Upsurge in HIV diagnoses among IDUs in Greece and Romania - are reduced prevention services the cause?

New diagnosis and prevalence of HIV increased sharply among injecting drug users in Greece and Romania in 2011, European investigators report. Several other countries in the European Union/European Economic Area (EU/EEA) also reported slight increases in diagnoses or risk behaviour among injecting drug users.

Increased HIV detection among injecting drug users in Greece and Romania occurred within a context of low or falling levels of prevention services.

“These outbreaks show that there is a continuous need to keep public health and sufficient preventative services on the agenda in challenging economic times,” caution the researchers.

HIV prevalence among injecting drug users in the EU/EEA varies between less than 1% to more than 60%. In 2010, approximately 27,000 new HIV diagnoses were reported in the 28 member states of the EU/EEA. A total of 1212 of these infections involved individuals with a history of injecting drug use. The overall trend across these countries has been for a fall in the proportion of HIV infections involving injecting drug users.

Opioid substitution therapy and the provision of sterile syringes and needles remains key to controlling transmission of HIV and other blood-borne infections among drug users.

However, occasional clusters of HIV infection have been reported among injecting drug users in a number of countries.

In November 2011, health officials in Romania informed the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) of a substantial increase in the number of new HIV diagnoses among injecting drug users.

Between 2007 and 2009, only a handful of new diagnoses with injecting drug use as the risk factor were reported in Romania. This increased to twelve cases in 2010 and to 62 cases by September 2011. Diagnoses among injecting drug users accounted for 15% of all new HIV diagnoses in the country in 2011, compared to just 1% in 2009.

Approximately 50% of people with new infections had a CD4 cell count above 500 cells/mm³, suggesting recent infection with HIV. Most of the individuals diagnosed in 2011 (87%) were also co-infected with hepatitis C virus.

Routine HIV testing at drug treatment services in Romania have also found that HIV prevalence is increasing among their clients, from 1% in 2008 to 4% in 2010.

There appear to have been significant changes in the patterns of injecting drug use in the country. A survey conducted in Bucharest in 2010 showed that injecting frequency was increasing, as was use of stimulant drugs such as amphetamine.

These changes occurred when access to sterile injecting equipment was declining. Exchange programmes are only established in Bucharest, and the withdrawal of Global Fund support lead to the closure of one of sites in 2010. Another closure is expected by 2012. The proportion of injecting drug users who report visiting exchange programmes has fallen from 76% in 2009 to just 49% in 2010. At the same time there has been a significant fall in the number of syringes distributed.

Access to opioid substation therapy in Romania is limited. In 2010 only 601 patients were provided with this treatment.

Health authorities in Greece have also reported a sharp increase in the new of HIV infections involving injecting drug users.

The country has a low-level, concentrated HIV epidemic in this population. The maximum number of new infections among injecting drug users in recent years has never been above 16, approximately 2 to 3% of total infections.

However, in the first ten months of 2011 some 190 new infections were diagnosed with injecting drug use as the risk factor. These infections represented a quarter of all new diagnoses in the country.   

Overall HIV prevalence among Greek drug users had been approximately 2%, but this increased to 5% by the end of 2011.

Data from one source suggested sustained transmissions among injecting drug users. Analysis also showed genetic linkage between new infections.

“Unless efficient and comprehensive interventions can be established, the outbreak may result in rapid establishment of long-term high prevalence among this vulnerable group,” warn the investigators.

The Greeks have responded by increasing access to both sterile injecting equipment and opioid substitution therapy. However, in the Athens region, individuals still have to wait over four years to access the latter intervention.

There is also modest evidence of increases in HIV diagnoses or prevalence among injecting drug users in Luxembourg, Lithuania, Bulgaria and Italy. In several other countries, low coverage of prevention services has been reported.

 “There are reasons to suspect that the current economic turmoil has had and will continue to have adverse effects on HIV prevention in Europe,” write the investigators. They warn that: “the current economic crisis is…expected to have an impact on public health budgets.”

The investigators believe “these outbreaks show that there is a continuous need to keep public health and sufficient preventative services on the agenda, even in challenging economic times.”