title: National income inequality and declining GDP growth rates are associated with increases in HIV diagnoses among people who inject drugs in Europe: a panel data analysis.
abstract: BACKGROUND
  There is sparse evidence that demonstrates the association between macro-environmental processes and drug-related HIV epidemics. The present study explores the relationship between economic, socio-economic, policy and structural indicators, and increases in reported HIV infections among people who inject drugs (PWID) in the European Economic Area (EEA).
  
  
  METHODS
  We used panel data (2003-2012) for 30 EEA countries. Statistical analyses included logistic regression models. The dependent variable was taking value 1 if there was an outbreak (significant increase in the national rate of HIV diagnoses in PWID) and 0 otherwise. Explanatory variables included the growth rate of Gross Domestic Product (GDP), the share of the population that is at risk for poverty, the unemployment rate, the Eurostat S80/S20 ratio, the Gini coefficient, the per capita government expenditure on health and social protection, and variables on drug control policy and drug-using population sizes. Lags of one to three years were investigated.
  
  
  RESULTS
  In multivariable analyses, using two-year lagged values, we found that a 1% increase of GDP was associated with approximately 30% reduction in the odds of an HIV outbreak. In GDP-adjusted analyses with three-year lagged values, the effect of the national income inequality on the likelihood of an HIV outbreak was significant [S80/S20 Odds Ratio (OR) = 3.89; 95% Confidence Interval (CI): 1.15 to 13.13]. Generally, the multivariable analyses produced similar results across three time lags tested.
  
  
  CONCLUSIONS
  Given the limitations of ecological research, we found that declining economic growth and increasing national income inequality were associated with an elevated probability of a large increase in the number of HIV diagnoses among PWID in EEA countries during the last decade. HIV prevention may be more effective if developed within national and European-level policy contexts that promote income equality, especially among vulnerable groups.
authors: Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece; Hellenic Centre for Disease Control and Prevention, Amarousio, Greece.
authors: Georgios K
authors: GK
authors: Nikolopoulos
authors: Greek Reitox Focal Point of the EMCDDA, University Mental Health Research Institute, Athens, Greece; Department of Psychiatry, Athens University Medical School, Athens, Greece.
authors: Anastasios
authors: A
authors: Fotiou
authors: Greek Reitox Focal Point of the EMCDDA, University Mental Health Research Institute, Athens, Greece.
authors: Eleftheria
authors: E
authors: Kanavou
authors: Greek Reitox Focal Point of the EMCDDA, University Mental Health Research Institute, Athens, Greece; Panteion University of Social and Political Sciences, Athens, Greece.
authors: Clive
authors: C
authors: Richardson
authors: Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece.
authors: Marios
authors: M
authors: Detsis
authors: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors: Anastasia
authors: A
authors: Pharris
authors: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors: Jonathan E
authors: JE
authors: Suk
authors: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors: Jan C
authors: JC
authors: Semenza
authors: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal.
authors: Claudia
authors: C
authors: Costa-Storti
authors: Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece.
authors: Dimitrios
authors: D
authors: Paraskevis
authors: Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece.
authors: Vana
authors: V
authors: Sypsa
authors: Department of Psychiatry, Athens University Medical School, Athens, Greece.
authors: Melpomeni-Minerva
authors: MM
authors: Malliori
authors: National Development and Research Institutes, New York, New York, United States of America.
authors: Samuel R
authors: SR
authors: Friedman
authors: Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece.
authors: Angelos
authors: A
authors: Hatzakis
mesh_terms: D057217:Economic Development; D005060:Europe; D059066:Gross Domestic Product; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology*; D006801:Humans; D007267:Injections; D016015:Logistic Models; D011203:Poverty; D019966:Substance-Related Disorders / Q000191:economics / Q000453:epidemiology*