The highest rates of AIDS incidence related to injecting drug use are found in Latvia, with 23.8 cases per million population (down from 29.8 cases in 2010) and Estonia with 14.9 cases (up from 10.4 cases in 2010). Relatively high rates are also reported for Spain (6.5 cases) and Portugal (5.0 cases) – however, the data suggests a clear downward trend for both countries. In addition, six countries have a rate of between two and three cases per million population (Bulgaria, Switzerland [EMCDDA, 2013a]), Ireland, Italy, Lithuania, and Luxembourg], whereas ten countries report an incidence rate of less than 0.5 per million population (Belgium, the Czech Republic, Germany, Greece, the Netherlands, Finland, Sweden, the United Kingdom, Croatia and Norway) (EMCDDA, 2013a).
New psychoactive substances (NPS) have contributed to the increased risk of HIV and hepatitis transmission in several European countries, particularly in Hungary and Romania, where a significant share of heroin and amphetamine users have turned to injecting NPS. Since these substances may be injected more frequently (for example compared to heroin) this can result in an increased likelihood of sharing injection equipment (Harm Reduction International, 2012).
Viral Hepatitis: HCV and HBV
In contrast to relative low HIV prevalence rates among drug injectors in recent years, levels of viral hepatitis, in particular hepatitis C (HCV) remain disproportionately high among drug users in Europe with hepatitis C virus (HCV) being the most common infectious disease among those who inject.
Recent data available for 17 European countries indicate that the vast majority of hepatitis C infections are linked to injecting drug use. On average drug injection accounted for 58% of all HCV cases and for 41% of the acute diagnoses where the transmission route is known (EMCDDA, 2013c). In five countries (the Czech Republic, Germany, Hungary, Slovakia and Sweden) between approximately two thirds and three quarters of HCV cases are associated with drug injection, four countries (Denmark, Ireland, Finland and Norway) report proportions of more than 80% and five countries (Estonia, Lithuania, Malta, Luxembourg, the United Kingdom) of more than 90%. Low proportions, in comparison, are found in Latvia (29%-‐39%), Poland (7%-‐14%) and in particular in the Netherlands (2%) (EMCDDA, 2013a).
The extent to which Hepatitis C affects injecting drug users varies considerably across the countries. Of the 11 countries with recent national estimates (2010 or 2011) of HCV antibodies among injecting drug users, Norway, Greece, Italy and Portugal5 report the highest levels of more than 60%. Prevalence rates of more than 40% are found in Cyprus, Croatia and the United Kingdom, whereas Malta and Austria6 report a HCV infection rate of more than 30%. Slightly lower levels are found in Slovenia (28.5%), Hungary (24%) and the Czech Republic (18%). An additional eight countries reported sub-‐national data, with HCV prevalence among drug injectors ranging from 40% in Slovakia to more than 80% in Belgium7 and Latvia8 (Estonia: 76%, Bulgaria: 69%, Sweden: 56%, Germany: 56%-‐72%, the Netherlands: 50%-‐67%) (EMCDDA, 2013a). Trend data available for 13 countries for the period 2006-‐2011 show increasing rates of HCV infections among injecting drug users at a national level in Greece and Cyprus, whereas a downward trend can be seen in Italy, Portugal and Norway (EMCDDA, 2013a).
Data on the prevalence of hepatitis C among drug injectors aged under 25 years indicate an increase in Bulgaria, Greece, Cyprus and Austria, while there is no national data pointing to a decline of HCV in this cohort (EMCDDA, 2013a). In addition, increasing rates of HCV infections are found among new drug injectors (injecting less than two years) in Greece (EMCDDA, 2013a).
Data on the prevalence of HCV among drug injecting prisoners are rarely available and if so, the information is rather outdated. National or sub-‐national studies conducted in the 2000s show a wide range of HCV infection from as low as 11.5% (Hungary) to as high as 91% (Luxembourg). Of the other seven countries where data is available, Sweden reports HCV levels of up to 80%, Germany (Radun, 2007, September 13) and the Czech Republic of more than 50% and Croatia of more than 40%. Lower rates, of about a fifth to a quarter are found in Bulgaria, Finland and Belgium (EMCDDA, 2010b).
The high HCV prevalence among injecting drug users is likely to result in considerable numbers of deaths over time due to liver disease. It is estimated that about three quarters of those infected will go on to develop chronic infections. Of these, around 7% will develop cirrhosis within 20 years of exposure to the virus. Among those who develop cirrhosis, every year an
5 In Portugal data are available from two different studies with considerably varying estimates of 36.5% and 79.9%. 6 In Austria the reported HCV prevalence ranges from 34.2% to 48.5%.
7 For Belgium estimates of 42.3% to 81.5% are reported. 8 For Latvia estimates of 50% to 81.5% are reported.
estimated 4% will suffer from liver failure and 2% will develop liver cancer. Research further suggests that many drug users are unaware of their infection (EMCDDA, 2011a).
Regarding the epidemiology of hepatitis B virus (HBV) it is estimated that injecting drug users account for 7% of all diagnoses and for 15% of acute diagnoses recorded (EMCDDA, 2013c). Of the 16 countries with recent data, four (Malta, Finland, the Netherlands and the United Kingdom) report proportions of less than 1% of HBV transmissions attributable to injecting drug use and two countries (Denmark and Poland) of less than 10%. In an additional six countries (Slovakia, Germany, Latvia, Norway, Sweden, and the Czech Republic) injecting drug use accounts for less than a fifth to about a quarter of HBV infections, whereas in Hungary the proportion is estimated at a third. Very high percentage rates of HBV infections related to drug injection are found in Estonia (56%-‐69%), Luxembourg (86%) and Lithuania (100%). Increasing proportions of hepatitis B cases attributed to injecting drug use are reported for Hungary and Norway, whereas a decline can be seen in Sweden and the United Kingdom (EMCDDA, 2013a).
The proportion of injecting drug users infected with HBV (with HBsAg, the surface antigen of the hepatitis B virus indicating a current infection) varies profoundly across European countries, although the prevalence rates are generally much lower than for hepatitis C. Of the eleven countries providing national or sub-‐national data in 2010/2011 regarding the Hepatitis B prevalence among injecting drug users, four countries report levels of less than 2% (Germany, Norway, Cyprus and Hungary) and five countries of less than 5% (Belgium, Bulgaria, Greece, Croatia and Portugal). The highest HBV prevalence levels among injecting drug users of about 6% are found in Austria and Latvia. Trend data available for eight countries show decreasing levels of HBV infections in Bulgaria, Cyprus and to some extent in Greece and Portugal in recent years. Stable rates are reported for Belgium, Hungary, Austria and Norway, while no country has seen a significant increase in HBV infections among injecting drug users over the last years (EMCDDA, 2013a).
Cohort studies among problem drug users suggest that 5% to 10% may die because of viral hepatitis, though it often remains unclear whether these deaths caused by liver disease are related to viral hepatitis or to heavy alcohol use. In a Scottish study among young injecting drug users, for example, problematic alcohol use seemed to have played a larger role in liver-‐ related morbidity and mortality than HCV infections (McDonald et al., 2011). In an Australian study among older problem drug users, however, deaths caused by viral hepatitis were found to be twice as frequent as deaths due to alcoholic liver disease (Gibson, Randall, &
Degenhardt, 2011). These different findings may suggest that infected drug users often survive long enough to experience harms from this slowly developing liver condition (EMCDDA, 2011a). Furthermore, the interaction between viral hepatitis and alcohol use has to be taken into account since heavy alcohol use worsens liver disease originally caused by viral hepatitis (EMCDDA, 2013c).
Other Infectious Diseases
Although far less prevalent than HBV, HCV and HIV, drug users are at risk for other infectious diseases that carry a risk of death including other types of hepatitis viruses (e.g. A, D), sexually transmitted infections, tetanus, and endocarditis. Deaths among injecting drug users due to anthrax infections, most likely caused by contaminated heroin, have been recorded in Europe in recent years. The first case was reported from Norway in 2000, followed by an outbreak in 2009/2010 with 52 confirmed cases and 17 deaths in Scotland, five cases in England and three cases in Germany. Recently (between June 2012 and March 2013) 15 drug-‐related anthrax cases were reported in Germany, France, Denmark and United Kingdom, of which seven resulted in fatalities (EMCDDA, 2013c; Grunow et al., 2013). Available data on the prevalence of active tuberculosis among drug users in treatment show variations from 0% (in Austria and Slovakia) to 3.1% in Lithuania (Greece: 0-‐0.5%, Portugal: 0.1-‐1%). In four countries where information on the transmission route of new tuberculosis cases is available, Hungary reported the lowest proportion of (injecting) drug use (0.9%), followed by Belgium (1.2%), the United Kingdom/Wales and England (3.3%) and Latvia (5.9%). Furthermore, research suggests people infected with HIV have a 20-‐ to 30-‐fold greater risk for developing tuberculosis (EMCDDA, 2012).