EMCDDA logo Annual report on the state of the drugs problem in the European Union 2001

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Introduction to the annual report
Chapter 1: Drug demand and drug supply
Chapter 2: Responses to drug use
Chapter 3: Selected issues
Cocaine and 
base/crack cocaine
Infectious diseases 
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Chapter 4: The drugs problem in central and eastern European countries
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Infectious diseases

Infectious diseases: Prevalence and trends | Determinants and consequences, harm-reduction responses,


Determinants and consequences

Injecting drug use
Among drug users, infections such as HIV and hepatitis B and C are mainly transmitted through injecting drug use. This is largely due to sharing of injecting materials such as needles and syringes, and sharing of paraphernalia such as cotton, water and spoons. It is probable that in situations of increasing injecting drug use populations of injectors are especially vulnerable to rapid spread of HIV and hepatitis.

The timing and magnitude of the AIDS epidemics in different countries may have largely been determined by timing and magnitudes of epidemics of injecting drug use. These epidemics of injecting drug use probably occurred earlier in northern European countries such as the Netherlands (1970s and 1980s) but remained relatively contained, while occurring later in southern European countries such as Spain, Italy and Portugal (1980s and 1990s) and at higher rates. The occurrence of HIV epidemics may have therefore depended on a delicate balance between timing and magnitude of injecting drug use epidemics, awareness of AIDS (not existing in early years) and the timing and large-scale introduction of preventive measures.

The importance of injecting among drug users (in Europe mainly of heroin alone or together with other substances), may further depend on preferences and cultural habits of drug users or on the type of heroin available on the market (water-soluble and injectable or not). Also price and purity probably play a role, as injecting heroin is more efficient and therefore cheaper than smoking it. Fear of AIDS is thought to have much less influence on the decision to inject or not.

At the moment, it is not known how to prevent injecting drug use. Injecting drug use, or heroin use by any route, may depend on a range of personal and societal factors such as behavioural and/or family problems and unemployment. Substitution treatment, however, can be very effective in reducing injecting and injecting risk behaviour among heroin users. (9)

Injecting drug use has decreased strongly during the 1990s in most, but not all, countries. As a consequence, rates of injecting drug use (measured among opiate users entering treatment) differ strongly, from a low of about 10 % in the Netherlands to a high of about 70 % in Greece. Recent trends in injecting are not available except for Ireland, where they show a continuous increase, consistent with a recent increase in the number of IDU-related HIV positive tests.

Injecting risk behaviour
Among IDUs, spread of infections is mainly determined by injecting risk behaviour, notably 'needle sharing' (giving or receiving a used needle from or to another person). Transmission is also possible through the sharing of injecting equipment such as water, cotton or spoons, which are probably even more important in the case of hepatitis B and C. Unhygienic injecting may even cause transmission of hepatitis if no materials are shared, for example via blood contamination of hands, tables or other surfaces.

Other risk behaviours include front or backloading (injecting heroin from one syringe into another in order to measure even shares). Preliminary data on needle sharing indicate that this is, in general, still very high among IDUs, ranging from 10 to 17 % in the Netherlands (recent borrowing of used needles), to 64 % in Ireland (needle sharing in last four weeks) and 75 % in England and Wales (sharing of needles and paraphernalia). Most of these data may still underestimate the amount of risk behaviour through indirect sharing (front or backloading), sharing of materials other than needles, etc. On the other hand, needle sharing often occurs between steady partners who both know they are not infected, which may be relatively safe.

Table 6 OL Needle sharing among injecting drug users in some EU Member States

Sexual risk behaviour
Sexual transmission of HIV and HBV is much less efficient than transmission through needle sharing, while sexual transmission of HCV is thought to be very low. However, when the level of infection (prevalence) is high among IDUs, sexual transmission and transmission from mother to child of HIV and HBV may become important. IDUs may thus form so-called core groups or pockets of infection for continued transmission to the wider population. An efficient way of preventing sexual transmission is the use of condoms. Condom use has greatly increased among drug users since the 1980s, especially among sex workers who usually report high rates of condom use with their clients. However, condom use is usually low with private partners who therefore remain a major risk group for infection.

Consequences and costs
The consequences of an infection with HIV are severe. HIV infection leads to AIDS on average after about 10 years, which by that time incurs great costs to the individual and to society due to chronic infections, hospitalisations and premature death.

Infection with hepatitis B in the majority of cases resolves itself spontaneously, however, in an important proportion of cases (2 to 8 % among adults, 10 to 15 % in adolescents and much higher in children) it leads to chronic infection, which in the long term can lead to severe liver disease and premature death. As hepatitis B and HIV can easily be transmitted sexually or from mother to child, these infections among IDUs are an important threat to the population at large.

Figure 29

Sources M. J. Postma, L. G. Wiessing and J. C. Jager, 'Pharmaco-economics of drug addiction; Estimating the costs of HCV, HBV and HIV infection among injecting drug users in EU-countries'. Bull Narc. (in press).

Hepatitis C remains chronic in most cases (possibly 70 to 80 %) and therefore IDUs are still a potential major source of infection. Hepatitis C infection, like hepatitis B, has the potential of severe liver disease and premature death in the long run (decades). The combination of different hepatitis infections (including hepatitis A) at the same time can be especially dangerous and often leads to acute liver failure and death.

A preliminary estimate of future health care costs of one year of drug-related infections of HIV, HBV and HCV in the EU amounted to about 0.5 % of the total EU budget for health care (Figure 29).

Harm-reduction responses

In most of the EU, the introduction of harm-reduction measures - such as increased access to sterile needles and syringes, greater availability of condoms, and HIV counselling and testing - has helped to control HIV transmission among injectors. Substitution treatment, which can greatly reduce the frequency of injecting, is also available in all Member States, mostly in the form of oral methadone, but in most countries large improvement is still possible in terms of coverage. (See Chapter 2, demand reduction, treatment, substitution treatment).

While there is evidence that harm-reduction measures have helped to reduce the prevalence of hepatitis C among injectors, it has not controlled its spread (10). The persistence of hepatitis C infection among young injectors requires innovative approaches to harm reduction. The introduction of medically supervised injecting rooms and controlled heroin distribution are two such approaches being considered by some EU countries. However, both pose ethical and legal difficulties and may necessitate a change in drug laws. In those countries where injecting rooms have been established (United States, Australia, Germany, Switzerland and the Netherlands), their effectiveness has yet to be assessed.

Important aspects for gauging the availability of harm-reduction measures are provision of services and coverage of the IDU population. Based on estimates of problem drug use and rates of IDU among opiate users in treatment, preliminary estimates have been derived of the size of the IDU population in EU countries. Using these estimates a rough picture emerges of the provision of syringe exchange programmes (SEPs) (distribution points) per country (see Figure 30) and the number of needles exchanged through syringe exchange programmes per 1 000 IDUs per year.

Figure 30, Provision of syringe exchange programmes in some EU countries

Figure 18 OL Syringes distributed or exchanged through syringe exchange programmes per estimated IDU per year

Although country specific estimates may not be reliable, overall it appears that syringe exchange programmes in most countries for which data are available are still not providing a sufficient number of clean needles for IDUs, with the possible exception of the United Kingdom (England and Wales) and Spain.

A French study estimated the average number of injections for a daily injector (in the previous month) to be 3.6 per day, implying more than 1 300 injections per year per daily injector. (93 % of the sample of needle exchange attenders were daily injectors.) However, this average may strongly depend on substances injected (opiate users who also inject cocaine may inject much more frequently) or income (IDUs with little money may inject much less). Better and country specific estimates of IDU population size and number of injections are needed in order to assess the coverage of syringe exchange programmes and thus their potential for effective prevention of drug-related infections.

Table 7 OL Provision, utilisation and coverage of syringe exchange programmes (SEPs) for injecting drug users (IDUs) and coverage of pharmacies in some European countries, as reported by national focal points, 2000

Table 8 OL Provision of HIV counselling and testing, HIV treatment and HBV vaccination for injecting drug users (IDUs) in some European countries, as reported by national focal points, 2000


1. S. Darke, S. Kaye, J. Ross, 'Transitions between the injection of heroin and amphetamines', Addiction, Vol. 94, 1999, pp. 1795-1803.

2. M. C. Doherty, R. S. Garfein, E. Montorroso, 'Gender differences in the initiation of injection drug use among young adults', J Urban Health, Vol. 77, 2000, pp. 396-414.

3. D. L. Thomas, S. A. Strathdee, D. Vlahov, 'Long-term prognosis of hepatitis C virus infection', JAMA, Vol. 284, 2000, p. 2592.

4. A. J. Freeman, G. J. Dore, M. G. Law, et al, 'Estimating progression to cirrhosis in chronic hepatitis C virus infection, Hepatology, 2001, (in press).

5. European network on HIV/AIDS and hepatitis prevention in prisons, second annual report, 1998.

6. T. L. Lamagni, K. L. Davison, V. D. Hope, et al., 'Poor hepatitis B vaccine coverage in IDUs, England 1995 and 1996', Comm Dis Public Health, Vol. 2, 1999, pp. 174-177.

7. M. Fitzgerald, J. Barry, P. O'Sullivan, L. Thornton, 'Blood-borne infections in Dublin's opiate users', Ir J Med. Sci., Vol. 170, 2001, pp. 32-34.

8. Italian national focal point (2000 national report to the EMCDDA).

9. E. Drucker, P. Lurie, A. Wodak, P. Alcabes, 'Measuring harm reduction: the effects of needle and syringe exchange programs and methadone maintenance on the ecology of HIV', AIDS, Vol. 12 (Suppl. A), 1998, pp. S217-S223.

10. A. Taylor, D. Goldberg, S. Hutchinson, et al., 'Prevalence of hepatitis C virus infection among injecting drug users in Glasgow 199096: are current harm reduction strategies working?', J Infect, Vol. 40, 2000, pp. 176-183.

11. M. Valenciano, J. Emmanuelli, F. Lert, 'Unsafe injecting practices among attendees of syringe exchange programmes in France', Addiction, Vol. 4, pp. 597-606.


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