Update — risk of HIV outbreaks among drug injectors in the EU

Over the last decade, gains have been made within the EU in addressing HIV infection among injecting drug users — these include a greater availability of prevention, treatment and harm-reduction measures. Other factors, such as the decline in injecting drug use in several countries, are also likely to have played a role in the decrease in the number of new HIV infections.

The latest data show that the average rate of newly reported HIV cases continues to fall in Europe, reaching a low of 2.85 new cases per million population in 2009 (in total, about 1 300 cases). Here, the overall EU situation compares positively, both in a global and a wider European context (1,2).

Nevertheless, this year’s EMCDDA Annual report notes some worrying developments in respect of HIV among injecting drug users.

In July 2011, Greece — historically a low HIV-prevalence country — reported an outbreak of new HIV infections among drug injectors (170 cases at the time of writing) (3,4,5,6,7,8). Recent increases in new infections have also been reported by Bulgaria, Estonia and Lithuania, indicating a continued potential for HIV outbreaks among injecting drug users in some countries (see Figure INF-2 in the 2011 Statistical bulletin). At a recent EMCDDA meeting (October 2011), national experts noted further HIV increases among drug users in Romania and potentially worrying changes in risk factors reported in Hungary.

Despite the declines in HIV infections among drug injectors in the European Union over the last decade, complacency must be avoided. HIV infection can spread rapidly in vulnerable populations of injectors especially if service provision is low. Interventions (especially needle and syringe programmes, opioid substitution treatment, diagnosis and anti-retroviral treatment) can be effective in reducing the spread of the virus among drug injectors. Joint European guidelines on the prevention of HIV and other infections among drug injectors were launched in October 2011 by the European Centre for Disease Control and the EMCDDA.

HIV epidemics among drug injectors also continue to pose a major public health problem for many countries bordering the EU (see Annual report, Chapter 7, Figure 15) (2). Within the EU, the current financial situation means that budgets for drug services are likely to come under increased scrutiny. It is therefore important that the social and financial costs of potential new HIV outbreaks, as well as the guidance on what kinds of interventions are likely to prove most effective in this area, are borne in mind when making decisions on the provision of services.

Apart from the direction of trends over time, the actual rate of reported new HIV diagnoses (per million population) in 2009 related to injecting drug use remained relatively high in Estonia (63.4), Lithuania (34.9), Latvia (32.7), Portugal (13.4) and Bulgaria (9.7), suggesting ongoing transmission. Injecting drug use accounts for over 2 000 AIDS-related deaths a year in the EU.

Greek report on the HIV outbreak in drug injectors

Following the first warning of the outbreak in Greece (3), the EMCDDA commissioned a rapid analysis of the situation with regard to the latest epidemiological data and prevention measures being taken. The report notes that:

  • During 2011, the number of newly reported cases of HIV infection among injecting drug users in Greece has sharply increased. By the end of July, 113 cases had been reported in the Hellenic Centre for Disease Control and Prevention’s surveillance system while, from 2001 to 2010, the number of reported cases ranged from 3 to 19 a year. There were no changes reported in testing policy that could explain this increase. The overwhelming majority of new cases have been detected in Athens.
  • Preliminary data suggest that 62% of the reported injecting drug users were of Greek origin, 15% were immigrants and 23% were of unknown ethnicity.
  • Prevalence of antibodies to HIV among injecting drug users ranged from 0.3–0.8% during the years 2002–2010. In the first seven months of 2011, a sharp increase was observed in all data sources.
  • In 2011, molecular analysis revealed that 22 out of 23 positive samples (96%) were found to belong to injecting drug user networks. Analysis suggested that the origin of the virus was from Asia (12 cases), Greece (7 cases) and from South-western Europe (Portugal and Spain) (3 cases).
  • A number of hypotheses exist in regard to the possible contributory factors for the increased number of new HIV cases: they include increased levels of sexual and drug-related risk behaviour, and the absence of comprehensive HIV-prevention programmes. It has also been suggested that other factors, including targeting of drug injectors by the police may have inhibited service uptake or encouraged more risky forms of use.
  • Considering the estimated number of problem drug users, Greece has relatively few low-threshold programmes for drug injectors. The opioid substitution programme — a measure with high efficacy in preventing HIV transmission among injecting drug users — has a waiting list of five to seven years. At the end of June 2011, 5 573 drug users were reported to be actively enrolled in opioid substitution programmes in Greece. However, it was also reported that 7 428 (3 500 in Athens) additional applications for treatment were pending, resulting in relatively low coverage of opioid substitution treatment (see Figure HSR-1 in the 2011 Statistical bulletin). All HIV-positive injecting drug users, including illegal immigrants, are offered priority access to opioid substitution treatment and anti-retroviral therapy.
  • Anonymous HIV/AIDS screening and counselling, as well as anti-retroviral therapy for HIV-positive people and their sexual partners, are provided for by law and are widely available.
  • Syringe and injecting equipment exchange or distribution programmes are available, but their coverage is very limited (see Figure HSR-3 in the 2011 Statistical bulletin).
  • A number of steps are being taken to address the HIV outbreak, with a focus on improving the availability of prevention and health interventions for drug injectors. These include:
    • Intensification of programmes providing needles, syringes and condoms in downtown Athens (January 2011);
    • A switch in the kind of syringes being offered (from high to low dead space syringes) is under way (September 2011);
    • Systematic HIV screening of injecting drug users in treatment programmes has been initiated (September 2011);
    • An awareness campaign directed at injecting drug users was implemented in the centre of Athens (March 2011);
    • A molecular epidemiology surveillance programme was initiated to describe the transmission networks, determine the origin of HIV strains and to identify index cases (May 2011);
    • A major restructuring of opioid substitution programmes is also underway, and is expected to eliminate the waiting list by the end of 2011.