Sara Croxford

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.

An overview of the HIV epidemic among men who have sex with men in the United Kingdom, 1999-2013

We describe epidemiological trends in HIV among men who have sex with men (MSM) in the United Kingdom (UK) to inform prevention strategies. National HIV surveillance data were analysed for trends. Multivariable analyses identified predictors of late diagnosis (<350 copies/µL) and mortality. Between 1999 and 2013, 37,560 MSM (≥15 years) were diagnosed with HIV in the UK. New diagnoses rose annually from 1,440 in 1999 to 3,250 in 2013. The majority of MSM were of white ethnicity (85%) and UK-born (68%). Median CD4 count increased steadily from 350 cells/µL to 463 cells/µL. HIV testing in England increased from 10,900 tests in 1999 to 102,600 in 2013. One-year death rates after diagnosis declined among late presenters (4.7% to 1.9%). Despite declining late diagnosis (50% to 31%), the number of men diagnosed late annually has remained high since 2004. Older age (≥50 years), and living outside London were predictors of late presentation; older age and late presentation were predictors of one-year mortality. Increases in new diagnoses reflect increased testing and ongoing transmission. Over 900 men present late each year and mortality in this group remains high and preventable. Appropriate prevention and testing strategies require strengthening to reduce HIV transmission and late diagnosis.

The Human Immunodeficiency Virus Continuum of Care in European Union Countries in 2013: Data and Challenges

Summary Definitions for a 4-stage continuum of HIV care were standardized and applied to HIV surveillance and national cohort data in 11 European Union countries. These countries are nearing the UNAIDS 90-90-90 target, although reducing the proportion undiagnosed remains challenging.

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.

Trends in HIV diagnoses, HIV care, and uptake of antiretroviral therapy among heterosexual adults in England, Wales, and Northern Ireland.

Aim To examine epidemiological trends among heterosexual adults (≥15 years) in England, Wales, and Northern Ireland (E,W&NI) newly diagnosed as having HIV between 1992 and 2011, or seen for HIV care in 2011. Methods Trend analyses of heterosexual adults newly diagnosed as having HIV in E,W&NI in 1992 to 2011 was performed, as well as univariate and multivariate analyses examining the late diagnosis of HIV, integration into care, AIDS, uptake of antiretroviral therapy, and mortality in 2002 to 2011. Data are as reported to the national HIV and AIDS Reporting System. Results The number of heterosexual adults newly diagnosed as having HIV in E,W&NI increased steadily between 1992 (731) and 2004 (4676), before declining (2631 in 2011). Nonetheless, in 2011, heterosexuals accounted for 49% (2631/5423) of all newly diagnosed adults in E,W&NI. Of 38,228 heterosexual adults as having HIV between 2002 and 2011, 72% were black African, of whom 99% were born abroad. Over the decade, there was an increase in the percentage of HIV diagnosed heterosexuals integrated into care within 28 days of diagnosis (61%–78%) and in receipt of antiretroviral therapy within 1 year of diagnosis (45%–52%) and a decline in the percentage with AIDS (16%–7%; all, P < 0.01). Late HIV diagnoses (CD4 <350 mm3) among heterosexuals exceeded 60% in all years. Conclusions Our analyses highlight the impact of migration on the epidemiology of heterosexually acquired HIV in E,W&NI. Although there was evidence of an improvement in clinical care over time, continued high rates of late diagnosis suggest that current testing policies are failing among heterosexuals.

Monitoring of the HIV Epidemic Using Routinely Collected Data: The Case of the United Kingdom

We report on measures used to monitor the response to the UK HIV epidemic. We present analyses of routine data on HIV testing, diagnosis and care, and of CD4 back-calculation models to estimate country of HIV acquisition and incidence. Over the past decade, HIV and AIDS diagnoses and deaths declined while HIV testing coverage increased. Linkage into care, retention in care, and viral suppression was high with few socio-demographic differences. However, in 2013, incidence among MSM, and undiagnosed infection, also remained high, and more than half of heterosexuals newly diagnosed with HIV (the majority of whom were born-abroad) probably acquired HIV in the UK and were diagnosed late. HIV care following diagnosis is excellent in the UK. Improvements in testing and prevention are required to reduce undiagnosed infection, incidence and late diagnoses. Routinely collected laboratory and clinic data is a low cost, robust and timely mechanism to monitor the public health response to national HIV epidemics.

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.

Two decades of successes and failures in controlling the transmission of HIV through injecting drug use in England and Wales, 1990 to 2011

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.

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.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

Our objective was to present recent trends in the UK HIV epidemic (2007–2016) and the public health response.