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Hans Blystad 1 and Lucas Wiessing 2 1 Norwegian Institute of Public Health

Guidance on Provider-initiated Voluntary Medical Examination, Testing and Counselling for Infectious Diseases in Injecting Drug Users. Hans Blystad 1 and Lucas Wiessing 2 1 Norwegian Institute of Public Health 2 European Monitoring Centre for Drugs and Drug Addiction.

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Hans Blystad 1 and Lucas Wiessing 2 1 Norwegian Institute of Public Health

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  1. Guidance on Provider-initiated Voluntary Medical Examination, Testing and Counselling for Infectious Diseases in Injecting Drug Users Hans Blystad1and Lucas Wiessing 2 1 Norwegian Institute of Public Health 2 European Monitoring Centre for Drugs and Drug Addiction HIV in Europe, Stockholm 2-3. November 2009

  2. A package of basic operational guidance in the meeting between the injecting drug user and the health care provider with regards to infectious diseases. Published at http://www.emcdda.europa.eu/

  3. HCV antibody prevalence among injecting drug users – studies with national and subnational coverage 2005-2006

  4. HIV cases newly diagnosed in IDUs per million population, European Union 2003-2007 Source: ECDC/WHO 2008; Wiessing et al Eurosurveillance 2008

  5. Background • blood borne viral infections and bacterial infections plays an important role in the general health situation and well being of IDUs. • need to increase access to and uptake of testing for HIV and other infectious infections • most existing guidelines on HIV-testing do not cover the special needs of IDUs satisfactorily and there is a lack of guidance on other infections

  6. Methodology • Document a result of discussions at the annual EU expert meetings held by the EMCDDA on drug-related infectious diseases (DRID) • Review of reports, position statements, policy documents, journal articles, guidelines and clinical guidelines • Recommendations given are based on good clinical practice and evidence based medicine when appropriate • Intended as a practical tool for health care providersin the public and private sectors who provide health care to (injecting) drug users

  7. Objectives • Improve the general health of the individual IDU • Improve testing uptake for HIV and other drug related infections • Increase access of IDUs to treatment for HIV and other infectious diseases • Improve diagnosis of chronic infections which need specialist care • Increase vaccination coverage in IDUs • Improve access of IDUs to prevention counselling and information • Improve surveillance of HIV infection, hepatitis and other infections in IDUs

  8. Infections often found in injecting drug users • HIV infection • Hepatitis A, B, C and D • Skin and soft tissue infections:Staphylococcus aureus (including MRSA) and streptococcal infections • Severe systemic sepsis (e.g. infections with Clostridium novyi, Bacillus anthracis) • Sexually transmitted infections • Respiratory infections e.g. pneumonia, diphtheria, influenza • Tuberculosis (TB) • Wound botulism • Tetanus • HTLV - infections

  9. Elements included in the package • Medical history and physical examination • Pre-test counselling, informed consent and possibility to decline tests • Testing for infections • Post-test counselling • Prevention counselling • Vaccination • Follow-up, treatment and referral routines • Frequency of examination and testing • Ethical considerations

  10. Medical history and physical examination IDUs • General • Skin and mucous membranes • Lungs • Heart • Digestive system • Genitourinary system

  11. Basic panel of recommended tests • HIV • Hepatitis A, B, C and D (if evidence of chronic or recent hepatitis B) • Syphilis • Tests for tuberculosis disease or latent tuberculosis • Swab for culture from abscesses and skin lesions • Tests for biochemical analysis (ALAT, ASAT, bilirubin) • Other general blood tests (ESR or CRP, haemoglobin and white blood cell count

  12. Additional panel of recommended tests • Serology for HTLV-infections • Swab or urine testing for genital chlamydial infections • Swab or urine testing for gonorrhoea

  13. Counselling • Pre-test counselling includiing informed consent and possibility to decline tests • Post-test counselling • Prevention counselling

  14. Recommended vaccinations • Hepatitis A +B combination vaccine (or separate hepatitis A and hepatitis B vaccines) • Diphtheria / Tetanus vaccine (every 5-10 years) • Influenzae vaccine (season or pandemic) • Pneumococcal vaccine (esp. if HIV positive and > 50 years of age)

  15. Possible facilities • Primary health care including general practitioners and family doctors • Special health services for IDUs delivered through mobile clinics, in other community settings, through harm reduction programmes or through other types of outreach. • Low threshold service centres visited by IDUs • Prison health care facilities • Rehabilitation centres and other drug treatment services • Dedicated STI clinics • Infectious diseases clinics • Tuberculosis clinics (countries with high incidence of tuberculosis among IDUs)

  16. Special considerations • Informed consent and possibility to decline test(s) • Opt-out /opt-in approach ? • Testing for tuberculosis • Use of guidelines in closed settings e.g. prisons • Minimize potential risks of negative effects of testing like discrimination and stigmatisation • Importance of training, ongoing supervision and monitoring of health-care providers, esp. in closed settings

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