Dr Antonio Boschini
Q. Dr Boschini, when San Patrignano community was established, how many people have been hosted since and what is the current rate of rehabilitation?
Since its foundation in 1979, San Patrignano has hosted around 20.000 drug addicts, mainly opioid addicts (> 80%), followed by cocaine addicts (35%), with 15% being addicted to both drugs. About 30% were also alcoholics. Eighty-six percent of inmates were injection drug users (PWID), whereas 14% used drugs (heroin and/or cocaine) through non-parenteral routes,ie smoking or inhaling drugs (NIDU). In the last 10 years, the number of NIDU relative to PWID has gradually increased, this year the two populations having the same prevalence (50%).
The residential program lasts 3 to 4 years, is drug and tobacco-free and is based on recovery as opposed to harm-reduction. Opioid treatment is in place only for slow detoxification of pregnant women and in AIDS or sickest patients. Twenty-five percent of inmates are on psychopharmacological treatment for coexisting psychiatric symptoms/disorders.
Our rate of retention in treatment is 68%. The long-term outcome as assessed two years after concluding the rehabilitation program was studied both in 1995 by the University of Bologna and in 2005 jointly by the University of Bologna and Urbino: in both studies, 70% of subjects who completed the residential program had remained abstinent from any drug as confirmed with hair-strand analysis in the 2nd study, becoming socially reintegrated. A third study is currently ongoing.
Q. What are the epidemiological features of the inmates and their dominant diseases?
In the beginning, from 1980 to 1990, HBV and HDV were the major cause of morbidity and mortality , followed by STD like Syphilis, Herpes and gonorrhea.
Between 1990 and 2000, HIV infection became the major health problem. At first serological survey in 1985, 66% of inmates included in the program were found to be HIV-positive, all asymptomatic. More than 500 people died from AIDS between 1990 and 1997, before highly-active antiretroviral therapy (HAART) became available. In 1993 a Medical Center was built within the Community including an Infectious Disease Unit with fifty beds.
In 1990, when the serological test for HCV became available, more than 90% of inmates (at that time nearly all PWID), tested anti-HCV seropositive. Currently, about 500/ 1300 people are HCV infected, 20% have already been treated with IFN regimens or DAAs, our plan being to treat those remaining during the current year with DAAs .
More recently, the emerging problem in the Community have been psychiatric and neurological disorders related to an increased use of neurotoxic drugs, including stimulants and high-potency cannabis.
Q. What surveillance and care mechanisms are in place to protect health of the inmates?
Upon entry, every subject undergoes a medical screening that includes: (a) taking a toxicological and clinical history; (b) medical examination; (c) chest x ray; (d) PPD skin test; (e) ECG; (f) spirometry; (g) blood chemistry analysis including tests for HIV, HBV, HCV, and Syphilis. HCV or HBV-positive subjects undergo US examination and full virological analysis. Since 1985, frozen serum & plasma samples from each individual have been stored. All data is collected in a computerized data bank, available for research purposes.
Q. What is the time trend of HBV, HCV and HIV infection among inmates?
HIV, HBV, and HCV infections are all clearly related to the use and sharing of syringes, but with different epidemiological patterns and trends. The relative risk of seroconversion comparing PWID and NIDU is 9.2, 14.0, and 122,4 for HIV, HBV, and HCV, respectively. This means that HCV infection is a very frequent and early event in PWID, whereas it is an extremely rare event in NIDUs. The risk of HCV infection peaks amongst PWID even among those not sharing syringes – probably being related to the sharing of paraphernalia (spoons, filters, etc.). Among PWIDs who never shared syringes, 64% tested HCV seropositive. By comparison, HCV tested positive in 82% of those who shared syringes only with a partner or trustworthy friend, and in 94% of those who shared syringes with other unknown PWID.
In the last few years, the incidence of HIV, HBV, and HCV infection declined among all cathegories of inmates , perhaps due to an increased awareness of the risk of blood-borne infection.
Currently, the sero-prevalence of HCV, HBV, and HIV is 34%, 0,6%, and 3,2% among all inmates (1.300 people), and 59,4%, 0,7%, and 7,2% among 750 PWIDs.
Q. What about HBV vaccination coverage?
In a recent epidemiological survey we reported an expected decrease in incidence of HBV infection (measured with the presence of HBc antibody alone, or along with HBs antibody or HBs antigen). The rate of infection has been decreasing steadily from a rate of nearly 100% in early 80’s, to below 60% after 1990, 40% after 2000, and down to less than 10% in the last five years. Considering the presence of isolated HBs antibody as evidence of previous vaccination, there was a progressive increase from less than 10% before 1990, to more than 40% after 2000, and nearly 80% in 2010,however followed by a gradual decrease in the subsequent years to reach less than 40% in 2015. Owing to the 10 iu/ml LLOQ cutoff of anti HBs adopted in the NSH labs, true anti HBs negatives cannot be discriminated from anti HBs below 10 iu positives.