HIV among PWID in Europe:

Update of a regional risk

assessment

Joint project by EMCDDA and ECDC

DRD-DRID key indicator meeting, EMCDDA

Lisbon 18 October 2013

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Overview

• Background

• Indicators

• Results

• Discussion

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HIV incidence among IDU in EU/EEA steadily

decreasing since the early 2000s

2011 increases in HIV infection among IDU

- Greece (June-July 2011)

- Romania (November 2011)

15th November 2011: request from DG SANCO

to ECDC and EMCDDA to carry out a rapid

risk assessment at EU level.

Background

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Background

• Joint risk assessment covering 31 EU/EEA countries

(EMCDDA and ECDC, 2011; Pharris et al., 2011);

• Multilateral follow-up meetings: March 2012 Tallinn,

October 2012 Lisbon

• Updates Greece and Romania, commissioned by

EMCDDA: October 2012

• ECDC Risk Assessment Greece (2012)

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Updated Risk Assessment 2013: Indicators

• Trend in reported HIV diagnoses among PWID 2010-

2012;

• HIV prevalence increase;

• HCV prevalence increase;

• Other injecting risk increase (IDU increase, market

changes, new substances);

• Proportion of opiate users receiving OST;

• Number of syringes per PWID per year;

• Changes in prevention funding.

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Data

Results of rapid inquiry (May-June 2013) Recent changes in HIV case reports/prevalence, injecting risk

and/or prevention coverage

Plus:

1. HIV case reports 2010-2011(Tessy)

2. HIV and HCV prevalence (Stats Bull 2013)

3. OST and NSP coverage (Stats Bull 2013)

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Response/ available data

• Updated HIV diagnoses 2012: 22 countries • 2012-data not avaiable from: AT, BE,CY, FR, IT, SI, ES, TK.

2012-data preliminary, reporting delays likely;

Surveillance changes /increased testing in 4 countries.

• HIV prevalence 2010-2012: 19 national, 7

subnational data only

• OST coverage/client data: 20/25 countries

• NSP coverage/syringe data: 13/22 countries

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New HIV diagnoses among PWID in Greece and Romania, 2004-2012

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Results

Greece • 2005 to 2010: 9 - 22 cases of HIV among IDU annually

• 2011: 245 cases

• 2012: 522 cases

Romania • 2007 to 2010: 3 - 9 cases of HIV among IDU annually

• 2011: 108 cases

• 2012: 255 cases

10

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HIV infections diagnosed, transmission mode IDU,

per 100.000 population – 2010-2012

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Results 2013

NO ALERT- no evidence for increase/satisfactory coverage

ALERT- evidence for increase/low coverage

Information unknown/not reported to ECDC/EMCDDA

Country AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LI LT LU MT NL NO PL PT RO SK SI ES SE TR UK

Increase in HIV case reporting and/or

prevalence

Increase in transmission risk indicators

(↑ HCV, IDU prevalence, risk increase )

Low prevention coverage (< 30% OST and/or <100

syringes/ IDU/yr)

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Results HIV trends

• Most countries report a low incidence of HIV cases

among PWID

• Outbreaks in Greece and Romania continue • Rate per 100.000 population increased twenty-fold in Greece (0.2 to

4.6) and thirty-fold in Romania (0.04 to 1.2).

• Greece: mostly confined to Athens region.

• Romania: most cases male residents of Bucharest under 30 years.

• 25 countries stable or declining rates of HIV

diagnoses in PWID;

• Trends in HIV diagnoses unclear in: EE, LV, AT, BG.

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Results injecting risk and prevention coverage

• Increased injecting of stimulants: RO, HU • Methamphetamine injecting reported in 2011 risk assessment in EL

and AT not confirmed as replacing opiates

• Increases in HCV prevalence or very high HCV

prevalence in 9 countries • BE (Flemish Comm.), BG (Sofia), Cyprus, Estonia (Narva), Greece,

italy (5 regions), Latvia, Romania (Bucharest), Turkey.

• OST coverage 4-20%: six countries • CY, HU, LV, LT, PL, SK

• NSP coverage below 100/year: six EU countries • BE, CY, GR, HU, RO, SK. NSP unavailable in Turkey

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Coverage of Opioid substitution treatment

(opioid substitution treatment clients as % of problem opioid users, 2011)

0

10

20

30

40

50

60

70

80

90

100

Op

ioid

mai

nte

nan

ce t

reat

men

t cl

ien

ts (

%)

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Number of syringes per PWID Syringes distributed through specialised programmes, 2011

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Results: Changes in prevention funding

• Replies from 27 countries

• Does existing harm reduction funding (OST/NSP etc)

meet the needs of PWID in your country? • NO: 12 countries, incl. AT and FR highlighting the lack of responses in

prisons; and DE sees insufficient NSP coverage in rural areas. Others:

CY, EE, GR, HU, LT, LV, RO, SE and HR.

• YES: 9 countries.

• Missing data/no information: 6 countries

• Did prevention funding and harm reduction funding

targeting IDU change between 2010 and 2012? • Decrease: FI, HU, SK, ES (less need); drug-NFPs: GR, LT and inf-dis

Correspondents RO, HR.

• Increase: BG, EE, LU, Iceland; drug-NFPs: HR, RO. Inf-dis

Correspondent GR.

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Discussion

• HIV among PWID stable or declining in much of

EU/EEA;

• Implementation of prevention services relatively high;

• Ongoing outbreaks in GR and RO;

• Potential for further outbreaks in further 10 countries

where substantial proportions of PWID have limited

access to prevention services and recent sub-

national trends may indicate risk, or HIV incidence

remains high.

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Discussion

• Market changes, leading to transitioning of opiate

users to stimulant injecting;

• Changes in drug use patterns have important

imlications for HIV prevention, e.g. expanded syringe

provision necessary;

• Role of stimulant injecting to be further explored;

• More effort into attracting stimulant users into

treatment, e.g. active outreach;

• Importance of the risk environment and contextual

factors, e.g. repressive policing

• Economic crisis /limited funds challenge effective

response.

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Next steps

• Reitox Academy for IPA 4-Beneficiaries: Sarajevo 29-30

October 2013:Albania, Bosnia and Herzegovina, FYROM,

Kosovbo, Montenegro, Serbia.

• Joint ECDC-EMCDDA Expert meeting: Detecting and

responding to outbreaks of HIV among people who inject

drugs, 18-19 Nov 2013, Bucharest: RO, GR, BG, HU, SK, CY;

• Reitox regional Academy : Monitoring trends and responses

to drug-related infectious diseases among people who inject

drugs, 21-22 Nov 2013, Tallinn: EE, LV, LT, PL

• Evaluation and optimizing of the risk assessment method

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Acknowledgements

• EMCDDA Reitox Focal Points: DRID experts,

responses experts

• ECDC HIV/AIDS Surveillance contact persons

• Co-authors: Dagmar Hedrich, Eleni Kalamara, Otilia

Sfetcu, Anastasia Pharris, André Noor, Lucas

Wiessing, Vivian Hope, Marita van de Laar.

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• Thank you.