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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
• Pregnant women
 Low-threshold /
needle exchanges
• Hospitals
 Prisons (arrests)
 Community studies
• Overdose deaths
 Notifications
• Public Health Labs
• STD clinics
---
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
For guidance go to Notes worksheet
Results for geographical area
Indicate the geographical area described in question 3. If data for sub-areas are available - in particular for capital cities or ma
complete a separate copy of this page for each region/city or other area
What virus was reported (from 8a)
What marker was tested for (from 8b)
If data for more than one test is available use a separate copy of this page for each set of results
In
In
In
In
Row
Row
Row
Row
Row
1
2
3
4
1:
2:
3:
4:
Indicate
Indicate
Indicate
Indicate
the
the
the
the
total sample size of injectors.
number of injectors who tested positive only.
total number of injectors who tested positive or negative for the test indicated above.
percentage who tested positive (row 2 divided by row 3).
Year
1992
1993
1994
1995
1996
1997
Total sample size of injectors (IDUs)
No. of IDUs with a positive test result
Total no. of IDUs tested
Percentage infected
IF AVAILABLE
In Rows 5–13: Indicate the percentage of the sub-groups that are infected, then the number who were positive
and the total number tested for each of the sub-groups described.
Row
5
5a
Year
MALES
percent infected
Number Positive ¦ Number Tested
6
6a
FEMALES
percent infected
Number Positive ¦ Number Tested
7
7a
IDUS AGE < 25
percent infected
Number Positive ¦ Number Tested
8
8a
IDUS AGE 25 - 34
percent infected
Number Positive ¦ Number Tested
9
9a
IDUS AGE > 34
percent infected
Number Positive ¦ Number Tested
10
10a
RECENT ONSET IDU (see note) percent
Number Positive ¦ Number Tested
11
11a
LONGER TERM IDU (see note)
percent
Number Positive ¦ Number Tested
12
12a
OPIATE USING IDU
percent infected
Number Positive ¦ Number Tested
1992
1993
1994
1995
1996
1997
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)
Austria low threshold
HCV prevalence in IDUs, from different settings
Austria treatment
Belgium, Flemish Community, treatment treatment
Belgium, Antw erp, low threshold
Belgium, French Community, treatment
100%
Funen, Denmark, prison/treatment
Greece, northern region, methadone
Greece, Athens, public health lab
Greece, prisons
Greece, central region, treatment
75%
Greece, treatment
Ireland, Dublin, treatment
Ireland, prisons, saliva
Ireland, prisons, saliva
Luxembourg, prisons, saliva
the Netherlands, Heerlen/Maastricht, community w ide study
50%
the Netherlands, Den Haag, community w ide study
Coimbra, Portugal treatment
Porto, Portugal
Lisbon, Portugal, study
Finland, Helsinki, needle exchange, saliva
25%
Finland, overdose deaths
Finland, prisons saliva
Engl/Wales excl London, treatment, saliva
Engl/Wales excl London, comm. surveys, saliva
England, prisons, saliva
0%
London, treatment, saliva
1996
1997
1998
1999
2000
2001
London, comm.surveys, saliva
HCV prevalence in IDUs, prisons
Funen, Denmark,
prison/treatment
100%
Greece, prisons
75%
Ireland, prisons, saliva
50%
Ireland, prisons, saliva
Luxembourg, prisons,
saliva
25%
Finland, prisons saliva
0%
1996
1997
1998
1999
2000
2001
England, prisons, saliva
HCV prevalence in IDUs, drug treatment
Austria treatment
Belgium, Flemish Community, treatment
100%
Belgium, French Community, treatment
Greece, northern region, methadone
75%
Greece, central region, treatment
50%
Greece, treatment
Ireland, Dublin, treatment
25%
Coimbra, Portugal treatment
Engl/Wales excl London, treatment, saliva
0%
1996
1997
1998
1999
2000
2001
London, treatment, saliva
HCV prevalence in IDUs aged <25,
from different settings
Flemish Belgium, treatment, n=65
Greece, treatment, n=115; 248
Greece, Athens, publ hlth lab, n=324
100%
Ireland, Dublin, treatment, n=535
75%
Austria, Vienna, low threshold, n=50; 51
Coimbra, Portugal treatment, n=70
50%
Helsinki, Finland, needle exchanges,
n=97
England and Wales, excl London,
community w ide surveys, n=210
25%
Italy, treatment, n=226
England and Wales, excl London,
treatment, saliva, n=784; 843
0%
1996
1997
1998
1999
2000
England, London, treatment, saliva,
n=51; 95
HCV prevalence in recent onset
injectors (< 2 years injecting)
100%
England and Wales, community wide
study (Judd et al. AIDS 2000)
75%
n=137
50%
n=84
n=43
Coimbra, Portugal, diagnostic
testing in drug treatment
n=216
Ireland treatment, injected 1-12
months, selfreported (Smyth et al. J
Epidemiol Comm Health 1999)
25%
n=121
0%
1996
1997
1998
1999
2000
Ireland treatment, injected 13-24
months, selfreported (Smyth et al. J
Epidemiol 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 Salamina
Epidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
HCV prevalence among injecting drug users.
518 Italian Public Drug Addiction Treating Centres
.
100 %
N
90
80000
70000
80
60000
70
50000
60
50
40000
40
Total no. of IDUs tested
MALES
FEMALES
30000
30
20000
20
10000
10
0
0
1992
1993
1994
1995
1996
1997
1998
1999
2000
Giuseppe Salamina
Epidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
%
HCV prevalence by type of patient and gender: 518 italian drug treatment
centres
100
90
80
70
60
Old Females
Old Males
New Females
New Males
50
40
30
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
Giuseppe Salamina
Epidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
HCV in Italian IDUs in treatment, by region
100%
75%
50%
25%
0%
1997
1998
1999
2000
ITALY
Piemonte
Lombardia
Trentino
Veneto
Friuli
Liguria
Emilia Romagna
Toscana
Umbria
Marche
Lazio
Abruzzo
Molise
Campania
Puglia
Basilicata
Calabria
Sicilia
Sardegna
Source: Min. Health
HCV prevalence among injecting drug users by region.
518 italian drug treatment centres. 1999
Giuseppe Salamina
Epidemiological Centre for the Monitoring of Drug Addiction
Piedmont Region - Turin - Italy
VEdeTTE Study
(Valutazione dell’ Efficacia dei Trattamenti per le Tossicodipendenze 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
reported by
the patient
pos
neg
total
HCV test result from clinical records
pos
neg
4770
66
92.1
410
2322
97.2
5180
2388
Giuseppe Salamina
Epidemiological 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
100%
75%
routine
50%
study
25%
Em
a
Sa
rd
eg
na
Si
ci
li
am
pa
ni
a
La
zi
o
he
M
ar
c
om
ag
na
To
sc
an
a
C
ili a
R
Li
gu
ria
Fr
iu
li
0%
HCV prevalence Belgium, Flanders
s o urc e : D e S le ut e l, 2 0 0 0
100
total
80
male
60
female
40
<25
20
25-34
0
1997
1998
1999
>34
HCV among needle exchangers in
Helsinki, 2000 (n=157)
s o urc e : N a t io na l Ins t it ut e o f P ublic H e a lt h
100
80
60
40
20
0
total
males
females
<25
25-34
>34
Selfreported HCV prevalence in IDUs attending
specialist treatment centers, France
(so urce: natio nal fo cal po int; D R EES)
100
80
60
40
20
0
total
male
females
<25
25-34
1994 1995 1996 1997 1998 1999
>34
HCV prevalence among Needle exchange
attenders in France, 1998
(Valenciano et al. Addiction 2001)
to
ta
l
m
al
e
fe
m
al
e
<2
5
25
-3
4
>3
4
re
ce
nt
lo
ng
te
rm
op
ia
te
no
op s
ia
te
s
70%
60%
50%
40%
30%
20%
10%
0%
HCV prevalence among IDUs in treatment,
Coimbra, Portugal 1999-2000
source: national focal point IPDT
to
ta
l
m
al
es
fe
m
al
es
<2
5
25
-3
4
>3
4
re
ce
nt
lo
ng
te
rm
100%
80%
60%
40%
20%
0%
1999
2000
HCV prevalence among IDUs in England and
Wales, community surveys 1998
(Judd et al. AIDS 2000)
to
tal
m
ale
fe
ma s
l es
<2
25 5
-3
4
>3
re 4
lo n cen
gte t
op rm
no iate
op s
i at
es
50
40
30
20
10
0
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)
Spain
France
Italy
Total
70
60
T
50
n
40
30
S
F
I
20
10
0
1988
89
90
91
92
93
94
95
1996
Effectiveness needle exchanges
MacDonald 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)
(355)
(>100)
(6)
(6)
(8)
(2)
(2)
Sp
ain
UK
(E
+W
Cz
)
ec
h
Re
p
Fr
an
ce
Ge
rm
an
y
Fi
nla
nd
Sl
ov
ak
Re
p
Be
lgi
um
Sw
ed
en
Gr
ee
ce
40
35
30 (1007)
25
20
15
(420) (64)
10
5
0
lgi
d
en
an
Sw
ed
Fi
nl
(E
+W
)
Lu
xe
m
bo
ur
g
Cz
ec
h
Re
p
UK
ce
um
ec
e
Fr
an
Be
Gr
e
Pharmacies: rate per million
population
1000
800
600
400
200
0
Estimated rate of IDUs per 1000
population of all ages
low estimate
high estimate
5.0
4.0
3.0
2.0
1.0
Lu
xe
m
bo
ur
g
Fr
an
ce
Be
lgi
UK um
(E
+W
Sw )
ed
en
Sp
ai n
Gr
ee
ce
Fi
nla
nd
Cz
ec
hR
ep
Ge
rm
an
Sl
y
ov
ak
Re
p
0.0
Estimated provision of syringe
exchange programs/points per 1000
IDUs
high est.
low est.
25.0
20.0
15.0
10.0
5.0
Sp
ain
UK
(E
+W
Cz
)
ec
h
Re
p
Fr
an
ce
Sl
ov
ak
Re
p
Ge
rm
an
y
Fin
lan
d
Gr
ee
ce
Be
lgi
um
Sw
ed
en
0.0
Estimated coverage of syringe
exchange programs (syringes per IDU
per year)
high est.
low est.
UK
Gr
ee
ce
ed
en
Sw
Be
lgi
um
Fr
an
ce
(+
ph
ar
m)
Lu
xe
mb
ou
Cz
rg
ec
h
Re
pu
Sl
bli
ov
c
ak
Re
pu
bli
c
600
500
400
300
200
100
0
Availability of pharmacies
per 1000 estimated IDUs
low estimate
high estimate
Sw
ed
(E
+W
)
UK
nla
nd
Fi
c
ub
li
en
Lu
xe
m
bo
ur
g
Cz
ec
hR
ep
Fr
an
ce
um
lgi
Be
Gr
ee
ce
1000
800
600
400
200
0
SEPs and pharmacies developing
as complementary services?
Syringes / IDU / year
UK (+pharm)
360
Luxembourg
102
Czech Rep
68
Slovak Rep
30
France
18
Belgium
15
Sweden
15
Greece
4
Pharmac./ 1000 IDUs
Greece
675
Belgium
248
France
181
Czech Rep
150
Finland
147
UK (E+W)
140
Sweden
58
Luxembourg
46
Incidence of problem opiate use by back-calculation from drug treatment data (Amsterdam)
EMCDDA 2000; Rossi C, Ravà L et al. submitted
Incidence of problem opiate use by backcalculation from drug treatments (Italy)
EMCDDA 2000; Rossi C, Ravà L et al. submitted
60000
Gamma 1.51 0.30 - w ith cov
Gamma 1.51 0.30 - w ithout cov
Weibull 1.28 5.33 - w ith cov
Weibull 1.28 5.33 - w ithout cov
40000
30000
20000
10000
Year
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
0
1975
DUs Incidence
50000
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
Belgium
Denmark
France
Germany
Greece
Italy
Netherlands
Portugal
Spain
UK
0
200
400
600
800
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