Transcript Lysbilde 1 - hiveurope.eu

Guidance on Provider-initiated Voluntary
Medical Examination, Testing and
Counselling for Infectious Diseases in
Injecting Drug Users
Hans Blystad1 and Lucas Wiessing 2
1 Norwegian Institute of Public Health
2 European Monitoring Centre for Drugs and Drug Addiction
HIV in Europe, Stockholm 2-3. November 2009
A package of basic operational
guidance in the meeting
between the injecting drug user
and the health care provider
with regards to infectious
diseases.
Published at
http://www.emcdda.europa.eu/
Sweden
Lithuania
Luxembourg
Norway
Germany
Italy
Denmark
Netherlands
Belgium
Portugal
Poland
France
Greece
Romania
Slovakia
United Kingdom
Malta
Austria
Cyprus
Slovenia
Finland
National
Bulgaria
Hungary
Czech Republic
HCV antibody prevalence among injecting drug users –
studies with national and subnational coverage 2005-2006
100%
Subnational
75%
50%
25%
%
HIV cases newly diagnosed in IDUs per million
population, European Union 2003-2007
EU: Countries with 2 to
10 cases / M in 2006-2007
EU: Countries with over
10 cases / M in 2006-2007
15
250
200
10
150
100
5
50
0
0
2003
2003
2004
2005
2006
2007
Ireland
Luxembourg
Lithuania
Latvia
Portugal
Estonia
Germany
France
Malta
2004
Finland
Poland
Bulgaria
2005
2006
Cyprus
United Kingdom
Sweden
2007
Norway
Denmark
Austria
Source: ECDC/WHO 2008; Wiessing et al Eurosurveillance 2008
Background
• blood borne viral infections and bacterial infections plays
an important role in the general health situation and well
being of IDUs.
• need to increase access to and uptake of testing for HIV
and other infectious infections
• most existing guidelines on HIV-testing do not cover the
special needs of IDUs satisfactorily and there is a lack of
guidance on other infections
Methodology
• Document a result of discussions at the annual EU
expert meetings held by the EMCDDA on drug-related
infectious diseases (DRID)
• Review of reports, position statements, policy
documents, journal articles, guidelines and clinical
guidelines
• Recommendations given are based on good clinical
practice and evidence based medicine when appropriate
• Intended as a practical tool for health care providers in
the public and private sectors who provide health care to
(injecting) drug users
Objectives
• Improve the general health of the individual IDU
• Improve testing uptake for HIV and other drug related
infections
• Increase access of IDUs to treatment for HIV and other
infectious diseases
• Improve diagnosis of chronic infections which need
specialist care
• Increase vaccination coverage in IDUs
• Improve access of IDUs to prevention counselling and
information
• Improve surveillance of HIV infection, hepatitis and other
infections in IDUs
Infections often found in injecting drug users
• HIV infection
• Hepatitis A, B, C and D
• Skin and soft tissue infections:Staphylococcus aureus
(including MRSA) and streptococcal infections
• Severe systemic sepsis (e.g. infections with Clostridium
novyi, Bacillus anthracis)
• Sexually transmitted infections
• Respiratory infections e.g. pneumonia, diphtheria,
influenza
• Tuberculosis (TB)
• Wound botulism
• Tetanus
• HTLV - infections
Elements included in the package
• Medical history and physical examination
• Pre-test counselling, informed consent and possibility to
decline tests
• Testing for infections
• Post-test counselling
• Prevention counselling
• Vaccination
• Follow-up, treatment and referral routines
• Frequency of examination and testing
• Ethical considerations
Medical history and physical examination IDUs
•
•
•
•
•
•
General
Skin and mucous membranes
Lungs
Heart
Digestive system
Genitourinary system
Basic panel of recommended tests
• HIV
• Hepatitis A, B, C and D (if evidence of chronic or recent
hepatitis B)
• Syphilis
• Tests for tuberculosis disease or latent tuberculosis
• Swab for culture from abscesses and skin lesions
• Tests for biochemical analysis (ALAT, ASAT, bilirubin)
• Other general blood tests (ESR or CRP, haemoglobin
and white blood cell count
Additional panel of recommended tests
• Serology for HTLV-infections
• Swab or urine testing for genital chlamydial infections
• Swab or urine testing for gonorrhoea
Counselling
• Pre-test counselling includiing informed
consent and possibility to decline tests
• Post-test counselling
• Prevention counselling
Recommended vaccinations
• Hepatitis A +B combination vaccine (or separate
hepatitis A and hepatitis B vaccines)
• Diphtheria / Tetanus vaccine (every 5-10 years)
• Influenzae vaccine (season or pandemic)
• Pneumococcal vaccine (esp. if HIV positive and >
50 years of age)
Possible facilities
• Primary health care including general practitioners and
family doctors
• Special health services for IDUs delivered through
mobile clinics, in other community settings, through
harm reduction programmes or through other types of
outreach.
• Low threshold service centres visited by IDUs
• Prison health care facilities
• Rehabilitation centres and other drug treatment services
• Dedicated STI clinics
• Infectious diseases clinics
• Tuberculosis clinics (countries with high incidence of
tuberculosis among IDUs)
Special considerations
•
•
•
•
•
Informed consent and possibility to decline test(s)
Opt-out /opt-in approach ?
Testing for tuberculosis
Use of guidelines in closed settings e.g. prisons
Minimize potential risks of negative effects of
testing like discrimination and stigmatisation
• Importance of training, ongoing supervision and
monitoring of health-care providers, esp. in closed
settings