Drug-related infectious diseases – the current situation in Europe (European Drug Report 2024)

People who inject drugs are at risk of contracting infections through the sharing of drug use paraphernalia. On this page, you can find the latest analysis of drug-related infectious diseases in Europe, including key data on infections with HIV and hepatitis B and C viruses.

This page is part of the European Drug Report 2024, the EMCDDA's annual overview of the drug situation in Europe.

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Last update: 11 June 2024

Rebound in HIV notifications to pre-pandemic levels highlights service development needs

People who inject drugs are at risk of contracting infections such as viral hepatitis B and C (HBV and HCV, respectively) and the human immunodeficiency virus (HIV) through the sharing of drug use paraphernalia. These infections can cause chronic diseases that may result in severe health-related harms, including death. While the long-term trend in new HIV infections related to injecting drug use has been declining in the European Union, more than half of the reporting countries saw an increase in new HIV notifications in 2022 compared with 2021 (Figure 10.1). The increase observed in 2022 may, in part at least, reflect increased rates of HIV testing following the lifting of COVID-19-related restrictions on movement and the return to pre-pandemic functioning of health services (including HIV testing). Another possible contributory factor is the increased movement of people living with a known HIV diagnosis in European countries following the Russian invasion of Ukraine. Thus, these data need to be interpreted with caution, as they are not necessarily indicative of an increase in rates of new infections. Nor do they necessarily put into question the long-term decline in HIV notifications. Nevertheless, the decline of 38 % noted since 2010 falls short of the World Health Organization’s (WHO) target of a 75 % reduction, suggesting increased efforts are still needed in this area.

An additional concern is that, in 2022, over 40 % of new HIV diagnoses linked to injecting drug use in the European Union were diagnosed late. Patients with a late HIV diagnosis are at increased risk of HIV-related morbidity and mortality and may have a poorer response to antiretroviral treatment. Voluntary and confidential infectious disease testing of people who inject drugs is a prerequisite for linkage to care and treatment provision.

By 2022, no EMCDDA reporting country had yet reached all 95-95-95 WHO targets for the continuum of care among people who inject drugs living with HIV. These targets aim to have 95 % of people living with HIV tested, 95 % of these people on antiretroviral therapy and 95 % of those achieving viral suppression by 2030. Overall, among people living with HIV, those who inject drugs are less likely to be diagnosed, linked to care and achieve viral suppression. This implies a greater risk of HIV-related morbidity and mortality, as well as the possibility of more onward transmission. Recent guidance from the EMCDDA and ECDC on the prevention and control of infectious diseases among people who inject drugs supports the implementation of tailored community-based testing services. This includes testing outside formal healthcare settings, for example in outreach services, and highlights how a more integrated approach to testing and linkage to care is an effective way to reduce this persistent health inequity. Harm reduction approaches are now seen as fundamental to reducing HIV transmission among people who inject drugs, particularly the provision of sterile injecting equipment, including in prisons and through pharmacies. However, coverage and access to free needle and syringe provision remain insufficient in many countries, with only 5 of the 17 countries with available data achieving the WHO service provision targets in 2022 (Figure 10.3). Obtaining secure funding for harm reduction services working with people who inject drugs can be challenging in some countries. For example, non-governmental organisations in Bulgaria and Romania have experienced funding and procurement difficulties in recent years, leading to a reduction in provision. In Sofia, during the period of reduced syringe provision, HIV prevalence rates from routine diagnostic tests conducted in drug treatment centres increased, reaching 15 % in 2022, reflecting the risk of increased infections when service levels are inadequate.

Norway on track to eliminate HCV as a public health threat among people who inject drugs

In Europe, people who inject drugs also have a high burden of chronic viral hepatitis, and injecting drug use remains the most common risk factor for new HCV diagnoses. A recent study found that at least 36 % of the overall chronic HCV prevalence in the EU Member States, Norway and Iceland is associated with injecting drug use. There is also evidence that harm reduction services, such as needle and syringe programmes, as well as the provision of opioid agonist treatment, can reduce the risk of HCV transmission. As noted earlier, the coverage of and access to these interventions vary considerably between European countries (Figure 10.4). In addressing the harms associated with HCV infection, it is important to identify individuals who remain chronically infected with the virus, as they are at risk of cirrhosis and cancer, and can transmit the virus to others through the sharing of any injecting paraphernalia that has been in contact with their blood. However, barriers to the uptake of HCV testing and treatment exist in many countries and may result in many HCV infections not being diagnosed and treated.

Data are at NUTS levels 2 or 3. For information on NUTS (nomenclature of territorial units for statistics) visit the Eurostat website. The lack of data at NUTS levels 2 or 3 does not mean that the intervention is not available within a country.

Time trends in the prevalence of active HCV infection among people who inject drugs are useful for monitoring the impact of prevention and treatment. The EMCDDA monitors national progress through its elimination barometer. Among the countries reporting to the EMCDDA, only Norway has evidence that they have achieved an 80 % reduction in viraemic HCV prevalence among people who inject drugs between 2015 and 2021, which is needed to achieve the Sustainable Development Goal 3.3 on HCV elimination by 2030. The prevalence of active HCV infection, as measured by HCV-RNA in a large seroprevalence study among people who inject drugs and use harm reduction services in Oslo, decreased by more than 80 % between 2015 (46 %) and 2022 (8.9 %). A similar trend in prevalence of active infections was observed in Bergen and Stavanger, while modelling work suggests incidence among people who inject drugs has decreased by 79 % at the national level over the same period.

Responding to interactions between high-risk drug-taking and sexual behaviours requires multi-agency partnerships

The use of illicit stimulants and other drugs to facilitate group sexual encounters, sometimes of an extended duration, among men who have sex with men is known as chemsex. The drugs associated with this practice include synthetic stimulants, depressants and dissociatives, and both high-risk drug-taking and high-risk sexual behaviours may take place in some settings, making this an important area for outreach and harm reduction. High-risk consumption of some of these drugs, including injecting drug use, places people at risk of infectious diseases, acute drug toxicity and other health problems. People using drugs in this way often do not present as clients in drug treatment clinics but may be in contact with other services, including sexual health services. Providing effective harm reduction responses for people engaged in these high-risk behaviours remains a challenge, and the development of tailored interventions is needed. In Europe, treatment services for drug and sexual health problems are usually funded separately, have different eligibility criteria and are rarely co-located. This makes it difficult to provide integrated care for people exposed to the dual risks of unprotected sex and high-risk drug use in the context of sexualised drug use.

Greater investment still needed to meet global targets

EU policymakers have made a commitment to the WHO global health sector strategies to end AIDS and the epidemics of viral hepatitis and sexually transmitted infections by 2030. Achieving these objectives, however, still requires increased investment in harm reduction services, testing and linkage to treatment, as the provision in many countries remains insufficient. Greater efforts are therefore needed to prevent future outbreaks and reduce transmission, thereby reducing the burden of disease associated with HIV, HCV, HBV and other infections among people who inject drugs.

Key data and trends

HIV/AIDS

• In 2022, the number of new HIV notifications linked to injecting drug use in the European Union increased to 968, compared with 662 the previous year (Figure 10.5).
• The share of new HIV cases related to injecting drug use also increased between 2021 and 2022: from 4.8 % to 5.9 % of new cases with a known route of transmission. In 2022, the share of new HIV cases related to injecting drug use was greater than 10 % in Latvia (25 %), Finland (21 %), Luxembourg (19 %), Greece (15 %), Lithuania (14 %), Germany (11 %) and Norway (11 %).
• In 2022, 165 new AIDS diagnoses related to injecting drug use were notified in the European Union.
• Delayed diagnosis and treatment initiation among marginalised populations was a prominent characteristic of the latest HIV cluster detected in the European Union. Situated in the Lombardy region of Italy, it involved 20 analytically linked infections acquired between 2006 and 2022 traced back to the same HIV strain showing resistance-associated mutations.

HCV and HBV

• Five European countries have recent prevalence estimates of active HCV infection among people who inject drugs and access drug services. The prevalence of active HCV infection derived from seroprevalence studies ranged from just under 9 % (Oslo, 2022) to 27 % (Bavaria, 2022), while results from routine HCV diagnostic tests ranged from 15 % (Belgium, 2019) to 59 % (Austria, 2020) and 62 % (Sweden, 2014) (Figure 10.6).
• Snapshots of HCV diagnosis and treatment in several European countries provide insight into linkages to care. In 2022, data from treatment programmes in Greece indicated that of the 26 % of people who inject drugs who tested positive for HCV-RNA, 85 % reported being prescribed treatment, and 54 % of those who had a diagnosis of HCV completed treatment. In Norway, a yearly seroprevalence study conducted among ever-injectors attending drug services in Oslo found a significant decrease in HCV-RNA prevalence between 2015 (46 %) and 2022 (8.9 %), reflecting the impact of prevention and treatment measures.
• In 2023, people who inject drugs were reported to face clinical or financial restrictions in accessing direct-acting antiviral HCV treatment in 5 EU Member States.
• Estimates for HBV infection (as measured by the presence of the hepatitis B surface antigen), derived from the latest seroprevalence studies among people who inject drugs, ranged from 0.4 % (Czechia, 2022) to 5.3 % (Spain, 2021).
• In 2023, there were 20 EU Member States with a viral hepatitis policy that included people who inject drugs. Integrating testing and treatment for HCV, HBV and HIV into harm reduction, drug treatment and prison health services is key to achieving the continuum of care targets for people who inject drugs.

Source data

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