1. Injecting drug use and infections. Vivian Hope IDU Team, HIV & STI Department, Health Protection Services – Colindale Dr Vivian Hope, Dr Fortune Ncube & Katelyn Cullen Injecting Drug Use Team, HIV & STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England.

2. Part 1 BBV and bacterial infections among people who inject psychoactive drug injectors

3. 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.

4. HIV prevalence among PWID, England & Wales. Data source: UAM Survey of PWID.

5. Hepatitis C and Hepatitis B prevalence among PWID, England & Wales. Data source: UAM Survey of PWID.

6. Estimated HIV & HCV incidence among PWID, England & Wales. 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.

7. Spore forming bacterial infections among PWID: UK

8. 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.

9. 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.

10. Sharing of injecting equipment has been declining. Trends in sharing among current* PWID in England, Wales & NI: 2000-2011 * Those who had last injected in the four weeks preceding participation in the survey. Data source: UAM Survey of PWID.

11. 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.

12. Risks Indicators of risk Among those who injected in the last month: - Injected with cleaned works32% Injected crack-cocaine32% Injected into groin35% Had sex last year73% Men reporting male partner(s) in last year5% Ever homeless In last year 77% 28% Ever imprisoned (Data from 2010 suggest 1 in 5 imprisoned during preceding year year) 71% Data source: UAM Survey of PWID.

13. Factors associated with recent hepatitis C infection N Recent Infection Adjusted Odd Ratios (OR) n%OR95% CI Gender Male750121.6%1.0 Female23083.5%3.81.4-10 Anti-HBc Detected5658.9%6.32.1-18 Not detected924151.6%1.0 Had ever been to prison No36230.8%1.0 Yes, 1-4 times40592.2%3.70.95-14 Yes, >=5 times21383.8%8.72.0-37 Cullen et al. Forthcoming

14. 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.

15. Part 2 Injecting is changing

16. 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 steroids70,000228,000 Heroin47,000255,000 All & new clients attending agency based Needle and Syringe Programmes (NSPs) in Cheshire & Merseyside: 1991-2011. Image and Performance Enhancing Drug (IPED) Injecting British Crime Survey, 2012

17. 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

18. Markers of BBV infection Note: Oral Fluid sample test sensitivity for anti-HBc is 75% and anti-HCV 92%. Among the male injectors of psychoactive drugs taking part in the UAM Survey in 2011: 45% (95%CI 43%-48%) had anti-HCV; 16% (95%CI 14% -18%) had anti-HBc; 1.4% (95% CI 0.88% -2.2%) had anti-HIV. Hope et al. HIV Medicine 2013, & Forthcoming

19. 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.

20. 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.