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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.