Policy and practice briefingsReducing the spread of HIV, viral hepatitis and other infections associated with injecting drug use

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Issues

The sharing of injecting equipment increases the risk of the transmission and acquisition of blood-borne infections, such as HIV and hepatitis B and C viruses. Historically interventions targeting people who inject drugs — primarily OST, needle and syringe programmes and harm reduction measures to reduce risk behaviour — were mainly focused on reducing HIV transmission. The success of these measures can be seen in the low share of HIV transmission attributed to drug injecting (about 5 % of diagnoses for which the route of transmission is known), which has been stable for the past decade. Nevertheless, injecting drug use remains an important mode of HIV transmission in some countries and injecting-related HIV outbreaks still occur in Europe, especially where service coverage is low.

Hepatitis C is the most prevalent blood-borne virus infection among people who inject drugs. The development of highly effective treatments for hepatitis C has led to a shift in focus towards addressing the high rates of hepatitis C virus (HCV) infection found among people who inject drugs. Chronic HCV infection can result in deaths from severe liver disease, such as cirrhosis and liver cancer.

Response options

  • Providing opioid substitution treatment and other effective drug dependence treatment to people who inject drugs.
  • Needle and syringe programmes providing sterile injection equipment to injectors.
  • Vaccination against hepatitis A and B, tetanus and influenza, and also pneumococcal vaccine for HIV-positive individuals.
  • Routine testing for HIV, HCV (HBV for unvaccinated) and other infections including tuberculosis.
  • This needs to be linked to referral and treatment provision for those found to be infected, including the new direct-acting antiviral treatments for HCV that are now available.
  • Health promotion focused on safer injecting behaviour; sexual health, including condom use; and disease prevention, testing and treatment.
  • Developing proactive, multi-component approaches that are adapted user needs and local conditions.

European picture

  • Of the 30 countries monitored by EMCDDA, all except Turkey provide clean injecting equipment free of charge via specialised outlets. However, there are considerable differences in coverage, indicating a need to increase service provision in some countries.
  • All EU countries provide OST but coverage in some remains low, including countries which report risk factors for HIV or hepatitis C infection among injecting drug users.
  • An increasing number of European countries have adopted, or are preparing, hepatitis C strategies and alongside this new direct-acting antiviral treatments for HCV are being introduced in some countries with the aim of eliminating the infection.

Summary of the available evidence

Evidence-based guidance for controlling infectious diseases among people who inject drugs

Key intervention components are:

  • Injection equipment: Provision of, and legal access to, sterile needles, syringes and other equipment free of charge, as part of a multi-component approach that includes harm-reduction, counselling and treatment programmes.
  • Vaccination: Immunisation against hepatitis A and B, tetanus and influenza as well as pneumococcal vaccination for HIV-positive individuals.
  • Drug dependence treatment: Opioid substitution treatment and other effective forms of drug dependence treatment.
  • Testing: Routine voluntary and confidential testing with informed consent for HIV, HCV (HBV for unvaccinated) and other infections including tuberculosis, linked to treatment referral.
  • Infectious disease treatment: Antiviral treatment for those who are infected with HIV, HBV or HCV. Anti-tuberculosis treatment of active tuberculosis cases, prophylaxis for latent cases and treatment for other infectious diseases when clinically indicated.
  • Health promotion: Health promotion focused on safer injecting behaviour; sexual health, including condom use; and disease prevention, testing and treatment.
  • Targeted delivery of services: Services should be combined and delivered according to user needs and local conditions through outreach and fixed sites offering drug treatment, harm reduction, counselling and testing, and referrals to general primary health and specialist medical services.

The combination of these interventions enhances their effectiveness.

Adapted from: European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction. Prevention and control of infectious diseases among people who inject drugs. Stockholm: ECDC; 2011.

Implications for policy and practice

Basics

  • Core interventions in this area include needle exchange, OST provision, testing and treatment for infectious diseases, and health promotion activities.
  • Many people who use drugs are unaware of their HCV infection. Testing should be offered as part of the baseline package at any contact with drug services.
  • Vaccinating people who inject drugs against hepatitis A and B can substantially reduce these infections and their serious health effects.

Opportunities

  • Implementation of an integrated strategy to provide prevention, outreach, screening and the new highly effective oral hepatitis C treatments in co-ordination with harm reduction (including needle and syringe programmes) and drug treatment programmes (including OST) in the community and prisons could reduce liver disease and cancers and potentially eliminate hepatitis C as a public health threat among people who inject drugs.
  • Access to and uptake of testing and treatment of infectious diseases and sexually transmitted infections can be increased by developing on-site screening at services for drug users such as drug treatment centres, drug consumption rooms or needle and syringe programmes.

Gaps

  • Currently, access to needle and syringe programmes and OST is below recommended levels in many EU countries and needs to be improved. Better data on HCV treatment uptake are also needed to allow assessment of the adequacy of service provision.
  • HIV infection in people who inject drugs is often diagnosed late and there are still AIDS cases reported among this group. Enhanced HIV testing, immediate initiation of HIV treatment after diagnosis and improved retention in care are necessary.

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