Univariable associations between a history of incarceration and HIV and HCV prevalence among people who inject drugs across 17 countries in Europe 2006 to 2020 - is the precautionary principle applicable?

BackgroundPeople who inject drugs (PWID) are frequently incarcerated, which is associated with multiple negative health outcomes.AimWe aimed to estimate the associations between a history of incarceration and prevalence of HIV and HCV infection among PWID in Europe.MethodsAggregate data from PWID recruited in drug services (excluding prison services) or elsewhere in the community were reported by 17 of 30 countries (16 per virus) collaborating in a European drug monitoring system (2006-2020; n = 52,368 HIV+/-; n = 47,268 HCV+/-). Country-specific odds ratios (OR) and prevalence ratios (PR) were calculated from country totals of HIV and HCV antibody status and self-reported life-time incarceration history, and pooled using meta-analyses. Country-specific and overall population attributable risk (PAR) were estimated using pooled PR.ResultsUnivariable HIV OR ranged between 0.73 and 6.37 (median: 2.1; pooled OR: 1.92; 95% CI: 1.52-2.42). Pooled PR was 1.66 (95% CI 1.38-1.98), giving a PAR of 25.8% (95% CI 16.7-34.0). Univariable anti-HCV OR ranged between 1.06 and 5.04 (median: 2.70; pooled OR: 2.51; 95% CI: 2.17-2.91). Pooled PR was 1.42 (95% CI: 1.28-1.58) and PAR 16.7% (95% CI: 11.8-21.7). Subgroup analyses showed differences in the OR for HCV by geographical region, with lower estimates in southern Europe.ConclusionIn univariable analysis, a history of incarceration was associated with positive HIV and HCV serostatus among PWID in Europe. Applying the precautionary principle would suggest finding alternatives to incarceration of PWID and strengthening health and social services in prison and after release ('throughcare').

Recommendations for collection and integration of community-based testing and linkage to care data into national surveillance, monitoring and evaluation systems for HIV, viral hepatitis and sexually transmitted infections: results from the INTEGRATE Joint Action.

BACKGROUND: National testing strategy, including monitoring and evaluation, is critical in responding to HIV, sexually transmitted infections, and viral hepatitis. Community-based voluntary counselling and testing contributes to early HIV diagnoses among key populations. Countries providing community-based testing, should integrate some core data on testing and linkage to care in these services into national surveillance and monitoring and evaluation systems. This study aimed to support the integration of community-based voluntary counselling and testing data into respective national surveillance and M&E systems for those infections. METHODS: Preliminary consensus on indicators for the integration of community-based voluntary counselling and testing data into respective national surveillance and monitoring and evaluation systems was reached. Pilot studies were conducted in Estonia, Poland, Serbia, Slovakia, Slovenia and Spain. After pilot activities were implemented, the final consensus on indicators was reached. An analysis of the facilitators and barriers faced during pilot studies was conducted to inform the final recommendations for implementation. RESULTS: The minimum set of six indicators to be integrated into national surveillance and monitoring and evaluation systems were: number of tests, number of clients tested, reactivity rate for tests and clients, positivity (active infection) rates for tests and clients, linkage to care rates for clients with reactive and/or positive test result, proportion of all new diagnoses in a country with first reactive test result at community-based voluntary counselling and testing service. Seven additional indicators were identified. Each indicator should be disaggregated by key population, sex and age group. A list of 10 recommendations for the collection and integration of community-based voluntary counselling and testing data into national surveillance and monitoring and evaluation systems for HIV, sexually transmitted infections and viral hepatitis was identified. CONCLUSIONS: Integration of some community-based voluntary counselling and testing monitoring and evaluation data into national surveillance and monitoring and evaluation systems in all pilot countries was achieved. The recommendations will support such integration in other European countries. European Centre for Prevention and Control of Diseases included questions from the minimum list of indicators into their Dublin Declaration questionnaire 2020 to contribute to evidence based community testing policies in European countries.

Revealing HIV epidemic dynamics and contrasting responses in two WHO Eastern European countries: insights from modeling and data triangulation.

OBJECTIVES: In the early 2000s, Estonia and Latvia experienced a rapidly growing HIV epidemic among people who inject drugs (PWID), and had, with Russia, the highest diagnosis rates in Europe. Understanding epidemic dynamics in both countries and how responses to HIV impacted them is essential to ending injection-driven epidemics. DESIGN: Statistical modeling, programmatic data collection, and triangulation. METHODS: Data on newly diagnosed HIV cases were used in a back-calculation model to estimate, for each country, trends in HIV incidence, time to diagnosis, and undiagnosed infections. Modeled estimates were then triangulated with programmatic data on harm reduction services, HIV testing, and ART. RESULTS: From 2007 to 2016, HIV incidence decreased in Estonia by 61% overall, for all exposure groups, and particularly for male PWID (97%), except men who have sex with men, where it increased by 418%. In Latvia, it increased by 72% overall. Median time to diagnosis decreased for male PWID in Estonia, from 3.5 to 2.6 years, but not in Latvia. In 2016, most new and undiagnosed infections, ∼50% in Latvia and ∼75% in Estonia, affected individuals reporting heterosexual transmission, showing a gradual shift toward heterosexual route as the main reported exposure mode. Coverage of services had been higher in Estonia; for example, by 2016, for PWID, there were >200 needles and syringes distributed per PWID annually, and HIV testing and ART coverage reached ∼50% and 76%, respectively, in Estonia, against respectively less than 100%, 10% and 27% in Latvia. CONCLUSIONS: Estonia has turned the tide of its epidemic - large scale-up of prevention and care programs probably contributed to it - whereas in Latvia it remains very active.

The fentanyl epidemic in Estonia: factors in its evolution and opportunities for a comprehensive public health response, a scoping review.

BACKGROUND: The spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia. METHODS: this scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data. RESULTS: For an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as "Break the Cycle," to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability. CONCLUSION: Addressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments.

Mortality from suicide among people living with HIV and the general Swiss population: 1988-2017.

INTRODUCTION: In many countries, mortality due to suicide is higher among people living with HIV than in the general population. We aimed to analyse trends in suicide mortality before and after the introduction of triple combination antiretroviral therapy (cART), and to identify risk factors associated with death from suicide in Switzerland. METHODS: We analysed data from the Swiss HIV Cohort Study from the pre-cART (1988-1995), earlier cART (1996-2008) and later cART (2009-2017) eras. We used multivariable Cox regression to assess risk factors for death due to suicide in the ART era and computed standardized mortality ratios (SMRs) to compare mortality rates due to suicide among persons living with HIV with the general population living in Switzerland, using data from the Swiss National Cohort. RESULTS AND DISCUSSION: We included 20,136 persons living with HIV, of whom 204 (1.0%) died by suicide. In men, SMRs for suicide declined from 12.9 (95% CI 10.4-16.0) in the pre-cART era to 2.4 (95% CI 1.2-5.1) in the earlier cART and 3.1 (95% CI 2.3-4.3) in the later cART era. In women, the corresponding ratios declined from 14.2 (95% CI 7.9-25.7) to 10.2 (3.8-27.1) and to 3.3 (95% CI 1.5-7.4). Factors associated with death due to suicide included gender (adjusted hazard ratio 0.58 (95% CI 0.38-0.87) comparing women with men), nationality (1.95 (95% CI 1.34-2.83) comparing Swiss with other), Centers for Disease Control and Prevention clinical stage (0.33 (95% CI 0.24-0.46) comparing stage A with C), transmission group (2.64 (95% CI 1.71-4.09) for injection drug use and 2.10 (95% CI 1.36-3.24) for sex between men compared to other), and mental health (2.32 (95% CI 1.71-3.14) for a history of psychiatric treatment vs. no history). There was no association with age. CONCLUSIONS: Suicide rates have decreased substantially among people living with HIV in the last three decades but have remained about three times higher than in the general population since the introduction of cART. Continued emphasis on suicide prevention among men and women living with HIV is important.

Changes in patterns of retention in HIV care and antiretroviral treatment in Tanzania between 2008 and 2016: an analysis of routinely collected national programme data.

BACKGROUND: Tanzania is a high HIV burden country in Sub-Saharan Africa with 1.5 million people infected. Unless monitored and responded to, low levels of retention in care may lead to poor HIV associated clinical outcomes and an increased likelihood of onward viral transmission. Using routine data, we assessed changes in retention in care and on treatment for HIV over time in Tanzanian facilities, using the national care and treatment programme (CTC) database. METHODS: Data were extracted from the CTC database and analysed using two approaches: a series of cross-sectional analyses for each calendar year between 2008 and 2016 to assess the changing characteristics of the population in care and on treatment, and, a longitudinal analysis using survival analysis methods for a series of cohorts representing i) all engaging in care and ii) all initiating treatment in each calendar year from 2008 to 2015. Multivariate analyses were carried out to explore the independent effect of calendar year when controlling for other factors. RESULTS: The total number of individuals enrolled in care increased from 160 268 in 2008 to 548 296 in 2016. The percentage of the in-care population enrolled for more than 3 years increased from 9.9% in 2008 to 54.5% in 2016. The overall rates of retention in care were 80.9%, 57.3% and 45.4% at 12, 24 and 36 months respectively. The rates of retention on antiretroviral therapy (ART) ART at 12, 24 and 36 months after treatment-initiation were 83.9%, 64.0% and 53.5%. There were small but statistically significant differences in the retention rates between cohorts and evidence for a significant decrease in the rates of retention in the most recent years analysed. CONCLUSIONS: Data from Tanzania show that while the number of People Living with HIV (PLHIV) who were in care and monitored through the routine data system increased over time, the retention rates in care and treatment remained relatively stable. These rates were similar to other regional estimates. Systematic reviews of tracing studies indicate that mortality among those lost to follow up has decreased over time, partly underpinned by an increase in the numbers transferring between clinics. True retention rates may therefore be higher than we report here, and this underpins the need for data systems that can track patients between clinics.

Missed opportunities for HIV testing in people diagnosed with HIV, Estonia, 2014 to 2015.

Background: Studies of missed opportunities for earlier diagnosis of HIV have shown that patients with undiagnosed HIV often present to healthcare settings numerous times before eventually receiving their diagnosis. Aim: The aim of the study was to assess missed opportunities for HIV testing among people newly diagnosed with HIV. Methods: In this observational retrospective study, we collected data from the Estonian Health Board on new HIV cases in people aged 16­49 years diagnosed in 2014­15 and from the Estonian Health Insurance Fund database for treatment invoices on their contacts with healthcare services in the 2 years preceding diagnosis. Diagnoses on treatment invoices were categorised as HIV indicator conditions using ICD-10 codes. Results: Of 538 newly diagnosed HIV cases (62.5%; 336 men), 82% had visited healthcare services at least once during the 2 years before HIV diagnosis; the mean number of visits was 9.1. Of these, 16% had been tested for HIV and 31% had at least one ICD-10 code for an HIV indicator condition on at least one of their treatment invoices. In 390 cases of HIV indicator conditions, only 5% were tested for HIV. Of all new HIV cases aged 20­49 years from high-incidence regions (defined as priority groups in national testing guidance), 18% had been tested. Conclusions: The HIV testing rate in the 2 years before an HIV diagnosis was very low, even in the presence of an HIV indicator condition. This emphasises the importance of implementing the Estonian HIV testing guidelines.

Effects of Counselling on Adherence to Antiretroviral Treatment Among People with HIV in Estonia: A Randomized Controlled Trial.

To assess the efficacy of an education- and strengths-based counselling programme to promote antiretroviral therapy (ART) adherence in a cohort of HIV-infected individuals with high prevalence of injection drug use in Estonia. Parallel-group randomized (1:1) controlled trial (RCT). Adults receiving ART in two clinics were followed for 12 months. The trial compared: (i) an intervention (three sessions) incorporated into routine clinic visits, providing education about HIV, ART, the role of adherence, and tailoring regimen to daily routines using problem-solving skills to address adherence barriers versus (ii) usual care (control). Primary and secondary outcomes were self-reported ART adherence (3-day recall) and viral load (respectively). 519 patients were randomized and 82% completed the study. Recent optimal ART adherence (3-day recall ≥95%) was reported by 75.6% in the intervention group and 72.9% of controls at baseline and 76.7% and 67.5%, respectively, at 12 months (RR 1.14, 95% CI 1.00-1.28; adjusted RR 1.13, 95% CI 1.00-1.27). There was no difference in the proportion of patients with undetectable viral load. At 12 months the intervention group reported significantly higher perceptions of ART necessity versus ART concerns [mean ART necessity-concerns differential: intervention group 1.32 (SD 1.22) vs control group 1.08 (SD 1.12); p = 0.048]. All-cause mortality among study participants was 27.7 per 1000 person years (95% CI 15.6-44.8). A brief, clinic-based adherence intervention alone may assist with adherence but lacks impact on viral load at 12 months.

Suicidal Behavior Among People Living with HIV (PLHIV) in Medical Care in Estonia and Factors Associated with Receiving Psychological Treatment.

People living with HIV (PLHIV) have higher rates of suicidal behavior than the general population. This study assessed suicidal behavior (ideation and/or attempts, ever and in the past 12 months) among PLHIV receiving outpatient HIV medical care in Estonia and associations between suicidal behavior and psychological treatment. The cross-sectional study collected data from January to November 2013 using a self-report questionnaire. Eight hundred PLHIV participated, 39 % (n = 306) of whom had been suicidal. Lifetime prevalence was 36 % for suicidal ideation and 20 % for attempts. Younger age, incarceration, having ever abused alcohol and also injected drugs, having lived with HIV for more than 10 years, and being depressed were associated with lifetime suicidal behavior. Suicidal behavior within the past 12 months was reported by 20 % (n = 156) of respondents. Of these, 27 % received psychological treatment (counseling and/or psychotherapy), 20 % had taken antidepressants, and 49 % sedatives. Individuals perceiving a need for treatment were significantly more likely to receive psychological treatment when experiencing suicidal behavior (OR 25.65, 95 % CI 2.92-225.47). In conclusion, suicidal behavior is frequent among PLHIV but psychological treatment is not often received. One of the barriers to treatment is patients' lack of perceived need for help.