Drug users in Amsterdam: are they still at risk for HIV?

Examining trends in the incidence of HIV infection among people with a history of drug use to inform an outbreak investigation and response: A retrospective cohort study

BACKGROUND

In the context of an outbreak of HIV among people who inject drugs in Glasgow, Scotland, identified in 2015, our objectives were to: (1) develop epidemiological methods to estimate HIV incidence using data linkage, and (2) examine temporal changes in HIV incidence to inform public health responses.

METHODS

This was a retrospective cohort study involving data linkage of laboratory HIV testing data to identify individuals with a history of drug use. Person-years (PY) and Poisson regression were used to estimate incidence by time period (pre-outbreak: 2000-2010 and 2011-2013; early outbreak: 2014-2016; ongoing outbreak: 2017-2019).

RESULTS

Among 13 484 individuals tested for HIV, 144 incident HIV infections were observed from 2000 to 2019. Incidence rates increased from pre-outbreak periods (1.00/1000 PY (95% confidence interval, CI: 0.60-1.65) in 2000-2010 and 1.70/1000 PY (95% CI: 1.14-2.54) in 2011-2013) to 3.02/1000 PY (95% CI: 2.36-3.86) early outbreak (2014-2016) and 2.35 (95% CI 1.74-3.18) during the ongoing outbreak period (2017-2019). Compared with the pre-outbreak period (2000-2010), the incidence rates were significantly elevated during both the early outbreak (2014-16) (adjusted incidence rate ratio (aIRR) = 2.87, 95% CI: 1.62-5.09, p < 0.001) and the ongoing outbreak periods (2017-19) (aIRR = 2.12, 95% CI: 1.16-3.90, p = 0.015).

CONCLUSIONS

Public health responses helped to curb the rising incidence of HIV infection among people with a history of drug use in Glasgow, but further efforts are needed to reduce it to levels observed prior to the outbreak. Data linkage of routine diagnostic test data to assess and monitor incidence of HIV infection provided enhanced surveillance, which is important to inform outbreak investigations and guide national strategies on elimination of HIV transmission.

Increase in recreational drug use between 2008 and 2018: results from a prospective cohort study among HIV-negative men who have sex with men

AIMS

To test whether recreational drug use (RDU) and sexualized drug use (SDU) changed in the Amsterdam area between 2008 and 2018 and quantify associations of SDU with condomless anal sex (CAS), recent human immunodeficiency virus (HIV) or sexually transmitted infections (STI) among human immunodeficiency virus (HIV)-negative men who have sex with men (MSM).

DESIGN

Open prospective cohort study.

SETTING

Public Health Service of Amsterdam, the Netherlands.

PARTICIPANTS

A total of 976 HIV-negative MSM, aged ≥ 18 years.

MEASUREMENTS

Self-reported RDU and sexual behaviour in the past 6 months. Laboratory-confirmed HIV and STI (chlamydia, gonorrhoea and syphilis). We studied: any RDU; any SDU (i.e. any RDU during sex); specific SDU (i.e. use of mephedrone, methamphetamine, gamma-hydroxybutyric acid/gamma-butyrolactone, ketamine, amphetamine, cocaine and/or ecstasy during sex); use of individual drugs; and use of individual drugs during sex. We evaluated changes over calendar years in the proportion of individuals with these end-points [using logistic regression with generalized estimating equations (GEE)] and number of drugs (using negative binomial regression with GEE), adjusted for current age, country of birth and education level.

FINDINGS

Median age of participants in 2008 was 33.2 years (interquartile range = 27.8-40.1); 83.1% were born in the Netherlands. The proportion of any RDU increased from 67.2% in 2008 to 69.5% in 2018 [adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 1.03-1.51]. Any SDU increased from 53.8% in 2008 to 59.8% in 2013 (aOR = 1.23; 95% CI = 1.07-1.42) and remained stable afterwards. Specific SDU increased from 25.0% in 2008 to 36.1% in 2018 (aOR = 2.10; 95% CI = 1.71-2.58). The average number of drugs used increased for those reporting any RDU, any SDU and specific SDU (all P < 0.05. Among those engaging in sex, any SDU was associated with CAS (aOR = 1.36; 95% CI = 1.19-1.55), HIV (aOR = 5.86; 95% CI = 2.39-14.4) and STI (aOR = 2.31; 95% CI = 1.95-2.73). Specific SDU was associated with CAS (aOR = 1.58; 95% CI = 1.37-1.81), HIV (aOR = 6.30; 95% CI = 3.28-12.1) and STI (aOR = 2.15; 95% CI = 1.81-2.55).

CONCLUSIONS

Among human immunodeficiency virus (HIV)-negative men who have sex with men in Amsterdam, recreational drug use, including sexualized drug use, increased between 2008 and 2018. Sexualized drug use was strongly associated with condomless anal sex, HIV and sexually transmitted infections.

High proportions of liver fibrosis and cirrhosis in an ageing population of people who use drugs in Amsterdam, The Netherlands

BACKGROUND

The incidence and prevalence of hepatitis C virus (HCV) infection among people who use drugs (PWUD) peaked in the 1980s in Amsterdam. As liver cirrhosis develops several decades after HCV infection and PWUD have other risk factors for liver fibrosis, we hypothesized that significant liver fibrosis or cirrhosis is now common among PWUD in Amsterdam.

METHODS

PWUD were recruited from the Amsterdam Cohort Studies, methadone programmes and addiction clinics during 2009-2016. Transient elastography was performed to assess liver stiffness. We estimated METAVIR fibrosis levels on the basis of the following liver stiffness measurements (LSMs) cut-offs: F0-F2 (no/mild) less than 7.65 kPa; F2-F3 (moderate/severe) at least 7.65 to less than 13 kPa; and F4 (cirrhosis) at least 13 kPa. Using linear regression models, we assessed the association between LSM and sociodemographic, clinical and behavioural determinants in (a) all PWUD and (b) chronic hepatitis C virus (cHCV)-infected PWUD.

RESULTS

For 140 PWUD, the median LSM was 7.6 kPa (interquartile range=4.9-12.0); 26.4% had moderate/severe fibrosis and 22.9% had cirrhosis. Of 104 chronically infected PWUD, 57.7% had evidence of significant fibrosis (≥F2). In multivariable analysis including all PWUD, increased LSM was associated significantly with cHCV monoinfection and HIV/HCV coinfection. In cHCV-infected PWUD, older age was associated significantly with increased LSM. In all groups, longer duration of heavy alcohol drinking was associated with increased LSM.

CONCLUSION

A high proportion of PWUD had significant fibrosis or cirrhosis that were associated with cHCV infection, HIV/HCV coinfection and duration of heavy alcohol drinking. Increased uptake of HCV treatment and interventions to reduce alcohol use are needed to decrease the liver disease burden in this population.

HIV and hepatitis C treatment uptake among people who use drugs participating in the Amsterdam Cohort Studies, 1985-2015

BACKGROUND

HIV-positive people who use drugs (PWUD) start antiretroviral therapy (ART) later than other risk groups, and among HCV-positive PWUD, HCV treatment uptake is low. Nowadays, HCV direct-acting antivirals (DAAs) are available and reimbursed in the Netherlands (since 2014). The Amsterdam Cohort Studies (ACS), initiated in 1985, provides us the opportunity to describe temporal trends in ART and HCV-treatment uptake among PWUD through 2015.

METHODS

We analyzed data from PWUD participating in the ACS between 1985 and 2015. ART and HCV-treatment data were obtained from ACS questionnaires and medical records. Treatment uptake was defined by: treatment initiation (the proportion initiating any kind of ART/HCV treatment when treatment-naïve) and coverage (the proportion ever treated for HIV/HCV) among all HIV-/HCV-RNA-positive PWUD. Each was calculated per calendar year. We estimated the cumulative probability of ART uptake in the pre-cART (<1996) and cART era (January 1, 1996) among HIV seroconverters, with all-cause mortality as a competing risk.

RESULTS

Of 1305 PWUD, 263 (20.2%) were HIV-antibody positive and 810 (62.1%) were HCV-antibody positive, at study entry. ART coverage increased over time, from 5.7% in 1990 and 42.2% in 1996 to 91.7% in 2015. The proportion initiating ART ranged from 4.8% in 1990 to 33.3% in 2011. At 8 years after HIV seroconversion, cumulative probability of ART uptake was 42.5% in the pre-cART era and 61.5% in the cART era. HCV treatment initiation peaked in 2006 (9.7%). HCV-treatment coverage was 43.9% in 2015 but lower among HIV-coinfected (23.5%) than HCV-monoinfected PWUD (52.5%). In 2015, 3.0% initiated HCV treatment with DAAs.

CONCLUSION

We observed an increase in ART and HCV-treatment coverage among PWUD over time. As expected, ART uptake was higher in the cART era than the pre-cART era. Although in 2015 HCV treatment coverage was relatively high, DAA uptake was still low.

Temporal trends in mortality among people who use drugs compared with the general Dutch population differ by hepatitis C virus and HIV infection status

OBJECTIVES

We aimed to identify temporal trends in all-cause and cause-specific mortality rates among people who use drugs (PWUD) compared with the general Dutch population and to determine whether mortality trends differed by hepatitis C virus (HCV)/HIV (co) infection status.

DESIGN

Longitudinal cohort study.

METHODS

Using data from the Amsterdam Cohort Studies among 1254 PWUD (1985-2012), all-cause and cause-specific standardized mortality ratios (SMRs) were calculated; SMRs were stratified by serological group (HCV/HIV-uninfected, HCV-monoinfected, and HCV/HIV-coinfected) and calendar period. Temporal trends were estimated using Poisson regression.

RESULTS

The overall all-cause SMR was 13.9 (95% confidence interval 12.6-15.3). The SMR significantly declined after 1996, especially due to a decline among women (P < 0.001). The highest SMR was observed among HCV/HIV-coinfected individuals during 1990-1996 (SMR 61.9, 95% confidence interval 50.4-76.0), which significantly declined after this period among women (P = 0.001). In contrast, SMR for HCV-monoinfected, and HCV/HIV-uninfected PWUD did not significantly change over time. The SMR for non-natural deaths significantly declined (P = 0.007), whereas the SMR for HIV-related deaths was the highest during all calendar periods.

CONCLUSIONS

We found evidence for declining all-cause mortality among PWUD compared with the general population rates. Those with HCV/HIV-coinfection showed the highest SMR. The decline in the SMR seems to be attributable to the decline in mortality among women. Mortality rates due to non-natural deaths came closer to those of the general population over time. However, HIV-related deaths remain an important cause of mortality among PWUD when compared with the general Dutch population. This study reinforces the importance of harm-reduction interventions and HCV/HIV treatment to reduce mortality among PWUD.

Extremely low and sustained HIV incidence among people who inject drugs in a setting of harm reduction

This study created a retrospective cohort by linking repeat respondents in a large, national, annual cross-sectional sero-survey to estimate HIV incidence among people who inject drugs (PWID) in Australia. The results indicate extremely low and sustained rates of HIV incidence (0.11 per 100 person-years) over almost two decades (1995-2012). The findings demonstrate that sustained prevention of HIV transmission among PWID is possible and suggest that the early establishment and rapid scale-up of needle and syringe programmes, at a time when background prevalence was low, likely contributed to the prevention of an HIV epidemic among Australian PWID.

Translational HIV-1 research: from routine diagnostics to new virology insights in Amsterdam, the Netherlands during 1983-2013

An HIV-1 diagnostic laboratory was established in the Academic Medical Center (AMC) of the University of Amsterdam after the discovery of human immunodeficiency virus (HIV) as the cause of the acquired immunodeficiency syndrome (AIDS). The first AIDS patients were diagnosed here in 1981 and since 1983 we have tested the samples of 50992 patients using a variety of assays that greatly improved over the years. We will describe some of the basic results from this diagnostic laboratory and then focus on the spin-off in terms of the development of novel virus assays to detect super-infections and ultra-sensitive assays to measure the intracellular HIV-1 RNA load. We also review several original research findings in the field of HIV-1 virology that stem from initial observations made in the diagnostic unit. This includes the study of genetic defects in the HIV-1 genome and time trends of the replication fitness over 30 years of viral evolution, but also the description of novel HIV-1 variants in difficult-to-diagnose clinical specimen.