Katelyn J. Cullen

Hepatitis C Virus Infection Epidemiology among People Who Inject Drugs in Europe: A Systematic Review of Data for Scaling Up Treatment and Prevention

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.

Factors associated with recently acquired hepatitis C virus infection in people who inject drugs in England, Wales and Northern Ireland: new findings from an unlinked anonymous monitoring survey.

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.

Is the recent emergence of mephedrone injecting in the United Kingdom associated with elevated risk behaviours and blood borne virus infection

The recent, and rapid, emergence of injection of the short-acting stimulant mephedrone (4-methylmethcathione) has resulted in concerns about increased infection risks among people who inject drugs (PWID). Data from the bio-behavioural surveillance of PWID in the United Kingdom were analysed to examine the impact of mephedrone injection on infections among PWID. During the year preceding the survey, 8.0% of PWID (163/2,047) had injected mephedrone. In multivariable analyses, those injecting mephedrone were younger, less likely to have injected opiates, and more likely to have injected cocaine or amphetamines, used needle/syringe programmes or sexual health clinics, been recruited in Wales and Northern Ireland or shared needles/syringes. There were no differences in sexual risks. Those injecting mephedrone more often had hepatitis C antibodies (adjusted odds ratio (AOR) = 1.51; 95% confidence interval (CI): 1.08-2.12), human immunodeficiency virus (AOR = 5.43; 95% CI: 1.90-15.5) and overdosed (AOR = 1.70; 95% CI: 1.12-2.57). There were no differences in the frequency of injecting site infections or prevalence of hepatitis B. The elevated levels of risk and infections are a concern considering its recent emergence. Mephedrone injection may currently be focused among higher-risk or more vulnerable groups. Targeted responses are needed to prevent an increase in harm.

Sex work amongst people who inject drugs in England, Wales and Northern Ireland: Findings from a National Survey of Health Harms and Behaviours

a b s t r a c t Background: We provide the first national prevalence estimate of sex work amongst people who inject drugs (PWID) in England, Wales and Northern Ireland and investigate to what extent sex work is associ- ated with blood-borne virus (BBV) infection. Methods: PWID, recruited through drug services, provided a dried-blood spot and completed a ques- tionnaire. Demographics and risk behaviours were examined by gender and sex work status. Factors associated with BBV infection were explored using logistic regression. Results: Amongst 2400 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. Amongst 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. Conclusion: Services, including needle and syringe programmes, need to cater for the gendered differences in vulnerabilities amongst PWID, specifically addressing the complex needs of SWs.

Risk of HIV and Hepatitis B and C Over Time Among Men Who Inject Image and Performance Enhancing Drugs in England and Wales: Results From Cross-Sectional Prevalence Surveys, 1992-2013.

Background:Infection risks among people who inject drugs (PWID) are widely recognized, but few studies have focused on image and performance enhancing drugs (IPEDs). Globally, concern about IPED injection has increased and, in the United Kingdom, IPED injectors have become the largest group using Needle and Syringe Programmes. Blood-borne virus prevalence trends among IPED injectors are explored. Method:Data from 2 surveys of IPED injectors (2010–2011; 2012–2013) and the national bio-behavioral surveillance system for PWID (1992–1997; 1998–2003; 2004–2009) were merged. Psychoactive drug injectors and women were excluded. Logistic regression analyses explored temporal changes. Results:Between 1992 and 2009, median age increased from 25 to 29 years (N = 1296), years injecting from 2 to 4. There were 53 men who had sex with men (MSM). Overall, 0.93% had HIV, 4.4% ever had hepatitis B (HBV), and 3.9% hepatitis C (HCV, from 1998, N = 1083). In multivariable analyses, HIV increased in 2004–2009 [adjusted odds ratio (AOR) = 10 (95% confidence interval (CI): 0.94 to 106) vs. 1992–2003], and remained elevated (AOR = 4.12, 95% CI: 0.31 to 54, 2012–2013); HBV also increased in 2004–2009 (AOR = 3.98, 95% CI: 1.59 to 9.97). HCV prevalence increase was only borderline significant (AOR = 2.47, 95% CI: 0.90 to 6.77, 2010–2011). HIV and HBV were associated with MSM and HCV with sharing needles/syringes. Uptake of diagnostic testing for HIV and HCV, and HBV vaccination increased (to 43%, 32% and 44% respectively). Condom use was consistently poor; needle/syringe sharing occurred. Conclusion:Blood-borne virus prevalences among IPED injectors have increased and for HIV, is now similar to that among psychoactive drug injectors. Targeted interventions to reduce risks are indicated.

Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks?

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. METHOD 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 2011-2012 were explored using logistic regression. RESULTS Of the 2283 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. CONCLUSION 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 extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland.

BACKGROUND Overdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented. METHODS Data on self-reported overdose and receipt of naloxone during the preceding year for 2013-2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included. RESULTS Participants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types. CONCLUSION These data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.

Injection into the jugular vein among people who inject drugs in the United Kingdom: Prevalence, associated factors and harms

BACKGROUND While people who inject drugs (PWID) typically use peripheral veins, some inject into their central veins, including the femoral and jugular veins. Injection into the jugular vein can have serious adverse health consequences, including jugular vein thrombosis, deep neck infections, pneumothorax, endocarditis and sepsis. This study examined the prevalence of, and factors associated with, jugular vein injection among a large sample of PWID in the United Kingdom. METHOD Unlinked anonymous surveys (2011-14) recruited PWID from agencies providing services to this population. Self-reported demographic and injection-related data were collected from consenting respondents using a brief questionnaire and dried blood spot samples were tested for exposure to HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV). Univariate and multivariable logistic regression were used to examine factors associated with jugular vein injection. RESULTS Among 5261 PWID, one third had injected into a central vein in the previous 28 days, including 6% (n=339) who had injected into their jugular vein and 1% (n=52) who had used this site exclusively for recent injections. Factors independently associated with recent jugular vein injection in multivariable analysis included female gender, a lifetime history of imprisonment, sharing needles and syringes, poly-drug injection and injection into multiple body sites. Jugular vein injection was also associated with experiencing injection-related injuries, although no associations were identified with respect to exposure to blood borne viral infections. CONCLUSION A significant minority of PWID inject into the jugular vein in the United Kingdom. Public health responses should investigate ways to support and promote good injection site management in order to minimise vascular damage and reduce problems with peripheral venous access. Women who inject drugs, PWID with a history of imprisonment and those people who are experiencing early signs of injection-related skin and soft tissue injuries are priority sub-populations for interventions.