HIV infection among persons who inject drugs

Des Jarlais et al.[1] highlight how HIV transmission among persons who inject drugs (PWID) has decreased considerably since the implementation of harm-reduction policies. They provide a stimulating reflection on how to end old HIV epidemics and address new outbreaks in PWID [1]. Focusing on New York, Vancouver and France, their analysis shows how localized epidemics can still spread, even in countries where HIV seroprevalence has noticeably declined. However, some of the French data used are not suitable to reliably document the epidemic's current dynamic, and more recent data are available. The French surveillance data presented in the review by Des Jarlais et al.[1] come primarily from the HIV/AIDS case notification system, coordinated by the French Institute for Public Health Surveillance. One major concern is that the data presented are too focused on AIDS cases which do not constitute a reliable indicator of the dynamic of the epidemic. Furthermore, a comparison with other key populations is needed to contextualize the PWID situation. AIDS cases in PWID and other transmission groups dramatically decreased in France in the mid-1990s (PWID: 1900 in 1993 and 600 in 1997; MSM: 2900 in 1994 and 1100 in 1997), largely due to improved antiretroviral therapies. Since 1998, the number of AIDS cases has gradually decreased, with fewer than 100 AIDS cases diagnosed in PWID in 2013. New HIV diagnoses in PWID decreased between 2003 (233) (when monitoring started) and 2008 (less than 100) and then stabilized until 2013 [2]. To monitor HIV infection in France, as part of the national HIV-case-surveillance program, we implemented new routine incidence testing for recent HIV infections using an enzyme immunoassay for recent infection. In 2008, incidence in PWID (constituting the second most exposed group to transmission) was estimated at 86 per 100 000 person-years [3] and was stable until 2012 (last available estimation). This incidence was much higher than that in heterosexuals of French (5/100 000) or non-French (44/100 000) nationality [3]. When we consider each key population's size, we see that HIV in PWID is still a major problem. Furthermore, the two cross-sectional ANRS–Coquelicot studies, conducted in 2004 and 2011–2013 among representative samples (n = 1500 for each study, approximately) and including Time Location Sampling, helped us describe national HIV epidemiology among PWID. To date, they constitute the only French studies estimating national HIV prevalence from biological samples as: 11% in 2004 [4] and 13% in 2011–2013. Local levels differed greatly: 0% in Lille, 14% in Paris and 20% in Marseille [5]. Although we agree with the analysis by Des Jarlais et al.[1] suggesting that harm-reduction policies implemented in France after 1987 (with the liberalization of syringe sales in pharmacies) have impacted HIV transmission in PWID, some indicators are less optimistic. HIV screening and treatment access are still insufficient. Diagnosis in PWID is more likely at an advanced stage of infection (38% of new diagnoses in 2013) than in other transmission groups: MSM (17%) and heterosexually-infected people (33%) [2]. France is facing a difficult situation regarding injection-related infectious disease transmission. After a significant decrease in shared syringe practices between 1987 and 1996 [6], and particularly in subgroups (opioid users) in southern France between 1993 and 2004 [7], the ANRS–Coquelicot studies highlight a sharp increase in high-risk HIV transmission practices among PWIDs. In 2011–2013, 26% of PWID declared that they shared their syringes at least once during the previous month [8] compared with 13% in 2004 [9]. Cohort studies confirm this [10]. Furthermore, 30% of PWID declared difficulties in obtaining syringes, even in big cities including Paris [5]. All these indicators show that conditions favouring exposure to infectious disease transmission in PWID are still present, knowing that hepatitis C antibody prevalence is still high (64%) [5]. France is confronted with a paradox concerning harm-reduction policy, as it has one of the highest rates of opioid substitution treatment (OST) coverage in the world, with approximately 180 000 PWID on OST, representing 80% of that population [11]. Our data indicate that France should still remain vigilant with respect to the HIV epidemic in PWID. New harm-reduction policies, focusing more on socio-structural interventions, are urgently needed. Acknowledgements Conflicts of interest There are no conflicts of interest. We thank Jude Sweeney for english editing.

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