Post on 23-May-2020
transcript
16/06/2017
1
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
16/06/2017
2
17 11 11 15 16
266
551
272
106 70 58
4 3 2 3 3
33
54
36
1813 13
0
20
40
60
80
0
200
400
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
16/06/2017
3
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
10
20
30
40
50
60
70
80
90
100
0
1000
2000
3000
4000
5000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Pe
rce
nta
ge
of
est
ima
ted
pro
ble
m o
pio
d u
sers
in
OST
Nu
mb
er
of
op
ioid
use
rs o
n w
ait
ing
list
fo
r e
ntr
y in
OST
in A
the
ns
Key response #2: Increase availability of OST coverage
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
16/06/2017
4
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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 (%)
(%)
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
•
16/06/2017
5
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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)
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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)
16/06/2017
6
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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)
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
Rely on HIV notifications as proxy for trends in incident HIV infection among PWID in Athens
17 11 11 15 16
266
551
272
106 70 58
4 3 2 3 3
33
54
36
1813 13
0
20
40
60
80
0
200
400
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)
Fig. Trends in the number and proportion of HIV notifications associated with injection drug use in GreeceSource: Hellenic Centre of Disease Control & Prevention
16/06/2017
7
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
30
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
•
16/06/2017
8
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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)
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
Focal point data considered in model-derived estimations
16/06/2017
9
0
200
400
600
800
1000
1200
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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)
0
20
40
60
80
100
0
200
400
600
800
1000
1200
1400
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, %
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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 )
16/06/2017
10
0
200
400
600
800
1000
1200
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
Four key points
16/06/2017
11
Strengths• Annual samples• Core and optional DRID
and TDI variables• High coverage (units
and entries)• Not intervention-type
programs
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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!
Greek Reitox Focal Point of the EMCDDA at the Athens University Mental Health Research Institute
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: afotiou@ektepn.grT:+302106536902F:+302106537273