Asientos para registrar cuentas de materia prima

Screening of drug users in drug treatment on infectious diseases is increasingly part of routine care but test results are only available for a few treatment centres. Note that recruitment site can influence the prevalence point estimates. It has been shown that, among others in the Netherlands, HCV prevalence is significantly higher in IDUs recruited in drug treatment centres, compared with low threshold services and other settings (Rondy et al. 2012).

HIV Monitoring Foundation. A rather substantial data source on hepatitis infections in (former) IDUs is the database of the national HIV/ AIDS registration of the HIV Monitoring Foundation (SHM). In total 19,417 HIV-infected patients were tested for a co-infection with HBV and 18,718 for a co-infection with HCV (Van Sighem et al. 2013). In this cohort, chronic active HBV co-infection was found in 8% of HIV patients and 24% were successfully

vaccinated (anti-HBc-negative and anti HBs positive). The prevalence HCV antibody / HCV RNA positives was 12%. Of those with a known HCV RNA testresult, 20% cleared the virus spontaneously.

 13.9% of the tested injecting drug users were HBsAg positive, which is higher than in MSM (9.0%) and heterosexuals (8.3%) (Van Sighem et al. 2013).

 The vaccination rate (anti-HBc-negative and anti HBs positive) in (former) injecting drug users (7%) was much lower than in MSM (28%) and heterosexuals (20%) (Van Sighem et al. 2013).

 (Former) injecting drug users were heavily affected by HCV infections. The prevalence of chronic active HCV ranged from 54-61% between 1998 and 2012. In MSM, the

prevalence of chronic HCV infections was 4% in 1998, increased to 6% in 2005 and 2006 and dropped again to 4% in 2012.

 In contrast, the incidence of acute HCV-infections was low for injecting drug users (overall 0.4/1000 person years, 95% CI 0.01-2.22), compared with MSM (0.47 diagnoses/ 1000 person years in 2003, which increased to 4.5/ 1000 person years in 2011). The high background prevalence of HCV infections in drug users may explain these differences (Van Sighem et al. 2013). Overall, the treatment outcome (as a sustained virological response) of the 421 patients treated with peginterferon and ribaverin for a chronic hepatitis C virus infection ranged from 14% for patients with an unknown virus genotype to 42% of patients with virus genotype 3 (genotype 1: 22%; genotype 2: 30%; genotype 4: 35%) (Van Sighem et al. 2013).

The Public Health Service of Amsterdam (GGD Amsterdam) collects information on hepatitis B and C infections in methadone clients participating in low threshold services. Patients are tested exhaustive, but not every year. A selection bias in those being tested might be the case, e.g., because testing is voluntary and mostly patients are tested with unknown test result (see also 6.2.1) (personal communication M. de Wit, GGD Amsterdam). Data on HBV for 2013 are not available The HCV prevalence data of GGD Amsterdam are also presented in ST09 part 2.

 HCV antibodies were detected in 11 of 28 (39%) tested ever injecting drug users, 6 females and 5 males; they were all aged 34 years or over (source: M. de Wit, GGD Amsterdam).

67 The open and ongoing Amsterdam Cohort Studies (ACS) among drug users (see above) focuses among others on hepatitis C. The study generates a wealth of information, which is also described in the previous National Reports and in § 7.3.

 The HCV incidence has strongly declined in the last years, both in ever-injectors and in never-injectors. Since 2005, the incidence rate is 0.35 cases/ 100 person years (Grady et al 2012).

 However, the HCV prevalence is substantial. The modelled prevalence of chronic HCV infection in (ever) injecting drug users in Amsterdam (n=4353) is 80,7% (Matser et al. 2011).

 In the ACS, all cause and cause-specific standardized mortality ratios were calculated stratified and HCV and HCV status (Van Santen et al, 2014). The overall all-cause mortality was found to be 13.9 (95% CI 12.6-15.3). The all-cause mortality among drug users declined after 1996, compared with general population rates, which seems to be attributable to a decline in mortality among women. The highest standardized mortality ratios were found for drug users with an HCV/HIV co-infection (61.9; 95% CI 50.4-76.0). Mortality rates due to non-natural deaths also declined significantly (p=0.007) and became closer to those of the general population, although HIV-related mortality remained high compared to the general Dutch population. There were no statistically significant changes in the standardized mortality ratios for HCV monoinfected and HIV or HCV uninfected drug users (Van Santen et al, 2014).

 The study also showed that male sex, IL28B CC genotypes and BMI were independently associated with higher average HCV RNA levels, even after a median follow-up time of 10.8 years after seroconversion (Grady et al., 2014). This information contributes to the existing knowledge on the natural history of HCV infection and could play a role in clinical decision-making.

 The Dutch C (Drug Users Treatment for Chronic Hepatitis C) study takes place in the ACS drug users cohort with the aim to evaluate the possibility of HCV testing and treatment combined with methadone programmes (Van Sighem et al, 2013). The projet offers HCV screening and, for drug users who are chronically infected, medical and psychiatric screening and HCV treatment. Since various specialists cooperate, optimal care is provided. Almost 60% of drug users tested positive for HCV antibodies, and 64% of them were positive for HCV-RNA. Of 57 chronically infected drug users that started treatment and had sufficient follow-up after a treatment stop in 2010, 37 (65%) achieved a sustained virological response. Based on the initial success of the project, it was decided in 2007 to also include drug users not participating in the ACS. A total of 88 drug users from the ACS and from methadone clinics in Amsterdam were treated for HCV by the end of 2011. The first active drug user chronically infected with HCV genotype 1 started treatment with telaprevir combined with peginterferon and ribaverin at the public health service Amsterdam in 2012. Treatment and datacollection is still ongoing (Van Sighem et al, 2013).

 Methadone treatment in drug users with hepatitis C infection was found to be associated with common bile duct dilatation (Leopold et al., 2014). Almost a quarter of the studied 222 hepatitits C virus-infected drug users was found to have dilatation of the common bile duct, which was associated with current methadone use but not with regular heroin use. The authors concluded that dilatation of the common bile duct is likely to be a harmless side effect of opioid agonists.

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6.2.4 Sexually transmitted infections (STIs)

In total 26 low-threshold STI centres, mostly within the public health services, provide free- of-charge STI/HIV testing and care, targeted at several high risk groups (Van Aar et al., 2014). Although injecting drug use is not among the 8 formulated criteria for high risk, data are available for ever and past 6 months injecting drug use. The reporting of this national STI surveillance system has been organised in eight regions since 2006 and is coordinated by the RIVM.

 In 2013, 133,585 new STI consultations were registered, an increase of 10% compared to 2012. However,the proportion of positive tests declined, from 15.1 to 14.7%. Ever injecting drug use was reported by only 308 cases (102 women; 94 heterosexual men; 112 homosexual men). Another 140 persons indicated they had injected drugs in the past 6 months (35 women; 28 heterosexual men; 77 homosexual men).

 The STI test result in women reporting ever injecting drug use was positive in 13% of cases, in ever injecting drug using heterosexual men in almost 15% of cases and in MSM with ever IDU 27%.

In Amsterdam, the Amsterdam Cohort Studies (ACS, see above) has monitored STIs among their participants since the start of the study in 1986. Although in the first years of the study STIs were found in up to 10% of participants, reports of STI have remained relatively stable at around 3% in recent years (Van Sighem et al. 2013).

6.2.5 Risk behavior

The latest figures from the addiction care show that injecting drug use is still decreasing. Although 40% of opiate users who are client at an addiction care institute ever injected, last year injecting dropped to just above 8% and last month injecting was less than 8% in 2013 (Wisselink et al., 2014).

The ACS has been monitoring risk behavior among drug users in the past 28 years.  In HIV-negative drug users, injecting and borrowing of needles significantly declined

between 1985 and 2012 (van Sighem et al 2013). While more than 55% of drug users visiting the ACS in 1986 reported injecting, this declined to around 10% in 2012. In line with that, use of needle exchange also decreased to less than 10% and borrowing was reduced to virtually zero.

 Reports of high sexual risk behaviour decreased before 1996, remained relatively stable until 2005 and further decreased to approximately 24% (of drug users visiting the ACS) in 2012 (van Sighem et al. 2013).

 In an analysis of injecting behavior data, five distinct longitundinal trajectories of injecting were identified (Mikolajczyk et al, 2014). The majority of patients (69%) had stable risk injecting behavior, the others displayed a decrease in injecting over time. The patterns were related to sociodemographic and drug use variables and are reflected in the incidence of HIV infections. Those with longer duration of injecting at cohort entry and those who entered the cohort in earlier years tended to have continuing high risk behavior.

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6.3 Other drug-related health correlates and consequences

In this paragraph new data are presented on drug-related emergencies (§ 6.3.1), and psychiatric comorbidity (§ 6.3.2).

6.3.1 Drug-related emergencies

Like last year, this report restricts itself to one source for trend data on drug-related emergencies, being the Monitor drug-related emergencies, which collects information in a selected number of regions. The ambulance transportation data in Amsterdam, providing trends since many years, has been unable to report data from 2012 due to changes in the reporting system. The most important trend seen in 2013 is that the previous sharp increase in both the number of ecstasy-related emergencies, as well as in the level of intoxication in these emergencies, is leveling off.