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 transmission Prevalence 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 100
90
80 62
60
%
40
90
66
33
20 0
0-6
0-12
'12-24
24-36
>36 mois
DURATION OF INTRAVENOUS DRUG USE
Contamination by HCV was almost inevitable after 2 years 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 riskreduction 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
Organizations
1997
1998
1999
2000
2001
Syringe-exchangeprogrammes
86
88
100
102
106
Storefronts
32
32
34
36
42
Automated devices
150
200
220
250
272
Total number
268
320
354
388
420
66 MF
79 MF
Funds
86 MF 92 MF 94 MF
Labrosse-Solier N. Journée nationale de l’échange des seringues en pharmacie. Lyon 2001
2) opiate substitution Accessibility of IVDUs to substitution treatment from 1995 to 2003 (Siamois, InVS) 100 000 80 000 60 000 40 000 20 000 0 1995
1996
1997
1998
1999
2000
2001
2002
Average number of monthly users of Méthadone Average number of monthly users of Subutex
2003
3) screening for HIV and HCV Frequency of recent detection (past 20 months) of hepatitis C according to age among the users of lowthreshold organizations
2001
2002
2003
15-24 years
37 %
33 %
49 %
25-35 years
50 %
53 %
66 %
> 35 years
48 %
58 %
72 %
Total
46 %
50 %
63 %
Conférence de Consensus : Place des traitements de substitution. Lyon 2004
Does this policy work ?
Evolution of access to substitution treatment and of deaths by overdose from 1995 to 2003 (Siamois, InVS) UD under Deaths bu overdose
substitution 100000
500
90000
450
80000
400
70000
350
60000
300
50000
250
40000
200
30000
150
20000
100
10000
50
0
0 1995
1 996
1 997
1 998
1 999
UD under substitution
2 000
2 001
2 002
2003
Deaths by overdose
Dr. J.Emmanuelli / InVS
Progress of access to substitution treatment and sterile syringes from 1995 to 2003 (Siamois, InVS) Syringes
IVDU
20 000 000
100 000
18 000 000
90 000
16 000 000
80 000
14 000 000
70 000
12 000 000
60 000
10 000 000
50 000
8 000 000
40 000
6 000 000
30 000
4 000 000
20 000
2 000 000
10 000
0
0 1995
1996
1997
1998
1999
UDIV under substitution
2000
2001
2002
2003
syringes Dr. J.Emmanuelli / InVS
Indicators of infection in IVDUs from 1988 to 2002 : stated prevalence of HIV and HCV
IREP CESES HIV DREES PES 0FDT IREP CESES HCV DREES PES AIDES
1988
1991
1996
40%
34%
20% 14% 23%
COQUELICOT Emmanuelli J et al. BEH 2003
1998
1999
2002
14% 19% 10%
47% 60% 66%
63% 58% 53% 51%
Comments HCV prevalence = HCV incidence x duration of the illness (>10 years) => Prevalence reflects : long-term contamination and therefore ancient practices period prior to the rise of the risk-reduction policy
Prevalence is not a sensitive indicator of the course of the epidemic Incidence 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 lifetime whose 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 analysis 165 participants (71.4%) underwent a final HCV serum test Among the 165 enrollees, 16 seroconverted for HCV during follow-up No HIV seroconversion was detected The 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 P = NS
20
%
10,4
15 10
16,1
5,3
5 0
Méthadone (n=57)
Buprénorphine (n=77) Incidence of HCV
No maintenance therapy (n=31)
Comments The incidence of HCV infection remains rather high The 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 factors Assuming 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 100 80 60
%
40 20 0 0
2
4
6
8
10
France 1991
12
14
16
18
France 2001
20
What remains to be done ? 1- Prevent syringe use particularly among the youngest drug users 2- Continue the efforts of improvement of the accessibility of injection equipment aimed at preventing sharing and re-use behavior 3- Continue substitution policy but take into account its shortcomings 4- Reinforce screening of HCV infection in IVDUs particularly 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 has had a significant but markedly insufficient impact on the 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 100 80 60
%
40 20 0 0
2
4
France 1991
6
8
10
12
14
France 2001
16
18
20
France 2011 ?
Prevalence of HCV in relation to the duration of IV drug use
