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Opioid substitution treatment and needle and
syringe programmes: Evidence and international
perspectives
Anastasia PharrisEuropean Centre for Disease Prevention and Control
Drogfokus, 25th October 2012
An EU agency for prevention and control of communicable diseases
• In Stockholm since 2005
• 27 EU Member States, plus Iceland, Liechtenstein, Norway, Croatia
• Scientific advice body
< 0.2
0.2 to < 1
1 to < 3
≥ 3
Missing or excluded data
HIV infections diagnosed 2010Injecting Drug Use, EU/EEA
Rate as number per 100 000 population
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010
IDU accounted for 4% of HIV cases in the EU
in 2010
Prevalence of hepatitis C virus antibodies among people who inject drugs; Europe, 2008–2009
Not included, not reporting, or not known
40 < 60%
≥ 60%
0 < 40 %
Source: EMCDDA and Reitox National Focal Points; Nelson et al. 2011; IHRA, EHRN and WHO
IDU account for > 70% of HCV cases in most EU countries
• VACCINATION
• TESTING
• INFECTIOUS DISEASE TREATMENT
• HEALTH PROMOTION
• TARGETED DELIVERY OF SERVICES
What works to prevent infections among people who inject drugs?
• INJECTION EQUIPMENT
• Needle and syringe programmes (NSP)
• DRUG DEPENDENCE TREATMENT
• Opioid substitution treatment (OST)
• Other forms of drug treatment
What works to prevent infections among people who inject drugs?
• Thousands of studies about needle and syringe programmes (NSP)
• Hundreds of studies about opioid substitution treatment (OST)
• Lots of politics and controversy around delivery of these interventions
What works to prevent HIV and hepatitis C among people who inject drugs?
‘Review of reviews’ methodology
• Systematic literature search; over 2500 articles were screened
• High level evidence for effectiveness, measured in biological outcomes (HCV, HIV transmission and injecting risk behaviour as a proxy)
• Technical advisory group also assessed the evidence and recommendations were evidence conflicted or was insufficient
Review-level evidence for the effectiveness of opioid substitution treatment (OST) and needle and syringe programmes (NSP)
What works to prevent HIV and hepatitis C among people who inject drugs?
Level of evidence for
OST
Level of evidence for
NSP
Reduced injecting risk behaviour ++ ++
Reduced HIV transmission ++ +
Reduced HCV transmission + ?
Palmateer 2010; Cochrane review 2009 (Mattick et al); ECDC and EMCDDA 2011
What works to prevent HIV and hepatitis C among people who inject drugs?
• There is good evidence that provided alone, OST and NSP reduce injecting risk behaviour and HIV
• The evidence (at review level) is not as good for HCV reduction
• HCV is easier to transmit (shared equipment)
• Users cycle in and out of treatment programmes and NSP (and prison!)
• Recent new studies and meta-analyses have provided important information on combination prevention
(A) Effect of OST on HCV incidence
(N=1,083*)
Bristol
Birmingham
Leeds
Glasgow
Wales
London0.45 (0.25, 0.82)
1.00705 1 142
Pooled(I2=48%, p=0.09)
Glasgow
Wales
Bristol
Birmingham
Leeds
0.58 (0.30, 1.15)
1.0446 1 22.4
(B) Effect of NSP on HCV incidence
(N=926)
Pooled(I2=0%, p=0.8)
Effect of OST & NSP on new HCV infection
OST Defined as currently on OST (cross-sectional) or >6 months on OST in last year (cohort).
NSP Defined as ≥100% N/S obtained from NSP per injection in last month/six months.
Source: Turner et al, 2011
Adjusted
Incidence Rate Ratio
[95% CI]
No HR Ref
Incomplete HR 0.9 [0.5, 1.5]
Full HR 0.4 [0.2, 0.9]
HIV (N=710)
Hepatitis C(N=168)
Amsterdam Cohort Study – Combination prevention
Source: Van Den Berg et al. Addiction 2007
Adjusted
Incidence Rate Ratio
[95% CI]
No HR Ref
Incomplete HR 1.2 [0.6, 2.3]
Full HR 0.4 [0.1, 1.0]
No HR: No methadone and no NEP
Incomplete HR: Any dose methadone daily & irregular/no NEP; 0-59mg methadone daily & always use NEP
Full HR: ≥60mg methadone daily & no injecting; ≥60mg methadone daily & always use NEP
Accumulating and strong evidence for HCV!
Vickerman (2012): Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users
Reductions require long-term sustained intervention coverage.
Hagan (2011): Systematic review and meta-analysis of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions.
Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion (75% reduction).
European guidance recommends 7 key interventions
� INJECTION EQUIPMENT: Provision of and
legal access to clean drug injection
equipment, including sterile needles and
syringes, free-of-charge, as part of
combination multi-component prevention,
harm-reduction, counselling and treatment
programmes
� VACCINATION: hepatitis A and B, tetanus,
influenza vaccines, and, in particular for HIV-
positive individuals, pneumococcal vaccine
� DRUG DEPENDENCE TREATMENT: Opioid
substitution treatment and other effective
forms of drug treatment
� TESTING: Voluntary diagnostic testing with
informed consent for HIV, HCV, (HBV for
unvaccinated) and TB should be routinely
offered and linked to referral to treatment
INFECTIOUS DISEASE TREATMENT: Antiviral
treatment based on clinical indications for those
who are HIV, HBV or HCV-infected. Anti-
tuberculosis treatment for active TB cases. TB
prophylactic therapy should be considered for
latent TB cases.
HEALTH PROMOTION: health promotion focused
on safer injecting behaviour; sexual health
including condom use; and disease prevention,
testing and treatment
TARGETED DELIVERY OF SERVICES: Services
should be combined and organised and delivered
according to user needs and local conditions; this
includes the provision of services through fixed
sites offering drug treatment, harm reduction,
counselling and testing, and referrals to general
primary health and specialist medical services.
COMBINE THESE KEY INTERVENTIONS TO ENHANCE
PREVENTION SYNERGY AND EFFECTIVENESS
We know enough to act
How are we doing?
Year of introduction of OST in the community vs. prisons
OST not available: GR, CY, LT, LV, SK, TK, UK Source: EMCDDA Statistical Bulletin 2010
CYCZ, RO,
NO
SKLV, LT,
BG
FR, HU
BEPL,GR
DE, IE
SI, ES, HR
LU
SE
NL, UKDK
FI
IT
PTMT, AT
LU, BE, IT, IE
PT
ESFR, FI
SI
NL
DKDE
AT
NO
UK Scot
SE, RO, BG, EE
HU
PL, UK E&WCZ
0
5
10
15
20
25
30
1965 1970 1975 1980 1985 1990 1995 2000 2005
no
. co
un
trie
s p
rovi
din
g
OST in the community OST in prison
OST coverage among estimated opioid users, EU 2010*
*or most recent year available
Source: EMCDDA Statistical Bulletin 2012
Availability of at least 1 needle and syringe provision site per district (EU/EEA)
Source: EMCDDA 2011
Estimated number of syringes/IDU/year delivered through specialized programmes
Source: EMCDDA Statistical Bulletin 2011
0
50
100
150
200
250
300
350
400
Cypru
sSwed
enG
reec
eSlo
vakia
Latv
iaHun
gary
Croat
ia
Mal
taEsto
nia
Czech
Rep
.Por
tuga
lLu
xem
bour
gNor
way
Nu
mb
er
of
sy
rin
ge
s
Old and new challenges
• Effective treatment for stimulant dependence/injection
• Changing drug use patterns
• Economic crisis
• Outbreaks
EU overview of risk for HIV among IDU
Country AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LI LT LU MT NL NO PL PT RO SK SI ES SE TR UK
Increase in HIV
case reporting
and/or
prevalence
Increase in
transmission
risk indicators(↑ HCV, IDU
prevalence, risk
increase )
Low prevention
coverage(< 30% OST or
<100 syringes/
IDU/yr)
Source: ECDC and EMCDDA Risk assessment 2011
NO ALERT- no evidence for increase/satisfactory coverage
ALERT- evidence for increase/low coverage
Information unknown/not reported to ECDC/EMCDDA
Comprehensive Guidance document
Based on evidence and fully referenced (50 pages)
Guidance “in brief”
Condensed recommendations
(8 pages)
Two part evidence assessment
1. Needle and syringe programmes and other interventions for preventing hepatitis C, HIV and injecting risk behaviour (144 pages)
2. Drug treatment for preventing hepatitis C, HIV and injecting risk behaviour (62 pages)
Available at: www.ecdc.europa.eu
European guidance on prevention of infections among people who inject drugs
Thank you!
22
Seven interventions, one aim: no infections