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