evaluare rapida noi cazuri hiv in romania si grecia 2011

8/3/2019 Evaluare Rapida Noi Cazuri Hiv in Romania Si Grecia 2011

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Rapid communications

Human immunodefciency virus in injecting drug usersin Europe ollowing a reported increase o cases inGreece and Romania, 2011

A Phrr ([email protected].)1, L Wg2, O S1, D Hrh2, A B3, A F4, G K Nk5, MMr6, M S1, J E Sk1, P Grfh2, M J v Lr 1

1. European Centre or Disease Prevention and Control (ECDC), Stockholm, Sweden2. European Monitoring Centre or Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal3. National Observatory on Drugs, National Anti-Drug Agency, Bucharest, Romania4. National Focal Point o the EMCDDA, University Mental Health Research Institute, Athens, Greece5. Hellenic Centre or Disease Control and Prevention, Athens, Greece6. Organisation Against Drugs (OKANA), Athens, Greece

C y r h r :Pharris A, Wiessing L, Setcu O, Hedrich D, Botescu A, Fotiou A, Nikolopoulos GK, Malliori M, Salminen M, Suk JE, Griths P, van de Laar MJ. Humanimmunodefciency virus in injecting drug users in Europe ollowing a reported increase o cases in Greece and Romania, 2011.Euro Surveill. 2011;16(48):pii=20032. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20032

Article published on 1 December 2011

Greece and Romania reported an increased number ofHIV cases among injecting drug users (IDUs) during2011. Most European countries reported no changesin the rate of newly diagnosed cases of HIV or HIVprevalence in IDUs; however, six countries did reportincreases and several additional countries reportedincreases in injecting risk indicators or low coverageof prevention services. These indicate a potential risk

for increased HIV transmission and future outbreaksunless adequate prevention is implemented.

In 2010, the number o newly diagnosed humanimmunodeiciency virus (HIV) cases among inject-ing drug users (IDUs) represent only 4% o the totalnumber o reported HIV cases in the European Union(EU) [1]. However, increases in HIV inections amongIDUs in Greece were reported in July 2011, throughthe European Monitoring Centre or Drugs and DrugAddiction (EMCDDA), ollowed by a reported increasein Romania in November 2011. Preliminary results othe investigation on the Greek outbreak were releasedin September [2] and November 2011, respectively [3].These subsequently led to a request rom the EuropeanCommission to carry out a rapid risk assessment at EUlevel.

Epidemiological situation ofHIV in Greece in 2011Since the beginning o 2011, the number o newlydiagnosed HIV inections has increased among IDUsin Greece. Between nine and 16 cases were reportedannually among IDUs during 2006-2010, representing2-3% o the total newly diagnosed HIV inections, while

during the irst 10 months o 2011, cases among IDUssharply increased to 190, representing approximately25% o all reported HIV cases [2,3]. Prevalence studies

have also detected a steep increase o HIV among IDUsin 2011, mostly in Athens [3].

Prior to the 2011 outbreak, the coverage o preventionservices was low, with waiting times or opioid sub-stitution treatment estimated at 89 months in 2010and with an estimated distribution o only six sterilesyringes per IDU during the entire year o 2009, which

is ar lower than in most European countries that reportdata to calculate syringe distribution per IDU [4]. Inresponse to the outbreak, the Greek authorities havesought to rapidly expand opioid substitution treatmentservices and have started mobile prevention servicesoering inormation, voluntary testing, reerrals andclean needles and syringes [3].

Epidemiological situation ofHIV in Romania in 2011In November 2011, a strong increase o newly diagnosedHIV inections among IDUs during 2011 was reportedto EMCDDA based on the inormation provided by rou-tine monitoring and case reporting coordinated by theRomanian Ministry o Health. While reporting three toive cases annually rom 2007 to 2009, HIV inectionsamong IDUs increased to 12 cases in 2010 and to 62cases in the irst nine months o 2011. Routine moni-toring perormed at registration or drug treatmentservices indicated an increase in HIV positive casesamong IDUs tested (1.1% (2/182) in 2008, 3.3% (11/329)in 2009 and 4.2% (12/288) in 2010). Cases reported in2011 were mostly residents o Bucharest and the sur-rounding area (56/62), predominately males (55/62),and younger than 34 years (55/62). Twenty-nine cases

had conirmed CD4 cell counts at diagnosis higher than500 cells/mm3 suggesting recently acquired HIV inec-tions. No speciic HIV testing campaigns had been initi-


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ated and most cases were detected when seeking drugtreatment or hospital care or other conditions.

In behavioural surveillance surveys among IDUs, thereare reports o changes in drug use patterns rom 2009,where 97% o respondents reported heroin as the maindrug o injection, to 2010, where 67% reported her-

oin and 31% reported amphetamine-type stimulants,mostly synthetic cathinones, as the main drug o injec-tion. Stimulant use is associated with more requentinjection and there are reports o increased syringe-sharing [5].

While drug use and injection risk patterns appear tobe changing in Romania, access to sterile syringes hasdecreased. Numbers o sterile syringes distributedreportedly declined rom 1.7 million in 2009 to 965,203in 2010 and to approximately 700,000 up to November2011. Based on the estimated number o IDUs, syringeprovision in Bucharest has thus decreased rom 97

syringes per IDU in 2009 to 53 syringes in 2010. Whilethe overall provision o opioid substitution treatmentin Romania seems to be limited, the number o clientsin such programmes increased rom 424 in 2009 to 601in 2010 [6,7].

BackgroundHIV inection is one o the most serious potential healthconsequences associated with IDU, leading to chronicinection, acquired immunodeiciency syndrome (AIDS)and premature death i untreated [1]. In the EU andthe European Economic Area (EEA), the estimated HIV

prevalence rates among IDUs range rom less than 1%to more than 60% [8,9]. Although or the EU/EEA areaas a whole the number o new HIV diagnoses reportedannually among IDUs has declined by 44% since 2004,outbreaks have been observed within a number ocountries in recent years [9-13].

The risk or blood-borne virus inection outbreaksamong IDUs depends on multiple actors, includingthe requency o needle sharing, the number o needlesharing partners, the social network structures andmixing in the IDU population. Additional determinantsinclude the size o the IDU population, the types odrugs injected, exposure through commercial sex and

other risky sexual practices, and awareness o risksand prevention measures available. In a more generalperspective, public health and drug policies as wellas the legal environment can also determine inectionrisks [14].

Assessment of the situation of humanimmunodeficiency virus amonginjecting drug users in the EuropeanUnion/ European Economic AreaIn response to the notiied events in Greece andRomania, the European Centre or Disease Preventionand Control (ECDC) and the EMCDDA conducted a rapid

inquiry to HIV surveillance contact points and nationaldrug ocal points in the EU/EEA Member States, can-didate and potential candidate countries, in November2011, to investigate possible recent increases in HIVinections detected among IDUs. Inormation avail-able rom routine surveillance and monitoring o HIVand hepatitis C (HCV) as well as prevention coverageamong IDUs has been combined with results rom therapid inquiry (Table).

Increases in HIV case reports or prevalence amongIDUs were reported by six countries as compared to

2008-2010. Seventeen countries reported no changes,our reported ewer cases or lower prevalence, and twodid not have inormation available to assess a change.Countries reporting an increase in the most recent yearrom which data were available (2011 or 2010) wereBulgaria, Greece, Italy, Lithuania, Luxembourg, andRomania.

Table

Indicators of human immunodeficiency virus and hepatitis C virus transmission, injecting risk and intervention coverage,European Union and European Economic Area, 20082011

EU/EEA countryIncrease in

the number ofHIV cases1

HIVprevalence

increase

Hepatitis Cprevalence

increase

Otherinjecting risk

increase

Injectiondrug use

prevalenceincrease

Less than30% of

problemopioid users

in opioidsubstitutiontreatment2

Less than100 syringesper IDU peryear from

specialisedprogrammes3

Surveillancechanges

Austria 2010 2010 20104 5 52%

Belgium 2010 2010 2010

Bulgaria 2009 20106 20107 8

Croatia 2010 9 89

Cyprus 2010 201010 201011 9 27% in 2010 0

Czech Republic 2010 2010 9 32% 138

Denmark 2010 2008

Estonia 2010 164

Finland 2010 2009 2009 32%


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France 2010

Germany 2010 55%

Greece 2011 201112 201013 14 9 22% in 2010 6

Hungary 2010 201015 5,8 16 32% 69

Iceland 2010

Ireland 2010 8 51%

Italy 2010 200917 200918 50%

Latvia 2010 201019 20 2% in 2010 39Lichtenstein

Lithuania 2011 20 17% in 2010

Luxembourg 2010 201021 64% 204

Malta 2010 2010 2010 68% 193

Netherlands 2010 22 2008 60%

Norway 2010 2010 2010 9 57% 309

Poland 2010 2010 23 8% in 2010

Portugal 2010 2010 2009 144

Romania 2011 201124 201025 26 5327

Slovakia 2010 201028 2010 8 16 12% in 2010 19

Slovenia 2010 2010 2010 8

Spain 2010 2009

Sweden 2010 200829 2008 3

Turkey 2010 30

United Kingdom 2010 2010 2010 8 31 56% in 2009

ECDC: European Centre or Disease Prevention and Control; EEA: European Economic Area; EMCDDA: European Monitoring Centre or Drugsand Drug Addiction; EU: European Union; HIV: human immunodeiciency virus.

No alert: no evidence or increased cases/prevalence and/or no evidence o low intervention coverage/no changes in surveillance

Alert: ev idence or increased cases/prevalence and/or low intervention coverage/decreased surveillance

Inormation unknown/not reported to EMCDDA/ECDC1 HIV case increase taken rom 2010 HIV surveillance data. Source: [15]. Bulgaria case repor t increased in 2008-2009, but returned to 2008

level in 2010. Case increases or Romania and Greece or 2011 were reported rom country H IV surveillance and drugs ocal points. Focalpoints rom most other EU/EEA countries indicated no detected increase in new cases among IDUs in 2011 as compared to previous years.

2 For the purpose o this report a cut-o o 30% coverage was used in order to limit to the alert to the lowest range and likely highest HIV

risk. Coverage levels below 50-70% o the target population are considered sub-optimal. Source: [7].3 Syringes given out by specialised needle and syringe programmes, not including pharmacy sales. Source: [4].4 Increases in Graz and Vienna, 2005-2010.5 Based on the EMCDDA 2011 Annual report [9]: both Hungary and Austria reported notable increase o mephedrone injecting.6 The ratio o H IV positive IDUs or the last 10 months ( January to December 2011) increased with 8.9% in comparison with the whole 2010.

The available data is or the capital city (Soia) only.7 Increase among all IDUs and among young IDUs, Soia, 2005-2010.8 Country exper ienced severe heroin shortage in 2010-2011 and reported on possible increased injecting risks or some groups.9 IDU prevalence estimates (2010 data taken into account only or the Czech Republic and Greece).10 Increase among young IDUs 2004-2009 reported in the 2011 EMCDDA Annual report [9] is not continued in 2010.11 Increase in all IDUs 2005-2010.12 Source: [3].13 Increase nationally and in At tica, Central Macedonia and Thessaly, 2005-2010.14 Reports o increased injecting o stimulants (home-made) at expert meeting Greece, October 2011 [3].15

National trend data until 2009 show no increase, data or 2010 show zero prevalence in six regions.16 Trend data available but not recent.17 Decline at national level, increase in one out o 21 regions (Veneto), 2004-2009.18 Decrease nationally, increasing trend in three out o the 21 regions ( Abruzzo, Umbria, Valle dAosta), 2004-2009.19 Increase in sel-reported HIV prevalence 2004-2009 reported in the 2011 EMCDDA Annual report [9] is not continued in 2010.20 Varying prevalence in 2010 but no trend data available.21 Sel-reported data; increase in 2010 reported [16].22 Zero prevalence in Amsterdam and Rotterdam 2010, but small sample sizes and no trends data.23 Varying prevalence in 2009 but no trend data available.24 Reported in the present paper.25 Increase 2005-2008 in all IDUs, and in male IDUs only in 2008-2010.26 Users switched to injecting amphetamine type stimulants (mostly mephedrone and other synthetic cathinones).27 Sub-national estimate, Bucharest area.28 Increase in HIV prevalence 2004-2009 reported in the 2011 EMCDDA Annual repor t [9] is not continued in 2010.

29 Trend data, available only until 2008, suggest some non-signiicant increase.30 No trend data available, 2010 data suggest low prevalence.31 Injectors o opiates and/or crack-cocaine


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In Bulgaria, HIV case reports or IDUs increased by8.9% up to October 2011 in comparison with 2010,although 2011 data were only available or Soia.At national level, an increase in the number o casereports or HIV among IDUs was already documentedin 2009 in Bulgaria. In Luxembourg, drug surveillancedata showed an increased HIV inection prevalence in

current IDUs rom 4.3% in 2009 to 8.1% in 2010 (nodata available or 2011). However the proportion o allHIV cases who have injection drug use as a transmis-sion route declined rom 6.3% in 2010 to 3.6 % in 2011,as o November. In Italy, case reporting data or oneregion has increased, however the average nationalprevalence o HIV inection among IDUs continues todecline. Lithuania reported more than two times thenumber o HIV cases in 2009 and 2010 (180 and 153respectively) as compared to 2008 (95 cases), but alsoreported increased testing among IDUs in 2010.

In addition to HIV case or prevalence increases,

reports rom some countries where data are avail-able indicate a potential risk or HIV transmission inthe IDU population with changes in drug use patterns,rom mostly heroin in 2009 to more stimulant use in(Austria, Greece, Hungary, Romania); increased HCVrates among IDUs (Austria, Bulgaria, Cyprus, Greece,Italy, Romania); low coverage o opioid substitutiontreatment (Cyprus, Greece, Latvia, Lithuania, Poland,Slovakia) or low coverage o needle and syringe pro-grammes (Croatia, Cyprus, Greece, Hungary, Latvia,Romania, Slovakia and Sweden).

DiscussionOverall, the incidence o HIV among IDUs in EU/EEAhas been declining steadily since the early 2000s [15].However, as a conclusion rom the rapid risk assess-ment we note that two countries reported recent out-breaks o HIV, our countries reported increases inHIV cases or prevalence, and several other countriesreported increases in injecting risk indicators (includ-ing HCV prevalence) or low coverage o preventionservices among IDU. These actors combined indi-cate a potential risk or HIV transmission and utureoutbreaks.

There are clear indications o signiicant increased HIVtransmission in Greece and Romania. While the mag-nitude o the most recent increases in case reportscould be partially related to enhanced surveillance,particularly in Greece, the available evidence indicatesa real increase in HIV transmission in both countries.In Romania, it is likely that a recent rise in the com-bined use o opioids and amphetamine-type stimu-lants resulting in increased injecting requency couldhave contributed to HIV transmission. In both coun-tries, there is a temporal association between thisincrease and reduced provision o prevention services

(Romania) or initially low levels o) provision o preven-tion services (Greece). In Romania, these reductionshave coincided with the end o a grant rom the GlobalFund or AIDS, tuberculosis and malaria in June o 2010.

The most robust and recent evidence suggests that thelargest reduction o HIV and injection risk behaviourcan be achieved by providing comprehensive preven-tion services, with high coverage o both needle andsyringe programmes and opioid substitution treatmentin combination [17,18]. In light o the growing preva-lence o injection o amphetamine-type stimulants, as

is reported in Romania, an additional and importantchallenge is to identiy and implement eective treat-ment that targets this type o dependence [5, 9].

In order to prevent new outbreaks o HIV among IDUs,it is o utmost importance that countries that haveindicated a change in injecting drug use risk actorsor HIV and hepatitis C prevalence review their nationalor local prevention and control programmes in light othe current situation. Countries that experience ongo-ing increases or outbreaks would need to scale up theirservices urgently to prevent new cases. In the contexto signiicant increased transmission o HIV among

IDUs, rapid interventions in the orm o scaling-up oneedle and syringe programmes, provision o opioidsubstitution treatment and o condoms to reduce sex-ual HIV transmission are warranted.

The extent to which service reductions or changingpatterns o risk among IDUs have been related to thecurrent economic crisis in Europe cannot be easilymeasured and due to complex interactions betweenmany actors, causal links are extremely diicult toestablish. However, in past economic downturns,increased HIV incidence and increased injecting drug

use have been observed [19,20], and in a recent paper,Kentikelenis et al. have drawn links between the inan-cial crisis in Greece and the increased HIV incidence[21]. In addition to exacerbating vulnerabilities andrisk behaviours, economic downturns may also limitthe unding available to prevention programmes [22].The current outbreaks o HIV in IDUs in Greece andRomania show that there is a continuous need to keepprevention o HIV and public health on the agenda alsoin challenging economic times.

Acknowledgments

The authors wish to thank the national HIV surveillanceand drug ocal points who responded to the rapid requestor inormation, in particular Drs. Adriana Pistol, MarianaMardarescu, Florin Popovici, Argyro Antaraki and ManinaTerzidou. Treatment and low-threshold services who provid-ed the data are also acknowledged. Denis Coulombier, KatrinLeitmeyer, Emmanuel Robesyn, and Johan Giesecke providedimportant input.

References

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evaluare rapida noi cazuri hiv in romania si grecia 2011

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