title: Economic recession and emergence of an HIV-1 outbreak among drug injectors in Athens metropolitan area: a longitudinal study.
abstract: BACKGROUND
  During 2011, a dramatic increase (1600%) of reported HIV-1 infections among injecting drug users (IDUs) was noted in Athens, Greece. We herein assess the potential causal pathways associated with this outbreak.
  
  
  METHODS
  Our study employed high resolution HIV-1 phylogenetic and phylogeographic analyses. We examined also longitudinal data of ecological variables such as the annual growth of gross domestic product (GDP) of Greece in association with HIV-1 and HCV sentinel prevalence in IDUs, unemployment and homelessness rates and HIV transmission networks in Athens IDUs before and during economic recession (2008-2012).
  
  
  RESULTS
  IDU isolates sampled in 2011 and 2012 suggested transmission networks in 94.6% and 92.7% of the cases in striking contrast with the sporadic networking (5%) during 1998-2009. The geographic origin of most HIV-1 isolates was consistent with the recently documented migratory waves in Greece. The decline in GDP was inversely correlated with annual prevalence rates of HIV and HCV and with unemployment and homelessness rates in IDUs (all p<0.001). The slope of anti-HCV prevalence in the sentinel populations of IDUs and in "new" drug injectors was found 120 and 1.9-fold (p = 0.007, p = 0.08 respectively) higher in 2008-2012 (economic recession) compared with 2002-2006. The median (25th, 75th) size of transmission networks were 34 (12, 58) and 2 (2, 2) (p = 0.057) in 2008-2012 and 1998-2007, respectively. The coverage of harm reduction services was low throughout the study period.
  
  
  CONCLUSIONS
  Scaling-up harm reduction services and addressing social and structural factors related to the current economic crisis should be urgently considered in environments where HIV-1 outbreaks may occur.
authors.affiliation: National Retrovirus Reference Center, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Paraskevis
authors.forename: Georgios
authors.initials: G
authors.lastname: Nikolopoulos
authors.forename: Anastasios
authors.initials: A
authors.lastname: Fotiou
authors.forename: Chrissa
authors.initials: C
authors.lastname: Tsiara
authors.forename: Dimitra
authors.initials: D
authors.lastname: Paraskeva
authors.forename: Vana
authors.initials: V
authors.lastname: Sypsa
authors.forename: Marios
authors.initials: M
authors.lastname: Lazanas
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Gargalianos
authors.forename: Mina
authors.initials: M
authors.lastname: Psichogiou
authors.forename: Athanasios
authors.initials: A
authors.lastname: Skoutelis
authors.forename: Lucas
authors.initials: L
authors.lastname: Wiessing
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Friedman
authors.forename: Don C D E S
authors.initials: DC
authors.lastname: Jarlais
authors.forename: Manina
authors.initials: M
authors.lastname: Terzidou
authors.forename: Jenny
authors.initials: J
authors.lastname: Kremastinou
authors.forename: Meni
authors.initials: M
authors.lastname: Malliori
authors.forename: Angelos
authors.initials: A
authors.lastname: Hatzakis
mesh_terms: D002947:Cities / Q000191:economics* / Q000453:epidemiology*; D004196:Disease Outbreaks / Q000191:economics*; D055030:Drug Users / Q000706:statistics & numerical data*; D057172:Economic Recession; D005260:Female; D006115:Greece / Q000453:epidemiology; D059066:Gross Domestic Product / Q000706:statistics & numerical data; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission; D015497:HIV-1 / Q000235:genetics / Q000502:physiology; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D017720:Molecular Epidemiology / Q000191:economics; D058974:Phylogeography; D013997:Time Factors