Download Injecting drug use and infections

Injecting drug use and
infections.
Dr Vivian Hope, Dr Fortune Ncube & Katelyn Cullen
Vivian Hope
Injecting Drug Use Team, HIV & STI Department,
IDU Team, HIV & STI Department,
Centre
Infectious Disease
and Control,
HealthforProtection
ServicesSurveillance
– Colindale
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.
Proportion with antibodies to HIV (%)
5%
4%
3%
HIV prevalence higher in London:
typically around four times higher
than in the rest of England &
Wales.
In 2011, HIV prevalence among
PWID was 3.9% in London, 0.9%
elsewhere.
2%
1%
0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Survey Year
Data source: UAM Survey of PWID.
Hepatitis C and Hepatitis B prevalence among
PWID, England & Wales.
100%
Anti-HBc
Anti-HCV
80%
60%
40%
20%
0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Data source: UAM Survey of PWID.
Estimated HIV & HCV incidence among PWID,
England & Wales.
London
.7
.6
.2
HCV
.3
.4
.5
.06
1980
1985
1990
1995
2000
2005
2010
0
0
.1
.02
0
0
.1
.02
.2
.04
HCV
.3
.4
HIV
.04
.5
.06
.6
.7
.08
7 years injecting
.08
1st year injecting
1980
1985
1990
Year
1995
2000
2005
2010
2005
2010
Year
Rest of E&W
1980
1985
1990
1995
Year
2000
2005
2010
0
0
.1
.1
.005
0
0
.005
.2
HCV
.3
HCV
.3
HIV.015
.01
.4
.02
.5
.5
.025
7 years injecting
.2
.01
.015
.4
.02
.025
1st year injecting
1980
1985
1990
1995
Year
2000
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
Reported cases of Wound Botulism
Reported cases of Tetanus
Reported cases of Anthrax
50
Number of cases
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
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
100%
Direct sharing of needles and syringes
Indirect sharing of needles and syringes as well as other injecting paraphernalia
Proportion reporting sharing (%)
80%
60%
40%
20%
0%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Survey Year
* 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
77%
In last year
28%
Ever imprisoned
(Data from 2010 suggest 1 in 5 imprisoned during preceding year year)
Data source: UAM Survey of PWID.
71%
Factors associated with recent
hepatitis C infection
N
Recent
Infection
Adjusted Odd Ratios
(OR)
n
%
OR
95% CI
Male
750
12
1.6%
1.0
Female
230
8
3.5%
3.8
1.4- 10
Detected
56
5
8.9%
6.3
2.1- 18
Not detected
924
15
1.6%
1.0
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
Gender
Anti-HBc
Had ever been to
prison
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
Image and Performance Enhancing
Drug (IPED) Injecting
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
British Crime Survey, 2012
‘All’ & ‘new’ clients attending agency based
Needle and Syringe Programmes (NSPs) in
Cheshire & Merseyside: 1991-2011.
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
Markers of BBV infection
Note: Oral Fluid sample test sensitivity for anti-HBc is 75% and anti-HCV 92%.
15%
Among the male injectors of
psychoactive drugs taking
part in the UAM Survey in
2011:
Prevalence
10%
8.8%
5%
45% (95%CI 43%-48%) had
anti-HCV;
5.5%
16% (95%CI 14% -18%) had
anti-HBc;
1.5%
0%
Anti-HCV
positive*
Anti-HBc
positive*
Anti-HIV
positive
1.4% (95% CI 0.88% -2.2%)
had anti-HIV.
*Adjusted to test sensitivity
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.