[Show abstract][Hide abstract] ABSTRACT: Background
We provide the first national prevalence estimate of sex work among people who inject drugs (PWID) in England, Wales and Northern Ireland and investigate to what extent sex work is associated with blood-borne virus (BBV) infection.
PWID, recruited through drug services, provided a dried-blood spot and completed a questionnaire. Demographics and risk behaviours were examined by gender and sex work status. Factors associated with BBV infection were explored using logistic regression.
Among 2,400 PWID (75% men), 14% had experience of sex work (men: 8%; women: 31%). Sex workers (SWs) had been injecting longer than non-SWs (men: 14 vs. 12 years; women: 11 vs. 6 years) and more frequently shared needles/syringes (men: 23% vs. 14%; women: 28% vs. 18%). Proportionally more male SWs were non UK-born (12% vs. 7%) and had more same-sex partners (19% vs. 3%) than non-SWs. Among women, more SWs had a recent injection-site infection (46% vs. 31%), been imprisoned (58% vs. 48%) or homeless (57% vs. 40%). Sex work was not associated with BBV infection.
Services, including needle and syringe programmes, need to cater for the gendered differences in vulnerabilities among PWID, specifically addressing the complex needs of SWs.
International Journal of Drug Policy 10/2014; · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: SUMMARY Monitoring infections and risk in people who inject drugs (PWID) is important for informing public health responses. In 2011, a novel hepatitis C antibody (anti-HCV) avidity-testing algorithm to identify samples compatible with recent primary infection was introduced into a national surveillance survey. PWID are recruited annually, through >60 needle-and-syringe programmes and prescribing services. Of the 980 individuals that could have been at risk of HCV infection, there were 20 (2%) samples that were compatible with recent primary infection. These were more common among: those imprisoned ⩾5 times [8/213; adjusted odds ratio (aOR) 8·7, 95% confidence interval (CI) 2·04-37·03]; women (8/230; aOR 3·8, 95% CI 1·41-10·38); and those ever-infected with hepatitis B (5/56; aOR 6·25, 95% CI 2·12-18·43). This study is the first to apply this algorithm and to examine the risk factors associated with recently acquired HCV infection in a national sample of PWID in the UK. These findings highlight underlying risks and suggest targeted interventions are needed.
Epidemiology and Infection 08/2014; · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.
Methods and Findings: We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7–28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally ‘difficult to treat’ genotypes (G1+G4) showed large variation (median 53, IQR 43–62). Twelve countries reported on HCV chronicity (median 72, IQR 64–81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2–28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38–64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5–15). Burden of disease, where assessed, was high and will rise in the next decade.
Conclusion: Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.
PLoS ONE 07/2014; 9(7):e103345. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Responses to injecting drug use have changed focus over the last 20 years. Prevalence and incidence of human immunodeficiency virus (HIV) among people who inject drugs (PWID) in England and Wales were examined in relation to these changes. A voluntary unlinked-anonymous surveillance study obtained a biological sample and questionnaire data from PWID through annual surveys since 1990. Prevalence and incidence trends were estimated via generalised linear models, and compared with a policy time-line. Overall HIV prevalence among 38,539 participations was 1.15%. Prevalence was highest among those who started injecting before 1985; throughout the 1990s, prevalence fell in this group and was stable among those who started injecting later. Prevalence was higher in 2005 than 2000 (odds ratio: 3.56 (95% confidence interval (CI) 1.40–9.03) in London, 3.40 (95% CI 2.31–5.02) elsewhere). Estimated HIV incidence peaked twice, around 1983 and 2005. HIV was an important focus of policy concerning PWID from 1984 until 1998. This focus shifted at a time when drug use and risk were changing. The increased incidence in 2005 cannot be ascribed to the policy changes, but these appeared to be temporally aligned. Policy related to PWID should be continually reviewed to ensure rapid responses to increased risk
Euro surveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 04/2014; 19(14):pii=20762. · 5.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: SUMMARY People who inject drugs are vulnerable to infections and injuries at injection sites, but these have rarely been studied in those injecting image- and performance-enhancing drugs (IPEDs). This study examined the factors associated with reported symptoms of injection site infections and injuries in IPED injectors. Of the 366 male IPED injectors surveyed, 42% reported ever having redness, swelling and tenderness (36% in the preceding year), and 6·8% had ever had an abscess or open wound at an injection site. Having these symptoms was associated with a range of factors related to drug use and healthcare utilization. One sixth (17%) of those reporting redness, tenderness and swelling had ever sought treatment, as had the majority (76%) of those reporting an abscess, sore or open wound. Most common sources of advice were emergency clinics and General Practitioners. Interventions are needed to support access to appropriate injecting equipment and provide targeted harm reduction advice.
Epidemiology and Infection 04/2014; · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
People who inject drugs (PWID) are at risk of injection site infections and injuries. The factors associated with recent symptoms of these problems are examined.
PWID recruited using respondent driven sampling, underwent a computer-assisted interview and provided a dried-blood spot sample. Weight data were examined using logistic regression.
The mean age of the 855 participants was 32 years, and 25% were women. During the preceding 28 days, 94% had injected heroin and 50% crack-cocaine; with 41% injecting into their arms and 47% their groin. The passing on of used needles/syringes was reported by 9.7% and receiving by 8.0%. During the preceding 28 days, 21% reported having redness, swelling and tenderness, 6.1% an abscess, and 5.2% a sore/open wound at an injection site; with a quarter (24%) reporting one or more of these. A range of factors were associated with these symptoms; all three symptoms were associated with more frequent injection and the use of multiple injection sites; two of the symptoms were also associated with having recently overdosed and the use of particular injection sites.
Injection site infections and injuries are common among PWID and targeted interventions are needed to reduce risk
International Journal of Drug Policy 03/2014; 25(2):303-307. · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: SUMMARY People who inject drugs (PWID) are vulnerable to infections and injuries at injection sites. The factors associated with reporting symptoms of these, seeking related advice, and hospital admission are examined. PWID were recruited in Birmingham, Bristol and Leeds using respondent-driven sampling (N = 855). During the preceding year, 48% reported having redness, swelling and tenderness (RST), 19% an abscess, and 10% an open wound at an injection site. Overall, 54% reported ⩾1 symptoms, with 45% of these seeking medical advice (main sources emergency departments and General Practitioners). Advice was often sought ⩾5 days after the symptom first appeared (44% of those seeking advice about an abscess, 45% about an open wound, and 35% for RST); the majority received antibiotics. Overall, 9·5% reported hospital admission during the preceding year. Ever being diagnosed with septicaemia and endocarditis were reported by 8·8% and 2·9%, respectively. Interventions are needed to reduce morbidity, healthcare burden and delays in accessing treatment.
Epidemiology and Infection 02/2014; · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The sharing and reuse of injecting equipment are associated with acquiring infections. Even in countries with large-scale needle and syringe programmes (NSP), injections using cleaned needles/syringes continue.
People who inject drugs recruited through services completed a short questionnaire and provided a dried blood spot sample. Factors associated with injecting using cleaned needles/syringes in 2011-12 were explored using logistic regression.
Of the 2,283 participants who had injected during the preceding 28 days (mean age 34.5 years, 23% women), 71% had ever been imprisoned and 37% had recently been homeless. Overall during the preceding 28 days, 34% reported injecting with a needle/syringe that had been cleaned, and 36% had shared any injecting equipment. Of those who had shared, 51% reported injecting with cleaned needles/syringes, compared with 24% of those not sharing. In the multi-variable analysis, injecting using a cleaned needle/syringe was associated with: sharing injecting equipment, injecting more frequently, injecting into hands, injecting crack-cocaine, recent abscess/open wound, homelessness, and poor NSP coverage.
The associations suggest that sub-groups are at particular risk. Using a cleaned needle/syringe could be due to issues with managing injecting equipment supply. Policy should promote good injecting equipment management and use of appropriate cleaning methods.
The International journal on drug policy 01/2014; · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe drug use, sexual risks and the prevalence of blood-borne viral infections among men who inject image and performance enhancing drugs (IPEDs).
A voluntary unlinked-anonymous cross-sectional biobehavioural survey.
19 needle and syringe programmes across England and Wales.
395 men who had injected IPEDs.
Of the participants (median age 28 years), 36% had used IPEDs for <5 years. Anabolic steroids (86%), growth hormone (32%) and human chorionic gonadotropin (16%) were most frequently injected, with 88% injecting intramuscularly and 39% subcutaneously. Two-thirds also used IPEDs orally. Recent psychoactive drug use was common (46% cocaine, 12% amphetamine), 5% had ever injected a psychoactive drug and 9% had shared injecting equipment. 'Viagra/Cialis' was used by 7%, with 89% reporting anal/vaginal sex in the preceding year (20% had 5+ female-partners, 3% male-partners) and 13% always using condoms. Overall, 1.5% had HIV, 9% had antibodies to the hepatitis B core antigen (anti-HBc) and 5% to hepatitis C (anti-HCV). In multivariate analysis, having HIV was associated with: seeking advice from a sexual health clinic; having had an injection site abscess/wound; and having male partners. After excluding those reporting male partners or injecting psychoactive drugs, 0.8% had HIV, 8% anti-HBc and 5% anti-HCV. Only 23% reported uptake of the hepatitis B vaccine, and diagnostic testing uptake was poor (31% for HIV, 22% for hepatitis C).
Previous prevalence studies had not found HIV among IPED injectors. HIV prevalence in this, the largest study of blood-borne viruses among IPED injectors, was similar to that among injectors of psychoactive drugs. Findings indicate a need for targeted interventions.
BMJ Open 09/2013; 3(9):e003207. · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: People who inject drugs’ vulnerability to infection is widely
recognised; however, studies have rarely focused on image and performance
enhancing drug (IPED) use. IPEDs, such as anabolic steroids, are used for
cosmetic and aesthetic reasons, as well as to improve athletic performance. In
the United Kingdom, Needle and Syringe Programme (NSP) use by IPED
injectors has grown substantially, and in many areas the majority of NSPs
users are now IPED injectors.
Methods: A voluntary unlinked-anonymous survey recruited male IPED
injectors through 19 NSPs. Participants completed a questionnaire and
provided an oral-fluid sample.
Findings: Of the 395 participants (median age 28 years) 36% had used IPEDs
for <5 years. Anabolic steroids (86%), growth hormone (32%) human chorionic
gonadotropin (16%) and melanotan I/II (8.6%) were most frequently injected;
with 88% injecting intramuscularly and 39% subcutaneously. Two-thirds also
used IPEDs orally (57% anabolic steroids; 23% anti-oestrogens; and 20%
ephedrine). Overall, 133 (34%) had used _3 types of IPED during the
preceding year. Recent psychoactive drug use was common (46% cocaine,
12% amphetamine); and 5% had ever injected a psychoactive drug.
Phosphodiesterase type 5 inhibitors (“Viagra/Cialis”) were used by 7%; with
86% reporting sex in the preceding year (20% had 5+ female-partners, 3%
male-partners). Injection site problems were common. Overall 1.5% had anti-
HIV, 9% anti-HBc, and 5% anti-HCV, with multivariate analyses indicating
sexual behaviours and psychoactive drug use as risks. Anti-HIV positivity was
associated with: older age; seeking advice from a sexual health or STI clinic
during the preceding year; ever had an abscess, sore or open wound at the
injection site; and having had male sexual partners. However, 9% had ever
shared injecting equipment (including drug vials).
Conclusions: Previous prevalence studies had not found HIV among IPED
injectors. The HIV prevalence in this, the largest study of BBVs among IPED
injectors, was similar to that among injectors of psychoactive drugs in the
United Kingdom. Anti-HBc prevalence was about four times higher than found
in a smaller study undertaken in the 1990’s. The findings suggest that level of
infection may be increasing, and indicate a need for targeted interventions.
Those providing voluntary confidential testing and care related to HIV should
be alert to the use of IPEDs.
19th Annual Conference of the British HIV Association (BHIVA), Manchester, UK, 16–19 April 2013; 04/2013
[Show abstract][Hide abstract] ABSTRACT: Since 2000 in the United Kingdom, infections caused by spore-forming bacteria have been associated with increasing illness and death among persons who inject drugs (PWID). To assess temporal and geographic trends in these illnesses (botulism, tetanus, Clostridium novyi infection, and anthrax), we compared rates across England and Scotland for 2000-2009. Overall, 295 infections were reported: 1.45 per 1,000 PWID in England and 4.01 per 1,000 PWID in Scotland. The higher rate in Scotland was mainly attributable to C. novyi infection and anthrax; rates of botulism and tetanus were comparable in both countries. The temporal and geographic clustering of cases of C. novyi and anthrax into outbreaks suggests possible contamination of specific heroin batches; in contrast, the more sporadic nature of tetanus and botulism cases suggests that these spores might more commonly exist in the drug supply or local environment although at varying levels. PWID should be advised about treatment programs, injecting hygiene, risks, and vaccinations.
[Show abstract][Hide abstract] ABSTRACT: Healthcare workers (HCWs) are at significant risk of exposure to blood-borne viruses (BBV).
To investigate HCW perceptions concerning occupational exposures to BBV and possible barriers involved in reporting incidents.
A total of 120 HCWs based at the Dental Institute, King's College Hospital NHS Foundation Trust, completed an anonymous questionnaire as part of a multicentre study.
Eighty-six percent (99/115) of respondents worried about developing a BBV infection at work. Of those who feared hepatitis C virus (HCV) the most, 69% (31/45) also believed that HCV posed the greatest risk to their health, versus 53% (10/19) and 13% (5/40) with regard to hepatitis B virus (HBV) and HIV infection, respectively (P < 0.001). Of respondents with ≥21 years of health service experience, 75% (18/24) knew the risk of HIV transmission versus 13% (2/16) of respondents with <5 years of health service experience (P = 0.002). All (23/23) respondents with ≥21 years of service were aware of HIV PEP versus 20% (12/60) with <21 years of service. Ninety-two percent of respondents (104/113) agreed that it was important to report all body fluid exposure incidents but only 58% (28/48) had reported all their exposure incidents. Fifty-nine percent (60/102) agreed that an electronic reporting system would improve reporting of such incidents.
This study identified a need to improve HCWs' knowledge of BBV infection risks and their management. Data gathered in this study will be used to inform the development of a web-based system for the surveillance of occupational exposures to BBV in the UK.
The Journal of hospital infection 07/2012; 82(1):36-9. · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the UK, although transmission of HIV among injecting drug user (IDUs) has been limited since the 1980s, IDUs and men who have sex with men (MSM) have higher HIV and hepatitis C virus (HCV) prevalences than the general population. MSM who are also IDUs (MSM-IDUs) may therefore have a higher risk of infection than male IDUs who only have sex with women.
Analysis of data from a national survey of IDUs attending services (England, Wales and Northern Ireland) between 1998 and 2007, which collected demographic and behavioural data and oral fluid samples for HIV and HCV antibody testing.
Of the 8671 men who reported injecting drugs and having sex during the preceding year, 96% (8354) were men who only had sex with women (MSW). MSM-IDUs and MSW-IDUs had similar age and number of years of injecting. MSM-IDUs had a higher prevalence of HIV (adjusted OR=4.08, 95% CI 1.9 to 8.5) and of HCV (adjusted OR =1.34, 95% CI 1.1 to 1.8) and were about four times (adjusted OR =3.78, 95% CI 2.9 to 4.9) more likely to have unprotected sex with multiple partners. Among those who injected in the 4 weeks prior to participation, the MSM-IDUs had a higher level of needle/syringe sharing (adjusted OR =1.72, 95% CI 1.3 to 2.2).
MSM-IDUs have a fourfold higher risk of HIV; HCV prevalence in MSM-IDUs is a third higher than among MSW-IDUs, suggesting elevated risk from injecting and possibly sexual transmission. These findings emphasise the need for public health interventions specifically targeted at MSM-IDUs.
[Show abstract][Hide abstract] ABSTRACT: In many high income countries men who have sex with men (MSM) and injecting drug users (IDUs) are the two groups with the highest HIV prevalence. Yet these two groups are not mutually exclusive, and those MSM who are also IDUs (MSM-IDUs) may be particularly vulnerable to HIV infection. This may be particularly relevant to the IDU population in countries, like the UK, with a much lower HIV prevalence amongst IDUs than MSM, as the MSM-IDUs could provide a route of HIV infection into the IDU population. In this research two alternative modelling approaches that describe the transmission dynamics of HIV within the IDU, MSM, and heterosexual populations are proposed. These models are constructed with two aims. The first is to investigate the possible impact of interventions that target HIV transmission in the MSM and IDU populations, and the second aim is to investigate the impact of the model structure on the model results. An examination of the assortativity of mixing between risk groups is also undertaken. The models are parameterised for England and Wales. While the MSM-IDU population is small, targeting MSM-IDUs was the most efficient intervention strategy in terms of cases averted per 100 individuals targeted with the intervention. Sensitivity analysis showed that variations in the assumed assortativity of mixing between the population groups in both models have a large impact on model results. This means that to generate quantitatively robust estimates for the impact of different intervention strategies it will be necessary to obtain estimates for assortativity values through empirical work.
[Show abstract][Hide abstract] ABSTRACT: Around 80% of hepatitis C virus (HCV) infections in England are among injecting drug users (IDUs). The HCV Action Plan launched in 2004 includes targets to reduce HCV prevalence in recent initiates (those starting injecting in the preceding 3 years), and to increase HCV voluntary confidential testing (VCT). The Action Plan's impact is examined using surveillance data from recent initiates participating in an annual survey of IDUs in contact with specialist services across England, 2000-2008. Participants provided an oral fluid sample (tested for anti-HCV) and completed a short questionnaire (including HCV VCT and result of last test). Overall, anti-HCV prevalence among the recent initiates was 18% (619/3463); in 2004, it was 20% (59/291), other than being lower in 2000 [11%, 73/672, adjusted odds ratio (AOR) = 0.63 95%CI 0.42-0.93] there was no change over time. Prevalence increased with age; was higher among those ever imprisoned, using a needle exchange, and having a HCV VCT; and varied by region. Overall, 42% (1460) had ever had a HCV VCT; in 2004 uptake was 45% (130/291) having increased from 26% (175/672, AOR = 0.57 95%CI 0.42-0.77) in 2000, and it rose to 62% (197/320, AOR = 2.12 95%CI 1.50-2.99) in 2008. The proportion of anti-HCV-positive IDUs aware of their infection was higher in 2006-2008 than in earlier years. The HCV Action Plan has probably helped increase recent initiates' uptake of HCV VCT and the proportion of those diagnosed with HCV infection. However, its impact on HCV transmission is unclear. There is a need to reinvigorate, and improve coverage of, interventions to prevent HCV transmission.
Journal of Viral Hepatitis 01/2012; 19(1):55-64. · 3.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The recent anthrax outbreak among injecting drug users (IDUs) in Europe has highlighted an ongoing problem with severe illness resulting from spore-forming bacteria in IDUs. We collated the numbers of cases of 4 bacterial illnesses (botulism, tetanus, Clostridium novyi, and anthrax) in European IDUs for 2000 to 2009 and calculated population rates. Six countries reported 367 cases; rates varied from 0.03 to 7.54 per million people. Most cases (92%) were reported from 3 neighboring countries: Ireland, Norway, and the United Kingdom. This geographic variation needs investigation.
American Journal of Public Health 11/2011; 102(1):122-5. · 3.93 Impact Factor