1. Drug users in Amsterdam: are they still at risk for HIV? Nienke van der Knaap, Bart Grady, Maarten Schim van der Loeff, Titia Heijman, Arjen Speksnijder, Ronald Geskus, Maria Prins Cluster of Infectious Diseases, Public Health Service Amsterdam AIDS 2012, Washington

2. Background  Drug users (DU) are at risk for contracting blood-borne viruses  Harm-reduction programmes contributed to stabilisation or decline of HIV incidence (van den Berg 2007, Crawford 2010)  Between 1985 and 2005 we observed a decline in injecting risk behaviour among DU in Amsterdam (Lindenburg et al. 2006)  However, sexual risk behaviour remained substantial and was considered to be the main risk factor for HIV acquisition Abstract #: A-452-0147-08988

3. Objective  To examine whether drug users in Amsterdam are still at risk for HIV  To assess whether there is a need for interventions to reduce sexual risk behaviour. Abstract #: A-452-0147-08988

4. Methods (1)  The Amsterdam Cohort Studies among drug users  Open, ongoing cohort study since 1985  Visits every 4-6 months  Detailed questionnaires on self-reported sexual risk behavior, (injecting) drug use and Sexual Transmitted Infections (STI)  Blood is tested for HIV antibodies and collected for storage Abstract #: A-452-0147-08988

5. Methods (2)  Trends in HIV incidence rate per calendaryear: –Person-time techniques –Modelled using poisson regression –Among all HIV negative DU at ACS entry  Trends in sexual and injecting risk behaviour –Modelled using logistic regression –Adjusted for multiple visits per individual (GEE)  STI screening among all participants with a cohort visit between November 2010 and June 2011. –Chlamydia trachomatis, Neisseria gonorrhoeae, Trepanoma pallidum Abstract #: A-452-0147-08988

6. Results All visitors N=1658 Gender, male (%)1035 (62%) Dutch Nationality1183 (71%) Age, median (IQR)30 (26-35) HIV Positive at study entry322 (19%) Unprotected sex, past 6 months721 (44%) Ever injected drugs1158 (69%) Injected drugs, past 6 months868 (52%) Alcohol (any daily), past 6 months333 (20%) Methadone prescription, past 6 months636 (38%) [b1] geen baseline data [b2] among those that entered the cohort from 1991? Geen 1658 Baseline characteristics Abstract #: A-452-0147-08988

7. Results  Median follow-up time was 9.2 years (IQR 3.7-14.8)  Total follow-up time was 12,921 person-years  By December 2011, 464 participants had died  During a given calendar year about 93% (IQR 90-95) returned for a follow-up visit the next year  97 participants seroconverted for HIV Abstract #: A-452-0147-08988

8. HIV incidence Abstract #: A-452-0147-08988

9. Injecting and sexual risk behaviour Abstract #: A-452-0147-08988

10. Recent visitors All visitorsRecent visitors N=1658N = 197 Gender, male (%)1035 (62%)141 (72%) Dutch Nationality1183 (71%)166 (84%) Age, median (IQR)30 (26-35)49 (43-54) HIV Positive at study entry322 (19%)15 (8%) Unprotected sex, past 6 months721 (44%)72 (36%) Ever injected drugs1158 (69%)124 (63%) Injected drugs, past 6 months868 (52%)23 (12%) Alcohol (any daily), past 6 months333 (20%)116 (59%) Methadone prescription, past 6 months636 (38%)123 (62%) Abstract #: A-452-0147-08988

11. Multivariable OR ( 95% CI)p-value Partner type0.001 Casualref Steady3.77 (1.46-9.75) Client0.34 (0.07-1.63) CSW0.32 (0.10-1.05) HIV status0.002 HIV-negative ref HIV-positive 0.07 (0.02-0.37) Determinants of unprotected sex CSW: Commercial Sex Worker

12. Conclusions  Continuing very low HIV incidence rate  Injecting risk behavior and sexual risk behaviour are declining over time.  Unprotected sex was still substantial in 2011, but mainly among those having a steady partner and being HIV negative  STI prevalence was low  DU no longer play a role in the spread of HIV in Amsterdam Abstract #: A-452-0147-08988

13. Acknowledgements  All participants from the ACS among drug users  Evidence for harm reduction? A. de Vos –Session room 8, 17:30 Abstract #: A-452-0147-08988