The HIV epidemic is spreading rapidly in some of the new EU countries and their neighbours. Estonia, Latvia, Russia and the Ukraine are among the countries with the fastest growing HIV epidemics in the world. Prevalence rates vary widely in the other new EU countries, and several are still at risk for similar outbreaks. Among the ‘old’ EU countries, some that have so far avoided large HIV epidemics among injecting drug users (IDUs) are now showing signs of increased risk.
Analysis of case reporting data for IDUs suggests that HIV incidence peaked in Estonia and Latvia in 2001, at rates of 991 and 281 cases per million population respectively, being followed by a decline in 2002 to what are still very high rates of 525 and 170 per million per year (Figure 13) (EuroHIV, 2004). Possible reasons for the observed decline are reporting artefacts, saturation of the IDUs at highest risk and/or behaviour change. Of the new EU countries, Estonia (6.2–13 %), Latvia (6.6–14.6 %) and Poland (6.8–9.1 %) reported the highest prevalence in different national samples of IDUs tested in 2001–2003, while in those years local highs of 41 % (out of 964), 22 % (out of 205) and 29.7% (out of 165) were found in these three countries respectively. In Estonia, HIV prevalence data from multiple sources seem to confirm a recent decline in prevalence among tested IDUs (6.2 % in 2002 among 1 186 IDUs sampled at national level, down from 13 % of 2 078 in 2001). In Latvia, national data from drug treatment centres also show declining prevalence in tested IDUs (13.7% in 2001 to 6.6 % in 2003), however, data from other national sources (hospitals and arrests data: 7.8 % in 2000 to 14.6 % in 2002) and local sources (multiple settings in the Riga region and in Tukums: 18.3 % in 2000 to 22.0 % in 2003) suggest a continued increase in prevalence in other samples of tested IDUs. In Lithuania, a large increase in newly reported HIV cases occurred as recently as 2002, due to a major outbreak in a prison; however, prevalence among IDUs remains low (in 2002 and 2003: 1.0 % of 2 831 and 2.4 % of 1 112 IDUs from multiple settings at national level, and 0.6 % of 641 IDUs and 0.4 % of 235 IDUs attending a needle exchange programme in Vilnius respectively). The prison outbreak exemplifies both the urgency of implementing prevention measures in this country and other regions where prevalence among IDUs is still low and the important role that prisons can play in the spread of HIV among IDUs (Dolan, 1997–98; Dolan et al., 2003).
Black square = samples with national coverage; blue triangle = samples with local/regional coverage.
Differences between countries have to be interpreted with caution owing to different types of settings and/or study methods; national sampling strategies vary.
Data for Portugal and Italy include non-IDUs and therefore may underestimate prevalence among IDUs (proportion of non-IDUs in the samples: Italy 5–10 %, Portugal not known). For France, this is the case in some of the samples.
Data for Germany, Italy, Hungary, Portugal and Slovakia are limited to HIV prevalence among IDUs in treatment and may not be representative of HIV prevalence among IDUs who are not in treatment.
Data for Germany and Luxembourg, and part of the data for Belgium and France, are based on self-reported test results, which are less reliable than clinically documented tests.
In Poland, national prevalence data from public health laboratories suggest a decline in prevalence among tested IDUs, from 10.7 % (of 3 106) in 2000 to 6.8 % (of 2 626) in 2002. This decline is consistent with the trend in newly reported cases in IDUs, which declined from a high of 8.6 per million population in 2000 to rates of 5.1 and 6.9 in 2001 and 2002 respectively. Local prevalence data however suggest high prevalence in the region of Pomorskie in 2002 (30 % of 165 IDUs recruited in drug treatment and on the street; 15 % of 69 in the street sample only), although it should be noted that prevalence among IDUs in drug treatment may overestimate prevalence in the IDU population as a whole. In the other new EU countries HIV prevalence among IDUs was still very low in 2000–01, although more recent data are mostly lacking. HIV prevalence was on average less than 1 % in the Czech Republic, Slovenia and Slovakia, similar to the findings in neighbouring EU candidate countries Romania and Bulgaria (EMCDDA, 2003a). Although these countries have so far avoided HIV epidemics among IDUs, increases in injecting drug use may lead to increases in the prevalence of HIV infection and hepatitis in the near future if prevention measures are not sufficient (see section Reducing drug-related infections in this chapter).
In the former 15 EU Member States, the HIV epidemic among IDUs seems mostly to have stabilised or to be in decline according to HIV case reporting data, with rates in 2002 ranging from 1.3 new cases per million population in Greece to 115.7 in Portugal (the latter declining to 88.4 in 2003) (EuroHIV, 2004). However, as national case reporting is not established in the countries with the largest IDU-related epidemics, time trends from case reporting can be misleading at EU level and seroprevalence data from IDUs are an important complement. Available national-level prevalence data suggest great variation between, as well as within, countries: from 0–1 % in Finland (data from needle exchanges) to 9.7–35 % in drug users in different national samples in Spain (2001–2003) (Figure 14). Prevalence in tested IDUs is in general stable or declining (74), although stable prevalence does not mean that transmission is no longer occurring, and in some countries increases in prevalence since the mid-1990s have occurred at local or regional level. In addition, in some areas where rises have previously been reported more recent data are lacking. The increases in prevalence suggest that prevention measures in those areas may be insufficient, even in some areas with long-established epidemics. Ongoing transmission among IDUs in several areas is further evidenced by a high prevalence in young (under 25) and new IDUs (who have been injecting less than two years) (EMCDDA, 2003b) (75). Where HIV prevalence has remained high among IDUs, sustained prevention efforts are important to prevent transmission to new IDUs, sexual partners of IDUs and from mother to child.