1. Guidance on Provider-initiated Voluntary Medical Examination, Testing and Counselling for Infectious Diseases in Injecting Drug Users Hans Blystad 1 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

2. 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/

3. HCV antibody prevalence among injecting drug users – studies with national and subnational coverage 2005-2006

4. HIV cases newly diagnosed in IDUs per million population, European Union 2003-2007 Source: ECDC/WHO 2008; Wiessing et al Eurosurveillance 2008

5. 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

6. 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

7. 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

8. 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

9. 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

10. Medical history and physical examination IDUs General Skin and mucous membranes Lungs Heart Digestive system Genitourinary system

11. 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

12. Additional panel of recommended tests Serology for HTLV-infections Swab or urine testing for genital chlamydial infections Swab or urine testing for gonorrhoea

13. Counselling Pre-test counselling includiing informed consent and possibility to decline tests Post-test counselling Prevention counselling

14. 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)

15. 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)

16. 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