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Increase in diagnosed newly acquired hepatitis C in HIV-positive men who have sex with men across London and Brighton, 2002–2006: is this an outbreak?

Objectives: To determine the incidence of diagnosed newly acquired hepatitis C virus (HCV) in HIV-positive men who have sex with men (MSM) across London and Brighton in order to inform public health interventions. Methods: Cases were defined as MSM attending London and Brighton HIV/genitourinary medicine clinics from January 2002 to June 2006, with HCV PCR RNA or antibody positive, and a negative HCV test in the previous three years. The yearly number of cases and HCV screening policy in MSM were examined. A negative binomial regression model was used to estimate HCV incidence density rate ratio and 95% CI. Results: 20 out of 38 clinics provided information, covering 84% of the HIV-positive MSM workload in London and 100% in Brighton. The estimated overall incidence was 9.05 per 1000 HIV-positive MSM patient-years. It increased from 6.86 per 1000 in 2002 to 11.58 per 1000 during January–June 2006. Incidence at clinics ranged from 0 to 15.4 (median 6.52) per 1000 HIV-positive MSM patient-years. There was some evidence of difference in the incidence and trend (p = 0.02) in each clinic. The average annual rise in incidence of HCV was 20% (95% CI 4% to 39%, p = 0.001). There was little evidence of such transmission among MSM with negative or unknown HIV status. Conclusions: HCV incidence clearly increased among HIV-positive MSM in London and Brighton during January 2002 to June 2006. Prospective enhanced surveillance of HCV in MSM, including HIV status and behavioural risk factors, is recommended to help inform control measures and better determine the frequency of transmission in all MSM.

Hepatitis C virus (HCV) prevalence, and injecting risk behaviour in multiple sites in England in 2004

Summary.  We sought to corroborate geographical differences in hepatitis C virus (HCV) prevalence and assess whether these can be explained by differences in injecting risk behaviour. A community recruited interview survey of 1058 injecting drug users (IDU) – including a blood spot specimen for antibody testing – was undertaken in seven cities in England. HCV prevalence varied from 27% to 74% across sites (χ2(6) = 115.3, P < 0.001). There was a significant variation in crack‐injection, prison history, injecting frequency, homelessness, groin injecting, syringe reuse and sharing between the sites. Adjustment for clustering by site and other covariates attenuated the odds ratios (OR) for most variables: e.g. crack injection changed from an unadjusted OR of >2 to an adjusted OR of 1.4 (95% CI 0.9–2.0). Remaining significant covariates included: homelessness (OR 2.2; 1.4–3.6); ever imprisonment (OR 1.7; 1.2–2.5); syringe sharing >18 months ago (OR 2.0; 1.3–3.0); injecting duration and age. Introducing site as a second level variable did not reach significance (P = 0.10). HCV prevalence among IDU reporting ‘never sharing’ was 48%. Geographical variation in HCV prevalence remains poorly explained, but should be the key focus of our surveillance effort. Measures of sharing and their interpretation require greater scrutiny.

Measuring the incidence, prevalence and genetic relatedness of hepatitis C infections among a community recruited sample of injecting drug users, using dried blood spots.

Summary.  Monitoring hepatitis C virus (HCV) infection among injecting drug users (IDUs) in the community is complicated by difficulties in obtaining biological specimens and biases in recruitment and follow‐up. This study examined the utility of dried blood spot (DBS) specimens from IDUs recruited using respondent‐driven sampling (RDS). Active IDUs underwent a computer‐assisted interview and provided a DBS sample, tested for HCV antibody (anti‐HCV) and HCV‐RNA. HCV incidence was estimated from the proportion of anti‐HCV‐negative subjects found HCV‐RNA‐positive and estimates of the duration of this state. Results were adjusted according to RDS derived sample weights. HCV‐RNA testing was performed on 288 DBS samples; 173 were anti‐HCV‐positive (54% weighted), of which 70 (42%, 95%CI 34–50% weighted) were RNA‐negative indicating cleared infection. Among the 115 anti‐HCV‐negatives, 14 were RNA‐positive suggesting an incidence of 38–47 per 100pyrs. Incident infections were younger than anti‐HCV‐negative and prevalent infections: 25 vs. 29 and 34, respectively. Incidence was highest among individuals with poor needle exchange coverage. One hundred and fourteen were genotyped (60 1a, 46 3a): a cluster of 14 had homology of >98.5% including 10 incident infections. Public health surveillance of HCV among IDUs could be enhanced through the collection of DBS samples with appropriate recruitment approaches. DBS allow differentiation between individuals with cleared infections, ongoing infection and those recently infected. They also enable virus characterization at genotype and nucleotide level. This would allow surveillance to inform development of harm reduction interventions, and the international evidence base for these.

Body piercing in England: a survey of piercing at sites other than earlobe

Objectives To estimate the prevalence of body piercing, other than of earlobes, in the general adult population in England, and to describe the distribution of body piercing by age group, sex, social class, anatomical site, and who performed the piercings. To estimate the proportion of piercings that resulted in complications and the proportion of piercings that resulted in professional help being sought after the piercing. Design Cross sectional household survey. Setting All regions of England 2005. Participants 10 503 adults aged 16 and over identified with a two stage selection process: random selection of geographical areas and filling predefined quotas of individuals. Results weighted to reflect the national demographic profile of adults aged 16 and over. Main outcome measures Estimates of the prevalence of body piercing overall and by age group, sex, and anatomical site. Estimates, in those aged 16-24, of the proportion of piercings associated with complications and the seeking of professional help. Results The prevalence of body piercing was 1049/10 503 (10%, 95% confidence interval 9.4% to 10.6%). Body piercing was more common in women than in men and in younger age groups. Nearly half the women aged 16-24 reported having had a piercing (305/659, 46.2%, 42.0% to 50.5%). Of the 754 piercings in those aged 16-24, complications were reported with 233 (31.0%, 26.8% to 35.5%); professional help was sought with 115 (15.2%, 11.8% to 19.5%); and hospital admission was required with seven (0.9%, 0.3% to 3.2%). Conclusions Body piercing is common in adults in England, particularly in young women. Problems are common and the assistance of health services is often required. Though serious complications requiring admission to hospital seem uncommon, the popularity of the practice might place a substantial burden on health services.

Recent trends in HIV and other STIs in the United Kingdom: data to the end of 2002

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49 500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

Frequency, factors and costs associated with injection site infections: Findings from a national multi-site survey of injecting drug users in England

BackgroundInjection site infections among injecting drug users (IDUs) have been associated with serious morbidity and health service costs in North America. This study explores the frequency, factors and costs associated with injection site infections among IDUs in England.MethodsUnlinked-anonymous survey during 2003/05 recruiting IDUs from community settings at seven locations across England. Self-reported injecting practice, symptoms of injection site infections (abscess or open wound) and health service utilisation data were collected using a questionnaire, participants also provided dried blood spot samples (tested for markers blood borne virus infections). Cost estimates were obtained by combining questionnaire data with information from national databases and the scientific literature.Results36% of the 1,058 participants reported an injection site infection in the last year. Those reporting an injection site infection were more likely to be female and aged over 24, and to have: injected into legs, groin, and hands in last year; injected on 14 or more days during the last four weeks; cleaned needles/syringes for reuse; injected crack-cocaine; antibodies to hepatitis C; and previously received prescribed substitute drug. Two-thirds of those with an injection site infection reported seeking medical advice; half attended an emergency department and three-quarters of these reported hospital admission. Simple conservative estimates of associated healthcare costs range from £15.5 million per year to as high as £30 million; though if less conservative unit costs assumptions are made the total may be much higher (£47 million). The vast majority of these costs are due to hospital admissions and the uncertainty is due to little data on length of hospital stays.ConclusionSymptoms of injection site infections are common among IDUs in England. The potential costs to the health service are substantial, but these costs need more accurate determination. Better-targeted interventions to support safer injection need to be developed and evaluated. The validity of self-reported symptoms, and the relationship between symptoms, infection severity, and health seeking behaviour require further research.

Hepatitis C Infection Among Injecting Drug Users in England and Wales (1992-2006): There and Back Again?

Changes in hepatitis C virus (HCV) prevalence from 1992 to 2006 were examined by using 24,311 records from unlinked anonymous surveillance of injecting drug users in England and Wales. Bayesian logistic regression was used to estimate annual prevalence, accounting for changing recruitment patterns (age, gender, injecting duration, geographic region, interactions) and the sensitivity and specificity of different oral fluid testing devices. After controlling for these differences, the authors found that the adjusted HCV prevalence decreased from 70% (95% credible interval: 62, 78) in 1992 to 47% (95% credible interval: 43, 51) in 1998 before rising again to 53% (95% credible interval: 48, 58) in 2006. Women injecting drug users had a higher HCV risk than did men (odds ratio = 1.50, 95% credible interval: 1.31, 1.73). Two regions (London and North West) had a markedly higher HCV prevalence than did the rest of England and Wales. Among individuals who had injected for less than 1 year, the adjusted HCV prevalence in 2006 was higher than that in 1992 (28% vs. 19%, respectively). HCV infection can be prevented. The public health challenge in England and Wales is to increase action in order to regain a downward trend in HCV risk and the benefit that has been lost since 1998.

Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study

Objective To describe drug use, sexual risks and the prevalence of blood-borne viral infections among men who inject image and performance enhancing drugs (IPEDs). Design A voluntary unlinked-anonymous cross-sectional biobehavioural survey. Setting 19 needle and syringe programmes across England and Wales. Participants 395 men who had injected IPEDs. Results 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). Conclusions 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.

A comparison between the force of infection estimates for blood-borne viruses in injecting drug user populations across the European Union: a modelling study.

Summary.  A number of studies have been conducted in injecting drug user (IDU) populations in Europe, in which the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) was measured together with demographic and epidemiological information such as age and the age at first injection. A measure of the risk of becoming infected is the force of infection (FOI), defined as the per capita rate at which susceptible individuals acquire infection. The objective of this study was to estimate the FOI and its heterogeneity for HBV, HCV and HIV (where available) for IDU populations in a number of countries in Europe. Data were obtained from five countries: Belgium, the United Kingdom, Spain and Italy, and the Czech Republic, which provided two data sets. The model describes the prevalence of infection as a function of the FOI that may vary over time or duration of IDU. In addition to this, if two or more infections were being considered then a parameter describing the potential heterogeneity of the FOI within the IDU population was also estimated. The results here add to the growing evidence that new initiates to injecting are at an increased risk of blood‐borne viral infection compared with more experienced IDUs. In addition, there is evidence of individual heterogeneity of FOI estimates within the overall IDU populations. This suggests that different proportions of individuals in each population are at increased risk of infection compared with the rest of the population. Future interventions should identify and target these individuals. Moreover, changes over time in individual heterogeneity estimates of IDU populations may provide an indicator for measuring intervention impacts.

Wound botulism in injectors of drugs: upsurge in cases in England during 2004.

Wound infections due to Clostridium botulinum were not recognised in the UK and Republic of Ireland before 2000. C. botulinum produces a potent neurotoxin which can cause paralysis and death. In 2000 and 2001, ten cases were clinically recognised, with a further 23 in 2002, 15 in 2003 and 40 cases in 2004. All cases occurred in heroin injectors. Seventy cases occurred in England; the remainder occurred in Scotland (12 cases), Wales (2 cases) and the Republic of Ireland (4 cases). Overall, 40 (45%) of the 88 cases were laboratory confirmed by the detection of botulinum neurotoxin in serum, or by the isolation of C. botulinum from wounds. Of the 40 cases in 2004, 36 occurred in England, and of the 12 that were laboratory confirmed, 10 were due to type A. There was some geographical clustering of the cases during 2004, with most cases occurring in London and in the Yorkshire and Humberside region of northeast England.