HIV/AIDS and viral hepatitis

Surveillance system for HIV infection and new AIDS cases

The estimate of the number of new HIV patients since HIV reporting became mandatory in 2003 was 55,168 on 31 December 2010¹³⁷. Given reporting delays and under-reporting, in 2010 the

136 The definition for fatal overdose is the same throughout all European countries:

http://www.emcdda.europa.eu/publications/methods/drd-overview

137 Data corrected due to delays in reporting and under-reporting.

number of positive notifications was estimated at 6,265, which is slightly lower than the two preceding years (6,341 in 2009 and 6,340 in 2008).

In 2010, people infected through intravenous drug use represented no more than 1.13%

(71/6,265) of these new cases of infection. The most frequent contamination route is heterosexual intercourse (57% of cases) followed by homosexual intercourse between men (40%) (Cazein et al. 2011). It is still too early to assess the impact of the recommendations (generalised screening and repeated screening amongst exposed populations) of the 2010-2014 French national HIV-AIDS and Sexually Transmitted Infection plan on HIV surveillance data. In 2008, the incidence of HIV amongst IDUs was estimated at 86 per 100,000 person-years [95%

CI, 0-192] (Le Vu et al. 2010). (Table 6-1).

Table 6-1: Number of new HIV-1 infections and incidence amongst IDUs in France in 2008 New HIV-1 infections

[95% CI]

Estimated population Incidence per 100,000 person-years [95% CI]

IDUs (all nationalities combined, both genders)

70 [0-190] 81,000 86 [0-192]

Source, InVS, BEH, n°45-46, 2010

The number of new AIDS cases amongst IDUs has fallen continuously since the mid-1990s.

Whereas IDUs represented a quarter of the people diagnosed at the AIDS stage at that time, they represented only slightly fewer than 8% in 2008 and approximately 5% in 2010 (provisional data).

Table 6-2: Number of new AIDS cases amongst IDUs and total number of new cases 2000-2010.

<2003 2004 2005 2006 2007 2008 2009* 2010*

IDUs 12,919 170 127 102 87 82 54 53

Total new AIDS

cases 58,929 1405 1361 1169 1000 1033 919 888

IDU proportion

(%) 21.9 12.1 9.3 8.7 8.7 7.9 5.9 6.0

*: provisional data not yet adjusted for delays in reporting

Source: InVS, “Base de données sida” (AIDS database), (http://www.invs.sante.fr/surveillance/vih-sida/default.htm), consulted on 19 July 2012.

Hepatitis B surveillance system

The number of acute hepatitis B cases reported between 2004 and 2009 was 894; of these 23 cases (2.6%) were related to drug use.

Survey of the prevalence of HIV, HCV and HBV amongst drug users

The prevalance data based on biological samples are only available for 2004 (Coquelicot data) and 2006 (BioPRELUD data) and cannot be easily compared with each other given the significant differences in survey methodology and surveyed populations (see the introduction to

chapter 6). Until now, the evolution of prevalence rates could only be compared using declarative data.

Data based on biological samples

The biological (blood) presence of HIV in users who have injected at least once in their lives as measured in the 2004 Coquelicot survey was 11.3%. Two percent of users wrongly believed that they were HIV negative. The prevalence was the same whether or not the user injected. It is higher in older generations: only 0.3% of drug users under the age of 30 were infected. This prevalence varied widely from city to city: from 1% in Lille (in the North of France) to 31.5% in Marseille (South of France). Nearly all HIV-positive drug users were also HCV-positive (Jauffret-Roustide et al. 2009).

The biological (blood) presence of HCV in the same population was 73.8%. A significant proportion of drug users (27%) wrongly believed that they were seronegative.

Table 6-3: Estimate of the prevalence of HIV and HCV in blood samples from drug users by city taking part in the Coquelicot study, 2004

HIV HCV

% positive Population % positive Population

Bordeaux 5.1 97 70.7 97

Lille 1.5 63 60.3 63

Marseille 33.7 106 73.3 106

Paris 10.8 228 76 228

Strasbourg 4.4 109 64.4 109

All five cities 11.3 603 73.8 603

Source: InVS (Jauffret-Roustide et al. 2009)

According to the BioPRELUD study, the prevalence of HIV infection amongst people encountered in CAARUDs was 8.5% in 2006. The proportion of people who tested positive amongst those who said they were negative was 5.0%.

Table 6-4: Estimated prevalence of HIV infection from saliva samples of CAARUD users who took part in the BioPRELUD survey (by injection status and age group) 2006

Injected at least once during life Injected and/or snorted at least once during life

No Yes

All N = 136 N = 348 N = 467

All N = 484 8.5% 9.6% 8.0% 8.8%

< 25 yrs N = 134 6.0% - 5.6% 6.2%

25 to 34 yrs N = 211 7.1% - 5.5% 7.4%

> 34 yrs N = 139 13% - 13% 13%

Source: PRELUD 2006, Trend / OFDT

Regarding hepatitis C, the BioPRELUD survey in 2006 indicated a prevalence of 32% of all users who accepted to be tested. Amongst IDUs, the estimated prevalence was 42%. The proportion of people who tested positive of those who said they were negative was 8.5%, indicating that people were ignorant of their serological status.

Table 6-5: Estimated prevalence of HCV infection from saliva samples of users frequenting low threshold structures surveyed in the BioPRELUD survey (by injection status and age group)

All Injected at least once during

life Injected and/or snorted at least

once during life

No Yes

Population N=500 N=138 N=362 N=483

All N=500 32 % 7 % 42 % 33 %

< 25 yrs N=138 13 % - 15 % 14 %

25-34 yrs N=214 31 % - 42 % 32 %

> 34 yrs N=148 51 % - 62 % 53 %

Source: PRELUD 2006, Trend / OFDT

As mentioned in the introduction, the prevalence figures obtained from these two surveys were difficult to compare. The data based on the saliva samples probably tended to underestimate prevalence values. Furthermore, users surveyed within the BioPRELUD study were five years younger on average than those surveyed as part of the Coquelicot study. Nevertheless, both studies showed that prevalence values rose sharply with age. The differences between the cities in which the surveys were conducted also explained the differences in prevalence: the absence of Paris and Marseilles in BioPRELUD - cities known for their high prevalence of infectious diseases among drug users – contributes to minimizing prevalence figures in this survey; the heavy weight of users in both of these cities in the Coquelicot study had the reverse effect.

Declarative data

PRELUD data (2003-2006)

The data obtained in the nine PRELUD cities revealed a decline in HIV infection from 2003¹³⁸ (10.2%) to 2006 (6.2%). The reported prevalence of hepatitis C declined from 2003 (43.4%) to 2006 (34%). The decrease is especially marked in people under the age of 25 (from 17.6% in 2003 to 8.4% in 2006).

138 The latest edition of the “Première Ligne” (low threshold) survey in 2003 replaced in 2006 by the PRELUD survey.

For the hepatitis B virus, more than a third of users from urban harm reduction support centres did not know their hepatitis B viral status in 2006, regardless of the users’ age. This virus can be transmitted through needle sharing or sexual intercourse. However, far more people over 34 years of age than under reported being infected (17% compared with 4% of 25- to 34-year-olds and 2.1% of those under 25 years of age). Of those who reported in 2006 that they had been vaccinated, 45% reported having received three vaccine injections, 25% claimed to have been given two and 28% only one.

ENa-CAARUD data

This national survey, which was conducted for the third time in 2010, questioned 2,505 users seen over the span of one week in 112 CAARUDs¹³⁹. In 2010, the majority of drug users underwent one of these screening tests at least once (87.0% underwent HIV screening 83.9%

underwent HCV screening).

Of people who had used drugs intravenously at least once in their life and underwent screening, 7,2% reported being HIV positive in 2010. This percentage was 8.7% in 2006 and 7.7% in 2008.

The data obtained from CAARUD users indicate a decrease in reported HIV seropositivity since the screening rate was stable and the proportion of screening performed less than six months ago increased (44.7% in 2010 vs. 41.8% in 2008 for the entire CAARUD population).

Although the data on hepatitis C was declarative, they also suggest a decline in hepatitis C prevalence amongst drug users (see graph 6.1). This decrease in reported seropositivity is especially marked amongst people under the age of 25 who had injected at least once in their life: declared HCV seropositivity was 22.5% in 2006, 14.3% in 2008 and 8.5% in 2010 for respective populations of 222, 237 and 201 people (Cadet-Taïrou 2012).

However, it should be noted that amongst people who had already injected at least once in their life, 11.9% had never been tested for HIV infection and 11.9% had never been tested for HCV infection.

The vast majority of HIV-positive people (91.8%) consulted at least one physician during the previous 12 months for the disorder in 2010 and 74.6% received treatment over the same period (compared with 68.5% in 2006). Of HCV seropositive subjects, 77.2% consulted a physician during the same period and 36.3% received treatment for this illness (vs. 28% in 2008 and 22.5% in 2006).

Questions on hepatitis B status were introduced into the ENa-CAARUD 2010 study. They demonstrated that users were ignorant of their status. Half (50%) of users stated that they had been vaccinated, but of these, one third were fully vaccinated (three injections, 32.5%), one third had begun the vaccination process (one to two injections, 34.5%) and one third (33%) did not know how many injections they had received. Moreover, 5.3% stated having been infected (whether cured or not) and 23.3% thought they had neither been infected nor been vaccinated.

Finally, 21.4% had no idea what their hepatitis B status was (Cadet-Taïrou 2012).

For HIV as for HCV, since the early 2000s there has been a decline in the reported prevalence of these infections in IDUs (Graph 6-1). This evolution can be explained by different factors: the impact of the different public health measures taken in France, greater accessibility to treatment, greater access to screening and changes in practices by most drug users. Nevertheless, HIV

139 The 2006 survey was on 3,349 users recruited in 114 CAARUDs.

prevalence amongst IDUs in 2010 was definitely below 10%, and that of HCV was at even higher levels, since the reported prevalence seemed to remain clearly below the actual prevalence.

Graph 6-1: Change in the prevalence of hepatitis C virus infection amongst IDUs in France

Sources:

CSSTH: Housed IDUs, reported prevalence

RECAP/CSAPA: IDUs treated in specialised treatment centres, reported prevalence PRELUD/CAARUD: IDUs seen in low-threshold structures (CAARUDs), reported prevalence ENa-CAARUD: IDUs seen in low-threshold structures (CAARUDs), reported prevalence PES: IDUs using an SEP (syringe exchange programme), reported prevalence Coquelicot: IDUs, biological data

BioPRELUD/CAARUD: IDUs seen in low-threshold structures (CAARUDs), biological data DREES/CSAPA: IDUs treated in specialised treatment centres

Note: Injecting drug user (IDU) means a person who has injected at least once in their life.

Psychiatric comorbidities

Almost half of drug users consider that they are in poor psychological health (according to 45%

of those seen in CAARUDs in 2006). This impression increases with age (with 38% of those under 25 years of age reporting this compared to 46% of 25-to 34-year-olds and 49% of those over 35 years of age). Users describe symptoms of depression or anxiety, suicidal impulses and even delusional episodes. More than one out of every five hospitalisations in the last 12 months mentioned by CAARUD users was related to psychiatric problems in 2010 (except for withdrawal, which also represented one out of every five hospitalisations)¹⁴⁰. In women, the percentage of self-reported hospitalisations for psychiatric problems (excluding withdrawal) was 25% (Cadet-Taïrou 2012).

140 Out of the 34.9%, or 854 users who reported having been hospitalised in the last year.

60,4 62,163,1

51 53 57

62,1

63,1 57,6

55,051,7 50,3 49,7

48,5 47,0 46,0 60

52

42 58,4

73,8

47,2

40,0 36,4

42

0 10 20 30 40 50 60 70 80

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

CSSTH DREES/CSAPA RECAP/CSAPA PRELUD/CAARUD

PES Coquelicot (bio) ENa-CAARUD BioPRELUD/CAARUD

%

Dans le document 2012 NATIONAL REPORT (2011 data) TO THE EMCDDA (Page 92-98)