EMCDDA key indicator : 'HIV and hepatitis B/C in IDUs

Reitox academy training
Lucas Wiessing

European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal, Lucas.Wiessing@emcdda.org

EMCDDA5 key indicators of drug use

• Surveys of drug use in general population
• Estimates of problem drug use / IDU
• Data from drug treatment services
• Drug related deaths and mortality
• Drug related infectious diseases (hepatitis B/C and HIV in IDUs)

Outline of talk

• Background key indicator
• Collecting existing data - methods, issues
• Community wide studies- methods, issues
• Collecting existing data - results

- HIV
- Hepatitis B/C

Background

• HIV, hepatitis B/C largest health burden IDUs, IDUs main risk group HIV/HCV
• Prevalence in IDUs often very high -> cost-effective for policy action (prevention)
• Hepatitis B/C monitoring not existing at EU level
• HIV monitoring incomplete but improving

Objectives

• To compare epidemiological situation between countries and regions on HIV, HCV and HBV in drug injectors
• To give timely insight in new trends and developments, for policy action
• To serve as an indirect indicator of patterns in drug injecting and risk behaviour

Methods

1. Collect existing data on prevalence rates in IDUs (HIV, hepatitis B/C) using standardised data collection form ('standard table')
2. Stimulate seroprevalence studies and screening in routine settings using comparable methods / questionnaire (EU Network established)

1. Using existing data sources as indicators of prevalence

Data sources / settings

• Drug treatment
• Low-threshold / needle exchanges
• Prisons (arrests)
  - Overdose deaths
  - Public Health Labs
  - STD clinics
  -Pregnant women
  -Hospitals
  - ---
• Community studies
• Notifications

Data sources / settings 2

• Routine diagnostic data from different settings
• Prevalence studies in routine settings (treatment, needle exchange, prisons...)

EMCDDA data collection

• 2 Standard reporting tables of aggregated epidemiological data and HR responses
• Data reported through expert networks and national drug focal points to EMCDDA -> annual report (http://annualreport.emcdda.org/)
• Yearly EU expert meeting, national meetings
• Definition and mapping of potential data sources
• Data from other networks (EuroHIV, Prison Nw)

Data collected in standard table

• Methodological items such as type of data source, def. IDU, serological markers
• Total sample size, nr valid tests, number positive tests, % HIV positive in IDUs
• Same data, broken down for age (<25, 25-34, >34), gender, years injected (<2, >=2), opiate use or not

Notified cases at European level

• Depend on testing and/or reporting practices, and little background information, but OK for trends
• HIV positives: methods development and data collected by EuroHIV; shared with EMCDDA
• HIV : by year of report, lag 'smoothed' thus masked
• HIV : outbreaks have been first detected through notifications, (e.g. Finland) possibly good 'early warning system'
• Hepatitis B/C cases: aggregated data collected by EMCDDA,. some standards development by other networks.
• Hepatitis B/C : acute cases or also chronic included? Laboratory confirmation required? Breakdown by IDU essential.

2. Community wide studies

Community studies - background

• EU network of cross-sectional and longitudinal studies among IDUs
• EU consensus questionnaire based on longitudinal studies
• No funds at present to set up and coordinate comparable EU wide study
• Joint data analysis from existing studies

Study questions

• Prevalence and incidence of HCV, HBV and HIV in (new) IDUs
• Use, needs and knowledge of services for IDUs
• Drug careers, transitions to and from injecting
• Determinants, risk factors

Community studies, issues

• New injectors or all injectors
• Saliva or serum samples
• Sample size and power
• Sampling technique (snowballing?)
• Settings (in treatment and outside treatment)
• Avoiding double interviews (payment)
• Collaborating with local services
• Choice and frequency of cities
• Lab expertise (hepatitis from saliva)
• Data entry, handling and analysis
• Back-reporting to local community and press

Saliva vs. blood spots

	Saliva	Dried blood spots
Use in outreach settings	++	+
Acceptability/fear respondent	++	+
Acceptability/safety interviewer	++	+
Response/participation rates	+	+
Cheapness collection devices *#	+	++
Quality HIV test	++	++
Quality HCV test &#	+	++
Quality HBV test *^#	+/++	++
Ease of handling / time in laboratory	+	++
Ease of transportation *	++	+/++
Genotyping / subtyping possible	.	++
Detection recent HIV/HCV infections	+?	++

Results:
1 Existing data collected through 'standard tables'

Problems / limitations

• Data from many ad hoc sources (comparability)
• Non-injectors not always excluded
• Self reported test results (esp. HCV!)
• Some small sample sizes (esp. breakdowns)
• Sampling/selection procedures not always clear
• Often local data (but OK to follow trends)
• Much drug treatment data available, other sources much less
• Few studies that are repeated (follow trends)

Start-up year of SEP's in Spain, France and Italy (PESESUD, CEESCAT 1998)

Health care costs of HCV (red), HBV (yellow) and HIV (green) in millions of Euros for ten EU-countries Postma et al. Bull Narc. in press

Conclusions

• More data are becoming available on HIV (and HCV, HBV) infection among IDUs
• Quality and comparability need to be improved
• Countries need to strengthen funds and expertise at focal points
• Fund seroprevalence studies and routine screening of IDUs on HIV, hepatitis B/C