HCV in injecting drug users: developing indicators of prevalence and responses

1. 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, Lucas.Wiessing@emcdda.org

2. EMCDDA activities on HCV, HBV and HIV in IDUs • Collect existing data on prevalence rates in IDUs (HIV, hepatitis B/C) using standardised data collection form (‘standard table’) • Stimulate seroprevalence studies and screening in routine settings using comparable methods / questionnaire (EU Network established)

3. 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

4. Drug treatment Low-threshold /needle exchanges Prisons (arrests) Overdose deaths Public Health Labs STD clinics Pregnant women Hospitals --- Community studies Notifications Existing Data : sources / settings

5. 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

8. 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)

15. 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

16. . Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

17. Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

18. Source: Min. Health

19. 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

20. VEdeTTE Study ( V alutazione dell’ E fficacia de i T rattamenti per le T ossicodipendenze da E roina) 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 SalaminaEpidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

21. Giuseppe SalaminaEpidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

29. 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)

30. Prevention / responses to HIV and HCV in IDUs

31. Spain France Italy Total 70 60 T 50 40 n 30 S 20 F I 10 0 1988 89 90 91 92 93 94 95 1996 Start-up year of SEP’s in Spain, France and Italy (PESESUD, CEESCAT 1998)

32. 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

33. “Stéricup” - hepatitis prevention (E. Imbert et al: http://www.steribox.tm.fr/

40. SEPs and pharmacies developing as complementary services?

41. Incidence of problem opiate use by back-cal-culation from drug treatment data (Amsterdam) EMCDDA 2000; Rossi C, Ravà L et al. submitted

42. Incidence of problem opiate use by back-calculation from drug treatments (Italy)EMCDDA 2000; Rossi C, Ravà L et al. submitted

43. 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

44. 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…)

45. 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

47. 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

48. 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