Injecting drug users and HCV infection : prevention strategies and results

Damien Lucidarme M.D.

Hôpital saint Philibert,

Lomme, France

Introduction

Intravenous drug use has become the principal route of HCV transmissionPrevalence reported from Europe, the USA and Australia are usually high : 50 % -> 90 %

Prevalence of HCV markers according to the duration of IV drug use in 1991 in Lille

Contamination by HCV was almost inevitable after 2 years of intravenous drug use

%33

62 66

90 90

0

20

40

60

80

100

0-6 0-12 '12-24 24-36 >36 moisDURATION OF INTRAVENOUS DRUG USE

Lucidarme et al. Gastroenterol Clin Biol 1994

Introduction

In order to prevent HIV and HCV transmission among IDUs, in 1993 the French health authorities implemented a national risk-reduction program based on :1) easy access to syringes, 2) opiate substitution, 3) screening for HIV and HCV and counselling

1) easy access to syringes : Evolution of the number of organizations and of

funding dedicated to the risk-reduction policy

94 MF92 MF86 MF79 MF66 MFFunds

420388354320268Total number

272250220200150Automated devices

4236343232Storefronts

1061021008886Syringe-exchange-programmes

20012000199919981997Organizations

Labrosse-Solier N. Journée nationale de l’échange des seringues en pharmacie. Lyon 2001

2) opiate substitutionAccessibility of IVDUs to substitution treatment from 1995 to 2003 (Siamois, InVS)

0

20 000

40 000

60 000

80 000

100 000

1995 1996 1997 1998 1999 2000 2001 2002 2003

Average number of monthly users of MéthadoneAverage number of monthly users of Subutex

3) screening for HIV and HCVFrequency of recent detection (past 20 months) of hepatitis C according to age among the users of low-threshold organizations

63 %50 %46 %Total

72 %58 %48 %> 35 years

66 %53 %50 %25-35 years

49 %33 %37 %15-24 years

200320022001

Conférence de Consensus : Place des traitements de substitution. Lyon 2004

Does this policy work ?

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

1995 1 996 1 997 1 998 1 999 2 000 2 001 2 002 20030

50

100

150

200

250

300

350

400

450

500

UD under substitution Deaths by overdose

UD under substitution Deaths bu

overdose

Evolution of access to substitution treatment and ofdeaths by overdose from 1995 to 2003 (Siamois, InVS)

Dr. J.Emmanuelli / InVS

02 000 0004 000 0006 000 0008 000 000

10 000 00012 000 00014 000 00016 000 00018 000 00020 000 000

1995 1996 1997 1998 1999 2000 2001 2002 2003010 00020 00030 00040 00050 00060 00070 00080 00090 000100 000

UDIV under substitution syringes

Progress of access to substitution treatment and sterile syringes from 1995 to 2003 (Siamois, InVS)

Syringes IVDU

Dr. J.Emmanuelli / InVS

Indicators of infection in IVDUs from 1988 to 2002 : stated prevalence of HIV and HCV

1988 1991 1996 1998 1999 2002

IREP 40% 34% 20%CESES 14%DREES 23% 14%PES 19%0FDT 10%IREP 47%CESES 60%DREES 66% 63%PES 58%AIDES 53%COQUELICOT 51%

HIV

HCV

Emmanuelli J et al. BEH 2003

Comments

HCV prevalence = HCV incidence x duration of the illness (>10 years)=> Prevalence reflects :

long-term contamination and therefore ancient practicesperiod prior to the rise of the risk-reduction policy

Prevalence is not a sensitive indicator of the course of the epidemicIncidence is a more sensitive indicator of the course of the epidemic

Incidence and risk factors of HCV and HIV infections in a prospective cohort of IVDU in the North and East of France*

Between March 1999 and July 2001, we conducted, in closed partnership with InVS, a prospective cohort study of antibodies to HCV and HIV among IDUs negative for both viruses recruited in the North and East of France

*Lucidarme D, Bruandet A, Ilef D et al. Epidemiology and Infection 2004

Patients and methods

The persons eligible were drug user attendees of 6 care centers in Northern and Eastern France :

who had injected drugs at least once in their lifetimewhose HCV serology was presumed to be negative

A blood sample for HCV and HIV tests was taken and a standard questionnaire on their drug habits and injecting practices was administered from all the participants at inclusion and at the end of the follow-up one year later

Results

Of the 231 HCV-seronegative IDUs enrolled in the study, 3 (2%) died and 63 (27%) did not undergo a final serum test and were excluded from the analysis165 participants (71.4%) underwent a final HCV serum testAmong the 165 enrollees, 16 seroconverted for HCV during follow-upNo HIV seroconversion was detectedThe crude incidence density rate for HCV infection is therefore 9.0 PY (95%CI: 4.57-13.4)

Incidence of HCV infection according to maintenance therapy

0

5

10

15

20

Méthadone (n=57)

Buprénorphine (n=77)

No maintenancetherapy (n=31)

Incidence of HCV

16,1 P = NS

5,3

10,4%

Comments

The incidence of HCV infection remains rather highThe still high proportion of sharing of injection and preparation equipment and continuance of regular injecting practices, perhaps favored by the use of cocaine and the risky nature of occasional and unplanned injections are among the most contributing factorsAssuming that 40 000 active IVDUs are HCV negative we could speculate that 2 700-4 400 IVDUs are contaminated every year in France

Is HCV contamination of intravenous drug users

really unavoidable ?

Prevalence of HCV markers in relation to the duration of intravenous drug use

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

%

France 1991 France 2001

What remains to be done ?

1- Prevent syringe use particularly among the youngest drug users

2- Continue the efforts of improvement of the accessibilityof injection equipment aimed at preventing sharing andre-use behavior

3- Continue substitution policy but take into account its shortcomings

4- Reinforce screening of HCV infection in IVDUsparticularly among those with poor veins and those who had never been tested

5- Reinforce acessibility of IVDUs to treatment

Conclusion

We may conclude that the risk-reduction policy hashad a significant but markedly insufficient impact onthe hepatitis C epidemic in the drug-user population

Much remains to be done in order to inflect the prevalence curve of the infection by 2011

Conclusion

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

%

France 1991 France 2001 France 2011 ?

Prevalence of HCV in relation to the duration of IV drug use

Thank you