Infectious diseases among people who inject drugs in France: the importance of acting on risk environment in an evolving crisis

Introduction: France’s harm reduction model is generally considered efficient, featuring high OST coverage, HAART treatment for People Who Inject Drugs (PWIDs), and facilitated access to HCV treatment. However, the country currently faces an HCV crisis among PWIDs. In this study, we aimed to describe the current HCV exposure crisis by measuring the prevalence of at-risk injection practices and HCV incidence. We also sought to identify factors associated with high level risk exposure, and to contextualize epidemiological data using a sociological analysis of the characteristics of French harm reduction compared to similar European countries.

Methods: Our study combined a sociological analysis of harm reduction models at the European level with an analysis of epidemiological data from ANRS-Coquelicot seroprevalence cross-sectional surveys carried out in France in 2004 and 2013. These studies used the same methodology and were based on a time-location random sampling design integrating the generalised weight share method (GWSM) and blood testing. Fingerstick blood samples were collected on dried blood spots (DBS). We estimated HCV incidence in two ways: first by using a statistical comparison method between the two cross-sectional surveys; second by measuring the presence of HCV-RNA from biological data among people testing negative for anti-HCV (i.e. HCV antibodies).

Results: The ANRS-Coquelicot Studies show that needle sharing has increased significantly from 13.3% in 2004 to 23.6% in 2013. Results showed that the PWID studied in 2013 were more precarious than in 2004. In 2013, 38,3% of PWID said they had slept on the street or in a squatting area the night preceding the survey, compared to 11.3% in 2004. Multivariate analysis shows that the time period is significantly associated with needle sharing only among the most precarious PWID (IRR=4.2). Other factors associated with needle sharing within this group include alcohol (IRR=4.0) and crack and cocaine consumption in the last month (IRR=3.8), reusing syringes (IRR=3.3) as well as being a woman (IRR=3.2) and a subjective poor health condition (IRR=2.1). In 2013, HCV incidence was estimated at 11% per year based on the statistical comparative method. Another estimation was performed with a biological method and showed a very high HCV incidence (49%).

Conclusion: The estimated HCV incidence and the increase in at-risk practices in France were among the highest observed in all high-income countries currently providing harm reduction measures. This critical epidemiological situation may be partly explained by France’s harm reduction model. France began to enforce harm reduction policies, later than the Netherlands, Switzerland, or Germany. France currently features a neutral, weak, and exclusively sanitary approach to harm reduction that is profoundly influenced by drug prohibition. In this context, harm reduction has been less efficient compared to other European countries, especially for the most vulnerable PWIDs. It is now urgent that France implement a new harm reduction model that really takes into account risk environment in order to improve conditions for PWIDs.