OBJECTIVES:We aimed to evaluate the effect of the implementation of electronic-prescribing protocols for infectious diseases on outpatient antimicrobial prescribing patterns in Greece. METHODS:In 2018-2019, in the context of policies to control antimicrobial use in Greece, electronic-prescribing protocols for acute pharyngitis, community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and urinary tract infection (UTI) were introduced. We conducted a retrospective nationwide Interrupted Time Series analysis of monthly outpatient antimicrobial prescription counts overall and for targeted infectious syndromes during the preintervention and postintervention periods. Data were extracted from the official nationwide electronic prescription database covering July 2017 to December 2021. RESULTS:Overall reductions in median monthly antimicrobial prescription counts between the pre- and postintervention periods were 71.3% (95% CI: -78.5% to -56.4%) for pharyngitis, 90.0% (95% CI: -94.3% to -85.3%) for CAP, 92.6% (95% CI: -94.1% to -87.9%) for AECOPD, 85.8% (95% CI: -86.6% to -83.0%) for UTI. Despite these syndrome-specific reductions, the median monthly number of total outpatient antimicrobial prescriptions did not decrease (417 633 vs. 424 592 prescriptions per month). Before the intervention, the protocol-targeted syndromes collectively accounted for a median of 27.6% of total antimicrobial prescriptions per month, whereas 'other nonprotocol conditions' represented a median of 72.4%. After implementation, these proportions shifted dramatically to a median of 4.5% and 95.5% respectively (p < 0.001 for both changes), indicating a shift in diagnostic coding associated with antimicrobial prescribing. CONCLUSIONS:Although the protocols were designed to promote targeted antimicrobial use, their complex implementation may have inadvertently encouraged suboptimal prescribing practices. Improper coding and inconsistent antimicrobial prescribing data hinder antimicrobial stewardship efforts and should prompt a national health policy action plan.

BACKGROUND & AIMS:Long-term outcome data in patients with chronic hepatitis B (CHB) treated with high-genetic-barrier nucleos(t)ide analogues (NAs) beyond year 10 are scarce. We assessed the incidence and predictors of hepatocellular carcinoma (HCC), liver transplantation (LT), all-cause and liver-related death, and HBsAg loss among patients treated with NAs for >10 years. METHODS:The long-term PAGE-B cohort included 1,644 Caucasian patients with CHB treated with entecavir or tenofovir. Cumulative incidence was estimated using Kaplan-Meier methods or cumulative incidence functions accounting for competing events. Incidence rates (IRs) per 100 person-years (/100 PYs) were calculated. RESULTS:Of 1,644 patients, 903 were followed beyond year 10 (mean:14 ± 2 years). The 10- and 15-year cumulative incidences of HCC were 10.9% and 13.2%, respectively. The HCC IR was 1.25 before year 10 and 0.55/100 PYs after year 10 (p <0.001), with similar findings after inverse probability weighting. The IR of death or LT was lower before vs. after year 10 (1.50 vs. 1.95/100 PYs, p = 0.069), whereas the IR was similar for liver-related death/LT between the two periods (0.74 vs. 0.70/100 PYs, p = 0.840). HCC development and baseline platelet count were independently associated with LT-free liver-related or overall survival, which was also associated with older age and diabetes. The 10- and 15-year cumulative incidences of HBsAg loss on NA(s) were 8.3% and 14.3%, respectively; the IR of HBsAg loss increased from 0.94 before year 10 to 1.42/100 PYs after year 10 (p = 0.025). HBsAg loss was independently associated with older age and baseline HBeAg positivity. NA therapy was discontinued in 125 (7.6%) patients who remained HBsAg positive. CONCLUSIONS:Despite >10 years of NA therapy, patients with CHB remain at risk of HCC, although the incidence rate declines significantly. HCC remains the main determinant of mortality. The rate of HBsAg loss increases after year 10 but remains low, occurring more frequently in older patients and those who were initially HBeAg positive. IMPACT AND IMPLICATIONS:Despite more than 10 years of effective nucleos(t)ide analogue therapy, patients with chronic hepatitis B remain at risk of hepatocellular carcinoma, highlighting the need for continued long-term surveillance. Although the incidence of hepatocellular carcinoma declined after year 10, it remained the main determinant of long-term outcomes. These findings reinforce the importance of sustained risk stratification, particularly among patients with lower baseline platelet counts or other risk factors. The gradual increase in hepatitis B surface antigen loss beyond 10 years provides further evidence that prolonged antiviral therapy may offer ongoing benefits, although functional cure remains uncommon and is more likely among older patients and those who were initially HBeAg-positive.

OBJECTIVES:Αn HIV-1 outbreak was identified among people who inject drugs (PWID) in Thessaloniki, Greece, during 2019-2021. We aimed to investigate the characteristics of this outbreak by means of molecular epidemiology. METHODS:We analysed 57 sequences from PWID sampled in Thessaloniki during 2019-2023. Phylogenetic trees were inferred using all subtype A sequences from PWID sampled since 1999 in Greece and reference sequences (n=4824). Phylodynamic analysis was performed using the Bayesian birth-death skyline serial model. RESULTS:Most of the 57 study sequences belonged to sub-subtypes A6 (49, 86%) and A1 (4, 7%). Phylogenetic analysis revealed that two (50%) A1 sequences clustered together and 47 (95.9%) A6 sequences fell within three PWID-specific phylogenetic clusters. The 99.6% and 77.9% of pairwise genetic distances within the largest and second largest PWID clusters were lower than 0.015 substitutions/site. Using a more stringent threshold (0.0015 substitutions/site), we identified five networks of sequences from PWID infected within 1 year. The effective reproduction number (Re) started to increase at the beginning of 2019 and remained high almost until the end of 2021. The estimated time from HIV-1 infection to diagnosis showed an increasing trend during 2020-2023 (p<0.001). CONCLUSIONS:The regional clustering of the PWID sequences and their low genetic divergence confirm its local spreading and the recent nature of the outbreak. Using a stringent genetic distance threshold, we showed that HIV-1 transmission occurred among large groups of PWID. The time of epidemic growth coincided with the time of the initial identification, and HIV-1 transmission continued at high rates until 2021.

We collected social contact data in Greece to measure contact patterns before (January 2020) and during the COVID-19 pandemic (March 2020-October 2021) and assess the effects of social distancing over time. During lockdowns, mean daily contacts decreased to 2.8-5.9 (mean prepandemic 20.4). Persons >65 years of age retained the fewest contacts during the pandemic (2.1- 4.1). Compared with the first lockdown (March-April 2020), the second lockdown (November-December 2020) and third lockdown (April 2021) showed higher numbers of contacts (incidence rate ratio 1.50 [95% CI 1.27-1.76] in second lockdown and 2.19 [95% CI 1.86-2.58] in third lockdown). In 2021, an increase in contacts was apparent, which persisted during the April 2021 lockdown among persons 18-64 years of age. Our study provides evidence of the waning observance of physical distancing. Effective risk communication alongside targeted social distancing could offer alternatives to repeated lockdowns.

Telehealth holds the potential to expand healthcare access for people who use drugs (PWUD). However, limited data exist on their digital infrastructure access, a prerequisite for telehealth participation. We studied digital healthcare accessibility among PWUD. We employed respondent-driven sampling to recruit 162 PWUD in Athens, Greece to assess current internet and computer access and telemedicine experience via a structured questionnaire. Participants were at least 18 years with an injection drug use (IDU) history. We utilized logistic regression to evaluate sociodemographic associations. Participants’ mean (SD) age was 45.9 (8.8) years, 84.0

People living in prisons have higher mortality rates compared to the general population. We undertook a retrospective analysis of deaths recorded between 2010 and 2018 at the sole prison hospital in Greece (Korydallos Prison Special Health Centre for men) to assess the causes of death overall and by type of offence (drug-related or other), sociodemographic characteristics by cause of death, and mortality trends over time. Permission to access forensic reports and criminal files was obtained from the relevant authorities. Deaths were categorized as either non-natural (drug overdose, suicide, and homicide) or natural (cardiovascular disease, cancer, and others). Between 2010 and 2018, 236 deaths were reported; 80.9% were natural deaths, and 19.1% were non-natural deaths. The primary causes of death were circulatory disease (34.7%), cancer (17.8%), suicide (10.2%), respiratory disease (8.9%), and overdose (6.4%). Suicide and overdose accounted for 53.3% and 33.3% of non-natural deaths, respectively. The mean (SD) age at death was 52.4 (16.2) years, with individuals experiencing non-natural deaths being significantly younger than those experiencing natural deaths [39.1 (10.5) vs. 55.5 (15.7), p < 0.001]. Among individuals incarcerated for drug-related offences, 23.8% died from non-natural causes, with drug overdose accounting for 60% of non-natural deaths. A significant peak in mortality was observed in 2013. This study emphasizes the need to closely monitor mortality rates, including drug-related fatalities, to implement suicide prevention training as well as measures to prevent deaths by overdose, including comprehensive harm reduction strategies, overdose education, and naloxone training.

Drug-related infectious diseases (DRID), such as HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV), contribute to high morbidity and mortality among people who inject drugs (PWID). The European Union Drugs Agency (EUDA) is responsible for monitoring DRID and related behaviours for PWID in Europe. We updated the EUDA DRID technical protocol which covers all steps from planning to data analysis needed for a survey among PWID. Drug-related infectious disease-specific indicators were revised. To enable a more effective monitoring of the current epidemiological situation, we added specific core indicators, such as prevalence of viraemic HBV, HCV and HIV care cascades and harm reduction-related indicators. HIV pre-exposure prophylaxis and take-home naloxone were added as optional indicators. The process was informed by a European working group, who shared best-practice examples of (repeated) cross-sectional and cohort surveys using different methods in various settings. To reach the World Health Organization’s goal of ending HIV and the viral hepatitis epidemics, comprehensive DRID monitoring among the disproportionately affected PWID population is needed.

BACKGROUND:Accurate population size estimation of people who inject drugs (PWID) is essential for evidence-based drug policy and service planning, yet it remains challenging. An emerging HIV outbreak in Thessaloniki, Greece's second-largest city, highlighted the urgent need for evidence-based population size estimates. METHODS:We applied capture-recapture analysis to five respondent-driven sampling (RDS) rounds conducted during 2019-2021 to estimate PWID population size in Thessaloniki for the 2019-2021 period. These RDS rounds were part of a community-based program aimed at increasing HIV/HCV testing and linkage to care among PWID. We treated each RDS round as a capture source and used log-linear models to estimate PWID population size (past 12 months and past 30 days), accounting for potential dependencies between rounds through interaction terms. We then estimated HIV/HCV disease burden and assessed prevention and harm reduction service coverage against international standards (HIV testing, OAT, NSP). RESULTS:Based on data from 1093 unique participants across five rounds (53.9% currently injecting, 20.3% currently in OAT), capture-recapture analysis estimated 1512 PWID (95% confidence interval (CI): 1345-1741) who had injected drugs in the past 12 months. The estimated prevalence of injecting drug use was 0.22% (95% CI: 0.20-0.25) among adults aged 18-64 years. We estimated 106 people living with HIV (95% uncertainty interval (UI): 83-130) and 945 HCV-antibody-positive individuals (95% UI: 815-1077) among PWID. Needle and syringe program coverage was 36 (95% CI: 31-40) syringes per PWID in 2021. CONCLUSION:Based on this community-based population size estimate, the prevalence of injection was nearly double the official national Greek average. The annual distribution of syringes should increase by 5.6 times to reach the WHO target (≥200 syringes/PWID/year). These findings demonstrate how community-based programs with multiple RDS rounds can also yield population estimates essential for evidence-based drug policy interventions.

People who inject drugs (PWIDs) remain underserved in HIV care. Evidence on rapid antiretroviral therapy (ART) for PWID is limited. We evaluated feasibility, effectiveness, safety, and patient-reported outcomes (PROs) for rapid initiation of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) supported by a peer navigation in Greece. This is a single-arm, multicenter pilot study including PWIDs (≥18 years) newly diagnosed or relinking after >3 months off ART. Participants started BIC/FTC/TAF on the same day or within 7 days and received peer navigation for 48 weeks. Co-primary endpoints were Week-24 virologic suppression (HIV-1 RNA < 50 copies/mL; FDA Snapshot) and grade 3–4 adverse events (AEs). Secondary endpoints included complete-case suppression at Weeks 24/48, CD4 recovery, retention, and PROs. Outcomes were compared with historical controls from the same centers. Thirty-seven participants were enrolled (83.8% male; median age 33.3 years). Median time to ART was 0 days (vs 78 in controls, p < 0.001). Retention was 67.6% at Week 24 and 54.1% at Week 48. In the primary (FDA Snapshot) analysis, suppression was 62.2% and 54.1% at Weeks 24 and 48; in complete-case analyses, results were 92.0% and 100%, respectively. Mean CD4 count increased by 208 cells/μL (95% CI 141–275) at Week 48. Quality of life improved and symptom burden decreased. No grade 3–4 AEs occurred. Rapid BIC/FTC/TAF with peer navigation eliminated delays to ART and achieved favorable virologic, immunologic, and PROs among those retained, with good tolerability. Despite retention challenges, this model appears feasible for PWID and may help close HIV care gaps toward UNAIDS 95–95–95 targets.

A new COVID-19 reality is emerging globally. Despite the 'global health emergency' being downgraded to a global health threat by the World Health Organization, several countries around the world promote COVID-19 vaccination programs by months, in response to changes in the virus due to the new emerging variants. New hospital admissions and number of beds occupied by COVID-19 patients are globally on the rise. Where do we stand amidst all this, in Greece? In this narrative review, we bring forward five immediate priorities for our scientific societies, our health care colleagues and the State, in order to stay vigilant in the face of COVID-19 unpredictability. A team of experts put the minimum of measures in place to ensure a level of readiness that would allow our healthcare system to sustain the management of the COVID-19 challenge. We hope that our action-oriented proposals can contribute to the discussion on how we can strengthen our responses and sustain our successes in fighting COVID-19, for the winter ahead of us and beyond.

BackgroundLate HIV diagnosis (CD4+ T-cell count < 350 cells/μL, or with an AIDS-defining event) remains a persistent challenge in Greece, indicating potential missed opportunities (MOs) for earlier testing.AimTo determine the frequency of HIV indicator conditions (ICs) preceding diagnosis and to quantify MOs for earlier testing at a nationwide level in Greece.MethodsThis multicentre retrospective study analysed data on 823 antiretroviral therapy-naive adults (≥ 18 years) diagnosed with HIV during 2019-21. Medical records were reviewed to identify pre-diagnosis healthcare contacts (HCCs) and ICs justifying HIV testing. Univariable and multivariable logistic regression identified factors associated with ≥ 1 MO. A Bayesian model estimated the time from seroconversion to diagnosis.ResultsAmong 517 participants with HCC data, 249 had ≥ 1 HCC. Of these, 59.0% (147/249) were late presenters. These cases had 365 HCCs, and 191 (52.3%) were MOs for testing. The most common ICs were sexually transmitted infections (39.8%; 76/191) and fever (11.0%; 21/191). Non-Greek origin was associated with lower odds of experiencing ≥ 1 MO (adjusted odds ratio: 0.48; 95% CI: 0.22─1.02), while higher education increased odds of MOs for early HIV diagnosis. Median time from seroconversion to diagnosis was 3.2 years for the full sample and 3.7 years for those with HCC, with about half of the latter reporting MOs post-estimated seroconversion. Recognising MOs would have potentially spared approximately 1 year of delay in diagnosis.ConclusionMOs for earlier HIV diagnosis were prevalent in Greece. Leveraging IC-guided testing and addressing barriers could support earlier diagnosis and treatment, limiting adverse health outcomes and preventing transmission.

BackgroundBangladeshi migrants residing in Athens, Greece, represent a unique and vulnerable population, particularly during the COVID-19 pandemic. This study explores their experiences, information sources, motivations, and perceptions regarding pandemic-related measures, vaccination, and information dissemination.MethodsSeven focus groups were conducted with 38 Bangladeshi participants, who provided insights into their pandemic experiences.ResultsQualitative analysis revealed four key themes: information sources for COVID information, fear as a motivator to test and vaccinate, experiences with vaccination roll-out, and enthusiasm for narrative-driven information dissemination. Participants relied on varying information sources, including mainstream local media outlets, interpersonal networks, and word-of-mouth, with trust placed in medical professionals and the World Health Organization. Fear emerged as a potent motivator, influencing compliance with COVID-19 guidelines. While many praised Greece's vaccination initiative, barriers related to documentation were identified. Participants welcomed narrative-driven short videos for information dissemination, emphasizing expert involvement, Bengali language, relatable stories, and community leaders as essential elements.ConclusionsThese findings have significant implications for public health interventions, policy formulation, and communication strategies targeting migrant populations. Customized messaging in migrants' native languages, addressing misinformation, understanding the multifaceted role of fear, overcoming vaccination barriers, and leveraging multimedia narratives can promote informed decision-making and community resilience. Community-driven solutions and context-specific approaches are crucial for achieving health equity among migrants.

One of the World Health Organization's targets for the 2030 viral hepatitis elimination strategy is to reduce new hepatitis C (HCV) infections. In Athens, Greece, people who inject drugs (PWID) have a high HCV prevalence, with increasing trends since the 2000s. This analysis aims to assess primary HCV incidence among PWID during 2012-2020. Two community-based interventions were implemented in 2012-2013 and 2018-2020 with repeated sero-behavioural surveys in each period. Participants enrolled in multiple surveys were identified through linkage. To assess trends in HCV transmission, three indicators were estimated: (i) anti-HCV prevalence among 'new' injectors (those injecting ≤2 years), (ii) indirect HCV incidence among 'new' injectors, assuming infection occurred at the midpoint between initiating injection and the first positive test, and (iii) HCV incidence from repeat participants. There were 431 and 125 'new' injectors, respectively, in 2012-2013 and 2018-2020. Αnti-HCV prevalence [95% CI] declined from 53.6% [48.8%, 58.3%] in 2012-2013 to 40.0% [31.3, 49.1%] in 2018-2020 (25.4% reduction, p = .007). The indirect estimate [95% CI] of HCV incidence among 'new' injectors decreased from 56.1 [49.3, 63.8] to 39.0/100 person-years (PYs) [29.6, 51.5] (30.5% reduction, p = .020). HCV incidence [95% CI] based on seroconversions in repeat participants (16/63 in 2012-2013 and 9/55 in 2018-2020) declined from 64.6 [39.6105.4] to 13.8/100 PYs [7.2, 26.5], respectively (78.6% reduction, p < .001). Primary HCV incidence remains high among PWID in Athens. Consistent implementation of combined interventions, including high-coverage harm reduction programs and initiatives tailored to increase access to HCV treatment, is essential to sustain the declining trends documented during 2012-2020.

Background: New diagnoses of HIV-1 infection among people who inject drugs (PWID) in Athens, Greece, saw a significant increase in 2011 and a subsequent decline after 2013. Despite this, ongoing HIV-1 transmission persisted from 2014 to 2020 within this population. Our objective was to estimate the time of infection for PWID in Athens following the HIV-1 outbreak, explore the patterns of HIV-1 dispersal over time, and determine the duration from infection to diagnosis. Methods: Time from HIV-1 infection to diagnosis was estimated for 844 individuals infected within 4 PWID-specific clusters and for 8 PWID infected with sub-subtype A6 diagnosed during 2010-2019. Phylogeny reconstruction was performed using the maximum-likelihood method. HIV-1 infection dates were based on molecular clock calculations. Results: In total 86 of 92 (93.5%) sequences from PWID diagnosed during 2016-2019 were either related to the previously identified PWID-specific clusters (n = 81) or belonged to a new A6 cluster (n = 5). The median time between infection and diagnosis was 0.42 years during the outbreak period and 0.70 years during 2016-2019 (p < 0.001). The proportion of clustered sequences from PWID was very low at 5.3% during the pre-outbreak period (1998-2009), saw an increase to 41.7% one year before the outbreak in 2010, and consistently remained high during the whole period after 2011, spanning the post-outbreak period (2016-2019) with a range from 92.9% to 100%. Conclusions: The substantial proportion of clustered infections (93.5%) during 2016-2019 implies a persistent 'slow burn' HIV outbreak among PWID in Athens, suggesting that the outbreak was not successfully eliminated. The consistently high proportion of clustered sequences since the onset of the outbreak suggests the persistence of ongoing HIV-1 transmission attributed to injection practices. Our findings underscore the importance of targeted interventions among PWID, considering the ongoing transmission rate and prolonged time from infection to diagnosis.

Background: Mortality among people who inject drugs (PWID) is high, with overdose and HIV infection being the main causes of death. In Greece, there have been no data on mortality, and two HIV outbreaks have been recorded in this population in the past decade. In this study, we aim to estimate the all-cause crude mortality rate and the standardised mortality ratio in this population during 2018-2022. Methods: PWID recruited from two community-based programs in Athens and Thessaloniki during 2018-2021 were interviewed and tested for HIV/HCV. Data on vital status (deceased/alive) and date of death were obtained from death registries through December 31, 2022. All-cause crude mortality rates (CMR) and standardised mortality ratios (SMR) were estimated. Determinants of mortality were assessed using Cox proportional-hazards model. Results: Of 2,530 participants, 301 died over 8,543 person-years (PYs) of follow-up. The CMR (95 % CI) was 3.52 (3.15-3.94) deaths per 100 PYs; 3.10 per 100 PYs (2.68-3.58) in Athens and 4.48 per 100 PYs (3.74-5.37) in Thessaloniki. An increasing trend in CMR was identified over 2018-2022 in Athens (from 2.90 to 4.11 per 100 PYs, 41.5 % increase, p = 0.018). The pooled SMR (95 % CI) was 15.86 (14.17-17.76) for both cities and was particularly increased in younger individuals, females, those injecting daily, not enrolled to opioid agonist treatment and HIV -infected individuals. Older age, living in Thessaloniki, Greek origin, homelessness, history of injection in the past 12 months, and HIV infection were independently associated with higher risk of death. Conclusion: Mortality among PWID in the two largest cities (Athens and Thessaloniki) in Greece in 2018-2022 was high, with the population in Thessaloniki being particularly affected. The increasing trend in mortality in Athens may reflect the long-term impact of the COVID-19 pandemic. Preventive programs such as take-home naloxone, screening and treatment for HIV, are urgently needed.