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Please note that the information on this page is based on the EMCDDA Annual report 2010: the state of the drugs problem in Europe. Most statistical data relate to the year 2008 (or the last year available).


Drug situation in Europe
Drug-related infectious diseases and drug-related deaths

Published: 10 November 2010

Drug-related infectious diseases

Infectious diseases such as HIV and hepatitis B and C are among the most serious health consequences of drug use. Even in countries where HIV prevalence in injecting drug users is low, other infectious diseases including hepatitis A, B, C and D, sexually transmitted diseases, tuberculosis, tetanus, botulism, anthrax and human T-lymphotropic virus may disproportionately affect drug users. The EMCDDA is systematically monitoring HIV and hepatitis B and C infection among injecting drug users (1).


By the end of 2008, the rate of reported new HIV diagnoses among injecting drug users has remained low in most countries of the European Union, and the overall EU situation compares positively in a global context (ECDC and WHO-Europe, 2009; Wiessing et al., 2009). This may, at least partly, follow from the increased availability of prevention, treatment and harm-reduction measures, including substitution treatment and needle and syringe programmes (Wiessing et al., 2009). Other factors, such as the decline in injecting drug use that has been reported in some countries, may also have played an important role. Nonetheless, in some parts of Europe, data suggest that HIV transmission related to injecting drug use continued at relatively high rates in 2008, underlining the need to ensure the coverage and effectiveness of local prevention practice.

Trends in HIV infection

Data on reported newly diagnosed cases related to injecting drug use for 2008 suggest that infection rates are still generally falling in the European Union, following the peak in 2001–02, which was due to outbreaks in Estonia, Latvia and Lithuania (2). In 2008, the overall rate of newly diagnosed infections among injecting drug users in the 23 EU Member States for which national data are available was 2.6 cases per million population, down from 3.7 per million in 2007 (3). Of the four countries reporting the highest rates of newly diagnosed infections (Estonia, Latvia, Lithuania, Portugal), all continued their downward trend, with a marked decline in Estonia and Latvia ('Figure 12: Trends in newly reported HIV infections in injecting drug users in four EU Member States reporting high rates of infection'). In Estonia, the decrease was from 86 cases per million in 2007 to 27 in 2008, and in Latvia from 62 cases per million in 2007 to 44 per million in 2008.

Overall, marked increases in newly diagnosed HIV infection among injecting drug users have not been observed between 2003 and 2008, and reported rates remain low. However, in Bulgaria, the rate for injectors accelerated from 0.0 new cases per million population in 2003 to 6.8 per million in 2008, whereas in Sweden a peak at 6.7 cases was observed in 2007, suggesting a continued potential for HIV outbreaks among injecting drug users.

Trend data from HIV prevalence monitoring in samples of injecting drug users are an important complement to data from HIV-case reporting. Prevalence data are available from 24 countries over the period 2003–08 (4). In 16 countries, HIV prevalence remained unchanged. In seven countries (Bulgaria, Spain, France, Italy, Poland, Portugal, Norway) HIV prevalence showed decreases, six of these being based on national samples, while in France the trend is based on data from five cities. Regional increases were reported in three countries: in Bulgaria (Sofia); in Italy, in two out of 21 regions, and in Lithuania (Vilnius). There is however a downward trend in the newly diagnosed cases of HIV infection among injecting drug users in these three countries.

The comparison of trends in newly reported infections related to injecting drug use with trends in HIV prevalence among injecting drug users suggests that the incidence of HIV infection among injecting drug users is declining in most countries at national level.

Despite rapidly declining trends, the rate of reported new HIV diagnoses in 2008 related to injecting drug use is still high in Latvia (44 cases per million population), Estonia (27), Portugal (20.7) and Lithuania (12.5), suggesting that transmission is still occurring among injecting drug users in these countries.

Further indications of ongoing HIV transmission in recent years are provided by reports of prevalence levels of over 5% among young injecting drug users (samples of 50 or more injecting drug users under age 25) in several countries: Estonia (two regions, 2005), France (five cities, 2006), Latvia (one city, 2007), Lithuania (one city, 2006) and Poland (one city, 2005) (5). Though caution is needed, as some of the sample sizes are small, the data show statistically significant increases in HIV prevalence among young injectors between 2003 and 2008 in Belgium (Flemish Community) and Bulgaria, whereas declines can be seen in Sweden and Spain. Data on HIV prevalence in new injectors (injecting less than two years) further support a likely decrease in this group in Sweden (6).

AIDS incidence and access to HAART

Information on the incidence of AIDS, though not a good indicator of HIV transmission, can be important for showing the new occurrence of symptomatic disease. High incidence rates of AIDS may indicate that many injecting drug users infected with HIV do not receive highly active antiretroviral treatment at a sufficiently early stage in their infection to obtain maximum benefit from the treatment. A recent review confirms that this may still be the case in some EU countries (Mathers et al., 2010).

Estonia is the country with the highest incidence of AIDS related to injecting drug use, with an estimated 30.6 new cases per million population in 2008, down from 33.5 new cases per million in 2007. Relatively high levels of AIDS incidence are also reported for Latvia, Lithuania, Portugal and Spain: 25.5, 10.7, 10.2 and 8.9 new cases per million, respectively. Among these four countries, the trend is downward in Spain and Portugal, but not in Latvia and Lithuania (7).

Hepatitis B and C

While high prevalence levels of HIV infection are found only in some EU Member States, viral hepatitis and, in particular, infection caused by the hepatitis C virus (HCV), is highly prevalent in injecting drug users across Europe. HCV antibody levels among national samples of injecting drug users in 2007–08 vary from about 12% to 85%, with eight out of the 12 countries reporting levels in excess of 40% (8). Three countries (Czech Republic, Hungary, Slovenia) report a prevalence of under 25% in national samples of injecting drug users; though infection rates at this level still constitute a significant public health problem.

Within countries, HCV prevalence levels can vary considerably, reflecting both regional differences and the characteristics of the sampled population. For example, in Italy, regional estimates range from about 31% to 87% ('Figure 13: Prevalence of HCV antibodies among injecting drug users').

Recent studies (2007–08) show a wide range of prevalence levels among injecting drug users under 25 years and those injecting for less than two years, suggesting different levels of HCV incidence in those populations across Europe (9). Nonetheless, these studies also show that many injectors contract the virus early in their injecting career. This implies that there is only a small time window for initiating effective HCV prevention measures.

The prevalence of antibodies to hepatitis B virus (HBV) also varies to a great extent, possibly partly due to differences in vaccination levels, although other factors may play a role. The most complete data set available for HBV is that for the antibody to the hepatitis B core antigen (anti-HBc), which indicates a history of infection. For 2007–08, four of the nine countries providing data on this virus among injecting drug users report anti-HBc prevalence levels of over 40% (10).

HCV prevalence is observed to be declining in nine countries and increasing in three others, while a further four countries have datasets showing both types of trends, although caution is warranted given the limited sample size in some instances (11). Studies on young injectors (under age 25) suggest mostly stable prevalence and some declining trends, although an increase is reported in one region in Greece (Attica). This is confirmed in data for new injectors (injecting less than two years) for Greece, both in Attica and at national level. Data for new injectors also show an increase in Slovenia, although sample sizes are small, and declines in Portugal (national) and Sweden (Stockholm).

Trends in notified cases of hepatitis B and C show different pictures, but these are difficult to interpret as data quality is low. However, some insight into the epidemiology of these infections may be provided by the proportion of injecting drug users among all notified cases where risk factors are known (Wiessing et al., 2008). For hepatitis B, the proportion of injecting drug users has declined between 2003 and 2008 in eight out of 17 countries. In the case of hepatitis C, the proportion of injecting drug users among notified cases has declined in six countries between 2003 and 2008, and has increased in three other countries (Czech Republic, Malta, United Kingdom) (12).

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(1) For details on methods and definitions, see the 2010 statistical bulletin.

(2) Reporting procedures for HIV infection have changed in recent years, and data are now available by year of diagnosis rather than by year of report (ECDC and WHO-Europe, 2009). This results in lower figures in some countries that are likely to reflect more accurately true incidence (e.g. Portugal). In some cases, however, reporting delays may also have resulted in an underestimation of incidence.
See Table INF-104 in the 2010 statistical bulletin.

(3) National data are not available for Denmark, Spain, Italy and Austria.

(4) See Table INF-108 in the 2010 statistical bulletin.

(5) See Table INF-109 in the 2010 statistical bulletin.

(6) See Table INF-110 in the 2010 statistical bulletin.

(7) See Figure INF-1 and Table INF-104 (part ii) in the 2010 statistical bulletin.

(8) See Table INF-111 in the 2010 statistical bulletin.

(9) See Figure INF-6 (part ii) and (part iii) in the 2010 statistical bulletin.

(10) See Table INF-115 in the 2010 statistical bulletin.

(11) See Table INF-111 in the 2010 statistical bulletin.

(12) See Tables INF-105 and INF-106 in the 2010 statistical bulletin.

Bibliographic references

ECDC and WHO Regional Office for Europe (2009), HIV/AIDS surveillance in Europe 2008, European Centre for Disease Prevention and Control, Stockholm.

Mathers, B., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M. et al. (2010), ‘HIV prevention, treatment and care for people who inject drugs: a systematic review of global, regional and country level coverage’, Lancet 375, pp. 1014–28.

Wiessing, L., Guarita, B., Giraudon, I., Brummer-Korvenkontio, H., Salminen, M. and Cowan, S.A. (2008), European monitoring of notifications of hepatitis C virus infection in the general population and among injecting drug users (IDUs): the need to improve quality and comparability’, Euro Surveillance 13(21):pii=18884 (available online).

Wiessing, L., Likatavicius, G., Klempová, D., Hedrich, D., Nardone, A. and Griffiths, P. (2009), ‘Associations between availability and coverage of HIV-prevention measures and subsequent incidence of diagnosed HIV infection among injection drug users’, American Journal of Public Health 99, pp. 1049–52.

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Page last updated: Tuesday, 26 October 2010