Impact of drug consumption rooms on non-fatal overdoses, abscesses and emergency department visits in people who inject drugs in France: results from the COSINUS cohort.

BACKGROUND: The effectiveness of drug consumption rooms (DCRs) for people who inject drugs (PWID) has been demonstrated for HIV and hepatitis C virus risk practices, and access to care for substance use disorders. However, data on other health-related complications are scarce. Using data from the French COSINUS cohort, we investigated the impact of DCR exposure on non-fatal overdoses, abscesses and emergency department (ED) visits, all in the previous 6 months. METHODS: COSINUS is a 12-month prospective cohort study of 665 PWID in France studying DCR effectiveness on health. We collected data from face-to-face interviews at enrolment, and at 6 and 12 months of follow-up. After adjusting for other correlates (P-value < 0.05), the impact of DCR exposure on each outcome was assessed using a two-step Heckman mixed-effects probit model, allowing us to adjust for potential non-randomization bias due to differences between DCR-exposed and DCR-unexposed participants, while taking into account the correlation between repeated measures. RESULTS: At enrolment, 21%, 6% and 38% of the 665 participants reported overdoses, abscesses and ED visits, respectively. Multivariable models found that DCR-exposed participants were less likely to report overdoses [adjusted coefficient (95% CI): -0.47 (-0.88; -0.07), P = 0.023], abscesses [-0.74 (-1.11; -0.37), P < 0.001] and ED visits [-0.74 (-1.27; -0.20), P = 0.007]. CONCLUSION: This is the first study to show the positive impact of DCR exposure on abscesses and ED visits, and confirms DCR effectiveness in reducing overdoses, when adjusting for potential non-randomization bias. Our findings strengthen the argument to expand DCR implementation to improve PWID injection environment and health.

[Drug Consumption Rooms : Opinion and willingness among people who inject drugs in Marseille, France]. / Salles de consommation à moindre risque : opinion et volonté d'utilisation des personnes injectrices de substances psychoactives à Marseille, France.

BACKGROUND: In France, people who inject drugs (PWID) are still one of the most at risk population for contracting hepatitis C virus (HCV). Drug consumption rooms (DCR) have shown their effectiveness on HCV risk behaviors abroad and in France, where they have been recently evaluated with the COSINUS study. In France, two DCRs opened in 2016, one in Paris and another in Strasbourg. The objective of this sub-analysis was to explore the willingness to use a DCR in PWID living in Marseille, where no DCR is opened. METHODS: The COSINUS study is a prospective multicenter cohort that included 665 PWID recruited in Bordeaux, Marseille, Paris and Strasbourg between 2016 and 2019. Investigators administered questionnaires face-to-face at regular intervals at baseline, 3 months, 6 months and 12 months. In Marseille, 199 PWID were recruited. A multivariable logistic regression model was performed to assess factors associated with willingness to use DCR among this population. RESULTS: Among 545 observations corresponding to 195 distinct participants selected for analyses, 57% declared they were willing to attend a DCR. The main reason given was "to consume more cleanly". Receiving allowances (OR = 2.38; 95% confidence interval (CI) (95% CI) = 1.17-4.81), not having health insurance (OR = 3.61; 95% CI = 1.49-8.75), injecting daily (OR = 1.97; 95% CI = 1.05-3.70) and in a public space (OR = 2.66; 95% CI = 1.29-5.47) were all positively associated with willingness to use a DCR. CONCLUSIONS: DCR are devices that target PWID exposed to high sanitary or social risks, i.e. people living in precarious conditions, who have to inject in public spaces, in deleterious sanitary environments and with rapid gestures in order not to be seen. These analyzes highlight that the people who most want to attend a DCR are aware of the harms associated with their practices and show a desire to seek protection from street-based drug scenes.

Do DSM-5 substance use disorder criteria differ by user care settings? An item response theory analysis approach.

AIM: To examine differences in the psychometric characteristics of diagnostic criteria for Substance Use Disorders (SUD) between substance users in harm reduction settings (HR) and substance users seeking treatment (Tx). METHODS: Differential Item and Test Functioning (DIF & DTF) analysis were performed to examine differences in the difficulty of endorsement and in discrimination of the 11 diagnostic criteria and to test if the criteria set as a whole (the "test") functioned differently by care settings (Tx vs. HR) for alcohol, cocaine, cannabis, opiates and tobacco. To test uniform and nonuniform DIF, multiple indicator multiple cause (MIMIC) structural equation models were used. RESULTS: Regardless of the substance, the DSM-5 criteria "craving", "large amount", "time spent", "tolerance" and "activities given up" had similar functioning by care settings. Little evidence for DIF was found for other criteria. The criteria set as a whole did not function differently by care settings for alcohol, cocaine and tobacco. At the same trait severity, compared to HR, the Tx subgroup had a greater number of endorsed criteria for cannabis and a smaller number of endorsed criteria for opioids. CONCLUSION: The unidimensionality of the 11 DSM-5 criteria and applicability of all criteria and diagnosis was confirmed in this large sample of problematic substance users. While the majority of the criteria related to loss of control of substance use, functioned well in both care settings, the criteria related to consequences of substance use had several differential functioning.

The civil society monitoring of hepatitis C response related to the WHO 2030 elimination goals in 35 European countries.

BACKGROUND: People who inject drugs (PWID) account for the majority of new cases of hepatitis C virus (HCV) infection in Europe; however, HCV testing, and treatment for PWID remain suboptimal. With the advent of direct acting antivirals (DAAs) the World Health Organization (WHO) adopted a strategy to eliminate HCV as public health threat by 2030. To achieve this, key policies for PWID must be implemented and HCV continuum of care needs to be monitored. This study presents results of the first monitoring led by civil society that provide harm reduction services for PWID. METHODS: In 2019, harm reduction civil society organizations representing focal points of Correlation-European Harm Reduction Network in 36 European countries were invited to complete a 27-item online survey on four strategic fields: use/impact of guidelines on HCV testing and treatment for PWID, availability/functioning of continuum of care, changes compared to the previous year and, the role of harm reduction services and non-governmental organizations (NGOs) of PWID. A descriptive analysis of the responses was undertaken. RESULTS: The response rate was 97.2%. Six countries reported having no guidelines on HCV treatment (17.1%). Twenty-three (65.7%) reported having treatment guidelines with specific measures for PWID; guidelines that impact on accessibility to HCV testing/treatment and improve access to harm reduction services in 95.6% and 86.3% of them, respectively. DAAs were available in 97.1% of countries; in 26.4% of them they were contraindicated for active drug users. HCV screening/confirmatory tests performed at harm reduction services/community centers, prisons and drug dependence clinics were reported from 80.0%/25.7%, 60.0%/48.6%, and 62.9%/34.3% of countries, respectively. Provision of DAAs at drug dependence clinics and prisons was reported from 34.3 to 42.9% of countries, respectively. Compared to the previous year, HCV awareness campaigns, testing and treatment on service providers' own locations were reported to increase in 42.9%, 51.4% and 42.9% of countries, respectively. NGOs of PWID conducted awareness campaigns on HCV interventions in 68.9% of countries, and 25.7% of countries had no such support. CONCLUSION: Further improvements in continuum-of-care interventions for PWID are needed, which could be achieved by including harm reduction and PWID organizations in strategic planning of testing and treatment and in efforts to monitor progress toward WHO 2030 elimination goal.

Estimating prevalence from dried blood spots without using biological cut-offs: application of a novel approach to hepatitis C virus in drug users in France (ANRS-Coquelicot survey).

Seroprevalence estimation using cross-sectional serosurveys can be challenging due to inadequate or unknown biological cut-off limits of detection. In recent years, diagnostic assay cut-offs, fixed assay cut-offs and more flexible approaches as mixture modelling have been proposed to classify biological quantitative measurements into a positive or negative status. Our objective was to estimate the prevalence of anti-HCV antibodies among drug users (DU) in France in 2011 using a biological test performed on dried blood spots (DBS) collected during a cross-sectional serosurvey. However, in 2011, we did not have a cut-off value for DBS. We could not use the values for serum or plasma, knowing that the DBS value was not necessarily the same. Accordingly, we used a method which consisted of applying a two-component mixture model with age-dependent mixing proportions using penalised splines. The component densities were assumed to be log-normally distributed and were estimated in a Bayesian framework. Anti-HCV prevalence among DU was estimated at 43.3% in France and increased with age. Our method allowed us to provide estimates of age-dependent prevalence using DBS without having a specified biological cut-off value.

Effectiveness and cost-effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs: The case of France.

Direct-acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost-effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated the following: improved needle/syringe programmes-opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age = 36). Outcomes were as follows: life expectancy in discounted quality-adjusted life years (QALYs); direct lifetime discounted costs; incremental cost-effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20 762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, which increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER = €5300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy = 16.701 QALYs, 41% decrease in new infections) but was not cost-effective (ICER = €105 600/QALY); it became cost-effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base-case scenario. This study illustrated the high effectiveness, and cost-effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This "Test and treat" strategy should play a central role both in improving the life expectancies of HCV-infected patients, and in reducing HCV transmission.

Hepatitis B virus in drug users in France: prevalence and vaccination history, ANRS-Coquelicot Survey 2011-2013.

People who use drugs (PWUD) are a key population for hepatitis B virus (HBV) vaccination and screening. We aimed to estimate the seroprevalence of HBs antigen (HBsAg) and self-reported HBV vaccination history in French PWUD attending harm reduction centres using data from the ANRS-Coquelicot multicentre survey conducted in 2011-2013 in 1718 PWUD. Self-fingerprick blood samples were collected on dried blood spots to detect the presence of HBsAg. HBsAg seroprevalence was estimated at 1·4% [95% confidence interval (CI) 0·8-2·5]. It varied between PWUD born in high (7·6%, 95% CI 2·7-19·1), moderate (2·2%, 95% CI 0·8-5·7) and low (0·7%, 95% CI 0·3-1·5) endemic zones. Factors independently associated with HBsAg carriage were being born in a moderate or high endemic zone or reporting precarious housing. Self-reported HBV vaccination history varied from 47·4% in high endemic zones, to 59·3% and 62·6% for moderate and low endemic zones, respectively. Our results suggest that drug use plays a small and substantial role, respectively, in HBsAg carriage in PWUD born in high/moderate and low endemic zones.

[Out of addictions: Alcohol, or alcohol to alcohol]. / Sortir des addictions : à l'alcool, par l'alcool ou vers l'alcool.

Pathways from alcoholism to recovery are documented; less often are those from drug addiction to alcoholism. Biographical approaches allow analyzing how people change their uses and talk about their trajectories of recovery. METHODS: Three hundred and forty-one people (34% women) in the Paris area were questioned on their trajectories with a biographical questionnaire. Some open questions were aimed to understand the connection they made between events in their lives, how recovered they felt and what they considered strengths or obstacles. All the participants had stopped at least one product. Their mean age was 43, and 26% were over 50. STUDY OBJECTIVES: How can the differences between one substance addicts and dual abusers be explained? Can we hypothesize a better result for the patients with a single dependence to alcohol in their lives for the following two reasons? (1) They could really be taken in charge for their alcoholism whereas the dual abusers mostly receive cared for their illicit drug problems with an under estimation of their problem with alcohol. In this case, they turn to alcohol after weaning themselves from their drug dependence so as to return to a social consumption, especially when they are given an opiate treatment. (2) Conversely could we suggest that the dual substance abusers had different trajectories from their childhood (more adverse events, more social difficulties, mental health problems), and that this accumulation explains their skipping from one substance or behaviour to another without any real recovery for decades? RESULTS: All respondents were polydrug users. Eighty-two had been dependent mainly on alcohol. One hundred and twenty-one people had been drug addicts (mostly heroin), which they had stopped on average ten years before the survey. The last group included 138 persons who had been heroin or cocaine addicts and alcoholics in their lives, a third of whom had been dependent on alcohol before their drug addiction (35%), a tenth on both at the same time (10%) and more than half of the users (55%) had turned from drug addiction to alcoholism. The group concerning alcohol dependence includes the oldest participants, on average 49.7, and 55% of them were abstinent at the survey. Conversely, the group "with no alcohol dependence" had mainly turned to opiate treatments. Their histories in dependence and in various social statuses also showed a longer duration out of employment, in sickness or invalidity, or in prison, for the drug dependents as opposed to the "mainly" alcoholics. The population with dual substance abuse experienced twice as many adverse childhood events as the others (P<0.005): it was the case for 19.5% in "mainly alcohol" dependence compared to 38.4% in dual abuse. The recovery capital gave a mean score of 7.56±2.35 (median 7). A score below 6 was considered low. The score was significantly different according to the dependence groups: while 7.3% of "mainly alcohol" dependents had a score below 6, this was the case for 30.4% of the dual group (with alcohol and drugs), and 19% for the "mainly drug dependence" group. Controlling ages, sexes and groups of dependence in a logistic regression, the risk of having a recovery capital below six was more than four times higher for the dual dependents as opposed to the "mainly alcohol" dependents. CONCLUSION: Some people stay for decades in drug addiction centers switching from one dependence to another. Their alcohol drinking should be addressed earlier to prevent them from turning to drinking excessively in order to wean themselves from their drug addiction.

Age- and time-dependent prevalence and incidence of hepatitis C virus infection in drug users in France, 2004-2011: model-based estimation from two national cross-sectional serosurveys.

Hepatitis C virus (HCV) infection is a public health issue worldwide. Injecting drug use remains the major mode of transmission in developed countries. Monitoring the HCV transmission dynamic over time is crucial, especially to assess the effect of harm reduction measures in drug users (DU). Our objective was to estimate the prevalence and incidence of HCV infection in DU in France using data from a repeated cross-sectional survey conducted in 2004 and 2011. Age- and time-dependent HCV prevalence was estimated through logistic regression models adjusted for HIV serostatus or injecting practices. HCV incidence was estimated from a mathematical model linking prevalence and incidence. HCV prevalence decreased from 58·2% [95% confidence interval (CI) 49·7-66·8] in 2004 to 43·2% (95% CI 38·8-47·7) in 2011. HCV incidence decreased from 7·9/100 person-years (95% CI 6·4-9·4) in 2004 to 4·4/100 person-years (95% CI 3·3-5·9) in 2011. HCV prevalence and incidence were significantly associated with age, calendar time, HIV serostatus and injecting practices. In 2011, the highest estimated incidence was in active injecting DU (11·2/100 person-years). Given the forthcoming objective of generalizing access to new direct antiviral agents for HCV infection, our results contribute to decision-making and policy development regarding treatment scale-up and disease prevention in the DU population.

Hepatitis C virus and HIV seroprevalences, sociodemographic characteristics, behaviors and access to syringes among drug users, a comparison of geographical areas in France, ANRS-Coquelicot 2011 survey.

BACKGROUND: People who use drugs (PWUDs) are at a high risk for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but they have different characteristics depending on the local context. In France, seroprevalence, sociodemographic, and behavior information have only been studied at a national level rather than at a local level. The aim of this study was to describe and examine profile and drug use practice differences in seven French cities and departments and to assess whether these differences can explain HCV and HIV seroprevalence variations between French geographical areas. METHODS: Data were collected from the cross-sectional ANRS-Coquelicot survey conducted for the second time in 2011 among drug users having injected or snorted drugs at least once in their life. Professional interviewers administrated a face-to-face questionnaire in six different areas in France: Paris, Marseille, Bordeaux, Lille, Strasbourg and the Seine-Saint-Denis department (Paris suburbs). Participants were asked to self-collect a fingerpick blood sample in order to search for the presence of anti-HIV and anti-HCV antibodies and to estimate seroprevalence in PWUDs. RESULTS: Overall, HCV and HIV seroprevalence was 44% [95% CI: 39.6-47.9] and 10% [95% CI: 7.5-12.6] respectively. The highest HCV seroprevalence was 56% in Marseille and the lowest was 24% in Bordeaux and for HIV the highest was 18% in Seine-Saint-Denis and the lowest was 0% in Lille. The population's age differed between areas and could mostly explain HCV seroprevalence variation but not exclusively. Profiles and practices, different in each area, can also explain this variation. In multivariate analysis, HCV seroprevalence was lower in Bordeaux (prevalence ratio [PR]=0.64), Strasbourg (PR=0.76), and Seine-Saint-Denis (PR=0.8) than in Paris. Nearly one-third of injectors declared having had difficulties to obtain syringes in the 6 previous months, but disparities existed between areas. CONCLUSION: HCV risk exposure in PWUDs remains high in France and varies between different areas. Innovative harm reduction strategies including educative programs about safe injecting and supervised consumption rooms need to be developed.

Dynamic modelling of hepatitis C virus transmission among people who inject drugs: a methodological review.

Equipment sharing among people who inject drugs (PWID) is a key risk factor in infection by hepatitis C virus (HCV). Both the effectiveness and cost-effectiveness of interventions aimed at reducing HCV transmission in this population (such as opioid substitution therapy, needle exchange programmes or improved treatment) are difficult to evaluate using field surveys. Ethical issues and complicated access to the PWID population make it difficult to gather epidemiological data. In this context, mathematical modelling of HCV transmission is a useful alternative for comparing the cost and effectiveness of various interventions. Several models have been developed in the past few years. They are often based on strong hypotheses concerning the population structure. This review presents compartmental and individual-based models to underline their strengths and limits in the context of HCV infection among PWID. The final section discusses the main results of the papers.

Prevalence of human immunodeficiency virus and hepatitis C virus among French prison inmates in 2010: a challenge for public health policy.

We evaluated prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among prison inmates in France in 2010, in a cross-sectional single-day study based on a two-stage design. Sampling favoured larger establishments and included all types of prisons. Establishments were stratified by geographical region. Estimates were adjusted by post-stratification of the total population of inmates in France. From 60,975 inmates in all 188 prisons on the sampling day, 2,154 were selected from 27 prisons, and 1,876 questionnaires completed. HIV prevalence was estimated at 2.0% (95% confidence interval (CI): 0.9­4.2), 2.6% (95% CI: 0.7­8.8) in women and 2.0% (95% CI: 0.9­4.3) in men; 75% of inmates were receiving treatment for HIV. HCV prevalence was estimated at 4.8% (95% CI: 3.5­6.5) and was higher for women (11.8%; 95% CI: 8.5­16.1) than men (4.5%; 95% CI: 3.3­6.3). Almost half of HCV-infected inmates had chronic hepatitis C and 44% were receiving or had received treatment. HIV and HCV prevalence was six times higher than in the general population, and 2.5% of inmates had viraemic hepatitis C. The moment of incarceration provides an ideal opportunity for testing and treating, limiting spread of HCV and improving patients' prognosis.

Mandatory immunization: the point of view of the French general population and practitioners.

This survey studies the opinion of the French general population, general practitioners and pediatricians regarding mandatory immunization. Data were collected through standardized telephone questionnaires administered to representative samples of the French population (n=4112) and of French general practitioners and pediatricians (1285 general practitioners (GPs) and 742 pediatricians). 56.5% of the general population is in favor of mandatory vaccination. Being in favor of hepatitis B vaccination, agreeing that "it would be important to continue immunizing against diphtheria in case immunization was made optional" or saying that "if immunization against diphtheria was discontinued, the disease would spread again", are some of the main determinants of a favorable opinion regarding mandatory immunization. The percentage of GPs and pediatricians in favor of mandatory immunization is 42%. Female pediatricians and those who would "insist on families in the importance of continuing immunizing all children against diphtheria in case this vaccination was only recommended" more often declare themselves in favor of mandatory immunization. The adoption of the principle of mandatory immunization seems to stem from the adoption of immunization as an individual and collective prevention tool.

[Limited impact of the harm-reduction policy on HCV among drug-users. The ANRS-Coquelicot survey example]. / L'impact limité de la réduction des risques sur la transmission du VHC chez les usagers de drogues. L'exemple de l'étude ANRS-Coquelicot.

BACKGROUND: In France, a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users, and to examine determinants of at-risk behaviors. METHODS: In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. RESULTS: The self-reported and biologically documented prevalence rates of HIV infection were identical (22 %). In contrast, the self-reported prevalence of HCV infection was 52 %, while the biologically documented prevalence was 73 %. Overall, 30 % of HCV-infected drug users were unaware of their status. Forty-four per cent of drug users under 30 years of age were HCV-seropositive, suggesting that they had been infected early during drug use. CONCLUSION: The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users, but a much more limited impact on HCV transmission.

Impact of a harm-reduction policy on HIV and hepatitis C virus transmission among drug users: recent French data--the ANRS-Coquelicot Study.

In France a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus (HCV) infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users and to examine determinants of at-risk behaviors. In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use intervention and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. The self-reported and biologically documented prevalence rates of HIV infection were identical (22%). In contrast, the self-reported prevalence of HCV infection was 52%, whereas the biologically documented prevalence was 73%. Overall, 30% of HCV-infected drug users were unaware of their status. Forty-four percent of drug users under 30 years of age were HCV seropositive, suggesting that they had been infected early during drug use. The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users but a much more limited impact on HCV transmission. The limitations and implications of the study are discussed.