COMPLACENCY IS THE NEW PROBLEM: COMPARATIVE ANALYSIS OF RECENT OUTBREAKS OF HIV AMONG PERSONS WHO INJECT DRUGS IN EUROPE AND NORTH AMERICA D. Des Jarlais1, V. Sypsa2, J. Feelemyer1, A.O. Abagiu3, V. Arendt4, D. Broz5, C. Devaux6, J.M. Duwve7, C. Fierbinteanu8, M. Fitzgerald9, D.J. Goldberg10, A. Hatzakis2, D. Igoe9, E. Keenan9, A. McAuley10, S. Skinner11, I. Khan12, S. Konrad12, D. Chemtob13, E. Katchman14, , D. Paraskevis2 L. Wiessing15 1Global College of Public Health, New York University; 2National and Kapodistrian University of Athens, Athens Greece; ; 3National Institute for Infectious Diseases, Bucharest, Romania; 4CHL, Luxembourg City, Luxembourg; 5Centers for Disease Control and Prevention, Atlanta, United States; 6Luxembourg Institute of Health, Luxembourg City, Luxembourg; 7Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, United States; 8Romanian Association Against AIDS, Bucharest, Romania; 9Health Services Executive, Dublin, Ireland; 10NHS National Services Scotland, Glasgow, United, Kingdom; School of Health and Life Sciences, Glasgow Caledonian University, United Kingdom; College of Medicine, University of Saskatchewan, Saskatoon, Canada ; 12First Nations Inuit Health Branch, Indigenous Services Canada, Regina, Canada; 13Department of Tuberculosis and AIDS, Ministry of Health, and Faculty of Medicine, Hebrew University, Jerusalem, Israel; 14Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel; 15European Monitoring Center for Drugs and Drug Abuse, Lisbon, Portugal

BACKGROUND Dates of Prior Conditions/ Public Health Response/ DISCUSSION Location Size of Outbreak High Vulnerable Groups • When implemented at a public health scale, “Combined Outbreak Precipitating Factors Current situation • There was substantial variation in the size of the outbreaks 1100 new HIV cases A very large seek, test, and treat intervention using respondent driven from under 100 (Dublin, Luxembourg, Tel Aviv) to prevention and care” for HIV among persons who inject Severe economic disruption due to Great Recession, among PWID from sampling (Project ARISTOTLE) was implemented and incidence drugs (PWID) has been remarkably effective in preventing Athens disruption of injecting networks, homelessness in particular approximately 1000-1200 (Athens, Bucharest) new HIV 2011-2013 2011-2013 Homeless, Migrant PWID declined rapidly. NSP, OST and ART were expanded. The reported Greece among migrant PWID, and low levels of harm reduction infections. Outbreaks occurred in areas that had not HIV transmission among PWID Prior average: 10-20 annual number of new diagnoses among PWID decreased substantially services cases/year but is still higher than in pre-outbreak years implemented large-scale combined prevention • The combination of needle and syringe programs (NSP), programming (Athens, Indiana) or where funding was opiate substitution treatment (OST) for opioid use New psychoactive drugs including legal highs and bath salts interrupted (Bucharest) but also in areas where combined disorders, and anti-retroviral treatment (ART) for HIV were increasingly used by PWID. Stimulants cause more Increase in distribution of syringes from 1,000,000 in 2013 to 2,000,000 frequent daily injections compared to heroin. NSP coverage in 2014-2015. Note: The reduction in the new HIV cases among IDU's prevention had been implemented but changes in patterns infection has prevented HIV epidemics among PWID and 1195 new HIV was severely down due to funding interruption of the Global seen after 2013 is caused partially by the “backshift” of many users to Bucharest of drug use (increased use of cocaine or novel psychoactive has “ended” many ongoing high-seroprevalence epidemics 2011 infections among PWID Fund. Also a lack of correct information, the difficulties of MSM PWID heroin after seeing how "worse" the stimulants are, but also by the fact Romania substances (NPS)) may have led to high rates of injection among PWID (where the epidemics occurred prior to (2011-2016) reaching medical services due to new "health card" that many active users don't want to be tested anymore, saying they regulations, the increasing poverty level that makes general prefer to die "drugged and happy", not stressed also by knowing they risk behavior (Bucharest, Dublin, Glasgow, Luxembourg, implementation of combined prevention and care) population more "selfish" toward PWID, the fear of have also HIV Tel Aviv) • Despite the known effectiveness of “combined prevention withdrawal, combined to create the epidemic situation • Community economic problems preceded the outbreaks in and care,” outbreaks of rapid HIV transmission have Increased awareness among drug users (risk reduction for HIV: safe Athens, Dublin and Indiana and homeless/economically 57 new HIV cases injecting, safe sexual practices, risks of use of snow blow).Increase recently occurred in Europe, North America, and the among PWID (39 Homeless PWID; Female disadvantaged PWID were particularly vulnerable in all Dublin Increased use of a new psychoactive substance (NPS) alpha- engagement in OST, HIV testing and access to NSP; focus on homeless 2014-2015 newly infected) PWID (40% of PWID Middle East—areas where sufficient resources should Ireland pyrrolidinovalerophenone (“snow blow”) and poly drug use individuals, early treatment with ART, point of care testing for PWID. outbreaks compared to <20 in female) have been available to prevent the outbreaks Current situation - HIV cases and risks reduced but poly drug use • Public health responses included introduction (Indiana) or previous years continues as do underlying vulnerabilities • These outbreaks not only threaten the health of PWID and expansion of standard prevention interventions (NSP, OST, others in their communities but may undermine public PWID HIV Cases: Increasing awareness of the risks of HIV, education of at-risk population ART) but coverage of interventions varied 2015: 48 cases Transmission among a population who inject psychoactive Homeless PWID: PWID and addiction services regarding HIV, increasing provision of NSP (e.g., Glasgow • HIV transmission among PWID has continued in the large confidence in the effectiveness of HIV prevention for 2015-ongoing 2016: 31 cases drugs within Glasgow city center, mainly heroin with or involved in criminal justice greater evening availability), improving frequency and accessibility of Scotland PWID 2017: 37 cases without cocaine system HIV testing and proactively supporting the early treatment of those outbreak locations. Despite substantial decreases in some Prior average: 10 cases newly diagnosed through outreach and community based prescribing settings (Athens, Indiana, Dublin, Tel Aviv), the number of • Understanding how/why these outbreaks occurred should Since 2011, the drug market landscape has considerably Increased access to HIV testing, improved awareness of HIV infection in reported cases has not yet been reduced to pre-outbreak contribute to avoiding future outbreaks and/or greatly changed in Luxembourg with the aggressive introduction of PWID and in drug center’s personnel, together with prompt access to Average of 20 new HIV levels in any of the sites (except Israel) limiting any future outbreaks that do occur cocaine supply restricting the access to heroin for opioid antiretroviral therapy were actively used during the last 3 years to Luxembourg 2012-2015 infections per year Young, female PWID CONCLUSION injectors. The precarious situation of drug users combined contain the outbreak. 82% of the 68 new HIV cases were under among PWID OBJECTIVE with the lack of universal medical coverage in Luxembourg antiretroviral therapy and 73% had an undetectable viral load in • Earlier outbreaks (e.g. Estonia, Finland, Sweden, likely contributed to the outbreak December 2017. Increase in syringe provision in 2017 among PWID Lithuania) should have served as warnings about the • Describe recent HIV outbreaks globally in order to understand why the outbreaks occurred, and what can be Rapid mobilization of an integrated response between government possibility of additional outbreaks jurisdictions and communities focused on patient-centered and culturally • Despite these warnings, new outbreaks have occurred, done to avoid similar outbreaks in the future 21 new HIV cases safe services. The response included the addition of NSPs, testing events, Homelessness, poverty, drug use, and stigma were possibly increasing in frequency Saskatchewan among PWID (average and HIV/HCV care and treatment services, including OST. There was a METHODS 2016-ongoing precipitating factors for this rural outbreak. The rate of HCV Indigenous PWID Canada of less than one case focus in prompt linkages to care and early ART initiation. A community- • Complacency for HIV prevention is emerging as an in the area was high and one NSP operated in the area • An international research group of public health per year) drive and led outreach center was established by an Indigenous important threat to the success of combined HIV community. As of 2017, there were 21 new diagnoses, of which 86% prevention for PWID professionals battling HIV outbreaks among PWID was were co-infected with HCV formed by the European Monitoring Center for Drugs and • Successful HIV prevention for PWID needs to be After the reformulation of a commonly misused prescription conceptualized as implementing and maintaining high Drug Addiction, with the aim to conduct a comparative Rapid public health response initiated in 2015, including outreach and opioid OxyContin in 2010 to discourage inhalation and analysis of the outbreaks testing and introduction of ART by a community primary care provider coverage prevention programs, in particular OST, NSP and injection, drug use shifted to extended release oxymorphone, Tightly knit community and university physicians. The Indiana Governor declared a public • Publications and conference presentations on the Opana ER with crush-resistant formulation, INTAC. The ART, and adapting to changes in patterns of drug use with ‘drug houses’ where health emergency that permitted the immediate establishment of a NSP. Large for the area, with multi-step process of preparing Opana ER for injection • Particular attention should be paid to people who inject outbreaks were compiled and a standardized template was PWID shared pills, NSPs were legalized statewide by the State legislature several months almost 200 new HIV resulted in solution volume that exceeded the volume Scott County injection equipment and later. OST services were co-located with NSP beginning in July 2016 stimulants (e.g. cocaine and NPS), communities constructed for structured comparisons 2014 contained by a 1 mL syringe. Thus to inject the entire infections among an after a US federal increase in the buprenorphine prescribing limit. More • A mixed quantitative/qualitative synthesis was developed Indiana (USA) solution during a single injection episode resulted in multiple injected together. Families undergoing economic difficulties, and homeless PWID estimated 500-600 with multi-generational than 200 people have since accessed OST in the community. HIV viral through successive rounds of data analyses and PWID injections. The high frequency of injection, syringe sharing REFERENCES sharing of injection suppression rates are 75% of diagnoses, and HIV incidence has been 1. Andkhoie M, Kupchanko D, Cyr C, Chhetri A, Khan I. Epidemiology of HIV Outbreak in Southeastern Saskatchewan First Nations Communities.April 26-29. CAHR 2018 and drug sharing due to the high cost of the pill occurred in a 2. Broz D, Zibbell J, Foote C, Roseberry JC, Patel MR, Conrad C, et al. 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