Expert meeting on drug-related infectious diseases (DRID) 2020

Are drug users at a higher risk of SARS-Cov-2 infection and severe COVID-19 outcomes?

As of 6 November 2020, ECDC reported 235 648 deaths (~46 per 100 000 inhabitants) linked to the SARS-Cov-2 virus, for a total of more than 8.5 million confirmed cases in EU/EEA and UK (ECDC). Are drug users at a higher risk of SARS-Cov-2 infection? Given the transmission mode of this respiratory virus, some common exposures among drug users can be considered as risk factors. They include – among others - social gathering in closed settings, sharing of drugs and paraphernalia, and poor access to soap, hand sanitiser and masks for marginalised populations. A seroprevalence study conducted in Czechia during the first wave of the pandemic (April 2020) among 4255 clients from drug services showed a prevalence of SARS-Cov-2 antibodies of 0.26% in this population. SARS-Cov-2 seroprevalence studies conducted in France, Spain and Switzerland at the end of the first wave (May-June), showed that between 4% and 10% of the general population had already been infected. While the Czech study was done early on, it might nevertheless suggest that the risk of getting COVID-19 was not higher among drug users than in the general population.

Prevalence of drug use is high in prison settings and there are concerns that people in prison might be disproportionally affected by COVID-19. Preliminary data from the French prison of Villeneuve les Maguelone showed that by mid-May 2020, among inmates (the prison has a capacity of 570), 24 people were tested, 2 were positive for COVID-19, and a further 67 high-risk contacts had to quarantine. As France is facing its second pandemic wave in October 2020, the prison guarantees the continuity of OST and support for patients with somatic and psychiatric disorders.  

Are drug users at a higher risk of severe COVID-19 outcomes? Early observational studies have shown a strong and consistent association between underlying medical conditions (including cardiovascular diseases and lung diseases) and severe COVID-19 outcomes (leading to hospitalisation, ICU, deaths). Given the high prevalence of these underlying chronic conditions among high-risk drug users, they can be considered at high risk of developing severe outcomes when infected with Sars-Cov-2. A study of electronic health records in the United States in June 2020 showed that people with a recent diagnosis of substance use disorder (opioid, cocaine or cannabis) were at increased risk of COVID-19 and at increased risk of experiencing severe outcomes such as hospitalisation and death.

How is the pandemic affecting harm reduction services working on HIV, hepatitis and STIs?

Besides the direct impact COVID-19 is having on drug users, the pandemic is disrupting the functioning of essential drugs services that play a central role in the prevention and treatment of other infectious diseases such as HIV, viral hepatitis and sexually transmitted infections (STIs). In Germany, the RKI conducted a survey among 41 harm reduction services doing testing and counselling for drug users. The results showed that the 2020 spring lockdown led to an increase in the demand for needle exchange, but the limited number of clients and shortened duration of stay in facilities led reduced contact with clients, while testing services and counselling were discontinued. A second survey round will be conducted in December 2020.

The German survey, as well as a study from the civil society Correlation network and an ECDC report on medically and socially vulnerable populations during the pandemic, outlined the challenges faced by European harm reduction services and drug users during the pandemic, but also point to the capacity of drug services to innovate and provide flexible solutions to maintain service continuity. Examples include new outreach services, home delivery of OST, the use of telemedicine and the extension of prescription lengths for patients. Similarly, in Israel, HIV prevention among PWID was adapted during the lockdown to prevent the re-occurrence of the 2012-13 outbreak. NSP staff were declared essential staff, NSP services were moved outdoors to comply with COVID-19 regulations, OST was given for longer periods, and telemedicine encouraged. WHO Europe is currently assessing the disruptions to HIV services in Eastern Europe and Central Asia. As Europe is facing its second COVID-19 epidemic wave, the Euro-TEST initiative is conducting an assessment of the impact of the pandemic on testing for HIV, viral hepatitis and sexually transmitted infections in the WHO European Region.

Monitoring SDG among PWID in Europe

The year 2020 is an important year for the monitoring of HIV and viral hepatitis-related targets. People who inject drugs (PWID) constitute a vulnerable population for these infectious diseases both in terms of transmission (requiring higher levels of combined prevention) and burden (requiring better access to treatment). The 2020 targets (in terms of prevention, policy, continuum of care and impact) are detailed in the WHO action plan for the health sector response to viral hepatitis in the WHO European Region and the UNAIDS Fast track Commitments to End AIDS by 2030. To illustrate the scale of the challenge still ahead for Europe in terms of combined NSP and OST interventions, the EMCDDA viral hepatitis elimination barometer data show that only one EU country, Luxembourg, has so far reached the 2020 targets. In terms of HIV continuum of care, ECDC monitoring data of the implementation of the Dublin Declaration show that the proportion of HIV infected PWID receiving ART (50%) and the proportion of HIV infected PWID with undetectable viral load (39%) were still below target (90% and 73%) in 2018.

HBV Prevention: vaccination in prisons

Besides NSP and OST, HBV vaccination is a cost-saving intervention. While some MS have included HBV vaccine in their universal vaccination schedule, some have not or have done so recently only, meaning that cohorts of unvaccinated adults remain at risk. While people in prison often have multiple risk factors associated with HBV infection, including injecting drug use, prisons are settings where catch-up vaccination should be offered.  A retrospective analysis of data submitted to the WHO’s Health in Prisons European Database looked at the epidemiology of HBV in prisons and related interventions, including vaccination programmes. Of the 26 reporting countries, vaccination programmes in prisons were reported as available by 21 countries. In four countries (Bulgaria, Latvia, Lithuania, Romania), HBV vaccination was not available to people in prison, while in Poland it was only available upon request by a physician. For countries with a vaccination programmes, it was reported to be available variously on an opt-in basis, to at-risk groups or to eligible individuals. HBV vaccination is one of the seven key intervention components recommended in the ECDC and EMCDDA Guidance on prevention and control of infectious diseases among PWID that is currently being updated.

HCV continuum of care: barriers and integrated treatment

Documenting the continuum of care for HIV and HCV infection among PWID can help identify critical barriers to and guide interventions for improving linkage to care. In France, the FANTASIO research project is looking for factors associated with access to antiviral drugs for hepatitis C. There is universal access to direct acting antivirals (DAA) to treat chronic HCV infection in France since 2016. Based on anonymised records from the French national health system, researchers found that being a female, having an untreated alcohol disorder and living in a district with fewer than 7 hepatologists per 100 000 inhabitants were risk factors for lower DAA uptake among infected PWID.

A strategy to improve the continuum of HCV care among PWID is the concept of integrated treatment, where HCV testing, counselling, treatment and post-treatment follow-up are delivered by multidisciplinary teams at OST clinics or community care centers for drug users. A research team at the university of Bergen in Norway is conducting a randomised controlled clinical trial that is comparing the efficacy of integrated treatment of HCV in PWID with the current standard treatment. The primary outcomes are time to treatment initiation and sustained virologic response, defined as undetectable HCV-RNA 12 weeks after end of treatment. The results presented during the DRID meeting will be published in December 2020. Integration is a core principle of the tools developed by the EMCDDA within the HCV testing initiative and models of care, to help Member States increase access to testing and care for PWID through drug services.

Lessons learned from HIV outbreaks linked to injecting in Europe

Despite the overall downward trend in HIV notifications linked to injecting drug use in the EU since 2012 (966 cases in 2018), local HIV outbreaks among PWID (mostly linked to stimulant injecting) are still being documented in Europe and represent a serious threat to public health. Experts from Lithuania (prison outbreak in 2016-17), Germany (Bavaria outbreak 2016, linked to synthetic cathinone alpha-PVP/PV8), Luxembourg (2014-17 outbreak, linked to cocaine) and Glasgow (ongoing outbreak, linked to cocaine) reported on lessons learned from outbreak detection, identification of risk factors and interventions. Among recommendations for earlier detection, the experts mentioned close collaboration between regional and national levels and real-time molecular surveillance. There were always multiple risk factors identified besides stimulant injecting, such as homelessness, incarceration, and unsafe sex. In terms of interventions, intensification of outreach prevention (NSP, condom distribution) and screening activities to reach marginalised users, as well as integrated and decentralised ART treatment to all – including people in prisons – are key components of an effective response.      

Re-emergence of HCV after virtual elimination in a prison in Australia

The ongoing HIV outbreak among PWID in Glasgow is a reminder that outbreaks of preventable infectious diseases can occur among PWID despite comprehensive harm reduction services, especially when new high-risk drug use patterns (e.g. cocaine injecting) emerge among marginalised populations. Another illustration of this comes from Australia, where in 2019 the Lotus Glen Corretional Centre, in the state of Queensland, had almost eliminated hepatitis C after a successful local treatment programme. Since mid-2019, however, health services notified an increase in HCV cases among detainees (174 new notifications from June 2019 to July 2020). Identified risk factors for the outbreak included overcrowding, injecting initiation among young indigenous prisoners with low awareness of safe injecting practices and HCV, and a lack of places in the OST programme. The health services have responded by increasing opportunistic testing, rapid initiation of DAA treatment, heath education and OST access.

Respondent-driven sampling studies

In the aftermath of the HIV outbreak affecting PWID in Luxembourg, the team at the Luxembourg institute of Health in collaboration with an EPIET fellow are conducting a respondent-driven sampling (RDS) study to provide a detailed analysis of risk factors for HIV, HBV and HCV among drug users. The RDS methodology is being used or has been used in other EU countries (i.e. Belgium, Germany, Greece, Hungary, Lithuania, Romania) to monitor at city-level the burden of infectious diseases among PWID and to identify demographic, behavioural and social risk factors. While resource-intensive, these studies provide useful information on drug users who might not be in contact with drug services (for example, the Romanian RDS study found higher HIV and HCV prevalence than estimates from routine treatment centres or NSP). RDS studies can also provide parameters for the estimation of the prevalence of injecting drug use (for example, the Belgian RDS study provided a multiplier for a national estimate).  When done regularly, they are flexible enough to include new research questions (for example, the next Hungarian and Lithuanian RDS studies will include questions on the continuum of HIV and HCV care, and the Hungarian and Romanian study will include a section on the impact of COVID-19).

Continuous monitoring systems in drug services

Germany conducted an RDS study among PWID in 8 cities in 2011-14. The RKI is now piloting a continuous monitoring system for infectious diseases among PWID in Germany (DRUCK 2.0). Pilot data collection will be done in 30 low-threshold harm reduction and OST services in Berlin and Bavaria, among an expected sample size of 700 PWID (ever-injectors). The objective of the monitoring is to estimate the prevalence of HIV, HBV, HCV and syphilis and socio-demographic and behavioural factors among participating PWID. The questionnaire of 40 questions will be administered within routine work and the following infections will be screened for using dried blood spots: HIV (Anti-HIV and HIV-RNA), HBV (HBsAg, Anti-HBc, Anti-HBs, HBV-DNA), HCV (Anti-HCV, HCV-RNA), Syphilis (TPHA, FTA-ABS, VDRL). Different methods of data collection, feedback of test results, language mediation and digital training tools for study staff will be assessed for feasibility and acceptability by study staff and participants. The nationwide roll-out is planned for 2023 and it is envisaged to have additional topical modules in the future (stimulants, TB, migrants).

In the context of the COVID-19 pandemic, the EMCDDA’s DRID network is sharing information on drug-related infectious diseases and monitoring the progress towards the sustainable development goals related to people who inject drugs. Monitoring data, reports, guidance and activities of the DRID network can be found on this page. Experts from the DRID network can access the restricted DRID area for additional material.