HCV in injecting drug users: developing indicators of prevalence and responses VHPB WHO Consultation Meeting Geneva, 13 May 2002 Lucas Wiessing European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal,

EMCDDA activities on HCV, HBV and HIV in IDUs 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)

Data collection system for aggregated existing data Standard reporting tables for aggregated data on epidemiology and prevention Data from expert networks and national drug focal points to EMCDDA –> annual report ( Yearly EU expert meeting, national meetings Definition and mapping of potential data sources

Existing 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 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 ( 34), gender, years injected ( =2), opiate use or not

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

Italy: Surveillance data from Public Drug Addiction Treating Centres centres=518 in 1999; patients=142,651 - aggregated information annually collected - gender, age, type of client - type of substance - type of treatment - HIV, HBV, HCVtest results Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

. Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

Source: Min. Health

HCV prevalence among injecting drug users by region. 518 italian drug treatment centres Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

VEdeTTE Study (Valutazione dell’EfficaciadeiTrattamenti per leTossicodipendenze daEroina) Design of the study Cohort prospective Follow up At 36 months after enrollment (random sample of 1,500 patients) Update - 112/518 Public Drug Treatment Centres (12/20 regions) - 11,818 patients enrolled - preliminary analysis ongoing Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

Giuseppe Salamina Epidemiological Centre for the Monitoring of Drug Addiction Piedmont Region - Turin - Italy

Potential indicators of HCV prevalence in IDUs Prevalence in all IDUs in drug treatment Prevalence in IDUs getting first treatment Prevalence in IDUs in prisons Prevalence in IDUs under age 25 Prevalence in new IDUs (< 2yrs injecting)

Prevention / responses to HIV and HCV in IDUs

Start-up year of SEP’s in Spain, France and Italy (PESESUD, CEESCAT 1998) n SpainFranceItalyTotal I F S T

Effectiveness needle exchanges MacDonald M et al. preliminary results, for similar paper on HIV see: Hurley SF et al. Lancet 1997; 349: Ecological study: HCV prevalence/ incidence in cities with and without NSP 190 calendar years of data from 101 cities (41 cities without, 9 cities implemented between two studies, 51 already had NSP) Median prevalence: 75% without, 60% with NSP Little change before introduction, followed by decline of 1.5-2% /yr after introduction NSP Median prevalence in new injectors much lower in cities with NSP (25% vs 66%) HCV incidence /100 pyo: 16 (with NSP), vs. 25

“Stéricup” - hepatitis prevention (E. Imbert et al:

SEPs and pharmacies developing as complementary services?

Incidence of problem opiate use by back-cal- culation from drug treatment data (Amsterdam) EMCDDA 2000; Rossi C, Ravà L et al. submitted

Incidence of problem opiate use by back- calculation from drug treatments (Italy) EMCDDA 2000; Rossi C, Ravà L et al. submitted

Health care costs of HCV (red), HBV (yellow) and HIV (green) in millions of Euros for ten EU-countries Postma M, Wiessing L, Jager J. Bull Narc. in press

Conclusions Indicators of HCV (and HIV, HBV) prevalence among IDUs in Europe are being developed Quality and comparability need to be improved (EMCDDA working groups) Differences in prevalence observed (UK low), effect of prevention? Preliminary data on coverage of specialized needle exchange services suggests it may be low in most countries (but pharmacies…)

Acknowledgements Giuseppe Salamina, Italy Margaret MacDonald and Greg Dore, Australia Anna Rodes, Spain Carla Rossi and Lucilla Rava, Italy Maarten Postma and Hans Jager, the Netherlands Elliot Imbert and Julien Emmanuelli, France National Focal Points of the EMCDDA EMCDDA National EU Representatives on drug related infectious diseases

Modelled rate of progression to cirrhosis. Individual dot points (and 95% confidence intervals) correspond to cirrhosis prevalence at estimated mean duration of infection for each individual study Freeman AJ et al. Hepatology 2001; 34:809-16