Injecting drug use and infections.

Vivian HopeIDU Team, HIV & STI Department, Health Protection Services – Colindale

Dr Vivian Hope, Dr Fortune Ncube & Katelyn CullenInjecting Drug Use Team, HIV & STI Department,

Centre for Infectious Disease Surveillance and Control,

Public Health England.

Part 1

BBV and bacterial infections among people who inject psychoactive drug injectors

UAM Survey of People Who Inject Drugs (PWID)

Started in England & Wales in 1990 as a response to the HIV epidemic ( + Northern Ireland since 2002).

Uses the Voluntary Unlinked & Anonymous method.

Recruits PWID through sentinel collaborating drug services (e.g. needle & syringe programmes (NSPs); maintenance & prescribing programmes; etc.).

Involves collaborating services in approximately 45 English DATs each year (recruiting in about 60 locations).

Recruits participants (current & former injectors) to provide a biological sample and self-complete a brief questionnaire.

Survey Aims to:1. measure the prevalence of HIV and viral hepatitis in PWID.2. monitor changes in related behaviours.

HIV prevalence among PWID, England & Wales.

Data source: UAM Survey of PWID.

Hepatitis C and Hepatitis B prevalence among PWID, England & Wales.

Data source: UAM Survey of PWID.

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1980 1985 1990 1995 2000 2005 2010Year

1st year injecting

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IV1980 1985 1990 1995 2000 2005 2010

Year

7 years injectingLondon

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1980 1985 1990 1995 2000 2005 2010Year

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1980 1985 1990 1995 2000 2005 2010Year

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Estimated HIV & HCV incidence among PWID, England & Wales.

Data source: UAM Survey of PWID.Incidence modelled in a Bayesian framework using prevalence by time since first injection jointly for HIV and hepatitis C. Hope et al, Forthcoming.

Spore forming bacterial infections among PWID: UK

0

10

20

30

40

50

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Reported cases of Wound Botulism Reported cases of Tetanus Reported cases of Anthrax

Now - 1

Current HIV prevalence probably stable – at around 1.0% to 1.5%.

Current HIV incidence less clear, but also probably stable.

Majority (~80%) of PWID living with HIV are aware of their infection.

Hepatitis C prevalence – probably stable – but only half aware of their infection.

Around 1 in 17 are infected with hepatitis C for the first time each year.

Uptake of Voluntary Confidential testing for hepatitis C & proportion aware of their status: England

Data source: UAM Survey of PWID.

Now - 2

Hepatitis B – ever infection declining – mainly due to vaccination.

Very few with current hepatitis B infection (<1%).

Spore forming bacteria – so far in 2013, two probable tetanus cases, but no cases of anthrax or wound botulism among PWID.

Proportion reporting a ‘sore’ at injection site during the last year may be declining (28%, down from 38% in 2007).

Hepatitis B vaccine uptake: England

Data source: UAM Survey of PWID.

Sharing of injecting equipment has been declining.

Trends in sharing among current* PWID in England, Wales & NI: 2000-2011

* Those who had last injected in the four weeks preceding participation in the survey. Data source: UAM Survey of PWID.

Coverage of Needle and Syringe Programmes (NSP).

NSP are providing sterile injecting equipment throughout the UK.

• In England, an indirect measure of NSP coverage indicated that for 57% of PWID surveyed, the number of needles received from NSP was greater than the number of times they had injected.

• In Scotland, during 2009/10 approximately 4.7 million needles/syringes were distributed by 255 sites (up from 3.6 million by 188 sites in 2004/05). Estimated number distributed to each PWID during 2009/10 was approximately 200, less than the estimated average of 465 injections per year.

• In Wales, there were 247 NSP sites operating in 2011, which distributed 5,140,219 needles/syringes.

• In Northern Ireland, the number of packs dispensed by NSP increased to 25,530 in 2011/12; this is around 10,000 more than in 2007/08.

These data show that NSP provision in the UK is extensive, and that provision has increased. However, they also indicate a need to further increase the amount of equipment distributed.

 

Risks

Indicators of risk

Among those who injected in the last month: -  

Injected with cleaned works 32%

Injected crack-cocaine 32%

Injected into groin 35%

Had sex last year 73%

Men reporting male partner(s) in last year 5%

Ever homeless In last year

77%28%

Ever imprisoned (Data from 2010 suggest 1 in 5 imprisoned during preceding year year)

71%

Data source: UAM Survey of PWID.

Factors associated with recent hepatitis C infection

N

Recent Infection

Adjusted Odd Ratios (OR)

n % OR 95% CI

GenderMale 750 12 1.6% 1.0

Female 230 8 3.5% 3.8 1.4- 10

Anti-HBcDetected 56 5 8.9% 6.3 2.1- 18

Not detected 924 15 1.6% 1.0

Had ever been to prison

No 362 3 0.8% 1.0

Yes, 1-4 times 405 9 2.2% 3.7 0.95- 14

Yes, >=5 times 213 8 3.8% 8.7 2.0- 37

Cullen et al. Forthcoming

Forthcoming Data & Reports

Dates to be confirmed:-

•UAM Survey of PWID annual data tables (data to end of 2012) - around 19 July.

•Hepatitis C in the UK report - around 25 July.

•‘Shooting Up’ report - early November – proposed focus this year is on the possible impacts of the changing patterns of injecting drug use on infections.

•HIV in the UK report - late November.

Part 2

Injecting is changing

IPEDs are used to change physical appearance or improve performance / strength.

This sub-group of people who inject drugs (PWID) is rarely studied.

Anabolic steroids (AS) are probably the most commonly used type of IPED.

Drug (2011/12)Last year

Ever

Anabolic steroids 70,000 228,000

Heroin 47,000 255,000

‘All’ & ‘new’ clients attending agency based Needle and Syringe Programmes (NSPs) in

Cheshire & Merseyside: 1991-2011.

Image and Performance Enhancing Drug (IPED) Injecting

British Crime Survey, 2012

IPED injection and risk

A wide range IPED are used and injected. The Anabolic Steroids are the mostly commonly used and injected, but there is a wide range of others.

A recent study of 395 male IPED injectors (undertake by PHE with LJMU & Public Health Wales) found:-

IPEDs injected: Anabolic steroids (86%); growth hormone (32%); hCG (16%); Insulin (6%); Melanotan I/II (9%).

IPED taken orally: Anabolic steroids (57%); Anti–oestrogens (23%); Clenbuterol (15%); Ephedrine (20%); Phosphodiesterase type 5 inhibitors ("Viagra /Cialis“, 7%).

Overall, 9% had ever shared injecting equipment.

High levels of sexual activity, condom use poor; 3% had sex with a man in the past year.

High levels of non-injecting psychoactive drug use in past year: 46% cocaine, 12% amphetamine. 5% had ever injected a psychoactive drug.

Hope et al. Forthcoming

5.5%

8.8%

1.5%

0%

5%

10%

15%

Anti-HCVpositive*

Anti-HBcpositive*

Anti-HIVpositive

Pre

vale

nce

*Adjusted to test sensitivity

Markers of BBV infectionNote: Oral Fluid sample test sensitivity for anti-HBc is 75% and anti-HCV

92%.

Among the male injectors of psychoactive drugs taking part in the UAM Survey in 2011:

45% (95%CI 43%-48%) had anti-HCV;

16% (95%CI 14% -18%) had anti-HBc;

1.4% (95% CI 0.88% -2.2%) had anti-HIV.

Hope et al. HIV Medicine 2013, & Forthcoming

New Psychoactive Drugs

These are mostly not injected. However, there is increasing concern about the injection of these – particularly Mephedrone (M-Cat) and Ketamine.

Injecting Ketamine not new, but this had been ‘rare’ – but the numbers may be increasing.

First reports of Mephedrone injection in the UK in ~2011 – currently appears to be localised in a few areas.

Injecting synthetic cathinones –like Mephedrone – associated with recent HIV outbreak in Romania.

Injecting drug use among MSM

There have recently been concerns about the changing patterns of drug use among some sub-groups of MSM.

Particularly the use of new psychoactive drugs and the increased use of methamphetamine.

Injecting relatively rare among gay and bisexual identified men.

There is emerging evidence of a small number of MSM – mostly HIV positive gay identified men – ‘slamming’ (injecting methamphetamine) often in the context of ‘sex parties’. Concerns about transmission of STIs and hepatitis C.