Drug-related infectious disease (DRID): update from the expert network, October 2021

COVID-19 and people who use drugs

Low SARS-CoV-2 antibody prevalence among high-risk drug users shows they remain susceptible

As some EU Member States are facing their fifth COVID-19 wave, more data on SARS-CoV-2 seroprevalence among drug users are becoming available. They complement preliminary findings presented during the 2020 DRID meeting. These data tell us what proportion of the study population (in this case people with substance use disorder or high-risk drug users) had antibodies to SARS-CoV-2 due to natural infection with the virus. These data do not tell us what proportion were symptomatic, nor the severity of the disease, but provide information on the level of transmission that occurred among that group, and what proportion remained susceptible to the infection at the time of the surveys.

Lindqvist et al. (2021) tested 718 needle and syringe programme (NSP) clients in Stockholm, Sweden, between June and October 2020. The cumulative prevalence for SARS-CoV-2 antibodies was 5.4 %, ranging from 4.2 % in June 2020 to 9 % in October 2020. When comparing this result with a seroprevalence study based on healthy blood donors in Stockholm in June 2020 (11.4 %; 95 % CI 6.6–17.8), the authors concluded that compared to the general population in Stockholm, SARS-CoV-2 antibody prevalence was low among clients at the Stockholm NSP.

In Poland, the National Institute of Public Health NIH – National Research Institute conducted a cross-sectional bio-behavioural study among people who ever injected drugs using respondent-driven sampling in three cities (Warsaw, Chorzow and Wroclaw) between February and March 2021. Out of the 145 participants, 4 (2.8 %) tested positive for SARS-CoV-2 IgG/IgM. Again, these results contrasted with SARS-CoV-2 seroprevalence estimates from the general population, where prevalence almost reached 50 % in April-May 2021.

A study in Austria looked at the rate of COVID‑19 diagnosis in 2020 (laboratory-confirmed by PCR) among people on opioid agonist therapy (OAT) by linking the pseudonymised notifiable infectious diseases electronic register and the pseudonymised OAT register. The research team at the Austrian Public Health Institute identified 275 out of 26 297 OAT patients (1.05 %) who had a diagnosis of COVID‑19 based on a positive PCR test. In the general population aged 14-64 years, the COVID‑19 registered diagnostic rate was 5 % over the same period.

The Swedish and Polish data suggest that high-risk drug users (clients of NSP, people on OAT) might have been less exposed to SARS-CoV-2 transmission than the general population at the time of the studies. This could be explained, for example, by the limited size and homogeneity of their social networks. The Austrian study looked at COVID‑19 diagnosis among people on OAT (it did not measure infected people on OAT). The lower diagnostic rate in Austria might reflect a lower testing rate, rather than a lower transmission rate among OAT clients, raising the issue of access to COVID‑19 testing among this group.

Latest data confirm drug addiction is associated with higher risk of severe COVID-19 outcomes

A study from the Glasgow Caledonian University and Public Health Scotland confirmed earlier results from the analysis of French (EPI-PHARE, 2021) and American (Wang et al., 2021) electronic health insurance records suggesting a higher risk of hospitalisation and death among people with substance use disorders diagnosed with COVID‑19. The Scottish team assessed the risk of COVID‑19-related hospitalisation, intensive care admission and death by linking the OAT prescribing information system (involving approximately 35 000 individuals) to COVID‑19 and health data at Public Health Scotland. Compared with the general population (people not on OAT), and adjusting for age, gender and a deprivation index, they found 2-fold higher odds for hospitalisation or death with COVID‑19 among people on OAT in the last 5 years, and 3-fold higher odds for severe COVID‑19 disease (critical care/death). The association remained significant when adjusting for comorbidities.

Therefore, while infection rates might have been lower in some groups of high-risk drug users, the risk of developing severe forms of the disease when infected is likely to be higher than in the general population – partly due to the high prevalence of chronic diseases among this vulnerable population. Since many of them remain susceptible to the infection, they rely on COVID‑19 vaccination to minimise the mortality and morbidity impact of the ongoing pandemic.

COVID‑19 vaccination campaign for people who use drugs: need of equitable and tailored access

Effective and safe COVID‑19 vaccines are available in all EU Member States and the impact of COVID‑19 vaccination in terms of averted mortality (Meslé et al., 2021) in Europe has been documented. Vaccinating vulnerable groups and those at risk of more severe outcomes has been at the core of the COVID‑19 vaccination strategy in the European Union. Reaching out and providing vaccination to marginalised populations is not a challenge specific to the COVID‑19 pandemic, and models have been recommended, for example for hepatitis B vaccination (Haussig et al., 2018) and influenza vaccination (Vlahov et al., 2007) among people who use drugs in the past. Harm-reduction services and outreach programmes are once again key components to the successful implementation of vaccination campaigns among this group.

In Cyprus, following an initiative of the Cyprus National Addictions Authority, the Ministry of Health approved and provided COVID‑19 vaccination to high-risk drug users through its mobile unit. The programme had initially planned to deliver 200 doses of the AstraZeneca vaccine through this outreach team (Cyprus had 492 drug treatment entrants for drugs other than cannabis in 2019). From June to July 2021, 40 people were vaccinated through this initiative, including undocumented migrants. Barriers to vaccination included fear of side effects.

In Prague, Czechia, several initiatives from social and health services have been targeting the homeless and vulnerable people who use drugs. Prague City Hall in cooperation with day centres and outreach services organised at least eight vaccination days, with mobile vaccination teams and general practitioners visiting shelters and day care centres (Janssen). By August 2021, at least 400 people had been vaccinated through these services. In parallel, in one of the largest low-threshold services for people who use drugs in Prague, the mobile vaccination team from the Kralovske Vinohrady University Hospital offered COVID‑19 vaccination (Janssen) to clients. No registration or ID was required to get the vaccine.

Data from Scotland suggest that considerable progress has been made in vaccinating people in contact with drug services, but coverage remains markedly lower in this group compared to the wider population. By 24 August 2021, a lower COVID‑19 vaccine coverage was found among the OAT cohort (61 % with a first dose and 42 % with a second dose) compared to general population matched controls (76 % with a first dose and 68 % with a second dose). The research team found a higher uptake of vaccination among those in prison and with a history of OAT, compared to the overall OAT cohort.

As the COVD‑19 vaccination campaign continues across Europe (catch-up and booster doses, now mostly with mRNA vaccines), reaching the hard-to-reach and increasing access and vaccine uptake (including COVID‑19 vaccine) among the prison population in Europe is the objective of the RISE-Vac consortium funded by the European Union and coordinated by the University of Pisa. Bringing together stakeholders from national agencies, healthcare services, academia and NGOs from six European countries, the project describes and reviews different models of vaccination services in prison, including universal HBV vaccine, targeted influenza, pneumococcal and HPV vaccination, catch-up vaccinations and a universal offer of COVID‑19 vaccination. While all RISE-Vac countries started COVID‑19 vaccination programmes in prisons between March and May 2021, preliminary data from September 2021 show that vaccine coverage (full schedule) was generally lower than in the general population, underlining the need for more equitable and tailored access to vaccine for people in prison (Tavoschi et al., 2021). Identified barriers included vaccine hesitancy, logistical and organisational issues and prison transfer.

Outbreaks of drug-related infectious diseases

Concerns that the pandemic could halt progress towards ending HIV transmission

The number of new HIV infections linked to injecting drug use in the European Union (European Centre for Disease Prevention and Control and WHO Regional Office for Europe, 2021) reported by ECDC declined by 47 % between 2010 and 2019 – in 2019 there were 837 new diagnoses in this population (1.9 per million population), representing 5.5 % of all new HIV infections for which the route of transmission is known, a proportion that has remained stable for the last decade. The number of new AIDS diagnoses in people infected through injecting drug use also decreased over the period (from 1 241 in 2010 to 286 in 2019). The downward trend in new HIV diagnoses linked to injecting drug use reflects, to some extent, improved – yet insufficient – harm reduction coverage over the years (OAT, NSP) and better access to ART treatment. However, the European Union is still below the 2020 fast-track target (a 75 % reduction compared to 2010) and more than half of new diagnoses are diagnosed late (with CD4 count < 350 cells/mm³ at diagnosis). Moreover, the COVID‑19 pandemic has significantly disrupted harm reduction services (European Monitoring Centre for Drugs and Drug Addiction, 2021b) and testing activities (Simões et al., 2020), at least during the first lockdowns in 2020, which could have led to more infections. In 2020, there were 563 new HIV diagnoses and 128 new AIDS diagnoses linked to injecting drug use in the European Union, two numbers that need to be interpreted carefully in the light of reduced testing activity during the COVID‑19 pandemic. In terms of the continuum of HIV care among PWID, the latest progress report on the monitoring implementation of the Dublin Declaration (European Centre for Disease Prevention and Control, 2021a) showed that only two EU countries (France and Spain) reported data in 2020 to document that they reached the UNAIDS 90-90-90 targets among that key population, while Austria and Luxembourg were within 10 % of meeting the targets.

HIV transmission persists in cities where outbreaks linked to stimulant injecting had been notified in the past

In 2011, an HIV outbreak among PWID was detected in Athens (Paraskevis et al., 2011). After a combination of prevention and ‘seek-test-treat’ interventions were implemented (including scaled-up NSP, testing, linkage to AOT and antiretroviral treatment (ART), HIV incidence declined (Sypsa et al., 2017) from 7.8/100 person-years in 2012 to 1.7/100 person-years in 2013. However, preliminary data from the latest round of the ARISTOTLE study, conducted in 2018-20 (Roussos et al., 2021) among 681 PWID who were included in previous rounds, suggest that HIV prevalence increased from 14.2 % (2012-13) to 22 % (2018-20). While incidence estimates never returned to their 2011-12 levels, they ranged from 1.52 to 2.04/100 person-years, indicating ongoing transmission. The prevalence of homelessness (25.6 %) and cocaine injecting (28.1 %) had increased over the period. Predictors of seroconversion included lower education, larger network size and daily drug use. The authors concluded that the current level of prevention and treatment services was below levels that would be required to bring transmission down to pre-outbreak levels. They also noted that the COVID‑19 pandemic has severely impacted HIV prevention services for PWID, which could increase the risk of HIV transmission in this population. The study team conducted a similar study in Thessaloniki, the second-largest city in the country, where 1 101 PWID were recruited during 2019-20. They found high HIV incidence among the study population, suggesting that an outbreak was occurring at a time when COVID‑19 controls measures were in place. The authors highlighted that immediate interventions were required to control transmission.

In Luxembourg, the HIV outbreak among PWID detected in 2014 (Arendt et al., 2019) linked to cocaine injection led to the implementation of a combination of prevention and treatment interventions that brought down the number of new HIV diagnoses among PWID in 2019 to pre-outbreak levels. During the COVID‑19 pandemic, harm reduction services adapted to ensure service continuity. The innovative approaches included the opening of a new low-threshold medical service and AOT programme, the implementation of take-home OAT doses, the physical reorganisation of services to protect staff and clients, and the increased provision of remote services when possible. In a survey done among high-risk drug users during the pandemic, overall core harm reduction services were considered sufficient (Berndt et al., 2021). However, in terms of prevention, the total number of sterile syringes provided fell from 425 906 in 2019 to 393 692 in 2020. In terms of testing activity, the total number of people tested for HIV during Red Cross outreach activities targeting vulnerable populations decreased from 772 in 2019 to 291 in 2020. Despite this significant reduction in testing activity, four new HIV cases were diagnosed among PWID in 2020, suggesting that transmission might have increased since the beginning of the COVID‑19 pandemic.

Similarly to Athens and Luxembourg, the HIV outbreak detected in 2015 among PWID in Glasgow led the public health authorities to implement a combination of tailored interventions (Metcalfe et al., 2020) including scaled-up NPS, OAT, contact tracing, HIV testing and ART treatment as prevention among the affected population. However, despite high coverage of prevention measures, transmission continued to occur (McAuley et al., 2019) in 2019. Besides risk factors such as cocaine injecting, homeless and incarceration, sexual transmission appeared to be contributing to the outbreak. To strengthen the existing response, a multidisciplinary team of NHS Greater Glasgow and Clyde developed an outreach pre-exposure prophylaxis (PreP) service tailored to the needs of PWID (Grimshaw et al., 2021) based in the local homeless health centre. Based on the successful experience of HIV treatment delivery for PWID, the PreP service model relied on four elements: (1) active case finding by outreach sexual health nurses at homeless and addiction services and through partner notification; (2) flexible location for baseline assessment and monitoring with remote doctor review; (3) supervised dispensing at community pharmacies alongside OAT and reporting of adherence breaks; (4) follow-up by sexual health nurses. Preliminary results indicate that adherence was high, showing the feasibility and acceptability of the programme in the context of an outbreak, and regular HIV serology monitoring in patients receiving PreP showed no HIV seroconversion. The service relies on multi-agency, resource-intensive outreach provision, and should be used in conjunction with treatment as prevention, HIV testing programmes, needle exchange services and a comprehensive ART programme.

Following the DRID meeting, national experts from three additional EU countries have reported signals of increased HIV transmission among people who use drugs. In Sofia, Bulgaria, reports indicate that the pandemic seems to have worsened a situation that was already deteriorating with respect to harm reduction funding. According to data from the laboratory at the State Psychiatric Hospital for Treatment of Drug Addiction and Alcoholism in Sofia, reported by the national expert, the positivity rate for HIV infection among PWID in the capital of Bulgaria was significantly higher in 2019-20 (12.8-14.5 %) than in the previous years (when positivity rates were between 3-6 %). A parallel increase in HBV positivity (HBsAg) was also noted from 2019 (5.9 %) to 2020 (7.6 %). This comes after the Global Fund ended its financial support to harm reduction services in 2017. It consequently led to a disruption in needle and syringe programmes, and a reduction by more than half in the number of PWID being tested annually. The National Centre of Public Health and Analysis is organising a meeting with stakeholders and decision-makers to initiate legal changes in order to ensure sustainable financial support for harm reduction services.

The national expert from Slovenia reported that, by November 2021, four new HIV diagnoses among PWID were reported to the National Institute of Public Health among a total number of 28 reported new HIV diagnoses during 2021. This raised concerns that HIV infections might have started to spread more during the COVID‑19 pandemic among PWID in the country. Since 1986, when HIV reporting became mandatory in Slovenia, a total of 29 HIV infections among PWID have been reported, and such a high number of cases (four) were reported only once before, in 1996. The importance of reaching a good coverage of harm reduction services for PWID was re-emphasised.

Slovakia has long recorded one of the lowest HIV prevalence rates among people who inject drugs in Europe. The national expert reported that, in 2020, the yearly seroprevalence study conducted among 61 patients of drug treatment centres in Bratislava identified three HIV-positive cases for the first time among this group since 2015. All have been referred to treatment. The preliminary investigation showed that the patients had a history of methamphetamine injecting, but concluded that the most likely mode of transmission was sex between men (2) and heterosexual transmission (1). A history of the cases showed that infection probably occurred before the COVID‑19 pandemic. While the absolute number of new cases identified is still low, they highlight the importance of maintaining a high level of prevention and testing accessibility for a population that accumulates risk factors.

In the United States, after a steady decline during 2010–2014, the number of HIV diagnoses among PWID increased during 2016–2019, with 2 480 reported diagnoses occurring nationally in 2019, as reported by the CDC expert. A number of HIV outbreaks among PWID (Lyss et al., 2020) have contributed to the increase in diagnoses linked to injecting drug use. Polydrug use (opioids with methamphetamine or cocaine) was one of the characteristics described across outbreaks recently investigated by the CDC response team. Other similarities included injecting multiple times per day, homelessness or unstable housing, recent incarceration and exchange of sex for money or goods. Co-infections with HCV, HBV and STIs were also frequent. Most outbreaks occurred in metropolitan areas, where harm-reduction services were offered. Responding to these outbreaks was labour-intensive, with key components including increasing HIV testing (through contact tracing; testing in syringe services programmes, emergency departments and jails; and outreach testing) and efforts to improve the ability of PWID to access, link to and be retained in services such as harm-reduction, PrEP, HIV and drug treatment (expanding services into new geographic areas, flexible appointment times, assistance with transportation, co-locating and integrating services).

Infective endocarditis linked to the injection of diverted medicine

In addition to infections from human immunodeficiency virus (HIV) and viral hepatitis, PWID are at increased risk for acquiring invasive bacterial infections, including infective endocarditis. Infective endocarditis is defined as an infection of the endocardial surfaces of the heart and can be fatal if left untreated. PWID are at higher risk of infective endocarditis due to potential direct inoculation of bacteria into the bloodstream through non-sterile injecting equipment and injected drugs; direct mechanical damage due to impurities present in injected drugs.

In North America, the opioid epidemic has been followed by a rise in the incidence of infective endocarditis among PWID (Wurcel et al., 2016). A case-control study conducted in Ontario (Shah et al., 2020), Canada, where diverted controlled-release hydromorphone is commonly injected, showed that the odds of having infective endocarditis was significantly higher among female who inject drugs who did not use sterile injection equipment. The authors underline that the components of the hydromorphone capsules that provide the controlled release increase survival of Staphylococcus aureus (Kasper et al., 2019). The study findings highlight once again the importance of maintaining high levels of effective and cost-saving public health interventions such as the provision of sterile injecting material to prevent severe bacterial infections.

Few recent studies were conducted in Europe, but a retrospective study conducted in a referral hospital in Sweden in 2013 (Asgeirsson et al., 2016) had documented an increasing incidence of infective endocarditis (with 120 episodes among PWID identified between 2004-13). A recently published international prospective cohort study (including 13 EU countries) provided an epidemiological, etiological and clinical description of infective endocarditis among 591 PWID and 7 025 non-PWID patients (Pericàs et al., 2021). The authors concluded that a high proportion of infective endocarditis cases in PWID involved left-sided valves, prosthetic valves, or are caused by microorganisms other than Staphylococcus aureus. In Tunisia, a country participating in the EMCDDA’s EU4MD project, diverted buprenorphine is commonly misused by PWID. The infectious diseases department at the Rabta Hospital in Tunis conducted a retrospective study among 28 PWID who were admitted between 2010 and 2014 for infectious diseases other than viral infections. The mean age of the patients was 32 and all but one were males. The mean number of years of drug use at the time of hospitalisation was 8 years, ranging from 1 to 29. Fifteen (54 %) were diagnosed with endocarditis, followed by skin abscess (25 %), sepsis (18 %) and septic thrombophlebitis (4 %). Staphylococcus aureus was the most commonly identified causative agent (9/15). All patients were treated with appropriate antibiotics and five underwent surgical treatment. The outcome was favourable in 90 % of cases, with two patients lost to follow-up.

All studies emphasised that approaching PWID affected by infective endocarditis without discrimination and offering them the possibility of cardiac surgery when indicated, together with necessary harm reduction services and drug treatment, are crucial components of case management.

Eliminating viral hepatitis as a public health threat

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 (European Monitoring Centre for Drugs and Drug Addiction, 2021a). Under five building blocks, it brings together 10 epidemiological indicators and corresponding 2020 targets related to people who inject drugs for the European Union, Norway and Turkey, following the WHO monitoring frameworks. It is done in collaboration with ECDC and complements the European SDG monitoring on viral hepatitis (European Centre for Disease Prevention and Control, 2021b) and the civil society-led monitoring conducted by Correlation – European Harm Reduction Network.

For each indicator, the EMCDDA elimination barometer provides contextual information, references and definitions, an infographic showing national data, the related 2020 WHO target and an achievement status: how many countries have reached the target. Based on 2019 data, there is no indication that the European Union had reached the 2020 targets, and 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 PWID: 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. This section provides an update on some of these aspects.

Pockets of marginalised populations accumulate risk factors, high prevalence and barriers to healthcare

The Robert Koch Institute, in collaboration with two NGOs, conducted a sero-behavioural cross-sectional study in five low-threshold medical centres for the homeless in Berlin, Germany, from May-June 2021 (POINT study). Participants were homeless individuals over 18 years of age; 220 completed a questionnaire and provided a blood sample. In terms of risk factors, injecting drugs in the last 30 days, a history of incarceration and having a tattoo made by non-professionals were common. Preliminary results of the analysis of blood samples showed a low HBV vaccination coverage, and a high prevalence of active HCV infection (HCV-RNA+). Two thirds of those with HCV were aware of their infection and none reported being on antiviral treatment. Among the barriers to HCV care was the lack of health insurance, which was reported by more than two thirds of those with viraemic HCV. The high infection rate and exposure to risk factors among this vulnerable group call for improved cooperation between harm reduction, infectious diseases and homeless medical services, together with targeted interventions for the homeless.

Latest evidence on prevention of blood-borne infections among drug users: a focus on harm reduction equipment and drug consumption rooms

The EMCDDA is working jointly with ECDC, the Glasgow Caledonian University, Public Health Scotland, University of Bristol and Gesundheit Osterreich to update the guidance on control and prevention of infectious disease among PWID. Among the new components of the prevention interventions for HCV, HIV and injecting risk behaviour, the review will include low-dead space syringes, drug consumption rooms, OAT to prevent HCV reinfections, technology-based psycho-social interventions and the combination of OAT and NSP. The new guidance will also indicate that linkage to care following HCV diagnosis and adherence to treatment can be improved by cooperation between providers, integrated care approaches and peer mentoring.

Low dead space syringes are designed to reduce the amount of fluid left in the hub (i.e. dead space) once the plunger has been fully depressed and, theoretically, reduce the volume of blood that is transferred from one PWID to another when sharing syringes (Binka et al., 2015). Low dead space syringes were included in an EMCDDA project that gathered the evidence, expert interpretation and local implementation consideration on 11 types of harm reduction equipment. Besides low dead space syringes, the review included acidifiers, bleach and chlorine tablets, filters, cookers, water, foil, pipes, wound care kits, fentanyl test strips and naloxone. Both the joint EMCDDA/ECDC guidance and the harm reduction equipment technical guide will be published in 2022.

Drug consumption rooms (DCR) are places in which drug users can use illicit drugs under the supervision of medically trained staff. They exist in several European countries and are usually located in areas where there is an open drug scene and injecting in public places is common. Their primary goal is to reduce morbidity and mortality by providing a safer environment for drug use and training clients in safer forms of drug use. A recent INSERM report presents an assessment of the drug consumption rooms in France (Institut de Santé Publique de l’Inserm, 2021). In terms of injecting risk behaviour, the results of the cohort study suggested that PWID using a DCR (medium to high frequency) are less likely to report sharing injecting material, less likely to inject in public spaces and less likely to report abscesses compared to PWID who do not use DCR (or who report a low frequency of utilisation). The same cohort study did not find any significant difference in HCV testing. In terms of impact, the economic study projected that within 10 years, the two DCR (Paris and Strasbourg) could reach around 6 000 PWID, preventing among this group 6 % of HIV infections, 11 % of HCV infections, 77 % of abscesses and associated endocarditis, 69 % of overdoses and 71 % of emergency visits. The authors concluded that the corresponding healthcare savings make DCR a cost-effective intervention.

While PWID face the highest risk of HCV infection through sharing injecting material, HCV infection is also possible when using drugs through other modes of administration – especially using crack pipes (Fischer et al., 2008). In France, where crack use has become more visible in Paris in recent years (Cadet-Taïrou et al., 2021), the NGO SAFE has added to its panel of harm reduction material a safer smoking device (universal pipe) made of borosilicate glass that can resist high temperatures. The harm reduction device comes with disposable tips (to reduce microbial contamination) and a cellulose filter. It is currently being evaluated in the field in collaboration with users, harm reduction services, the Parisian Center of Evaluation and Information on Pharmacodependence and Addictovigilance (CEIP-A) and University College Dublin.

HCV continuum of care: decentralised small-scale initiatives are working but national scale-ups are needed

The Greek national focal point implemented the methodology proposed by the EMCDDA through its harm reduction initiative to increase access to HCV care through drug services. The team organised a national consultation involving three types of stakeholders: beneficiaries and NGOs (client level), health professionals (provider level), policymakers (system level). They reached a total of 16 institutions, analysed 78 questionnaires and facilitated three online meetings to identify obstacles and solutions to increase drug users’ access to diagnosis and treatment of HCV in Greece. Systemic weaknesses identified by the working group included the lack of a ‘one-stop-shop’ approach (Lazarus et al., 2019) that would provide testing and treatment in or near drug treatment services, and the lack of HCV integrated care in drug services and prisons in remote areas where there is no medical professional. Homelessness, comorbidities and discrimination in hospitals were identified as major factors preventing PWID with chronic HCV from getting the care they need. Proposed solutions included the development of a treatment manual for blood-borne infections for staff of drug treatment agencies, the implementation of mobile health units with diagnostic capacity to reach areas beyond large cities, the expansion of rapid tests and dried blood spot testing in drug treatment services, and the assessment of the feasibility and cost-effectiveness of the one-stop-shop approach for HCV elimination in Greece.

The decentralised initiative to link HCV-infected drug users to care in Vienna, Austria, continued and expanded. The programme started at the low-threshold service Ambulatorium Suchthilfe Wien, where a hepatologist from a centre for hepatitis C treatment comes on a weekly basis to initiate HCV treatment among newly diagnosed OAT patients, some receiving it as ‘directly observed therapy’ (Schmidbauer et al., 2021) at the low-threshold facility. As a second step, the project team started to work with pharmacies, allowing drug users to receive their HCV medication together with their OAT medication on a daily basis in one of over 100 pharmacies in Vienna and Lower Austria. By the end of 2020, 506 patients had started treatment as directly observed therapy, 322 had completed it, with documented sustained virologic response (SVR) for 320. Another pathway for testing and linking drug users to care in Vienna is through the health authority centres, where the 6 500 OAT patients renew their long-term OAT prescription every month (at least until the first lockdown in March 2020). Through this model, up to March 2020, 1 592 clients have been screened for HCV using rapid antibody tests (51 % positive) and tested for HCV-RNA (17 % positive). Due to the COVID‑19 pandemic and lockdowns, the project was put on hold. The project team noted that linking these patients to care proved more difficult than expected.

In Lisbon, the mobile outreach programme (including two mobile units) of the Ares do Pinhal NGO provides harm reduction and healthcare to a population of 1 200 drug users. The team has had experience with different HCV models of care. From 2015-17, the model was based around referral to a GP, with only 10 % of patients successfully linked. In 2017, a protocol was established with specialised services in hospitals. Appointments and transport to the hospital were organised by Ares do Pinhal, while follow-up and directly observed therapy were carried out in the mobile units. Participation in the consultations increased (to approximately 45 %), but was sub-optimal. Since February 2019, all the steps of the continuum of care (including the appointment with a hepatologist) can be performed in the mobile units, resulting in 80 % (172/213) of eligible patients being seen by a specialist, with 76 patients completing treatment. More specifically, among 85 PWID screened in Lisbon, 44 (52 %) were diagnosed with chronic HCV, 31 (70 %) were linked to care 26 (84 %) were cured.

On 3 May 2021, the EMCDDA launched its first bilateral technical cooperation project with Georgia, which aims at enhancing the national responses to drug-related health and security threats. The EMCDDA4Georgia project is funded by the European Union and will focus primarily on knowledge transfer and capacity-building in the areas of drug monitoring, reporting, prevention and treatment. There were an estimated 52 500 PWID in Georgia in 2016, a third of whom inject opioids (buprenorphine, heroin) while ephedra plant product (Otiashvili et al., 2017) is also commonly used among PWID. The country launched its HCV elimination programme in 2015 and has developed an advanced information system, which links screening, laboratory diagnostics and treatment data allowing for monitoring of the HCV continuum of care (Averhoff et al., 2019), including for key populations. It allows the National Centre for Disease Control to monitor the continuum of HCV care among the 10 500 people receiving methadone substitution treatment in the country. The 2019 data showed that the WHO targets among OAT patients were reached, paving the way for micro-elimination in this population. Remaining challenges include reaching those PWID not on OAT, and preventing and monitoring re-infections.

Together with Iceland (Olafsson et al., 2021) and Scotland, Georgia shows that it is possible to scale up integrated interventions to achieve a measurable impact among key populations disproportionally affected by viral hepatitis, and whose vulnerabilities require tailored and adapted services. Impactful scale-up requires political and financial commitment (including sustainable funding of harm reduction services and the ability to negotiate affordable medicines with the industry), coordination across stakeholders and tackling discrimination. The EU response to the COVID‑19 pandemic has shown that political and financial commitment to tackle a health crisis is possible. In terms of concrete implementation guidance, the evidence-based and theoretically informed recommendations for scaling up HCV testing and treatment for people who inject drugs from NHS Tayside in Scotland is an additional useful resource for countries, regions or cities looking to reach the elimination goal.

Monitoring mortality attributable to viral hepatitis among PWID

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 (baseline is 2015). The interim WHO guidance also proposes absolute mortality targets. In a systematic review and meta-analysis of all-cause and cause-specific mortality among people using extramedical opioids (Larney et al., 2020), Larney et al. provided some estimates of mortality rates attributable to liver disease, including viral hepatitis. Extramedical opioid use was defined as the use of heroin and other illicitly manufactured opioids and the use of pharmaceutical opioids outside the bounds of a medical prescription. Mortality from liver diseases was identified based on ICD codes for ‘viral hepatitis’, ‘digestive disease’, ‘liver disease’, ‘liver cancer’ and ‘liver-related’. The review included 31 cohort studies with data relevant to liver diseases, 12 of which came from EMCDDA countries (Austria, Czechia, Italy, Netherlands, Norway, Spain and Sweden). The pooled crude mortality rates per 100 person-years for EMCDDA countries were 0.06 (95 % CI: 0.04-0.07) for viral hepatitis, 0.06 (95 % CI: 0.04-0.12) for digestive diseases, and 0.15 (95 % CI: 0.11-0.19) for liver-related diseases. The pooled standardised mortality ratios (the ratio of mortality risk among those exposed to extramedical opioid use and the age- and sex-matched population) for EMCDDA countries were 54.5 (95 % CI: 40.1-74.0) for viral hepatitis, 10.1 (95 % CI: 6.9-14.3) for digestive diseases, and 21 (95 % CI: 17.3-25.3) for liver-related diseases. Overall, deaths attributable to liver diseases (5 %), cancer (6.5 %) and infectious diseases other than HIV/AIDS (4.4 %) accounted for 15.9 % of all-cause mortality among people using extramedical opioids. These data provide a first baseline against which to assess the progress towards the mortality targets, but more studies are needed to monitor cause-specific mortality among drug users. Study designs in which to invest include record linkage of administrative data (retrospective studies), prospective cohort studies among people who inject drugs or prospective cohort studies among people with viral hepatitis.

The WHO Regional Office for Europe is developing an eight-year (2022-2030) strategic document that will integrate regional action plans for HIV, viral hepatitis and STIs, focusing on health system delivery and people-centred healthcare services, as well as disease-specific actions with special attention to key populations. It has launched a wide consultation process that should lead to the endorsement of the plan by September 2022. The proposed strategic directions include a shared vision to disease responses nested in universal healthcare coverage, a health system approach, as well as new coverage and impact targets for 2030. In terms of EU funding opportunities, the European Commission has opened an action grant to support the implementation of best practices in community-based services for HIV/AIDS, TB, viral hepatitis and sexually transmitted infections.

Conclusion

Despite the multi-dimensional challenges posed by the COVID-19 pandemic, harm reduction and drug services as well as national public health agencies have shown resilience and have adapted to the health crisis to guarantee service continuity for drug users, including the provision of services for the prevention and control of drug-related infectious diseases. Harm reduction and drug services have also shown to be essential services in combating the COVID-19 pandemic by providing information, prevention equipment and shelter to their clients, by implementing safety protocols, and since 2021, by being actively involved in the COVID-19 vaccination campaign. This is particularly important as studies have shown that people suffering from drug addiction are more likely to face severe COVID-19 outcomes if infected.

However, disruption of prevention measures and reduction of face-to-face interactions with the most vulnerable clients – even if temporary and limited to the first lockdowns – might have had negative consequences on the risk of transmission of drug-related infectious disease such as HIV, viral hepatitis and invasive bacterial infections. The reduction of distributed sterile equipment reported by some countries and the drop in HIV and viral hepatitis testing activity in 2020 have put an additional strain on an existing fragile situation, with some signals suggesting increased HIV transmission. In this context, the commitment of the region to reach the infectious diseases-related sustainable development goals implies that Member States unsure sustainable funding and support for harm reduction and drug services in order to scale-up provision and access to integrated and people-centred healthcare for drug users.

The EMCDDA’s DRID network is sharing information on drug-related infectious disease threats and monitoring the 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 EMCDDA website. Experts from the DRID network can also access the restricted DRID area for additional material.

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