HIV Risk

assessment: Greece

Anastasios Fotiou

for the Greek Reitox focal point of the EMCDDA at the University Mental Health Research Institute, Athens, Greece

DR

ID m

eeti

ng

Comment: Data from the first 8 months into 2013 project a levelling-off or a decrease in

the number of HIV cases involving PWID compared to 2012

Number of

HIV cases604 962

59%a

1180

23%a

615

-27%a

784

Number of

HIV+ PWID15 260

1600%a

522

100%a

188

-81%a

341

%PWID 2.5 27.0 44.2 30.6 43.5

a Percentage change compared to previous year

Source: HIV Office-Hellenic CDCP (KEELPNO)

Jan-Aug.

'12

Jan-Aug.

'132010 2011 2012

Epidemiological

updatePWID in HIV+ notifications National surveillance system (KEELPNO)

Epidemiological

updateHIV+ in PWID accessing treatment routine testing; national samples

Comment: Sharp increases in HIV prevalence among PWID in ‘11 and ‘12―high prevalence

continued through ’13 but shows signs of levelling-off or even decrease. Figures may

overestimate prevalence as they include PWID tested positive and linked to treatment.

Epidemiological

updateHIV+ in PWID samples routine testing; community samples

Comment: HIV prevalence among PWID accessing treatment varies between settings.

Higher prevalence observed in hard-to-reach populations (community samples) suggesting

the need for implementing indicated interventions.

Comment: The epidemic

is restricted in Athens, it

affects mainly ‘mature’

male opiate users, and it

is associated with high-

risk injecting behaviour

2012: All HIV+ (n=187) n %

Male 148 79.1

<25 9 4.8

25-34 112 59.9

>34 66 35.3

Athens 175 93.6

Past treatments 101 65.2

≥2 years inj. history 171 91.9

Opioids 178 95.2

Cocaine (also) 11 7.2

Shared inj. equip. 133 88.1

Anti-HCV+ 145 96.7

Epidemiological

updateCharacteristics of HIV+ PWID routine testing

Comment:

Significant

increases

between 2011

and 2012 only

among ‘new’

injectors.

Observed

trends should

be treated with

caution due to

small sample

sizes.

Epidemiological

update

HIV+ in young (<25) and in ‘new’

(<2y inj.) PWID | National1 source; routine testing

Epidemiological

update

HIV+ in young (<25) and

‘new’ (<2y inj.) PWID | Athens1 source; routine testing

Comment:

Significant

increases

between ‘10

and ‘12 but not

between ’11

and ‘12.

High HIV

prevalence

among young

users should be

treated with

caution due to

small sample

sizes.

Interventions Self-assessing preventive

intervention situation (I)

Key Intervention STRENGTHS WEAKNESSES

INJECTION EQUIPMENT?

Provision and legal access

YES Sharp increases in the number

of syringes distributed; a newly

set up safe injecting facility in

Athens; expansion of sites

Limited coverage; restricted in

Athens; resource dependent; no

involvment of pharmacies

VACCINATION?

HBV, HAV, tetanus etc.

YES

(HBV)

Low levels of vacination among

PWID (~25% of those entering

treatment, with increasing trend)

DRUG DEPENDENCE

TREATMENT?

OST; drug free; detox

YES Sharp scaling up of OST;

availability of slots in drug-free

settings

Long and waiting lists for entering

OST in Athens; limited resources

TESTING?

HIV,HCV,HBV, TB etc

YES ~100% coverage among those

entering treatment

No consistent testing among those

already in treatment; low coverage

for hard-to-reach PWID

INFECTIOUS DISEASE

TREATMENT?

HIV, HCV, HBV, TB etc

YES free of charge (?) Lack of capacity; resource

dependent; cases of discriminatory

practicies against PWID; no easy

access for undocumented patients

Comment: Almost 3.5 times more syringes were distributed in 2012 compared to 2011,

resulting to a notable increase in NSP coverage. However, the average number of syringes

(n=53) available to every IDU in the country (n=7651 in 2012) is below international standards.

N=132 in Athens given that all interventions are implemented in the capital city.

Interventions NSP coverage

29782 3480964958 55109 68579 61516

119397

404124

3 4 7 7 6 715

53

0

20

40

60

80

100

120

140

160

180

200

0

60,000

120,000

180,000

240,000

300,000

360,000

420,000

2005 (9416)

2006 (9729)

2007 (9916)

2008 (8148)

2009 (10658)

2010 (61516)

2011 (7847)

2012 (7651)

Syri

ng

es p

er

cu

rre

nt in

jecto

r, N

Syri

ng

es d

istr

ibu

ted

/exch

an

ge

d, N

Number of syringes exchanged/distributed

NSP coverage (syringes per current injector per year)

Source: REITOX Focal Point of the EMCDDA - Greece.

Interventions Self-assessing preventive

intervention situation (I)

Key Intervention STRENGTHS WEAKNESSES

INJECTION EQUIPMENT?

Provision and legal access

YES Sharp increases in the number

of syringes distributed; a newly

set up safe injecting facility in

Athens; expansion of sites

Limited coverage; restricted in

Athens; resource dependent; no

involvment of pharmacies

VACCINATION?

HBV, HAV, tetanus etc.

YES

(HBV)

Low levels of vacination among

PWID (~25% of those entering

treatment, with increasing trend)

DRUG DEPENDENCE

TREATMENT?

OST; drug free; detox

YES Sharp scaling up of OST;

availability of slots in drug-free

settings

Long and waiting lists for entering

OST in Athens; limited resources

TESTING?

HIV,HCV,HBV, TB etc

YES ~100% coverage among those

entering treatment

No consistent testing among those

already in treatment; low coverage

for hard-to-reach PWID

INFECTIOUS DISEASE

TREATMENT?

HIV, HCV, HBV, TB etc

YES free of charge (?) Lack of capacity; resource

dependent; cases of discriminatory

practicies against PWID; no easy

access for undocumented patients

Comment: OST coverage has increased substantially during the last 2 years-especially

between 2011 and 2012 owing to the massive scaling-up of OST services. Almost one in

every 2 problem users (n=20429 in 2012) would be able to enter OST in Greece in 2012.

Interventions OST coverage

3596 3950

5045 5360

62646783

9821

19 2025 22

2833

48

0

10

20

30

40

50

60

70

80

90

100

0

2,000

4,000

6,000

8,000

10,000

2005 (19151)

2006 (20146)

2007 (20516)

2008 (20181)

2009 (24097)

2010 (22515)

2011 (20473)

2012 (20429)

Co

ve

rag

e, %

Nu

mb

er

of

pe

rso

ns r

ece

ivin

g O

ST

, N

Number of persons receiving OST

OST coverage (% of estimated PDU who receive OST)

Source: REITOX Focal Point of the EMCDDA - Greece.

Interventions Self-assessing preventive

intervention situation (I)

Key Intervention STRENGTHS WEAKNESSES

INJECTION EQUIPMENT?

Provision and legal access

YES Sharp increases in the number

of syringes distributed; a newly

set up safe injecting facility in

Athens; expansion of sites

Limited coverage; restricted in

Athens; resource dependent; no

involvment of pharmacies

VACCINATION?

HBV, HAV, tetanus etc.

YES

(HBV)

Low levels of vacination among

PWID (~25% of those entering

treatment, with increasing trend)

DRUG DEPENDENCE

TREATMENT?

OST; drug free; detox

YES Sharp scaling up of OST;

availability of slots in drug-free

settings

Long and waiting lists for entering

OST in Athens; limited resources

TESTING?

HIV,HCV,HBV, TB etc

YES ~100% coverage among those

entering treatment

No consistent testing among those

already in treatment; low coverage

for hard-to-reach PWID

INFECTIOUS DISEASE

TREATMENT?

HIV, HCV, HBV, TB etc

YES free of charge (?) Lack of capacity; resource

dependent; cases of discriminatory

practicies against PWID; no easy

access for undocumented patients

Interventions Self-assessing preventive

intervention situation (II)

Key Intervention STRENGTHS WEAKNESSES

HEALTH PROMOTION

safer injecting behaviour; sexual

health, etc

YES Relatively easy access

to drug scenes;

mobilisation and active

involvement of NGOs

Only in Athens; no

evaluation

TARGETED DELIVERY OF SERVICES

organised and delivered according

to user needs and local conditions

PARTLY Focus in Athens No needs assessment

IMPLEMENTED IN COMBINATION? YES Small geographical area

for implementation;

small number of

organisations

Resource dependent;

capacity dependent;

limited cooperation

between organisations

ExpenditureOST and harm reduction

expenditure (in million Euros)

ExpenditureOST and harm reduction

expenditure (in million Euros)

…almost 6 times

more clients in

OST than in

drug-free

Similar number

of units, and…

… similar

number of

treatment staff,

but…

Expenditure A case of (dis)proportionality1

About 20million Euros

state funding/year for each one of the these two types of treatment

Expenditure A case of (dis)proportionality2

Headline points

1. HIV case reporting in PWID shows signs of levelling off in 2013

compared to 2012—national prevalence ranges between 5% and

8% (higher in Athens and in community samples)

2. Significant scaling-up in OST and NSP services have resulted in

improved coverage but the latter still falls short of recommended

standards, i.e., >50% OST coverage with no waiting time for entry

and >200 syringes/IDU/year

3. Resources have been disproportionally distributed given the

needs (i.e., demand for OST, ongoing HIV epidemic in Athens)

4. Reductions in public spending threaten the sustainability of the

existing services and austerity measures the morale of the

personnel and thereby the quality of services―interventions

sustained primarily by EU funds

Thank you for your attention

Special thanks to data providers and to Manina Terzidou, Argyro Andaraki, Lia Malettou, Ioanna Siamou, Sonia Papadopoulou,

Clive Richardson and Ioulia Bafi at the Greek REITOX Focal Point for their early work on some of the data presented here.