Viral hepatitis elimination barometer among people who inject drugs in Europe

Computer simulation of a virus

Page last updated: November 2023

About the elimination barometer

The elimination barometer for hepatitis B and C among people who inject drugs is designed to support countries affiliated to the EMCDDA in monitoring their progress towards the Sustainable Development Goal 3.3 and the elimination of viral hepatitis as a major public health threat by 2030. Under five building blocks, it brings together 11 epidemiological indicators (2021 or latest) and corresponding 2020 targets related to people who inject drugs for the EU, Norway and Türkiye, following the WHO monitoring frameworks (WHO, 2016b, 2017, 2021).
UN Sustainable Development Goals emblem and text

For each indicator, the EMCDDA elimination barometer provides:

  • Contextual information, references and definitions
  • An infographic showing national data
  • The related 2020 WHO target
  • An achievement status: how many countries have reached the target
  • The corresponding data tables
Monitoring and evaluation framework: indicators to monitor and evaluate the health sector response to viral hepatitis B and C among people who inject drugs
HCV elimination iniatiative for people who inject drugs. Main building blocks:1.ninformation on the situation. 2. Is there an inclusive policy? 3. Prevention including vaccination. 4. Testing and treatment. 5. What is the impact?

Adapted from Monitoring and evaluation for viral hepatitis B and C: recommended indicators and framework, World Health Organization (2016).

The methods and data sources of the elimination barometer are described in more detail in a technical report (EMCDDA, 2019b). The EMCDDA is conducting this monitoring with the drug-related infectious diseases (DRID) network in close collaboration with ECDC, the EU agency that monitors the overall responses to the hepatitis B and C epidemics in EU/EEA Member States (ECDC, 2020c, 2021b).

Why it matters

In 2016, there were an estimated 10 million people in the European Union (EU) and European Economic Area (EEA) living with chronic hepatitis B or hepatitis C, including many with an undiagnosed infection (ECDC, 2016). Chronic viral hepatitis can result in serious liver diseases such as cirrhosis and cancer. In that year, the World Health Assembly endorsed the first global health sector strategy on viral hepatitis (WHO, 2016a). The aim of the strategy is to eliminate viral hepatitis as a major public health threat by 2030.

In Europe, people who inject drugs (PWID) constitute a key population for the elimination of these infectious diseases, both in terms of transmission (requiring higher levels of combined prevention) and burden (requiring better access to treatment). The years 2020-21 were marked by the COVID-19 pandemic, which has posed many challenges for health systems across Europe, including many harm reduction services already in the front line of hepatitis prevention and control. This period was also significant for the hepatitis action plan, which set important milestones and corresponding targets for 2020. 

Overview

What can we say from the 2021 monitoring data on people who inject drugs?

  • Overall result: The region has not reached the 2020 WHO viral hepatitis elimination targets for people who inject drugs.
  • Context and need: The prevalence of HCV and HBV remains very high among the estimated half a million people who inject drugs in the EU, exposing them to a high yet preventable morbidity and mortality burden through serious liver diseases such as cirrhosis and cancer.
  • Policy: A majority of EU Member States have or are in the process of adopting inclusive national hepatitis plans or policies, showing encouraging political commitment.
  • Prevention: Only 4 countries had data to document they reached harm reduction coverage targets in 2021, and in 4 countries HBV vaccination was still not accessible in prison to people who inject drugs, stressing sub-optimal provision of cost-effective interventions.
  • Testing and treatment: Thirteen countries reported that less than half of the people who inject drugs entering drug treatment had been tested for HCV in the last 12 months, and 6 countries still imposed restrictions on access to direct-acting antiviral agents for people who inject drugs in 2021, underlining inequities in the continuum of care.
  • Impact: HCV transmission among people who inject drugs remained high between 2015 and 2021, stressing the urgent need to scale-up access to integrated and stigma-free prevention and care among this population. While two countries were able to document a decrease in the prevalence of viraemic HCV among PWID from 2015-21, no country has evidence of a 80% decrease.  

Level of achievement for each indicator among people who inject drugs

Select an indicator

Indicator:
Data on key population size

Related 2020 target: data available on key population size to inform disease burden estimates.

Achievement status: 18 countries have recent data on the number of people who inject drugs.

Indicator:
Data on HCV antibody prevalence

Related 2020 target: data available on HCV antibody prevalence among people who inject drugs to inform disease burden estimates.

Achievement status: 20 countries have recent data on anti-HCV prevalence among people who inject drugs.

Indicator:
Data on HCV RNA prevalence

Related 2020 target: data available on the prevalence of viraemic HCV infection among people who inject drugs to inform disease burden estimates.

Achievement status: 6 countries have recent data on HCV RNA prevalence among people who inject drugs.

Indicator:
Data on HBV prevalence

Related 2020 target: data available on the prevalence of viraemic HBV infection among people who inject drugs to inform disease burden estimates.

Achievement status: 18 countries have recent data on HBsAg prevalence among people who inject drugs.

Indicator:
Inclusive national policy

Related 2020 target: costed and funded inclusive national hepatitis policy adopted.

Achievement status: 21 countries have adopted an inclusive national hepatitis policy or plan.

Indicator:
Needle and syringe provision (NSP) and opioid agonist treatment (OAT) coverage

Related 2020 target: number of syringes distributed by person who injects drugs = 200, proportion of high-risk opioid users in opioid agonist treatment = 40 %.

Achievement status: 4 countries have reached the combined prevention targets.

Indicator:
HBV vaccination availability in prisons

Related 2020 target: HBV vaccination is available to people who inject drugs in prison as part of a comprehensive package of harm reduction services.

Achievement status: 23 countries have HBV vaccination programmes targeting people who inject drugs in prisons.

Indicator:
HCV testing coverage

Related 2020 target: 50 % of people who are chronically infected with viral hepatitis are diagnosed.

Achievement status: 8 countries reported that >50 % of people injecting drugs entering drug treatment had been tested for HCV in the last 12 months.

Indicator:
Direct-acting antiviral agents (DAA) treatment availability without restrictions

Related 2020 target: Treatment, in line with international standards, to be available and affordable for all.

Achievement status: 23 countries have no clinical or financial restriction linked to drug use for DAA access.

Indicator:
HCV Incidence proxy over time

Related 2020 target: 30 % reduction in the number of new chronic hepatitis C infections (baseline: 2015)

Achievement status: No country has evidence of significant reduction in HCV transmission among people who inject drugs in 2015-21. One country has evidence of significant decrease in the prevalence of viraemic HCV among PWID. 

Indicator:
HCV Incidence proxy over time

Related 2020 target: 30 % reduction in the number of new chronic hepatitis C infections (baseline: 2015)

Achievement status: No country has evidence of significant reduction in HCV transmission among people who inject drugs in 2015-21. One country has evidence of significant decrease in the prevalence of viraemic HCV among PWID. 

Indicator:
Trends in HCV viraemic prevalence

Related 2020 target: Reduction in HCV viraemic prevalence by 80% (baseline: 2015)

Achievement status: No country has evidence of 80% reduction in viraemic HCV prevalence among people who inject drugs in 2015-21

The source data table for the main information in the interactive maps presented here is available in the Source data section on this page.

What are crucial data gaps for viral hepatitis monitoring among people who inject drugs?

While there has been progress since the last monitoring round, indicators from all five building blocks still require higher quality and completeness to efficiently guide and assess public health interventions. Four areas require particular attention for people who inject drugs:

  • Population size estimates, for burden estimates and prevention coverage
  • Prevalence of viraemic/chronic HCV infection from observational studies
  • Continuum of care data
  • Data on mortality attributable to HCV and HBV infections

The EMCDDA is working closely with the DRID network and its partners to update the elimination barometer on a yearly basis and monitor progress towards the Sustainable Development Goals related to people who inject drugs. Monitoring data, reports, guidance and activities of the DRID network can be found on the drug-related infectious diseases hub page.

Context and need

Number of people who inject drugs and prevalence of injecting drug use per country

Knowing the size of the population of people who inject drugs living in each country is necessary in order to quantify the burden of disease associated with injecting drug use and to plan harm reduction and health services accordingly. The main risk factor for blood-borne infections – including HBV and HCV – among this group is the sharing of needles, syringes and other drug equipment. The injection of stimulant drugs has been associated with higher-risk practices and blood-borne virus outbreaks (Arendt et al., 2019; Giese et al., 2015; Hanke et al., 2020; McAuley et al., 2019; Tarján et al., 2017). And while evidence from drug treatment centres suggests that injecting drug use is declining among heroin clients in the European Union (EMCDDA, 2020b), an EMCDDA study looking at the residual content of used syringes in sentinel cities suggests that stimulant injecting is common among people who inject drugs in Europe (EMCDDA, 2019a).

People who inject drugs are defined here as those aged between 15 and 64 years who have injected any psychoactive substance not according to medical prescription in the last 12 months. The prevalence of injecting drug use in a given country is calculated as the number of people who inject drugs estimated for a given year divided by the population aged 15 to 64 years and multiplied by 1 000, so that it is expressed per 1 000 population. Population data were provided by (Eurostat, 2020). The number of people who inject drugs is estimated through indirect statistical methods such as capture-recapture studies (Raag et al., 2019) and treatment multiplier studies (Larney et al., 2017), and comes with a high degree of uncertainty.

Figure 1. Estimated number of people who inject drugs and prevalence of injecting drug use by country, 2021 or latest available data
 
 

Method of estimation
TM: treatment multiplier; CR: capture-recapture; TP: truncated Poisson; CM: combined methods; HM: HIV multiplier; MM: mortality multiplier; MIM: multivariate indicator method; OT: other

The total number of people who inject drugs for the 27 EU Member States and Norway in 2019 was estimated by imputing the prevalence of injecting drug use for countries with missing data using estimates from EU countries with available data. Based on available national estimates from 2012-19, the prevalence of injecting drug use was 1.95 per 1 000 population aged 15-64 years (UI: 1.71-2.19), corresponding to an estimated 581 000 people who inject drugs living in the EU and Norway in 2019.

Prevalence of HCV antibodies and current HCV infections among people who inject drugs

The prevalence of antibodies to HCV (anti-HCV) among people who inject drugs indicating present or past infection, either cleared or treated is estimated from seroprevalence studies (well-designed observational studies) or routine diagnostic tests offered in drug treatment centres or low-threshold services (programme data), reported to the EMCDDA by EU Member States, Norway and Türkiye.

As the number of patients successfully treated with antivirals will increase, antibody prevalence will have more limited utility to measure the burden of HCV. A better indicator is the prevalence of chronic and/or current infections among people who inject drugs, using HCV RNA (or antigen) tests to confirm the presence of the virus (WHO, 2018).

Figure 2. Sero-prevalence studies. Prevalence of HCV antibodies among people who inject drugs, by country, 2021 or latest available data
 

Colour key:     = high level of evidence       = moderate level of evidence       = low level of evidence

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

 

Figure 3. Routine diagnostic tests. Prevalence of HCV antibodies among people who inject drugs, by country, 2021 or latest available data
 

Colour key:     = high level of evidence       = moderate level of evidence       = low level of evidence

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Figure 4. Prevalence (%) of active HCV infection (HCV RNA+) among people who inject drugs, by country, 2021 or latest available data
 

Colour key:     = high level of evidence       = moderate level of evidence       = low level of evidence

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Prevalence of current HBV infections among people who inject drugs

HBV infection is less common than HCV infection among people who inject drugs, but is still much higher than in the general population. This is so, despite the availability of an effective vaccine, which is included in the recommended vaccination schedules in most EU Member States (ECDC, 2020d). For HBV, the presence of the HBV surface antigen (HBsAg) indicates a current infection, which may be recent or chronic.

Figure 5. Sero-prevalence studies: Prevalence (%) of active HBV infection (HBsAg+) among PWID, by country, 2021 or latest available data
 

Colour key:     = high level of evidence       = moderate level of evidence       = low level of evidence

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

 

Figure 6. Routine diagnostic testing studies: Prevalence (%) of active HBV infection (HBsAg+) among PWID, by country, 2021 or latest available data
 

Colour key:     = high level of evidence       = moderate level of evidence       = low level of evidence

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

National hepatitis policy inclusive of people who inject drugs

The 'inputs' building block of the elimination barometer provides information on the existence of an official national inclusive viral hepatitis policy or action plan, which constitutes an important step towards the implementation of a sustainable elimination strategy (EMCDDA, 2020b). A national policy or plan in which people who inject drugs are explicitly mentioned, with access to harm-reduction, screening and HCV treatment not conditional on abstinence, is defined as being inclusive.

Figure 7. Countries with viral hepatitis policy inclusive of people who inject drugs, 2021
 

Prevention

Needle and syringe programme and opioid agonist treatment (OAT)coverage

Prevention is the next key building block of the barometer. Combined high levels of needle exchange coverage and opioid agonist treatment (OAT) are cost-effective interventions to reduce the risk of blood-borne infections, including viral hepatitis, among people who inject drugs (Ijioma et al., 2021; Platt et al., 2017). Needle and syringe programme (NSP) coverage is defined as the number of sterile needles/syringes distributed in a year per person who injects drugs. OAT coverage is defined as the proportion of people in need of opioid-related treatment who are receiving opioid agonist treatment in a given year. Prevention and harm-reduction measures prevent new infections but also provide an opportunity to reach out to high-risk populations for testing and linkage to care. The 2020 targets are 200 syringes per person who injects drugs per year and 40 % of the population of high-risk opioid users receiving opioid agonist treatment (OAT).

Figure 8. Number of sterile syringes distributed per person who injects drugs and proportion of high-risk opioid users in opioid agonist treatment (OAT), by country, 2021 or latest available data
 
Figure 9. Proportion of high-risk opioid users in opioid agonist treatment (OAT), European countries, 2021 or latest available data
 
Figure 10. Number of syringes distributed per year per PWID, European countries, 2021 or latest available data
 

The coverage is based on the latest national estimates of injecting drug use and high-risk opioid use matched by harm reduction activity data (within a maximum of 2 years). The estimate of coverage of opioid agonist treatment for Belgium is derived from a subnational study conducted in 2019.

Hepatitis B vaccination availability in prison

There is an effective vaccine against HBV, and HBV vaccination campaigns targeting people who inject drugs through appropriate settings are cost-saving (Hu et al., 2008). Due to the high prevalence of HBV infection and drug use among people in prisons, and based on available evidence regarding the implementation of HBV vaccination in prison settings, it is advisable to offer HBV vaccination to people in prison (ECDC and EMCDDA, 2018). It is recommended to offer HBV vaccination at entrance to all individuals with no/unknown vaccination history and/or negative serology, in order to prevent further transmission within the prison setting. The source of the data on the availability of HBV vaccination programmes targeting people who use drugs and are in prison is the EMCDDA’s Insights on prisons (EMCDDA, 2021).

Figure 11. Existence of a vaccination programme that provides access to HBV vaccination to people in prisons in 2021
 

Testing and access to treatment for people who inject drugs

To eliminate viral hepatitis as a public health threat, the WHO 'continuum of care' targets are for 50 % of people who are chronically infected with viral hepatitis to be diagnosed by 2020, 75 % of eligible patients to be receiving treatment and at least 90 % of them to be cured (HCV) or to obtain viral suppression (HBV). Yet, many infections still go undiagnosed and untreated among people who inject drugs. Few countries have a consolidated set of indicators that cover the entire sequence of the continuum of care among people who inject drugs (Aas et al., 2020; ECDC, 2020c; EMCDDA, 2019b, 2020a; Rojas Rojas et al., 2019). The elimination barometer provides a European overview of two pillars of the continuum of HCV care among people who inject drugs: testing and access to direct-acting antiviral (DAA) treatment.

HCV testing coverage among people who inject drugs

The availability of HCV and HBV testing in drug services and in prisons is crucial, but it may not always translate into actual testing. Data on people entering drug treatment, systematically collected by the EMCDDA through the treatment demand indicator (EMCDDA, 2012), includes information on the coverage of HCV testing, defined as the proportion (percentage) of people who inject drugs entering drug treatment who reported having taken an HCV test in the last 12 months. Increasing testing in drug treatment services is one focus of the EMCDDA harm reduction initiative (EMCDDA and Robert Koch Institut, 2018).

Figure 12. Percentage of people entering drug treatment reporting injecting drugs who had an HCV test in the previous 12 months, 2021 or latest data available
 

Absence of clinical and reimbursement restrictions for DAA treatment for people who inject drugs

Direct-acting antiviral agents (DAAs) are an effective treatment option for people who are chronically infected with HCV, including current injecting drug users (Grebely et al., 2018). The goals of DAA therapy are to cure HCV infection in order to prevent complications and mortality, improve quality of life, remove stigma and prevent onward transmission of HCV. The WHO and EASL recommend offering treatment to all individuals diagnosed with HCV infection who are 12 years of age or older (with the exception of pregnant women), irrespective of disease stage (WHO, 2018).

The guidelines also stress that treating people who inject drugs along with provision of harm reduction interventions (to reduce the risk of reinfection) is cost-effective, despite the fact that DAAs remain expensive in many high and upper middle income countries. Testing and linkage to treatment for infected people who inject drugs are therefore core components of the elimination strategy: in addition to the direct beneficial impact for the treated individual, treatment has the potential to reduce transmission in the community (treatment as prevention). The indirect benefits of treatment are increased when the risk of reinfection is reduced, for example in low prevalence settings or in settings with high coverage of harm-reduction measures such as NSP and OAT (Martin et al., 2016). However, people with drug or alcohol use dependencies still have to fulfil further criteria (such as being enrolled in OAT and/or being abstinent from drugs) before being eligible for DAA access and reimbursement in some EU countries (Marshall et al., 2018).

Figure 13. Countries with restrictive clinical or reimbursement guidelines for Direct-acting antiviral agents (DAA) access for people who use drugs, 2023
 

Integrated treatment

A strategy to improve the continuum of HCV care among people who inject drugs is integrated treatment, whereby testing, counselling, treatment and post-treatment follow-up are delivered by multidisciplinary teams in drug services or community care centres for drug users. There is growing evidence of the efficacy of this approach to link people who inject drugs to HCV treatment and to increase adherence (Messina et al., 2020). Correlation – European Harm Reduction Network is providing valuable information reported by harm reduction civil society organisations on several aspects of the continuum of care, including the type of settings where HCV testing and treatment are offered across Europe (Maticic et al., 2020).

Integration is a core principle of the HCV models of care for drug services in Europe documented by the EMCDDA (2019b) and Correlation – European Harm Reduction Network (Schatz et al., 2019). These case studies provide concrete examples to Member States on how to increase access to testing and care for people who inject drugs through drug and harm reduction services.

Impact

The elimination of viral hepatitis as a public health threat has been defined as a 90 % reduction in the number of new chronic hepatitis B and C infections and a 65 % reduction in the number of deaths by 2030, with milestones for 2020 set as 30 % and 10 % reductions respectively. The baseline is 2015. The indicators proposed by the WHO to monitor the impact of the elimination strategy include the incidence of HCV and HBV infections, and deaths from hepatocellular carcinoma (HCC), cirrhosis and chronic liver diseases attributable to HCV and HBV infections (WHO, 2017).

New notifications of HBV and HCV cases linked to injecting drug use

EU Member States report newly diagnosed cases of hepatitis B or C infection to ECDC using the EU case definitions. The EU case definitions are based on laboratory criteria and differentiate acute from chronic cases (ECDC, 2020a, 2020b, 2020c). When the information is available, the most likely route of transmission is also reported. A case attributed to injecting drug use might be diagnosed in a person who does not inject anymore, so the information refers to ever-injectors (people who have injected drugs at some point in their life). Notification data provide useful information on the distribution and trends in transmission route. In 2021, the percentages of all acute and chronic newly diagnosed HCV cases with known transmission route attributable to injecting drug use in the EU were 61 % (250/411) and 70 % (1058/1502), respectively. For HBV, the percentages were 8 % (22/283) and 8 % (77/990) (ECDC, 2023a). 

A large proportion of acute/chronic hepatitis B and C are asymptomatic so the notification data are strongly influenced by testing trends. The completeness of surveillance data and the availability of information on transmission route also varies by country. Because of the limitations in using notification data to estimate incidence, two related indicators are used to monitor the impact of prevention and treatment of HCV over time: trends in prevalence of anti-HCV in people who have started injecting recently and trends in HCV RNA among people who inject drugs.

Proxies for HCV incidence: trends in anti-HCV prevalence among young/new people who inject drugs

The trend in prevalence of anti-HCV among people who inject drugs aged less than 25 years ('young injectors') and among those who have been injecting for less than two years ('new injectors') can be used as a crude proxy for incidence. Prevalence among this group reflects relatively new transmission (incidence) and it is expected to decrease over time as prevention and treatment coverage increases. If HCV transmission is reduced by prevention measures (NSP, OAT but also treatment as prevention), this would affect incidence (the flow of new cases) and would lower the prevalence of anti-HCV among new and young people who inject drugs over time. Trends in anti-HCV prevalence are derived from seroprevalence studies or routine diagnostic tests conducted yearly, using the same protocol over time.

Figure 14. Trends in HCV antibody prevalence (%) among people who inject drugs aged less than 25 years: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
 
Figure 15. Trends in HCV antibody prevalence (%) among people who inject drugs, injecting for less than 2 years: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
 

Trends in prevalence of viraemic HCV infections among people who inject drugs

Another way to monitor the impact of prevention and treatment is to look at the prevalence of current HCV infections among people who inject drugs over time. A scale-up of DAA treatment is expected to reduce the burden of HCV as measured by HCV RNA prevalence over time (Gottfredsson et al., 2019, PHE, 2020). Trends in HCV RNA prevalence are derived from seroprevalence studies or routine diagnostic tests conducted yearly, using the same protocol over time. 

Figure 16. Trends in HCV RNA prevalence (%) among people who inject drugs: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
 

Endnotes

Author contributions

European Monitoring Centre for Drugs and Drug Addiction: Thomas Seyler, Filippo Pericoli, Iciar Indave, Isabelle Giraudon, Luk Van Baelen, André Noor. 

The Reitox national focal points and the expert network on drug-related infectious diseases (DRID) network: Irene Schmutterer, Els Plettinckx, Elena Damian, Jérôme Antoine, Georgi Shopov, Josipa-Lovorka Andreić, Lara Jezic, Ioanna Yiasemi, Evi Kyprianou, Barbora Orlíková, Mathilde Pihl Badse, Liis Lemsalu, Henrikki Brummer-Korvenkontio, Anna Ndiaye, Eric Janssen, Ruth Zimmerman, Anastasios Fotiou, Ioanna Siamou, Anna Peterfi, Gergely Csaba Horváth , Sean Millar, Barbara Suligoi, Maria Elena Tosti, Anda Kivite-Urtane, Viktorija Stifanoviciute, Lina Jurgelaitiene, Carole Devaux, Vic Arendt, Pierre Braquet, Carlo Olivari D' Emanuele, Esther Croes, Robert Neil Whittaker, Jasmina Burdzovic, Thomas Sandøy, Magdalena Rosińska, Karolina Zakrzewska, Domingos Duran, Viviana Manolache, Valentina Stefan, Peter Koren, Zuzana Kamendy, Irena Klavs, Begoña Brime Beteta, Noelia Llorens, Josefine Lundberg Ederth, Marie Nordahl, Maria Axelsson, Seda Kesemen, Peyman Altan  

Acknowledgments

Correlation – European Harm Reduction Network: Rafaela Rigoni

European Centre for Disease Prevention and Control: Erika Duffell, Lina Nerlander, Anastasia Pharris, Teymur Noori

World Health Organization : Antons Mozalevskis, Giorgi Kuchukhidze

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Source data

The source data for graphics on this page may be found below (or see the source data bundle in the Data catalogue which may include additional metadata).

List of tables

Table 1. Estimated number of people who inject drugs and prevalence of injecting drug use by country, 2021 or latest available data
Country Central Estimate Central Rate High Estimate High Rate Low Estimate Low Rate Method Year
FR 106857 2.7 110346 2.8 103368 2.6 CR 2020
IT 105652 2.8 130528 3.5 80776 2.1 OT 2021
CZ 40500 6.1 41200 6.2 39900 6 TM 2021
FI 25000 7.4         OT 2017
PT 13162 2.1 28497 4.5 6416 1 CR 2015
BG 9783 2.2 10386 2.4 9183 2.1 OT 2020
LT 8868 4.6 9364 4.9 8371 4.4 MIM 2016
EE 8606 10 9658 11.2 7736 9 CR 2015
ES 8582 0.3 12386 0.4 4778 0.1 OT 2020
NO 7878 2.2 8574 2.4 6719 1.9 MM 2021
LV 7715 6.1 8678 6.8 6751 5.3 TM 2016
BE 7018 0.8 9527 1 4794 0.5 CR 2019
HU 6707 1         CM 2015
HR 6344 2.2 8255 2.9 5147 1.8 MM 2015
EL 2462 0.4 3471 0.5 1841 0.3 CR 2021
NL 840 0.1 960 0.1 780 0.1 OT 2015
LU 822 1.9         CM 2019
CY 627 1 926 1.5 448 0.8 TP 2021

Method of estimation
TM: treatment multiplier; CR: capture-recapture; TP: truncated Poisson; CM: combined methods; HM: HIV multiplier; MM: mortality multiplier; MIM: multivariate indicator method; OT: other

Table 2. Sero-prelance studies. Prevalence of HCV antibodies among people who inject drugs, by country, 2021 or latest available data
Country Geographical coverage Location Study design Level of evidence Year Number tested Prevalence %
Belgium Subnational Brussels Sero-prevalence study High 2019 168 41
Bulgaria Subnational Multi-city Sero-prevalence study Moderate 2016 359 68.5
Croatia Subnational Multi-city Sero-prevalence study High 2022 517 56.9
Cyprus National National Sero-prevalence study Low 2018 80 61.3
Estonia Subnational Tallin Sero-prevalence study Moderate 2017 112 89.3
Estonia Subnational Narva Sero-prevalence study Moderate 2018 350 79.7
Finland Subnational Multi-city Sero-prevalence study High 2014 589 74
Finland Subnational Multi-city Sero-prevalence study Low 2019 203 70.4
Germany Subnational Berlin Sero-prevalence study Moderate 2021 143 76.2
Germany Subnational Bavaria Sero-prevalence study Moderate 2022 448 72.8
Hungary Subnational Budapest Sero-prevalence study Moderate 2018 218 42.7
Hungary Subnational Multi-city Sero-prevalence study Moderate 2018 221 44.3
Hungary National National Sero-prevalence study Moderate 2018 439 43.5
Hungary Subnational Multi-city Sero-prevalence study Moderate 2019 102 48
Latvia National Multi-city Sero-prevalence study Moderate 2017 386 85.2
Lithuania Subnational Multi-city Sero-prevalence study Moderate 2014 200 77
Lithuania National National Sero-prevalence study High 2018 369 85.9
Norway National National Sero-prevalence study High 2018 5929 38.8
Norway Subnational Oslo Sero-prevalence study Moderate 2021 256 73
Romania Subnational Bucharest Sero-prevalence study Moderate 2017 444 79.3
Slovakia Subnational Bratislava Sero-prevalence study Moderate 2021 73 47.9
Türkiye National National Sero-prevalence study High 2018 2409 49.2
Türkiye National National Sero-prevalence study High 2021 1465 43.8

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Average of available studies (63.30 per 1000 people)

Table 3. Routine diagnostic tests. Prevalence of HCV antibodies among people who inject drugs, by country, 2021 or latest available data
Country Geographical coverage Location Study design Level of evidence Year Number tested Prevalence %
Austria Subnational Vienna Routine diagnostic test Low 2021 202 79.2
Austria Subnational Vienna Routine diagnostic test Low 2021 202 39.1
Bulgaria Subnational Sofia Routine diagnostic test Low 2021 302 79.8
Cyprus National National Routine diagnostic test Low 2021 72 48.6
Czechia National National Routine diagnostic test Low 2021 2483 29.3
Greece Subnational Attica Routine diagnostic test Low 2021 243 64.6
Greece Subnational Multi-region Routine diagnostic test Low 2021 221 62.9
Greece Subnational Thessaloniki Routine diagnostic test Low 2021 106 60.4
Greece National National Routine diagnostic test Moderate 2021 570 63.2
Italy Subnational Umbria Routine diagnostic test Low 2013 62 71
Italy Subnational Emilia Romagna Routine diagnostic test Low 2013 1489 57.9
Italy Subnational Lombardia Routine diagnostic test Low 2013 405 54.1
Italy National National Routine diagnostic test Low 2021 7395 60.6
Latvia National National Routine diagnostic test Low 2021 299 45
Malta National National Routine diagnostic test Low 2019 121 43.8
Portugal National National Routine diagnostic test Low 2021 303 83
Spain National National Routine diagnostic test Low 2020 2587 53.6
Sweden Subnational Stockholm Routine diagnostic test Low 2012 65 95.4

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Average of available studies (60.64 per 1000 people)

Table 4. Prevalence (%) of active HCV infection (HCV RNA+) among people who inject drugs, by country, 2021 or latest available data
Country Geographical coverage Location Study design Level of evidence Year Number tested Prevalence %
Austria Subnational Vienna Routine diagnostic test Low 2020 202 59.4
Austria Subnational Vienna Routine diagnostic test Low 2021 202 39.1
Belgium Subnational Multi-city Routine diagnostic test Moderate 2019 211 15
Germany National National Routine diagnostic test Low 2016 2260 27.3
Germany Subnational Berlin Sero-prevalence study Moderate 2021 144 27.8
Germany Subnational Bavaria Sero-prevalence study Moderate 2022 447 26.9
Greece National National Routine diagnostic test Low 2021 143 55.9
Greece Subnational Attica Routine diagnostic test Low 2021 87 56.3
Norway Subnational Oslo Sero-prevalence study Moderate 2022 247 8.9
Sweden Subnational Stockholm Routine diagnostic test Low 2014 1386 62.1

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Average of available studies (37.87 %)

Table 5. Sero-prevalence studies: Prevalence (%) of active HBV infection (HBsAg+) among PWID, by country, 2021 or latest available data
Country Geographical coverage Location Study design Level of evidence Year Number tested Prevalence %
Bulgaria Subnational Multi-city Sero-prevalence study Moderate 2016 359 8.6
Cyprus National National Sero-prevalence study Low 2018 65 16.9
Estonia Subnational Tallin Sero-prevalence study Moderate 2017 112 8
Estonia Subnational Narva Sero-prevalence study Moderate 2018 350 5.7
Germany Subnational Berlin Sero-prevalence study Moderate 2021 143 1.4
Germany Subnational Bavaria Sero-prevalence study Moderate 2022 441 1.1
Hungary National National Sero-prevalence study High 2015 596 2.2
Latvia National Multi-city Sero-prevalence study Moderate 2017 386 3.6
Lithuania Subnational Multi-city Sero-prevalence study Moderate 2014 200 10.5
Lithuania National National Sero-prevalence study High 2018 286 4.9
Norway Subnational Oslo Sero-prevalence study Moderate 2021 212 0.5
Poland National National Sero-prevalence study Moderate 2017 172 2.9
Poland Subnational Warsaw Sero-prevalence study Moderate 2017 66 3
Romania Subnational Bucharest Sero-prevalence study Moderate 2017 444 8.7
Slovakia Subnational Bratislava Sero-prevalence study Moderate 2021 54 0
Türkiye National National Sero-prevalence study High 2018 2409 3.5
Türkiye National National Sero-prevalence study High 2021 1465 4.4

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Average of available studies (5.20 %)

Table 6. Routine diagnostic testing studies: Prevalence (%) of active HBV infection (HBsAg+) among PWID, by country, 2021 or latest available data
Country Geographical coverage Location Study design Level of evidence Year Number tested Prevalence %
Austria Subnational Vienna Routine diagnostic test Low 2021 192 3.1
Belgium Subnational Antwerp Routine diagnostic test Low 2014 373 1.9
Bulgaria Subnational Sofia Routine diagnostic test Low 2021 259 5.8
Cyprus National National Routine diagnostic test Low 2021 71 4.2
Czechia National National Routine diagnostic test Low 2021 1141 1.2
Greece National National Routine diagnostic test Moderate 2021 594 1.7
Greece Subnational Attica Routine diagnostic test Low 2021 262 1.1
Greece Subnational Multi-region Routine diagnostic test Low 2021 228 2.2
Greece Subnational Thessaloniki Routine diagnostic test Low 2021 104 1.9
Hungary Subnational Multi-city Routine diagnostic test Moderate 2013 223 2.2
Latvia National National Routine diagnostic test Low 2019 813 0
Portugal National National Routine diagnostic test Low 2021 297 6
Spain National National Routine diagnostic test Low 2020 1292 5.3
Sweden Subnational Stockholm Routine diagnostic test Low 2014 1386 2.1

The level of evidence is assessed separately for seroprevalence studies (SP) and routine diagnostic tests (DT), based on the case definition for people who inject drugs, sample size, type of settings, number of sites, type of biological sample. SP are also assessed for sampling method; and DT for timeliness, periodicity and geographical coverage.

Average of available studies (2.76 %)

Table 7. Countries with viral hepatitis policy inclusive of people who inject drugs, 2021
Country Country code Policy
Austria AT Inclusive policy
Belgium BE Inclusive policy
Bulgaria BG No policy
Croatia HR Policy in preparation
Cyprus CY Inclusive policy
Czechia CZ Inclusive policy
Denmark DK Inclusive policy
Estonia EE No policy
Finland FI Inclusive policy
France FR Inclusive policy
Germany DE Inclusive policy
Greece EL Inclusive policy
Hungary HU No policy
Ireland IE Inclusive policy
Italy IT Inclusive policy
Latvia LV Inclusive policy
Lithuania LT No policy
Luxembourg LU Inclusive policy
Malta MT Inclusive policy
Netherlands NL Inclusive policy
Norway NO Inclusive policy
Poland PL Policy in preparation
Portugal PT Inclusive policy
Romania RO Inclusive policy
Slovakia SK No policy
Slovenia SI Inclusive policy
Spain ES Inclusive policy
Sweden SE Inclusive policy
Türkiye TR Missing
Table 8. Needle and syringe distribution and opioid agonist treatment coverage in relation to WHO 2020 targets, 2021 or latest available estimate
Country Proportion in opioid agonist treatment Syringes per person who injects drugs Number people who inject drugs
Croatia 0.5 43 6344
Cyprus 0.17 8 627
Czechia 0.59 232 40500
Finland 0.18 264 25000
France 0.78 118 106857
Greece 0.85 234 2462
Italy 0.27 5 105652
Latvia 0.1 145 7715
Lithuania 0.15 30 8868
Luxembourg 0.86 523 822
Norway 0.86 482 7878
Portugal 0.64 86 13162
Spain 0.9 181 8582
Belgium 0.72 172 7018

The coverage is based on the latest national estimates of injecting drug use and high-risk opioid use matched by harm reduction activity data (within a maximum of 2 years). The estimate of coverage of opioid agonist treatment for Belgium is derived from a subnational study conducted in 2019.

WHO 2020 target for needles and syringe distribution per person who injects drugs = 200

WHO 2020 the proportion of high-risk opioid users receiving opioid agonist treatment = 0.4

Table 9. Proportion of high-risk opioid users in opioid agonist treatment (OAT), European countries, 2021 or latest available data
Country OAT, year of estimate Total number of OAT clients High-risk opioid use, year of estimate Number high-risk opioid users Proportion in OAT, lower estimate Proportion in OAT, central estimate Proportion in OAT, upper estimate
Austria 2021 20138 2021 39029 0.5 0.52 0.54
Belgium 2021 15426 2019     0.72  
Croatia 2021 4480 2015 8874 0.39 0.5 0.62
Cyprus 2020 208 2021 1258 0.1 0.17 0.25
Czechia 2021 6000 2021 10200 0.57 0.59 0.61
Denmark 2021 5533 2016 20412 0.16 0.27 0.39
Finland 2019 4729 2017 26200 0.16 0.18 0.2
France 2018 177100 2020 226057 0.77 0.78 0.8
Germany 2021 81300 2016 166294 0.48 0.49 0.49
Greece 2021 9039 2021 10593 0.56 0.85 1
Ireland 2019 10580 2019 19875 0.49 0.53 0.54
Italy 2018 75711 2021 279503 0.23 0.27 0.33
Latvia 2021 685 2017 7100 0.08 0.1 0.12
Lithuania 2021 1098 2016 7503 0.09 0.15 0.21
Luxembourg 2021 1231 2019 1427   0.86  
Malta 2021 796 2020 896 0.77 0.89 0.95
Norway 2018 7762 2013 9015 0.56 0.86 1
Poland 2019 3021 2014 14664 0.16 0.21 0.28
Portugal 2021 18185 2018 28287 0.42 0.64 0.98
Romania 2021 1769 2020 17024 0.08 0.1 0.13
Slovakia 2021 590 2021 2617 0.14 0.23 0.32
Slovenia 2021 3078 2021 4125 0.69 0.75 0.8
Spain 2020 55058 2020 61387 0.65 0.9 1

WHO 2020 target for the proportion of high-risk opioid users receiving opioid agonist treatment = 0.4

Table 10. Number of syringes distributed per year per PWID, European countries, 2021 or latest available data
Country People who inject drugs, year of estimate Number people who inject drugs Number of syringes, year of estimate Total number of syringes distributed Syringes per person who injects drugs, lower estimate Syringes per person who injects drugs, central estimate Syringes per person who injects drugs, upper estimate
Belgium 2019 7018 2021 1203860 126.36 171.54 251.12
Bulgaria 2020 9783 2021 534 0.05 0.05 0.06
Croatia 2015 6344 2021 269894 32.69 42.54 52.44
Cyprus 2021 627 2021 5224 5.64 8.33 11.66
Czechia 2021 40500 2021 9381890 227.72 231.65 235.14
Estonia 2015 8606 2021 1634981 169.29 189.98 211.35
Finland 2017 25000 2020 6595051   263.8  
France 2020 106857 2018 12572530 113.94 117.66 121.63
Greece 2021 2462 2021 576494 166.09 234.16 313.14
Hungary 2015 6707 2021 39925   5.95  
Italy 2021 105652 2017 515445 3.95 4.88 6.38
Latvia 2016 7715 2021 1116157 128.62 144.67 165.33
Lithuania 2016 8868 2021 264647 28.26 29.84 31.61
Luxembourg 2019 822 2021 430281   523.46  
Norway 2021 7878 2021 3800000 443.2 482.36 565.56
Portugal 2015 13162 2021 1132770 39.75 86.06 176.55
Spain 2020 8582 2020 1551973 125.3 180.84 324.82

WHO 2020 target for needles and syringe distribution per person who injects drugs = 200

Table 11. Existence of a vaccination programme that provides access to HBV vaccination to people in prisons in 2021
Country Country code Vaccination Beneficiaries
Austria AT Available Offered to at-risk groups
Belgium BE Available Available on request (opt-in)
Bulgaria BG Not available Not available to prisoners
Croatia HR Available Availabile on request (opt-in)
Cyprus CY Available Availabile on request (opt-in) AND upon request by a physician
Czechia CZ Available Offered to at-risk groups AND available on request (opt-out)
Denmark DK Available Availabile on request (opt-in)
Estonia EE Available Offered to at-risk groups
Finland FI Available Offered to all eligible prisoners
France FR Available Offered to all eligible prisoners
Germany DE Available Offered to all eligible prisoners (opt-out): 9 (North Rhine-Westphalia; Hesse; Thuringia; Rhineland-Palatinate; Mecklenburg-Western Pomerania; Brandenburg; Saarland; Berlin; Hamburg); Offered to those in high-risk groups: 5 (Lower Saxony; Saxony; Saxony-Anhalt; Baden-Württemberg; Bremen); Available on request (opt-in): 1 (Schleswig-Holstein); Other: 1 (Bavaria – if there is medical indication).
Greece EL Missing Missing
Hungary HU Available Available on request for at-risk groups (opt-in)
Ireland IE Available Offered to all eligible prisoners
Italy IT Available Offered to all eligible prisoners
Latvia LV Not available Not available to prisoners
Lithuania LT Not available Not available to prisoners
Luxembourg LU Available Offered to all eligible prisoners
Malta MT Available Offered to all eligible prisoners
Netherlands NL Available Offered to MSM
Norway NO Available Offered to at-risk groups
Poland PL Available Upon request by a physician
Portugal PT Available Offered to all eligible prisoners
Romania RO Not available Not available to prisoners
Slovakia SK Available Available on request (opt-in)
Slovenia SI Available Available on request (opt-in)
Spain ES Available Offered to all eligible prisoners
Sweden SE Available Offered to all eligible prisoners
Türkiye TR Missing Missing
Table 12. Percentage of people entering drug treatment reporting injecting drugs who had an HCV test in the previous 12 months, 2021 or latest data available
Country Percentage
Austria 58.2
Bulgaria 73.2
Cyprus 41.4
Czechia 58
Denmark 17.8
Estonia 21.4
Finland 52.6
France 53.1
Germany 36.1
Ireland 48.1
Italy 12.4
Latvia 24.6
Luxembourg 69.2
Malta 9.8
Poland 33.1
Portugal 15.3
Romania 26.8
Slovakia 48.4
Slovenia 35.1
Spain 54.5
Sweden 67.3
Table 13. Countries with restrictive clinical or reimbursement guidelines for Direct-acting antiviral agents (DAA) access for people who use drugs, 2023
Country Country code Restrictions on DAA
Austria AT No restriction
Belgium BE No restriction
Bulgaria BG Clinical and financial Restictions
Croatia HR Clinical restrictions
Cyprus CY No restriction
Czechia CZ No restriction
Denmark DK No restriction
Estonia EE Clinical restrictions
Finland FI No restriction
France FR No restriction
Germany DE No restriction
Greece EL No restriction
Hungary HU No restriction
Ireland IE No restriction
Italy IT No restriction
Latvia LV No restriction
Lithuania LT No restriction
Luxembourg LU No restriction
Malta MT No restriction
Netherlands NL No restriction
Norway NO No restriction
Poland PL No restriction
Portugal PT No restriction
Romania RO Clinical and financial Restictions
Slovakia SK Clinical and financial Restictions
Slovenia SI No restriction
Spain ES No restriction
Sweden SE No restriction
Türkiye TR Missing
Table 14. Trends in HCV antibody prevalence (%) among people who inject drugs aged less than 25 years: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
Country Study ID Geographical coverage Year Number tested Prevalence % 95% Confidence interval Study design
Czechia CZ0007 National 2014 318 11.9 8.3% - 15.5% Routine diagnostic test
Czechia CZ0007 National 2015 171 14 8.8% - 19.2% Routine diagnostic test
Czechia CZ0007 National 2016 298 11.7 8.1% - 15.3% Routine diagnostic test
Czechia CZ0007 National 2017 294 11.6 7.9% - 15.3% Routine diagnostic test
Czechia CZ0007 National 2018 218 11.9 7.6% - 16.2% Routine diagnostic test
Czechia CZ0007 National 2019 231 13.4 9% - 17.8% Routine diagnostic test
Czechia CZ0007 National 2020 116 12.9 6.8% - 19% Routine diagnostic test
Czechia CZ0007 National 2021 154 15.6 9.9% - 21.3% Routine diagnostic test
Italy IT0001 National 2014 439 28 23.8% - 32.2% Routine diagnostic test
Italy IT0001 National 2015 334 28.7 23.8% - 33.6% Routine diagnostic test
Italy IT0001 National 2016 294 29.6 24.4% - 34.8% Routine diagnostic test
Italy IT0001 National 2017 266 34.2 28.5% - 39.9% Routine diagnostic test
Italy IT0001 National 2018 331 26.6 21.8% - 31.4% Routine diagnostic test
Italy IT0001 National 2019 250 22.4 17.2% - 27.6% Routine diagnostic test
Italy IT0001 National 2020 166 18.1 12.2% - 24% Routine diagnostic test
Italy IT0001 National 2021 158 20.9 14.6% - 27.2% Routine diagnostic test
Türkiye TR0001 National 2018 798 40.9 37.5% - 44.3% Sero-prevalence study
Türkiye TR0001 National 2017 824 36.8 33.5% - 40.1% Sero-prevalence study
Türkiye TR0001 National 2015 1173 30.1 27.5% - 32.7% Sero-prevalence study
Türkiye TR0001 National 2014 1371 36.5 34% - 39% Sero-prevalence study
Table 15. Trends in HCV antibody prevalence (%) among people who inject drugs, injecting for less than 2 years: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
Country Study ID Geographical coverage Year Number tested Prevalence % 95% Confidence interval Study design
Czechia CZ0007 National 2014 88 8 2.3% - 13.7% Routine diagnostic test
Czechia CZ0007 National 2015 59 8.5 1.4% - 15.6% Routine diagnostic test
Czechia CZ0007 National 2016 96 8.3 2.8% - 13.8% Routine diagnostic test
Czechia CZ0007 National 2017 148 11.5 6.4% - 16.6% Routine diagnostic test
Czechia CZ0007 National 2018 109 9.2 3.8% - 14.6% Routine diagnostic test
Czechia CZ0007 National 2019 89 15.7 8.1% - 23.3% Routine diagnostic test
Czechia CZ0007 National 2020 32 6.2 -0.168 Routine diagnostic test
Czechia CZ0007 National 2021 93 7.5 2.1% - 12.9% Routine diagnostic test
Greece GR0014 Multi-region 2014 31 38.7 21.6% - 55.8% Routine diagnostic test
Greece GR0014 Multi-region 2015 41 36.6 21.9% - 51.3% Routine diagnostic test
Greece GR0014 Multi-region 2016 29 41.4 23.5% - 59.3% Routine diagnostic test
Greece GR0014 National 2014 90 48.9 38.6% - 59.2% Routine diagnostic test
Greece GR0014 National 2015 73 34.2 23.3% - 45.1% Routine diagnostic test
Greece GR0014 National 2016 65 35.4 23.8% - 47% Routine diagnostic test
Greece GR0014 National 2017 51 43.1 29.5% - 56.7% Routine diagnostic test
Greece GR0014 National 2018 48 27.1 14.5% - 39.7% Routine diagnostic test
Greece GR0014 National 2019 45 33.3 19.5% - 47.1% Routine diagnostic test
Greece GR0014 National 2020 37 29.7 15% - 44.4% Routine diagnostic test
Greece GR0014 National 2021 74 39.2 28.1% - 50.3% Routine diagnostic test
Spain ES0001 National 2014 26 42.3 23.3% - 61.3% Routine diagnostic test
Spain ES0001 National 2015 48 29.2 16.3% - 42.1% Routine diagnostic test
Spain ES0001 National 2016 61 27.9 16.6% - 39.2% Routine diagnostic test
Spain ES0001 National 2017 48 33.3 20% - 46.6% Routine diagnostic test
Spain ES0001 National 2018 69 29 18.3% - 39.7% Routine diagnostic test
Spain ES0001 National 2019 87 29.9 20.3% - 39.5% Routine diagnostic test
Spain ES0001 National 2020 70 30 19.3% - 40.7% Routine diagnostic test
Turkye TR0001 National 2014 885 21.1 18.4% - 23.8% Sero-prevalence study
Turkye TR0001 National 2015 222 24.3 18.7% - 29.9% Sero-prevalence study
Turkye TR0001 National 2017 78 29.5 19.4% - 39.6% Sero-prevalence study
Turkye TR0001 National 2018 112 29.5 21.1% - 37.9% Sero-prevalence study
Table 16. Trends in HCV RNA prevalence (%) among people who inject drugs: results from diagnostic tests and seroprevalence studies with national or multi-city coverage, 2014-2021
Country Study ID Geographical coverage Year Number tested Prevalence % 95% Confidence interval Study design
Austria AT0003 Vienna 2015 206 52.9 46.1% - 59.7% Routine diagnostic test
Austria AT0003 Vienna 2016 244 59.4 53.2% - 65.6% Routine diagnostic test
Austria AT0003 Vienna 2017 315 55.6 50.1% - 61.1% Routine diagnostic test
Austria AT0003 Vienna 2018 195 54.9 47.9% - 61.9% Routine diagnostic test
Austria AT0003 Vienna 2019 182 57.1 49.9% - 64.3% Routine diagnostic test
Austria AT0003 Vienna 2020 246 48.8 42.6% - 55% Routine diagnostic test
Austria AT0003 Vienna 2021 202 39.1 32.4% - 45.8% Routine diagnostic test
Greece GR0014 Attica 2016 89 50.6 40.2% - 61% Routine diagnostic test
Greece GR0014 Attica 2017 100 51 41.2% - 60.8% Routine diagnostic test
Greece GR0014 Attica 2019 74 56.8 45.5% - 68.1% Routine diagnostic test
Greece GR0014 Attica 2020 125 48 39.2% - 56.8% Routine diagnostic test
Greece GR0014 Attica 2021 87 56.3 45.9% - 66.7% Routine diagnostic test
Norway NO0001 Oslo 2015 214 45.8 39.1% - 52.5% Sero-prevalence study
Norway NO0001 Oslo 2018 283 26.1 21% - 31.2% Sero-prevalence study
Norway NO0001 Oslo 2021 256 14.5 10.2% - 18.8% Sero-prevalence study
Table 17. Overview of hepatitis elimination situation by country
Country PWID population size anti-HCV prevalence HCV RNA prevalence HBsAg prevalence Inclusive national policy Combined OAT/NSP coverage HBV vaccination in prison HCV testing coverage DAA Treatment restriction Impact - Incidence proxy over time Impact - Trends in HCV viraemic prevalence
Austria No recent data Data available Data available Data available Inclusive policy No data Available On target No restriction No data Below target
Belgium Data available Data available Data available Data available Inclusive policy Below target Available No data No restriction No data No data
Bulgaria Data available Data available No recent data Data available No policy No data Not available On target Clinical and financial restrictions No data No data
Croatia Data available Data available No recent data No recent data Policy in preparation Below target Available No data Clinical restrictions No data No data
Cyprus Data available Data available No recent data Data available Inclusive policy Below target Available Below target No restriction No data No data
Czechia Data available Data available No recent data Data available Inclusive policy On target Available On target No restriction No significant decrease No data
Denmark No recent data No recent data No recent data No recent data Inclusive policy No data Available Below target No restriction No data No data
Estonia Data available Data available No recent data Data available No policy No data Available Below target Clinical restrictions No data No data
Finland Data available Data available No recent data No recent data Inclusive policy Below target Available On target No restriction No data No data
France Data available No recent data No recent data No recent data Inclusive policy Below target Available On target No restriction No data No data
Germany No recent data Data available Data available Data available Inclusive policy No data Available Below target No restriction No data No data
Greece Data available Data available Data available Data available Inclusive policy On target Missing No data No restriction No significant decrease Below target
Hungary Data available Data available No recent data Data available No policy Below target Available No data No restriction No data No data
Ireland No recent data No recent data No recent data No recent data Inclusive policy No data Available Below target No restriction No data No data
Italy Data available Data available No recent data No recent data Inclusive policy Below target Available Below target No restriction No significant decrease No data
Latvia Data available Data available No recent data Data available Inclusive policy Below target Not available Below target No restriction No data No data
Lithuania Data available Data available No recent data Data available No policy Below target Not available No data No restriction No data No data
Luxembourg Data available No recent data No recent data No recent data Inclusive policy On target Available On target No restriction No data No data
Malta No recent data Data available No recent data No recent data Inclusive policy No data Available Below target No restriction No data No data
Netherlands Data available No recent data No recent data No recent data Inclusive policy No data Available No data No restriction No data No data
Norway Data available Data available Data available Data available Inclusive policy On target Available No data No restriction No data Below target
Poland No recent data No recent data No recent data Data available Policy in preparation No data Available Below target No restriction No data No data
Portugal Data available Data available No recent data Data available Inclusive policy Below target Available Below target No restriction No data No data
Romania No recent data Data available No recent data Data available Inclusive policy No data Not available Below target Clinical and financial restrictions No data No data
Slovakia No recent data Data available No recent data Data available No policy No data Available Below target Clinical and financial restrictions No data No data
Slovenia No recent data No recent data No recent data No recent data Inclusive policy No data Available Below target No restriction No data No data
Spain Data available Data available No recent data Data available Inclusive policy Below target Available On target No restriction No significant decrease No data
Sweden No recent data Data available Data available Data available Inclusive policy No data Available On target No restriction No data No data
Türkiye No recent data No recent data No recent data No recent data No data No data No data No data No data No significant decrease No data
On target (out of 29) 18 20 6 18 21 4 23 8 22 0 0

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