Human immunodeficiency virus in injecting drug users in Europe following a reported increase of cases in Greece and Romania , 2011

A Pharris (anastasia.pharris@ecdc.europa.eu)1, L Wiessing2, O Sfetcu1, D Hedrich2, A Botescu3, A Fotiou4, G K Nikolopoulos5, M Malliori6, M Salminen1, J E Suk1, P Griffiths2, M J van de Laar 1 1. European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden 2. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal 3. National Observatory on Drugs, National Anti-Drug Agency, Bucharest, Romania 4. National Focal Point of the EMCDDA, University Mental Health Research Institute, Athens, Greece 5. Hellenic Centre for Disease Control and Prevention, Athens, Greece 6. Organisation Against Drugs (OKANA), Athens, Greece

Greece and Romania reported an increased number of HIV cases among injecting drug users (IDUs) during 2011.Most European countries reported no changes in the rate of newly diagnosed cases of HIV or HIV prevalence in IDUs; however, six countries did report increases and several additional countries reported increases in injecting risk indicators or low coverage of prevention services.These indicate a potential risk for increased HIV transmission and future outbreaks unless adequate prevention is implemented.
In 2010, the number of newly diagnosed human immunodeficiency virus (HIV) cases among injecting drug users (IDUs) represent only 4% of the total number of reported HIV cases in the European Union (EU) [1].However, increases in HIV infections among IDUs in Greece were reported in July 2011, through the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), followed by a reported increase in Romania in November 2011.Preliminary results of the investigation on the Greek outbreak were released in September [2] and November 2011, respectively [3].These subsequently led to a request from the European Commission to carry out a rapid risk assessment at EU level.

Epidemiological situation of HIV in Greece in 2011
Since the beginning of 2011, the number of newly diagnosed HIV infections has increased among IDUs in Greece.Between nine and 16 cases were reported annually among IDUs during 2006-2010, representing 2-3% of the total newly diagnosed HIV infections, while during the first 10 months of 2011, cases among IDUs sharply increased to 190, representing approximately 25% of all reported HIV cases [2,3].Prevalence studies have also detected a steep increase of HIV among IDUs in 2011, mostly in Athens [3].
Prior to the 2011 outbreak, the coverage of prevention services was low, with waiting times for opioid substitution treatment estimated at 89 months in 2010 and with an estimated distribution of only six sterile syringes per IDU during the entire year of 2009, which is far lower than in most European countries that report data to calculate syringe distribution per IDU [4].In response to the outbreak, the Greek authorities have sought to rapidly expand opioid substitution treatment services and have started mobile prevention services offering information, voluntary testing, referrals and clean needles and syringes [3].

Epidemiological situation of HIV in Romania in 2011
In November 2011, a strong increase of newly diagnosed HIV infections among IDUs during 2011 was reported to EMCDDA based on the information provided by routine monitoring and case reporting coordinated by the Romanian Ministry of Health.While reporting three to five cases annually from 2007 to 2009, HIV infections among IDUs increased to 12 cases in 2010 and to 62 cases in the first nine months of 2011.Routine monitoring performed at registration for drug treatment services indicated an increase in HIV positive cases among IDUs tested (1.1% (2/182) in 2008, 3.3% (11/329) in 2009 and 4.2% (12/288) in 2010).Cases reported in 2011 were mostly residents of Bucharest and the surrounding area (56/62), predominately males (55/62), and younger than 34 years (55/62).Twenty-nine cases had confirmed CD 4 cell counts at diagnosis higher than 500 cells/mm 3 suggesting recently acquired HIV infections.No specific HIV testing campaigns had been initi-ated and most cases were detected when seeking drug treatment or hospital care for other conditions.
In behavioural surveillance surveys among IDUs, there are reports of changes in drug use patterns from 2009, where 97% of respondents reported heroin as the main drug of injection, to 2010, where 67% reported heroin and 31% reported amphetamine-type stimulants, mostly synthetic cathinones, as the main drug of injection.Stimulant use is associated with more frequent injection and there are reports of increased syringesharing [5].
While drug use and injection risk patterns appear to be changing in Romania, access to sterile syringes has decreased.Numbers of sterile syringes distributed reportedly declined from 1.7 million in 2009 to 965,203 in 2010 and to approximately 700,000 up to November 2011.Based on the estimated number of IDUs, syringe provision in Bucharest has thus decreased from 97 syringes per IDU in 2009 to 53 syringes in 2010.While the overall provision of opioid substitution treatment in Romania seems to be limited, the number of clients in such programmes increased from 424 in 2009 to 601 in 2010 [6,7].

Background
HIV infection is one of the most serious potential health consequences associated with IDU, leading to chronic infection, acquired immunodeficiency syndrome (AIDS) and premature death if untreated [1].In the EU and the European Economic Area (EEA), the estimated HIV prevalence rates among IDUs range from less than 1% to more than 60% [8,9].Although for the EU/EEA area as a whole the number of new HIV diagnoses reported annually among IDUs has declined by 44% since 2004, outbreaks have been observed within a number of countries in recent years [9][10][11][12][13].
The risk for blood-borne virus infection outbreaks among IDUs depends on multiple factors, including the frequency of needle sharing, the number of needle sharing partners, the social network structures and mixing in the IDU population.Additional determinants include the size of the IDU population, the types of drugs injected, exposure through commercial sex and other risky sexual practices, and awareness of risks and prevention measures available.In a more general perspective, public health and drug policies as well as the legal environment can also determine infection risks [14].

Assessment of the situation of human immunodeficiency virus among injecting drug users in the European Union/ European Economic Area
In response to the notified events in Greece and Romania, the European Centre for Disease Prevention and Control (ECDC) and the EMCDDA conducted a rapid inquiry to HIV surveillance contact points and national drug focal points in the EU/EEA Member States, candidate and potential candidate countries, in November 2011, to investigate possible recent increases in HIV infections detected among IDUs.Information available from routine surveillance and monitoring of HIV and hepatitis C (HCV) as well as prevention coverage among IDUs has been combined with results from the rapid inquiry (Table ).
Increases in HIV case reports or prevalence among IDUs were reported by six countries as compared to 2008-2010.Seventeen countries reported no changes, four reported fewer cases or lower prevalence, and two did not have information available to assess a change.Countries reporting an increase in the most recent year from which data were available (2011 or 2010) were Bulgaria, Greece, Italy, Lithuania, Luxembourg, and Romania.

Discussion
Overall, the incidence of HIV among IDUs in EU/EEA has been declining steadily since the early 2000s [15].However, as a conclusion from the rapid risk assessment we note that two countries reported recent outbreaks of HIV, four countries reported increases in HIV cases or prevalence, and several other countries reported increases in injecting risk indicators (including HCV prevalence) or low coverage of prevention services among IDU.These factors combined indicate a potential risk for HIV transmission and future outbreaks.
There are clear indications of significant increased HIV transmission in Greece and Romania.While the magnitude of the most recent increases in case reports could be partially related to enhanced surveillance, particularly in Greece, the available evidence indicates a real increase in HIV transmission in both countries.
In Romania, it is likely that a recent rise in the combined use of opioids and amphetamine-type stimulants resulting in increased injecting frequency could have contributed to HIV transmission.In both countries, there is a temporal association between this increase and reduced provision of prevention services (Romania) or initially low levels of) provision of prevention services (Greece).In Romania, these reductions have coincided with the end of a grant from the Global Fund for AIDS, tuberculosis and malaria in June of 2010.
The most robust and recent evidence suggests that the largest reduction of HIV and injection risk behaviour can be achieved by providing comprehensive prevention services, with high coverage of both needle and syringe programmes and opioid substitution treatment in combination [17,18].In light of the growing prevalence of injection of amphetamine-type stimulants, as is reported in Romania, an additional and important challenge is to identify and implement effective treatment that targets this type of dependence [5,9].
In order to prevent new outbreaks of HIV among IDUs, it is of utmost importance that countries that have indicated a change in injecting drug use risk factors or HIV and hepatitis C prevalence review their national or local prevention and control programmes in light of the current situation.Countries that experience ongoing increases or outbreaks would need to scale up their services urgently to prevent new cases.In the context of significant increased transmission of HIV among IDUs, rapid interventions in the form of scaling-up of needle and syringe programmes, provision of opioid substitution treatment and of condoms to reduce sexual HIV transmission are warranted.
The extent to which service reductions or changing patterns of risk among IDUs have been related to the current economic crisis in Europe cannot be easily measured and due to complex interactions between many factors, causal links are extremely difficult to establish.However, in past economic downturns, increased HIV incidence and increased injecting drug use have been observed [19,20], and in a recent paper, Kentikelenis et al. have drawn links between the financial crisis in Greece and the increased HIV incidence [21].In addition to exacerbating vulnerabilities and risk behaviours, economic downturns may also limit the funding available to prevention programmes [22].The current outbreaks of HIV in IDUs in Greece and Romania show that there is a continuous need to keep prevention of HIV and public health on the agenda also in challenging economic times.

Table
Indicators of human immunodeficiency virus and hepatitis C virus transmission, injecting risk and intervention coverage, European Union and European EconomicArea, 2008Area,  -2011