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EMCDDA conference. May 2009. HIV, HCV, and HBV in injecting drug users in Europe. Mirjam Kretzschmar Centre for Infectious Disease Control, RIVM, and Julius Center for Health Sciences & Primary Care University Medical Centre Utrecht, The Netherlands.

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Hiv hcv and hbv in injecting drug users in europe

EMCDDA conference

May 2009

HIV, HCV, and HBV in injecting drug users in Europe

Mirjam Kretzschmar

Centre for Infectious Disease Control, RIVM, and

Julius Center for Health Sciences & Primary Care

University Medical Centre Utrecht, The Netherlands


HIV infections newly diagnosed in injecting drug users, by year of report, by country, cases per million, 1996–2006.

Source: EMCDDA website


Hiv prevalence among injecting drug users studies with national and subnational coverage
HIV prevalence among injecting drug users — studies with national and subnational coverage.

100%

75%

All injecting drug users, 2005 and 2006

Young injecting drug users

(under age 25), 2005 to 2006

Black dots: national

Blue dots: subnational

Source: EMCDDA website


Estimated HCV antibody prevalence among injecting drug users — studies with national and subnational coverage

100%

100%

Young injecting drug users

(under age 25), 2005 to 2006

All injecting drug users, 2005 and 2006

Source: EMCDDA website


Prevalence of markers of HBV infection estimated among national and subnational samples of injecting drug users 2005 to 2006, where data are available

100%

16%

Percentage positive for

current infection (HBsAg)

Percentage positive for

ever infected (antiHBc)

Source: EMCDDA website


Questions
Questions national and subnational samples of injecting drug users 2005 to 2006, where data are available

  • How are HIV and HCV prevalence related?

  • And HBV?

  • How do these prevalences depend on risk behaviour, duration of injecting, intervention?

  • What is the impact of harm reduction on incidence and prevalence?

    Use statistical methods and mathematical modelling to get some answers


Project
Project national and subnational samples of injecting drug users 2005 to 2006, where data are available

  • First project: Sept. 2006 – Nov. 2007 tendered by EMCDDA and conducted as a collaboration between EMCDDA and School of Public Health, University of Bielefeld

    • Set up team of modellers to work on analysis of European data

    • Produce 5 draft papers for publication in international journals

    • Resulted in collaboration with epidemiologists (the ‘Study group‘)

  • Second phase: Collaboration with WHO Europe project: ‘Review statistical methods for estimating HIV incidence in countries with concentrated epidemics’

    • Discuss other modelling issues and approaches

    • Continue EMCDDA work, link with WHO interests

  • Background: EMCDDA EU network on drug related infectious diseases (HIV, hepatitis B/C in IDUs: experts, national focal points in 30 countries


Relationships between hiv and hcv prevalence
Relationships between HIV and HCV prevalence national and subnational samples of injecting drug users 2005 to 2006, where data are available

HIV and HCV prevalence data

for 310 regions

from published studies

Thresholds?

Vickerman et al. submitted


Force of infection links incidence and prevalence
Force of infection links incidence and prevalence national and subnational samples of injecting drug users 2005 to 2006, where data are available

  • Force of infection (FOI):

    • risk per time unit for a susceptible person to become infected

    • depends on exposure and therefore on prevalence

    • can be different for different groups of IDU

    • can change during drug use career

λ

B

susceptible

μ


Link between foi and heterogeneity
Link between FOI and heterogeneity national and subnational samples of injecting drug users 2005 to 2006, where data are available

Sutton et al. J Viral Hepatitis 2008

Estimates of force of infections from

seroprevalence studies in different

populations

Frailty function indicates heterogeneity

with respect to exposure


Force of infection as a function of time since start of injecting:

Exposure duration

  • Caveats:

  • steady state assumption

  • impact of intervention?

Hamata et al; in preparation


How effective have NEPs been? injecting:

Hurley et al Lancet 1997

Amundsen et al Eur J Pub Health 2003

How can we interpret ecological studies?


Decline hiv and hcv incidence in acs 1985 2005
Decline HIV and HCV incidence in ACS 1985-2005 injecting:

Amsterdam Cohort Studies among drug users

  • Prospective HIV testing

  • Retrospectively tested for HCV antibodies

  • 952 ever injecting DU

    58 HCV infections

    90 HIV infections

30

HCV

0

10

HIV

0

Van den Berg et al. Eur J Epidemiol 2007

1985 - 2004


Is it all really the effect of harm reduction
Is it all really the effect of harm reduction? injecting:

Possible other explanation:

Demographic changes in IDU population (e.g., ageing)

Disease related mortality in those groups at highest risk of infections in the first decade of the HIV epidemic might have led to a change in the composition of the IDU population with less risk behaviour and lower transmission rates at the population level over calendar time.

Smit et al, JAIDS 2008


Conclusions
Conclusions injecting:

  • Epidemiology of HIV and HCV is closely related, but need to understand better thresholds and transmission dynamics

  • Force of infection links incidence and prevalence, can say something about heterogeneity if we have data about more than on infection

  • The impact of calender time on these relationships is not yet clear, need cohort studies to analyse that

  • We need to disentangle impact of harm reduction from other influences – demographic changes, behaviour changes


Acknowledgements
Acknowledgements injecting:

  • Lucas Wiessing

  • Peter Vickerman

  • Ziv Shkedy

  • Emma White

  • Andrew Sutton

  • Viktor Mravcik

  • Cathy Matheï

  • Maria Prins

  • Fernando Vallejo

  • Barbara Suligoi

  • Lillebil Norden

    and all other members of the study group


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