indications for decline in hcv and hiv incidence among ... · entering drug services in athens, by...

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INDICATIONS FOR DECLINE IN HCV AND HIV

INCIDENCE AMONG PEOPLE WHO INJECT

DRUGS IN ATHENS, GREECE

EMCDDA - DRID National Expert Meeting

Session 4. Directions for the development of the DRID indicator

Lisbon, EMCDDA, 15-16 June 2017

Anastasios Fotiou • Greek Reitox focal point at the Athens University

Mental Health Research Institute

Collaboratively with Eleftheria Kanavou & Argyro Andaraki

Drug situation in Greece

• 2.4 per 1000 people (~17000) aged 18-64 use opioids ― ~1/3 current injectors and more than half live in Athens

• ~5 000 people enter treatment / OST) annually ― ~3/5 have entered treatment before

• Opioids responsible for ~3/4 of treatment entries

• The majority of entries in drug-free settings ― long and stagnant waiting list for entry in OST in Athens

• >60% OST coverage nationwide, just above 50% in Athens

• ~20% of current injectors report also current sharing of syringes

• ~109 syringes per current injector a year (2015), scant in other cities

• ~63% HCV antibody prevalence among entries in Athens, higher in OST

• ~14% HIV prevalence among treatment entrants in Athens, higher among active users (~17%, 2013 data)

Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute

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17 11 11 15 16

266

551

272

106 70 58

4 3 2 3 3

33

54

36

1813 13

0

20

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600

800

1000

1200

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016¹

Pe

rce

nta

ge

, %

Nu

mb

er,

Ν

HIV infections associated with injection drug use, N

% of HIV infections associated with IDU (among cases with known mode of tranmission)

Notes .¹ January-October 2016


Fig. Trends in the number and proportion of HIV notifications associated with injection drug use in GreeceSource: Hellenic Centre of Disease Control & Prevention

Sharp increases in the yearly number of HIV notifications associated with IDU in 2011 and 2012 — almost all reported in Athens

29782 3480964958 55109 68579 61516

119397

406898

435617

315706

267601

8 11 20 19 2116

43

133

223

139109

0

50

100

150

200

250

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

2005 (3537)

2006 (3243)

2007 (3206)

2008 (2855)

2009 (3194)

2010 (3910)

2011 (2803)

2012 (3069)

2013 (1956)

2014 (2272)

2015 (2451)

Syr

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s pe

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n dr

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ser,

N

Syr

inge

s di

strib

ute

d / e

xch

ange

d, N

Syringes exchanged/distributed, NSyringes per estimated injection* drug user, Ν

Reporting year

(Estimated number of current injection drug users; central estimate)

Source: Greek Reitox Focal Point of the EMCDDA, 2016

* Past 30 days injection


Fig. Trends in the number of syringes distributed and the number of syringes per estimated current PWID in Athens

Key response #1: Scaling up of the syringe programs in Athens following the 2011 outbreak

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Fig. Trends in the number of opioid users on the waiting list to enter OST and percent of estimated problem opioid users in OST in Athens (coverage)Source: Greek Reitox Focal Point of the EMCDDA

2757 2828

3157

35693771 3689

3838

2431

2301

1801

22 22

33

22

2832

4347

51

0

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2000

3000

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5000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pe

rce

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ge

of

est

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ted

pro

ble

m o

pio

d u

sers

in

OST

Nu

mb

er

of

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n w

ait

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list

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OST

in A

the

ns

Key response #2: Increase availability of OST coverage


Aim Seek, test, alert, link to care (as a response to the HIV outbreak)

Site Athens (metropolitan area)

Period Aug 2012-Dec 2013 (18 months)

Setting Community

Population PWID in the past 12 months, ≥18 years of age

Method Respondent driven sample, RDS; 5 rounds; incentives

Sample N=3,320 unique participants (≈36yo); 54% in ≥1 rounds

Coverage 71-100% (based on HRDU estimates for current injectors)

Data collection Blood sample and CAPI

Source Hatzakis et al Addiction, 2015

Key response #3: Seek, test, link to care, and prevent further harm – The ARISTOTLE program

Athens University Medical School, in collaboration with the Greek

Organisation Against Drugs (OST), the Hellenic Centre for Disease

Control & Prevention, and NGOs

Run by

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ARISTOTLE reported significant changes towards less risky behaviours from round 1 to round 5

• Decrease in daily injecting, from 45% to 19%

• Decrease in current sharing of syringes, from 37% to 26%

• Entry in OST doubled, from 12% to 28%

• HIV test uptake increased from 50% to 87%

• % of undiagnosed HIV-positives declined from 84% to 15%

• 48% of previously unlinked seropositives visited an infectious diseases unit, and one-fourth (25%) initiated ART after their participation and by the end of round 5

Source: Hatzakis et al Addiction 2015; Sypsa et al J Inf Dis 2017

8

1114

11

14

98

12

18

15

35

13

0

5

10

15

20

25

30

35

40

2008 2009 2010 2011 2012 2013 2014 2015 2016

PWID tested HIV positive in ARISTOTLE 2012-2013 (%)

HIV positive PWID entering all types of treatment in Athens (%)

HIV positive entering OST in Athens (%)

(%)


Fig. Prevalence of HIV infection among PWID entering (a) any type of drug-related services in Athens, (b) OST and (c) ARISTOTLE program Source: Greek Reitox Focal Point of the EMCDDA ; Hatzakis et al Addiction 2015; Sypsa et al J Inf Dis 2017

In ARISTOTLE

• The prevalence of HIV infection ranged across rounds from 12% to 16% — from 6% (last round) to 26% (first round) among ‘new’ injectors (not shown)

• Relatively higher prevalence compared to treatment settings in general, but lower compared to OST

ARISTOTLE enriched data on HIV prevalence by including PWID from wider networks in Athens

16.5%

• 2016 data are

preliminary, not to be cited

•

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ARISTOTLE data allowed the direct measurement of HIV incidence among PWID participating in the program

Infectious disease: HIV

Sample / data: PWID in the past 12 months

Participants of the 5-round RDS of the ARISTOTLE program

N = 1521 with >1 presentation in the program

Period: 2012-2013

Type of measurement: Direct, longitudinal follow up of PWID who where initially

negatives and seroconverted during the program

Seroconversion time: Mid-point between last negative and fist positive test

Risk years: 1004

# seroconversions: 45

Incidence rate: 4.5 infections per 100 person years

Source: Sypsa et al 2017 (JID)


Source: ARISTOTLE; Sypsa et al J Inf Dis., 2017

ARISTOTLE data suggested a 78% reduction in incident HIV infections between the start and end o f the program (18 months)

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Fig. Prevalence of HIV infection among PWID entering OST in Athens

Over-representation of HIV positives in OST entries coupled with reduced sample sizes in the recent yea rs threaten data reliability of HIV prevalence in this population

0

5

10

15

20

25

30

35

40

45

50

55

60

2008 2009 2010 2011 2012 2013 2014 2015

All entering OST in Athens (N tests = 95 in 2015)

< 25 years of age (OST) (N tests = 4 in 2015)

<2 injection years (OST) (N tests = 1 in 2015)

1st-ever-treatments (OST) (N testd = 23 in 2015)


Rely on HIV notifications as proxy for trends in incident HIV infection among PWID in Athens

17 11 11 15 16

266

551

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106 70 58

4 3 2 3 3

33

54

36

1813 13

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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016¹

Pe

rce

nta

ge

, %

Nu

mb

er,

Ν

HIV infections associated with injection drug use, N

% of HIV infections associated with IDU (among cases with known mode)

Fig. Trends in the number and proportion of HIV notifications associated with injection drug use in GreeceSource: Hellenic Centre of Disease Control & Prevention

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But

Fig. Trends in the number of treatment entries in Greece, total and by treatment modality Source: Greek FP

3630 3637

4269 4248

4847 4786 4682

55015645

58345696

48944740

4087

25112660

31313275

36203910

3767

42324451

3704

32333508

33713160

498

535

861597

888

509 475

862 940

1761

2135

10981122

771621

442277 376 339 367 440 407

254369 328

288 247 156

0

1000

2000

3000

4000

5000

6000

7000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nu

mb

er,

N

All entries

(any modality)

Entries in drug

free

Entries in OST

Presentations

in low

threshold

29782 3480964958 55109 68579 61516

119397

406898

435617

315706

267601

8 11 20 19 21 16

43

133

223

139109

0

50

100

150

200

250

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

2005 (3537)

2006 (3243)

2007 (3206)

2008 (2855)

2009 (3194)

2010 (3910)

2011 (2803)

2012 (3069)

2013 (1956)

2014 (2272)

2015 (2451)

Syr

inge

s pe

r cur

rent

inje

ctio

n dr

ug u

ser,

N

Syr

inge

s di

strib

ute

d / e

xch

ange

d, N

Syringes exchanged/distributed, NSyringes per estimated injection* drug user, Ν

Reporting year

(Estimated number of current injection drug users; central estimate)

Source: Greek Reitox Focal Point of the EMCDDA, 2016

* Past 30 days injection

Fig. Trends in the number of syringes distributed and the

number of syringes per estimated current PWID

in Athens

25 25

15

28 28

41 3943

54 52

65

48 55

3229

74

67 6663 65 63

5962

7176

78

70 71

6164

0

10

20

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40

50

60

70

80

90

100

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

anti-HCV prevalence in PWID with <2 years injection career (Athens)

anti-HCV prevalence in PWID with ≥2 years injection career (Athens)

(%)

Fig. Trends in the prevalence of anti-HCV among PWID entering drug services in Athens, by injection careersSource: DRID data of Greek Reitox Focal Point of the EMCDDA; Sypsa et al (poster) 2017

Based on treatment entry data:

• Antibody prevalence has been consistently higher among those with injection careers ≥2 years, compared to ‘new’ injectors

• Trend in antibody prevalence among new injectors parallels that of ‘old’, but fluctuations are sharper among ‘new’ injectors, perhaps associated with their small Ns


50%

95% CI:

45.0%,

54.7%]

(N=431)

‘New’

injectors in

ARISTOTLE

ARISTOTLE enriched data on HCV prevalence by including PWID from wider networks in Athens

• 2016 data are preliminary, not to be cited

•

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Infectious disease: HCV

Sample / data: Recent (past 12 months) PWID and ≤2 years injection history

Participants of the 5-round RDS of the ARISTOTLE program

N = 431

Period: 2012-2013

Type of measurement: Direct, longitudinal follow up of PWID who where initially

negatives and seroconverted during the program

Seroconversion time: Mid-point between last negative and fist positive test

# risk years: 28.4

# seroconversions: 16

Incidence rate: 56.3 infections per 100 person years

Source: Sypsa et al 2017 (poster EASL)

ARISTOTLE data allowed the direct measurement of also HCV incidence among ‘new ’ PWID in Athens

• HCV antibody prevalence (stratified) (DRID)

• Estimations of HRIDU population size (HRDU)

• Prevalence of syringe sharing among PWID (TDI / DRID)

• Age of onset of injecting (TDI / DRID)

• Duration of injection careers (TDI / DRID)

• Drug related deaths (DRD)

• NSP coverage (Responses & HRDU)

• OST coverage (Responses & HRDU)

• Length of stay in OST (Treatment data)


Focal point data considered in model-derived estimations

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0

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1400

HC

V in

cide

nt c

ases

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Year

Incidence 95% CRI


A possible outbreak of HCV infections among PWID in Athens from 2009 through 2011, followed by a declin e in incident cases in 2012 and stability thereafter

Fig. Trend in the estimated number of HCV incident cases among PWID in Athens based on a dynamic disease transmission model

Source: Gountas et al 2017 (oral present.)

22,7*

(17.3-27.4)Gountas et al

2017 (Addiction)

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2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Anti-H

CV

pre

vale

nce

, %

HC

V inci

dent

case

s, N

Estimated HCV incident cases based on disease transmission modelling, N

anti-HCV prevalence among PWID accessing drug services, %


Antibody prevalence grew together with the growth o f the epidemic and after the number of the incident cases started to fall

Fig. Trends in the estimated number of HCV incident cases among PWID and antibody prevalence among PWID accessing treatment services in Athens Source: Adapted from Gountas et al 2017 (oral presentation); Greek Reitox Focal Point of the EMCDDA

Notes Average yearly number of

tests = 1055 (range: 382, 1513 )

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1400

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Num

be

r o

f ca

ses

Newly diagnosed / reported HIV infections associated with IDU, N

HCV incident cases (estimation), N

Higher-risk injecting behaviour has seemingly taken place prior to the HIV outbreak among PWID in Athens in 2 011


Fig. Trends in the estimated number of HCV incident cases among PWID in Athens and number of newly diagnosed / reported HIV cases associated with injection drug use in GreeceSource: Adapted from Gountas et al 2017 (oral presentation); Adapted from Hellenic Centre of Disease Control & Prevention

Notes. Almost all HIV cases were reported in Athens

1. Strong indications for reductions in prevalence and incidence of HIV and HCV infections among PWID in Athens in the recent years

2. Positive trends likely associated with the impact of interventions and the resulting behavioural changes towards less risky injection and sexual routines

3. Infection risks are by no means eliminated in this population (e.g., ongoing economic recession, poverty, social exclusion and lack of social support, discontinuation of interventions)

4. New model-derived estimations of incidence draw on focal point data and provide new insights about the course of the epidemics among PWID in Athens


Four key points

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Strengths• Annual samples• Core and optional DRID

and TDI variables• High coverage (units

and entries)• Not intervention-type

programs


TDI / DRID data — A valuable tool for measuring / estimating incident infections

Weaknesses • Biased sample (e.g, PWID interested in

treatment, structural barriers in accessing services )

• Small sample sizes of recurrent entries• No measures about time / year of infection• Missing serological data owing to delays in

testing

Opportunities

• Direct measurement of incidence: Identify PWID who record multiple presentations in treatment services over a period of 15 years. Plus, possibility to assess risk factors for seroconversion

• Model-derived estimations: Feed in with data on important parameters (e.g., high risk injection use, injection careers, sharing partners etc)

Indicator ‘Drug Related Infectious Diseases’, Greece

Thank you for your attention!


Cited work

• Gountas, I., Sypsa, V., Anagnostou, O., Martin, N., Vickerman, P., Kafetzopoulos, E., et al. (2017). Treatment and primary prevention in people who inject drugs for chronic hepatitis C infection: is elimination possible in a high‐prevalence setting? Addiction, DOI: 10.1111/add.13764.

• Hatzakis, A., Sypsa, V., Paraskevis, D., Nikolopoulos, G., Tsiara, C., Micha, K., et al. (2015). Design and baseline findings of a large-scale rapid response to an HIV outbreak in people who inject drugs in Athens, Greece: the ARISTOTLE programme. Addiction, 110(9), 1453-1467.

• Sypsa V, Vickerman V, Wiessing L, Malliori M, & Hatzakis A. High levels of transmission of HCV infection among people who inject drugs in Greece (poster presented at EASL the International Liver Congress, Amsterdam 19-23 April 2017)

• Sypsa, V., Psichogiou, M., Paraskevis, D., Nikolopoulos, G., Tsiara, C., Paraskeva, D., et al. (2017). Rapid decline in HIV incidence among persons who inject drugs during a fast-track combination prevention program after an HIV outbreak in Athens. The Journal of Infectious Diseases, doi: 10.1093/infdis/jix100.

Contact person :Anastasios Fotiou, PhDUniversity Mental Health Research Institute (UMHRI)2, Soranou tou Efesiou, st. PO Box 66 517, 156 01, Papagou Athens GreeceE: [email protected]:+302106536902F:+302106537273

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