Injection of cocaine is associated with a recent HIV outbreak in people who inject drugs in Luxembourg

Abstract

Background An outbreak of HIV infections among people who inject drugs (PWID) started in 2014 in Luxembourg. Objectives We conducted phylogenetic and epidemiological analyses among the PWID infected with HIV in Luxembourg or attending the supervised drug consumption facility (SDCF) to understand the main causes of the outbreak. Methods Between January 2013 and December 2017, analysis of medical files were performed from all PWID infected with HIV at the National Service of Infectious Diseases (NSID) providing clinical care nationwide. PWID were interviewed at NSID and SDCF using a standardized questionnaire focused on drug consumption and risk behaviours. The national drug monitoring system RELIS was consulted to determine the frequency of cocaine/heroin use. Transmission clusters were analysed by phylogenetic analyses using approximate maximum-likelihood. Univariate and multivariate logistic regression analyses were performed on epidemiological data collected at NSID and SDCF to determine risk factors associated with cocaine use. Results From January 2013 to December 2017, 68 new diagnosis of HIV infection reported injecting drug use as the main risk of transmission at NSID. The proportion of female cases enrolled between 2013–2017 was higher than the proportion among cases enrolled prior to 2013. (33% vs 21%, p < 0.05). Fifty six viral sequences were obtained from the 68 PWID newly diagnosed for HIV. Two main transmission clusters were revealed: one HIV-1 subtype B cluster and one CRF14_BG cluster including 37 and 9 patients diagnosed since 2013, respectively. Interviews from 32/68 (47%) newly diagnosed PWID revealed that 12/32 (37.5%) were homeless and 27/32 (84.4%) injected cocaine. Increased cocaine injection was indeed reported by the RELIS participants from 53 to 63% in drug users with services contacts between 2012 and 2015, and from 5 to 22% in SDCF users between 2012 and 2016. Compared with PWID who injected only heroin (n = 63), PWID injecting cocaine and heroin (n = 107) were younger (mean of 38 vs 44 years, p≤0.001), reported more frequent piercing (≤0.001), shared and injected drugs more often (p≤0.01), and were more frequently HIV positive (p<0.05) at SDCF using univariate logistic regression analysis. Finally, in the multivariate analysis, use of heroin and cocaine was independently associated with younger age, piercing, sharing of drugs, and regular consumption (p<0.05). Conclusions Injecting cocaine is a new trend of drug use in Luxembourg associated with HIV infection in this recent outbreak among PWID.

Molecular Epidemiological Analysis of the Origin and Transmission Dynamics of the HIV-1 CRF01_AE Sub-Epidemic in Bulgaria

“…Since then, CRF01_AE has become the second most predominant subtype in Bulgaria, which to our knowledge represents the highest share of CRF01_AE in Europe [ 5 , 9 ]. Our results resemble those described for other HIV-1 outbreaks in PWID in multiple countries, including Greece, Luxembourg, and resulting from the opioid crisis in the United States with the introduction of specific subtypes into this vulnerable population followed by rapid dissemination [ 16 , 31 , 35 , 36 ]. The majority (52%) of CRF01_AE infections in Bulgaria are PWID compared to only 4.8% in MSM, and PWID had at least six times greater odds of CRF01-AE infection than risk groups with other subtypes.…”

“…A total of about 35,000 Vietnamese immigrants were estimated to be in Bulgaria from 1980 to 1991, but most returned to Vietnam in 1991 after Bulgaria became an independent democracy in 1991. Combined, these results and historical information suggest a possible introduction of CRF01_AE into Bulgaria from Vietnam immigrants between 1988 and 1990 with subsequent rapid transmission via PWIDs, which is similar to other recent global outbreaks [ 35 , 36 , 45 , 46 , 47 , 48 ].…”

HIV outbreaks among people who inject drugs in Europe, North America, and Israel

“…Between 2011-2016, HIV outbreaks occurred among PWID in Athens, Greece; [20][21][22][23][24][25][26][27][28] , Bucharest, Romania; [27][28][29][30][31] Dublin, Ireland; 32,33 Glasgow, Scotland; 34,35 Luxembourg; 36,37 Saskatchewan, Canada, 38,39 Scott County, Indiana, United States; 40,41 and Tel Aviv, Israel. 42 All sites (8/8) reported having HIV case reporting in place, which in most cases was the key system detecting the outbreak [Table 1].…”

“…Because of the short duration of the effect of injected cocaine, persons may inject cocaine 10 to 20 in a day. 48,49 Users often work together to purchase drugs, and then divide the drugs and inject together. If multiple injections occur in a group setting, it will be difficult to have sufficient supplies of sterile syringes to avoid sharing.…”

High-risk behaviors and their association with awareness of HIV status among participants of a large-scale prevention intervention in Athens, Greece

“…In particular, 15.6 million people inject drugs (PWID) globally and of these, around 3 million are infected with HIV [2]. Moreover, HIV outbreaks have recently been observed among PWID in many European settings [3][4][5][6][7] and in one location in the United States (US) [8].…”