Transcript presentation - Society for the Study of Addiction

All Change!
Infections, injecting drug use
and harm reduction.
Vivian
Hope
Dr
Vivian
Hope
IDU Team,
STI Department,
Injecting
DrugHIV
Use &
Team,
HIV & STI Department,
Centre
Infectious Disease
and Control,
HealthforProtection
ServicesSurveillance
– Colindale
Public Health England.
&
Honorary Senior Lecturer, Centre for Research on Drugs & Health Behaviour,
London School of Hygiene & Tropical Medicine.
The 1990’s
Heroin
Cocaine powder
Amphetamine
Prevalence of HIV, current and past hepatitis C
and B infection: PWID, England & Wales.
5.0%
100%
Anti-HBc
HIV
Anti-HCV
80%
4.0%
60%
3.0%
40%
2.0%
20%
1.0%
0%
0.0%
1990
1991
1992
1993
19942006
19952007
19962008
19972009
19982010
19992011
20002012
2001 2002
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
2002
2003
2004
2005
Data source: UAM Survey of PWID.
Risks and other infections in the
1990’s
Throughout the 1990’s just over half of PWID reported that
they had ever been tested for HIV.
But, only a quarter of PWID had taken up the vaccine
against hepatitis B.
General concerns about ‘hygiene’ related bacterial
infections.
Two cases of tetanus between 1984-2000.
Reported needle and syringe sharing declined from 24% in
1991 to 17% in 1998, before rising again to 33% in 1999.
Data sources: UAM Survey of PWID.
Shooting Up report 2010
The 2000’s
Heroin
Cocaine powder
Amphetamine
Crack-cocaine
Prevalence of current and past hepatitis C
and B infection: PWID, England & Wales.
100%
Anti-HBc
Anti-HCV
80%
60%
40%
20%
0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Data source: UAM Survey of PWID.
HIV prevalence:
PWID, England & Wales.
5.0%
4.0%
3.0%
HIV prevalence in London is
about four times higher than
elsewhere.
In 2012, it was 3.7% in London;
0.8% elsewhere.
2.0%
1.0%
0.0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Data source: UAM Survey of PWID.
Estimated HIV (& HCV) incidence among PWID,
England & Wales.
London
.7
.6
.2
HCV
.3
.4
.5
.06
1980
1985
1990
1995
2000
2005
2010
0
0
.1
.02
0
0
.1
.02
.2
.04
HCV
.3
.4
HIV
.04
.5
.06
.6
.7
.08
7 years injecting
.08
1st year injecting
1980
1985
1990
Year
1995
2000
2005
2010
Year
Rest of E&W
1980
1985
1990
1995
Year
2000
2005
2010
0
0
.1
.1
.005
0
0
.005
.2
HCV
.3
HCV
.3
HIV.015
.01
.4
.02
.5
.5
.025
7 years injecting
.2
.01
.015
.4
.02
.025
1st year injecting
1980
1985
1990
1995
Year
2000
2005
2010
Data source: UAM
Survey of PWID.
Incidence modelled in
a Bayesian framework
using prevalence by
time since first
injection, and
modelling for HIV and
hepatitis C together.
Hope et al,
EuroSurveilance in
press.
Bacterial infections
Spore formers.
• C. Noyvi outbreak in 2000.
• Since 2000, on-going
occurrence of wound
botulism and tetanus cases
– including clusters.
• Since 2009 also issues
with anthrax.
• Related to spores
contaminating heroin.
Spore forming bacterial infections
among PWID: reported cases in the UK
Also hygiene related bacteria
infections.
• Around one-third of PWID
report an abscess, sore or
open wound, all possible
symptoms of an injectingsite infection, during the
last year.
Data source: Shooting Up report 2013.
2010’s and the future
Heroin
Mephedrone
Cocaine powder
Amphetamine
Methamphetamine
Crack-cocaine
Injecting drug use has been ‘declining’
‘Drug’ treatment demand:
Injecting status at presentation, new
treatment journeys (Data Source: NTDMS).
(Data Source: NTA Website)
Currently Injecting
Previously Injected
Never Injected*
Missing / Inconsistent
Currently Injecting
Total inc. Missing / Inconsistent
100%
90,000
90%
80,000
80%
70,000
70%
60,000
60%
50,000
50%
40,000
40%
30,000
30%
20,000
20%
10,000
10%
0%
0
2007/08 2008/09 2009/10 2010/11 2011/12
Number
Prportion of total
Estimated number of opiates
and/or crack-cocaine users who
are injecting.
Drug use, and drugs injected, are changing.
‘Drug’ treatment demand: Presentations citing any
‘club’ drug, new treatment journeys
Looking at those only
using ‘Club drugs’,
that is, those who
report only using one or
more of mephedrone,
methamphetamine,
ketamine, GHB and
ecstasy.
The proportion currently
injecting has doubled
from:
5% (N=531) in 2011-12
to
10% (N=795) in 2012-13.
Data Sources: NTDMS / NTA; Shooting Up report 2013.
Main drug type injected*; England, Wales &
Northern Ireland: 2002 to 2012
.
* Among those who had injected during the preceding 28 days
Data sources: UAM Survey of PWID.
Shooting Up report 2013
‘New’ Psychoactive / ‘Club’ Drugs
These are mostly not injected.
There is increasing concern about the injection of these in
the UK – particularly Mephedrone (M-Cat).
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.
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
increased use of methamphetamine.
Historically injecting drug use was relatively rare among gay
and bisexual identified men.
There is evidence that a small number of MSM – mostly HIV
positive gay identified men – are ‘slamming’ (injecting
methamphetamine) often in the context of ‘sex parties’.
Low levels of condom use and high level of injecting
equipment sharing.
Concerns about transmission of STIs and hepatitis C.
Image and performance
enhancing drugs (IPED)
‘All’ & ‘new’ clients attending agency based
NSPs in Cheshire & Merseyside (1991-2011).
Data provided by Centre for Public Health at Liverpool JMU.
AS = Anabolic Steroid.
IPED use and risk
A wide range IPED are used and injected - Anabolic Steroids are the
mostly commonly used and injected.
A recent study of 395 male IPED injectors:• Main IPEDs injected: Anabolic steroids (86%); Growth hormone
(32%); hCG (16%); Insulin (6%); Melanotan I/II (9% ).
• Main 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.
• Overall, 5% had ever injected a psychoactive drug.
Hope et al. BMJ Open 2013
IPED use and BBV infection
Note: Oral Fluid sample test sensitivity for anti-HBc is 75% and for anti-HCV is 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.
A study of IPED injectors in the 1990s (N=149) found no HIV and 2.7% had
ever been infected with hepatitis B.
Hope et al. 2013 BMJ Open.
Crampin et al. 1998 Epidemiology & Infection.
Implications
Implications service provision
and harm reduction
“Traditional” focus of harm reduction services is on:
•
Heroin, and more recently heroin and crack, injection / use.
•
Small number of people injecting stimulants (such as, amphetamine and
cocaine), though in some areas, e.g. in parts of South Wales, the injection of
these has been more common.
•
An aging cohort.
Now (and the future?):
•
People who inject IPED.
•
Wider range of psychoactive drugs being injected.
•
Changes in demographics.
Issues:
•
‘Different needs’;
•
Sex & Drugs;
•
‘Health and fitness’;
•
Different settings.
Implications for research:
Harm reduction
What are the best ways to :1. Engage with IPED injectors/users so as to reduce harm?
2. Provide effective harm reduction services – particularly
NSPs – to a wide range of people, using a wide range of
drugs, who may have very different needs?
3. Address the harm related to drug use, including injecting,
around sexual activity?
And to address these issues in a time of austerity.
Currently among people who inject
psychoactive drugs
Hepatitis C stable around 45%. In 2012, 83% ever had a
diagnostic test for hepatitis C; but only 54% of those infected
are aware of their infection.
HIV prevalence probably stable at around 1.0% to 1.5%. Majority
(>80%) of PWID living with HIV are aware of their infection.
Hepatitis B declining (17%) mainly due to vaccination: currently
75% report uptake of vaccine against hepatitis B compared
with 58% in 2002.
Needle and Syringe sharing has been declining again, down
from 34% in 2002 to 14% in 2012.
Proportion reporting a recent injection site ‘wound or abscess’
may be declining (29% in 2012, down from 38% in 2007).
Data source: UAM Survey of PWID.
In conclusion
Changing patterns of psychoactive drug use and injection –
not a new issue (e.g. crack-cocaine a decade ago).
•
•
Could increase infection risks.
Different population groups.
Changing ‘nature’ of injecting drug use – increased use of
image and performance enhancing drugs.
•
•
Different population groups.
‘Health and fitness‘ – not ‘drug use’.
Need to be vigilant for emerging patterns of use and risk,
and to respond to these quickly.
www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfections/ShootingUp/
Thank you.
[email protected]