Ireland, prisons, saliva
Ireland, prisons, saliva
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
.
Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
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
Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
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
Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
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
Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
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