• EN

Please note that the information on this page is based on the EMCDDA Annual report 2011: the state of the drugs problem in Europe. Most statistical data relate to the year 2009 (or the last year available).


Annual report 2011: the state of the drugs problem in Europe
Drug-related infectious diseases and drug-related deaths

Published: 15 November 2011

Drug-related infectious diseases

The EMCDDA is systematically monitoring infection with HIV and hepatitis B and C viruses among injecting drug users (1). The infectious diseases caused by these viruses are among the most serious health consequences of drug use. Other infectious diseases, including hepatitis A and D, sexually transmitted diseases, tuberculosis, tetanus, botulism, anthrax and human T-lymphotropic virus, may also disproportionately affect drug users.


By the end of 2009, 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, both in a global and in a wider European context (ECDC and WHO-Europe, 2010; Wiessing et al., 2009) Figure 15). 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. Other factors, such as the decline in injecting drug use that has been reported in several countries, may also have played an important role (EMCDDA, 2010a). The average rate of newly diagnosed cases in the 26 EU Member States able to provide data for 2009 reached a new low of 2.85 per million population, or 1 299 newly reported cases (2). Nonetheless, in some parts of Europe, data suggest that HIV transmission related to injecting drug use continued in 2009, underlining the need to ensure the coverage and effectiveness of local prevention practice.

The available data on prevalence of HIV in samples of injecting drug users in the EU compare again positively with prevalence in neighbouring countries in the east (3), although comparisons between countries should be undertaken with caution due to differences in study methods and coverage.

Trends in HIV infection

Data on reported newly diagnosed cases related to injecting drug use for 2009 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. Of the five countries reporting the highest rates of newly diagnosed infections among injecting drug users between 2004 and 2009 (Estonia, Spain, Latvia, Lithuania, Portugal), three continued their downward trend, but the rate in Estonia and Lithuania increased again from 2008 levels (Figure 16) (4). In Estonia, the increase was from 26.8 cases per million in 2008 to 63.4 per million in 2009, and in Lithuania from 12.5 cases per million in 2008 to 34.9 per million in 2009. Over the same period, the rate of new infections among injectors in Bulgaria also increased from 0.9 new cases per million population in 2004 to 9.7 per million in 2009, whereas in Sweden the rate peaked at 6.7 new cases per million (61 new diagnoses) in 2007. These data indicate that a continued potential for HIV outbreaks among injecting drug users exists in some countries.

Trend data from HIV prevalence monitoring in samples of injecting drug users are an important complement to data from HIV-case reporting. Prevalence trend data are available from 27 European countries within the period 2004-09 (5). In 19 countries, HIV prevalence estimates remained unchanged. In five countries (France, Italy, Austria, Poland, Portugal) HIV prevalence data showed a decrease; in three, this is based on national samples, while in France the trend is based on data from five cities. In Austria, the national sample shows no change, but a decrease is observed in Vienna. Two countries report increasing HIV prevalence: Slovakia (national data) and Latvia (self-reported test results from seven cities). In Bulgaria, a decrease at national level is not reflected in the capital city (Sofia), where the trend is upward. In Italy, there is a nationally declining trend, with only one out of the 21 regions reporting an increase (6).

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 mostly declining trends since 2004, the rate of reported new HIV diagnoses (per million population) in 2009 related to injecting drug use is still relatively high in Estonia (63.4), Lithuania (34.9), Latvia (32.7), Portugal (13.4) and Bulgaria (9.7), indicating that considerable numbers of new infections continue to occur among injecting drug users in these countries (7).

Further indications of ongoing HIV transmission are observed in six countries (Estonia, Spain, France, Latvia, Lithuania, Poland), with prevalence levels above 5 % among samples of young (under age 25) injecting drug users in 2005-07 (8), and two countries (Bulgaria, Cyprus) where prevalence in young injecting drug users increased in 2004-09.

AIDS incidence and access to HAART

Information on the incidence of AIDS, though a poor 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 global review suggests that this may still be the case in some European countries (Mathers et al., 2010).

Latvia is now the country with the highest incidence of AIDS related to injecting drug use, with an estimated 20.8 new cases per million population in 2009, down from 26.4 per million in 2008. Relatively high AIDS incidence among injecting drug users is also reported for Estonia, Spain, Portugal and Lithuania, with 19.4, 7.3, 6.6 and 6.0 new cases per million population, respectively. Among these countries, the trend 2004 to 2009 was downward in Spain and Portugal, but not in Estonia and Lithuania (9).

Hepatitis B and C

Viral hepatitis, 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 2008-09 varied from 22 % to 83 %, with eight out of the 12 countries reporting findings in excess of 40 % (10). Three countries (Czech Republic, Hungary, Slovenia) report prevalences of under 25 %; 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 37 % to 81 % (Figure 17).

Recent studies (2008-09) show a wide range of HCV 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 (11). Nonetheless, these studies also show that many injectors contract the virus early in their injecting career. This implies that there may be only a small time window for initiating HCV prevention measures.

Over the period 2004-09, declining HCV prevalence in injecting drug users is reported from eight countries and increasing prevalence from one (Cyprus), while a further four countries report diverging trends in different datasets. Nonetheless, caution is warranted given the limited geographical coverage and/or sample size of the studies in some instances (12). Studies on young injectors (under age 25) again suggest that some countries may be experiencing declines in prevalence in this group at national (Bulgaria, Slovenia, United Kingdom) or sub-national level (Crete in Greece, Vorarlberg in Austria) which may indicate declining transmission rates. However, some increases are reported as well (Cyprus, Graz in Austria). Some of these trends are confirmed in data for new injectors (injecting less than two years). Increasing HCV prevalence among new injectors is reported in Greece (Attica), whereas declines are reported from Austria (Vorarlberg) and Sweden (Stockholm) (13).

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 informative serological marker of HBV infection is HBsAg (hepatitis B virus surface antigen), which indicates current infection. For 2004-09, four of the 14 countries providing data on this virus among injecting drug users report studies with HBsAg prevalence levels of over 5 % (Bulgaria, Greece, Lithuania, Romania) (14).

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). Averaged across the 20 countries for which data are available for the period 2004-09, injecting drug use accounts for 63 % of all HCV cases and 38 % of acute HCV cases notified, where risk category is known. For hepatitis B, injecting drug users represent 20 % of all notified cases and 26 % of acute cases. These data confirm that injecting drug users continue to form an important at-risk group for viral hepatitis infection in Europe (15).

Other infections

In addition to viral infections, injecting drug users are vulnerable to bacterial diseases (16). The outbreak of anthrax among injecting drug users in Europe (see EMCDDA, 2010b) has highlighted an ongoing problem with severe illness due to spore-forming bacteria among injectors. A European study collated data on reported cases of four bacterial infections (botulism, tetanus, Clostridium novyi, and anthrax) in injecting drug users in the past decade. During the period 2000-09, six countries reported 367 cases, with population rates varying from 0.03 to 7.54 per million population. Most cases of infection (92 %) were reported from three countries in the northwest of Europe: Ireland, United Kingdom and Norway. This geographical variation is not understood and needs further investigation (Hope et al., 2011).


(1) For details on methods and definitions, see the 2011 statistical bulletin.

(2) Data for Austria are missing. The average rate is 2.44 cases per million population for the EU Member States, Croatia, Turkey and Norway.

(3) See Table INF-1 in the 2011 statistical bulletin.

(4) Data for Spain do not have national coverage.

(5) Trend data are not available from Estonia, Ireland and Turkey. See Table INF-108 in the 2011 statistical bulletin.

(6) Data for Italy are for drug users in treatment where injection status is unknown, therefore a decline in HIV prevalence could also be due to a decline in injecting drug use among the tested population.

(7) See Table INF-104 in the 2011 statistical bulletin.

(8) See Table INF-109 in the 2011 statistical bulletin.

(9) See Figure INF-1 and Table INF-104 (part ii) in the 2011 statistical bulletin.

(10) See Tables INF-2 and INF-111 in the 2011 statistical bulletin.

(11) See Tables INF-112 and INF-113 and Figure INF-6 (part ii) and (part iii) in the 2011 statistical bulletin.

(12) See Table INF-111 in the 2011 statistical bulletin.

(13) See Tables INF-112 and INF-113 in the 2011 statistical bulletin.

(14) See Table INF-114 in the 2011 statistical bulletin.

(15) See Tables INF-105 and INF-106 in the 2011 statistical bulletin.

(16) See the box 'Tuberculosis among drug users' on this page.

Bibliographic references

ECDC and WHO Regional Office for Europe (2010), HIV/AIDS surveillance in Europe 2009, European Centre for Disease Prevention and Control, Stockholm.

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. 1 049-52.

EMCDDA (2010a), Trends in injecting drug use in Europe, Selected issue, Publications Office of the European Union, Luxembourg.

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. 1 014-28.

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.

EMCDDA (2010b), Annual report 2010: the state of the drug problem in Europe, Publications Office of the European Union, Luxembourg.

Hope, V., Palmateer, N., Wiessing, L., Marongiu, A., White, J., Ncube, F. and Goldberg, D. (2011), 'A decade of spore-forming bacterial infections among European injecting drug users: pronounced regional variation', American Journal of Public Health.

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

Contact us

Praça Europa 1, Cais do Sodré
1249-289 Lisbon
Tel. (351) 211 21 02 00

More contact options >>

Page last updated: Friday, 28 October 2011