Has the HCV cascade of care changed among people who inject drugs in England since the introduction of direct-acting antivirals?

BACKGROUND

In England, over 80 % of those with hepatitis C virus (HCV) infection have injected drugs. We quantified the HCV cascade of care (CoC) among people who inject drugs (PWID) in England and determined whether this improved after direct-acting antivirals (DAAs) were introduced.

METHODS

We analysed data from nine rounds of national annual cross-sectional surveys of PWID recruited from drug services (2011-2019; N = 12,320). Study rounds were grouped as: 'Pre-DAAs' (2011-2014), 'Prioritised DAAs' (2015-2016) and 'Unrestricted DAAs' (2017-2019). Participants were anonymously tested for HCV antibodies and RNA and completed a short survey. We assessed the proportion of PWID recently (current/previous year) tested for HCV. For participants ever HCV treatment eligible (past chronic infection with history of treatment or current chronic infection), we assessed the CoC as: HCV testing (ever), received a positive test result, seen a specialist nurse/doctor, and ever treated. We used logistic regression to determine if individuals progressed through the CoC differently depending on time-period, whether time-period was associated with recent testing (all participants) and lifetime HCV treatment (ever eligible participants), and predictors of HCV testing and treatment in the Unrestricted DAAs period.

RESULTS

The proportion of ever HCV treatment eligible PWID reporting lifetime HCV treatment increased from 12.5 % in the Pre-DAAs period to 25.6 % in the Unrestricted DAAs period (aOR:2.40, 95 %CI:1.95-2.96). There were also increases in seeing a specialist nurse/doctor. The largest loss in the CoC was at treatment for all time periods. During the Unrestricted DAAs period, recent (past year) homelessness (vs never, aOR:0.66, 95 %CI:0.45-0.97), duration of injecting (≤3 years vs >3 years; aOR:0.26, 95 %CI:0.12-0.60), never (vs current, aOR:0.31, 95 %CI:0.13-0.75) or previously being prescribed OAT (vs current, aOR:0.67, 95 %CI:0.47-0.95), and never using a NSP (vs past year, aOR:0.27, 95 %CI:0.08-0.89) were negatively associated with lifetime HCV treatment. The proportion of PWID reporting recent HCV testing was higher during Unrestricted DAAs (56 %) compared to Pre-DAAs (48 %; aOR:1.28, 95 %CI:1.06-1.54).

CONCLUSION

COC stages from seeing a specialist onwards improved after DAAs became widely available. Further improvements in HCV testing are needed to eliminate HCV in England.

Adverse health outcomes among people who inject drugs who engaged in recent sex work: findings from a national survey

OBJECTIVES

This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections.

STUDY DESIGN

The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland.

METHODS

Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi2 tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression.

RESULTS

Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03-11.33], P = 0.043).

CONCLUSIONS

Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.

Recent increases in crack injection and associated risk factors among people who inject psychoactive drugs in England and Wales

BACKGROUND

Crack use is higher in the United Kingdom (UK) than other European countries. Crack is a stimulant with a short half-life, requiring frequent injection to maintain its euphoric effects, thus increasing the risk of blood borne viruses (BBVs) and skin and soft tissue infections (SSTIs). We assessed trends in the prevalence of current crack injection among people who inject drugs (PWID) and investigated harms and other factors associated with its use.

METHODS

We used data from the annual Unlinked Anonymous Monitoring Survey of PWID, which recruits people who have ever injected psychoactive drugs through specialist services. Participants provide a biological sample and self-complete a questionnaire. We included participants from England and Wales who had injected in the past month. We examined trends in crack injection over time (2011-2021) and factors associated with crack injection using multivariable logistic regression (2019-2021).

RESULTS

The proportion of people self-reporting crack injection in the past month almost doubled between 2011-2020/21, from 34 % (416/1237) to 57 % (483/850). Crack injection was more frequently reported by males than females (adjusted odds ratio 1.46, 95 % confidence interval: 1.15-1.87) and injected alongside heroin (6.67, 4.06-10.97) more frequently than alone. Crack injection was independently associated with injecting equipment sharing (1.64, 1.30-2.07), groin injection (2.03, 1.60-2.56) in the past month, overdosing in the past year (1.90, 1.42-2.53), homelessness in the past year (1.42, 1.14-1.77) and ever having hepatitis C infection (1.64, 1.31-2.06).

CONCLUSION

Crack injection has increased significantly over the past decade in England and Wales. People injecting crack are more likely to engage in behaviours that increase the risk of BBV and SSTI acquisition, such as needle/syringe sharing, groin injection and polydrug use. Harm reduction and drug treatment services should adapt to support the needs of this growing population of people injecting stimulants.

The Effectiveness of Low Dead Space Syringes for Reducing the Risk of Hepatitis C Virus Acquisition Among People Who Inject Drugs: Findings From a National Survey in England, Wales, and Northern Ireland

Syringes with attached needles (termed fixed low dead space syringes [LDSS]) retain less blood following injection than syringes with detachable needles, but evidence on them reducing blood-borne virus transmission among people who inject drugs (PWID) is lacking. Utilizing the UK Unlinked Anonymous Monitoring cross-sectional bio-behavioral surveys among PWID for 2016/18/19 (n = 1429), we showed that always using fixed LDSS was associated with 76% lower likelihood (adjusted odds ratio  = 0.24, 95% confidence interval [CI]: .08-.67) of recent hepatitis C virus infection (RNA-positive and antibody-negative) among antibody-negative PWID compared to using any syringes with detachable needles.

Epidemiology of HIV infection and associated behaviours among people who inject drugs in England, Wales, and Northern Ireland: Nearly 40 years on

Introduction

People who inject drugs are at high risk of blood‐borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EW&NI) since 1981.

Methods

National HIV surveillance data were used to describe trends in diagnoses (1981–2019), prevalence (1990–2019), and behaviours (1990–2019) among people who inject drugs aged ≥15 years in EW&NI. HIV care and treatment uptake were assessed among those attending in 2019.

Results

Over the past four decades, the prevalence of HIV among people who inject drugs in EW&NI remained low (range: 0.64%–1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4 <350 cells/µl) was common (2010–2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (<200 copies/ml).

HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429).

Conclusion

The HIV epidemic among people who inject drugs in EW&NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks.

The impact of direct-acting antivirals on hepatitis C viraemia among people who inject drugs in England; real-world data 2011-2018

Direct-acting antiviral (DAA) therapy for anybody with viraemic HCV infection has been scaled-up in England since 2017. To assess early impacts, we investigated trends in, and factors associated with, HCV viraemia among people who inject drugs (PWID). We also examined trends in self-reported treatment access. Bio-behavioural data from an annual, national surveillance survey of PWID (2011-2018) estimated trends in viraemic prevalence among HCV antibody-positive PWID. Multivariable logistic regression identified characteristics independently associated with viraemia. Trends in treatment access were examined for PWID with known infection. Between 2011 and 2016, viraemic prevalence among antibody-positive PWID remained stable (2011, 57.7%; 2016, 55.8%) but decreased in 2017 (49.4%) and 2018 (50.4%) (both p < 0.001). After adjustment for demographic and behavioural characteristics, there remained significant reduction in viraemia in 2017 (adjusted odds ratio [aOR] 0.79, 95% CI 0.65-0.94) and 2018 (aOR 0.79, 95% CI 0.66-0.93) compared to 2016. Other factors associated with viraemia were male gender (aOR 1.68, 95% CI 1.53-1.86), geographical region, injecting in past year (aOR 1.26, 95% CI 1.13-1.41), imprisonment (aOR 1.14, 95% CI 1.04-1.31) and homelessness (aOR 1.17, 95% CI 1.04-1.31). Among non-viraemic PWID with known infection, the proportion reporting ever receiving treatment increased in 2017 (28.7%, p < 0.001) and 2018 (38.9%, p < 0.001) compared to 2016 (14.5%). In conclusion, there has been a small reduction in HCV viraemia among antibody-positive PWID in England since 2016, alongside DAA scale-up, and some indication that treatment access has improved in the same period. Population-level monitoring and focus on harm reduction is critical for achieving and evaluating elimination.

Post-vaccination HPV seroprevalence among female sexual health clinic attenders in England

BACKGROUND

The National HPV Immunisation Programme was introduced in England in September 2008 using the HPV16/18 bivalent vaccine. We conducted serological surveillance to explore vaccination coverage levels. We also conducted a case-control study to investigate a hypothesised cross-protective effect of the HPV16/18 vaccine against genital warts.

METHODS

Residual serum specimens from 16 to 20 year-old women attending six specialist sexual health services (SSHS) between 2011 and 2015 in England were tested for antibodies against HPV16 and HPV18 using a virus-like particle (VLP)-based multiplex serology assay. Patients were classified as having vaccine-induced seropositivity if they were seropositive for both HPV types and either had high antibody levels for at least one HPV type, or moderately high levels for both HPV types. Differences in vaccine-induced seropositivity by patient characteristics were investigated using logistic regression. Vaccine-induced seropositivity was then compared for patients with genital warts (cases) and matched patients without (controls).

RESULTS

Of 3,973 serum specimens collected, 3,870 (97.4%) had a valid result. The proportion of women with vaccine-induced seropositivity decreased with age (from 78.1% in 16-year-olds to 52.6% in 20-year-olds). Vaccine-induced seropositivity was lower among women born outside the UK, from more deprived areas and with a history of chlamydia diagnosis. A difference in uptake by ethnic group was also seen but this was largely confounded by differences in deprivation and country of birth. Among 537 cases and 1,515 controls, there was little evidence of a protective effect of the bivalent HPV vaccine against genital warts (adjusted odds ratio 0.93; 95% CI: 0.74-1.18).

DISCUSSION

Vaccine-induced seropositivity in this high-risk population was in line with vaccination coverage in the general population although was lower in some at-risk sub-groups. This study does not provide evidence to support a cross-protective effect of the HPV16/18 vaccine against genital warts.

Preliminary indications of the burden of COVID-19 among people who inject drugs in England and Northern Ireland and the impact on access to health and harm reduction services

Objective

The aim of the study was to describe the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on people who inject drugs (PWID) in England, Wales and Northern Ireland.

Study design

This is a cross-sectional Unlinked Anonymous Monitoring (UAM) Survey of PWID.

Methods

People who had ever injected psychoactive drugs were recruited to the UAM Survey by specialist drug/alcohol services in England, Wales and Northern Ireland. From June 2020, in addition to providing a dried blood spot sample and completing the UAM behavioural questionnaire, participants were asked to complete an enhanced coronavirus disease 2019 (COVID-19) questionnaire. Preliminary data are presented to the end of October and were compared with data from the 2019 UAM Survey, where possible.

Results

Between June and October, 288 PWID were recruited from England and Northern Ireland. One in nine (11%; 29/260) PWID reported testing positive for SARS-CoV-2 or experiencing COVID-19 symptoms. Fifteen percent (26/169) reported injecting more frequently in 2020 than in 2019; cocaine injection in the preceding four weeks increased from 17% (242/1456) to 25% (33/130). One in five PWID (19%; 35/188) reported difficulties in accessing HIV and hepatitis testing, and one in four (26%; 47/179) reported difficulties in accessing equipment for safer injecting.

Conclusions

Our preliminary findings suggest that PWID have experienced negative impacts on health, behaviours and access to essential harm reduction, testing and treatment services owing to the COVID-19 pandemic. Continued monitoring through surveillance and research is needed to understand the subsequent impact of COVID-19 on blood-borne virus transmission in this population and on health inequalities.

Factors associated with hepatitis C and HIV testing uptake among men who inject image and performance enhancing drugs

INTRODUCTION AND AIMS

Historically, people who inject image and performance enhancing drugs (IPED) were not perceived as being at high risk of HIV or hepatitis C virus (HCV) infection. However, recent studies indicate HCV and HIV prevalences are elevated, with many HCV infections undiagnosed.

DESIGN AND METHODS

Men who inject IPEDs recruited from community settings and specialist services, including needle-syringe programs, across UK during 2016 self-completed a questionnaire. Multivariate analyses examined factors associated with HCV/HIV testing.

RESULTS

The participants' (n=562; 24% service recruited) median age was 31 years, 4% identified as gay or bisexual, 18% had ever been imprisoned and 6% had ever injected a psychoactive drug. Those community recruited more often reported sharing drugs vials (16% vs. 8%, P=0.021) and, among those with 2+ sexual partners, poor condom use (50% vs. 36%, P=0.063), than those service recruited. Overall, one-third had ever been tested for HCV (31%) and/or HIV (34%). Testing uptake was associated with other risk factors for HCV/HIV, being recruited through services and having received metabolic tests. Participants' motivations for using IPEDs were associated with recruitment setting and HIV/HCV testing uptake.

DISCUSSION AND CONCLUSIONS

The majority were untested for HCV/HIV. HCV/HIV testing and risks were associated with recruitment through services. Previous needle and syringe program-based studies have potentially overestimated testing uptake and underestimated risk. Targeted interventions are needed, particularly for those not accessing services. The association between HCV/HIV testing uptake and receipt of metabolic tests suggests that developing a combined offer of these tests as part of health monitoring could improve uptake.

Factors associated with skin and soft tissue infections among people who inject drugs in the United Kingdom: A comparative examination of data from two surveys

BACKGROUND

People who inject drugs (PWID) are at high risk of injection-related skin and soft tissue infections (SSTI). If not treated promptly, these can lead to serious health complications, which are a considerable healthcare burden. Data from two community surveys, with different approaches, were used to assess SSTI prevalence and associated factors among PWID to inform intervention implementation.

METHODS

Data were analysed from two surveys, a national surveillance survey (n=2,874; 2017-18) of infections among PWID in the United Kingdom (UK) and an in-depth survey (n=455; 2018-19) of SSTI among PWID based in London, UK. Multivariable logistic regression models were constructed to ascertain the factors associated with self-reported SSTI.

RESULTS

High prevalence of SSTI were reported in both samples: 52 % of participants from the national surveillance survey reported having SSTI within the preceding 12 months and 65 % of the London sample reported a lifetime history of SSTI. The factors associated with SSTI in both surveys were similar, including older age; number of years injecting; number of attempts required to inject into the vein; injecting into the hands, feet, groin or neck and re-using or sharing needles/syringes.

CONCLUSIONS

The number of PWID reporting SSTI in the UK is concerningly high. The two surveys used different recruitment approaches but found similar associations. We provide strong evidence of a relationship between venous access difficulty and SSTI. To stem the increase of SSTI and related complications in the UK, it is crucial that interventions attend to the underlying causes of venous damage among PWID.

Consumer Perception Towards the Enhanced Color of Atypical Dark-Cutting Beef by Nitrite-Embedded Packaging

ObjectivesMeat color is often seen by consumers as an indicator of freshness and wholesomeness. Nitrite-embedded (NE) packaging forms nitric oxide myoglobin, which imparts a bright red color similar to oxymyoglobin. However, limited research has determined the effects of NE packaging to improve the appearance of atypically dark cutting beef. Consumers’ perception of NE packaging ultimately determines its success in the market. Educating consumers through infographics can transfer knowledge more effectively than text alone, potentially being a useful method to introduce and simplify the complexity of NE packaging’s role in improving the surface color of beef steaks. The objectives of this study were to evaluate FreshCase® nitrite-embedded packaging’s effect on atypical dark-cutting beef steaks and to evaluate student consumer perception of nitrite-embedded packaging improving the surface color of beef before and after exposure to infographics containing equal content.Materials and MethodsAtypical dark-cutting (n = 13, pH 5.70 ± 0.09) and normal-pH (n = 13, pH = 5.57 ± 0.1) USDA Low Choice beef strip loins were selected 3 d postharvest. Atypical dark-cutting loins were cut into 2.54 cm thick steaks and randomly packaged in polyvinyl chloride film (PVC) or NE film. Normal-pH control loins were cut 2.54 cm and randomly packaged in PVC overwrap. Packages were placed in a coffin-style retail case under fluorescent lighting for 6 d. Instrumental color was observed every 24 h using a HunterLab MiniScan XE spectrophotometer. The color was determined as a* values and chroma. In the second objective, surveys using a ten-point Likert sliding scale (0 = not familiar at all, 10 = extremely familiar) were randomly allocated and emailed via Qualtrics to students enrolled in the Introduction to Animal Science course at Oklahoma State University. These surveys used a pre-questionnaire to evaluate students’ pre-perception of their knowledge of beef color and NE packaging. After the pre-perception questionnaire students were provided one of the following: a static infographic presented as a still image with annotated graphics, a 46 s video infographic with audio and animated graphics, or both infographic formats. A post-questionnaire followed exposure to students’ respective infographic to evaluate changes in the perception of knowledge.ResultsAtypical dark-cutting steaks treated in NE packaging had higher (P < 0.05, more red intensity) chroma and a* values compared to atypical dark-cutting steaks in PVC on d 4, 5, and 6. There was a significant difference (P < 0.05) in the students’ (n = 288) pre- and post-questionnaire self-assessment of their familiarity with NE packaging. Prior to randomly viewing infographics, students were less familiar (= 3.18) with NE packaging than after viewing infographics (= 6.46). However, there was no significant difference in perceptions (P = 0.22) between viewing the different infographic formats.ConclusionThe results suggest that NE packaging with consumer education can improve their perceptions and knowledge and enhance the appearance of atypical dark-cutting beef.

Secondary distribution of injecting equipment obtained from needle and syringe programmes by people injecting image and performance enhancing drugs: England and Wales, 2012-15

BACKGROUND

People who inject image and performance enhancing drugs (IPEDs) are often the largest group using needle and syringe programmes (NSPs) in the UK. NSP providers report these clients repeatedly collecting large amounts of equipment for others. The extent of secondary distribution of injecting equipment is unknown.

METHODS

Data from national surveillance of people injecting IPEDs were used. Participants completed a questionnaire and provided a dried-blood spot sample. Data from two biennial surveys was combined; repeat participants were excluded. Self-reported data was used to explore the extent of secondary distribution.

RESULTS

Of the participants, 87% (467) reported NSP use; median age was 31 years; 98% were male. A third (34%, 157) reported collecting equipment for others. Of those collecting for others, 154 reported how many people they had collected for: 55% had collected for one person, 27% for 2-9 people, 5% for 10-19 and 13% for 20 or more (no difference by psychoactive drug use). Those vaccinated for hepatitis B were more likely (22% [15/68] vs 6% [5/86], p = 0.003), and those reporting redness/swelling at an injection site were less likely to collect equipment for at least 20 others (8% [8/106] vs 25% [12/48], p = 0.003). Overall, 154 people collected equipment for 639-1569 people injecting IPEDs.

CONCLUSIONS

Secondary distribution of injecting equipment is common among those injecting IPEDs and using NSPs. Whilst not allowing for rotational collection within groups, our analysis suggests that many of those injecting IPEDs are not in direct contact with NSPs. Innovation approaches for harm reduction interventions are needed.

Sexualised drug use in the United Kingdom (UK): A review of the literature

BACKGROUND

Sexualised drug use (SDU) refers to the use of drugs in a sexual context. This includes 'Chemsex'- the use of drugs (specifically crystal methamphetamine, GHB/GBL and mephedrone) before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience. Here we aimed to synthesise available UK prevalence data for Chemsex, SDU and the use of Chemsex drugs in an undefined context (CDU) in men who have sex with men (MSM).

METHODS

Papers published between January 2007 and August 2017 reporting Chemsex, SDU and/or Chemsex drug use (CDU) prevalence in MSM were identified through PubMed. Citations were searched for further eligible publications. We also conducted a review of national surveillance data, extracting prevalence data for Chemsex, SDU or CDU. Synthesized data were then assessed to determine the time at which these drugs were taken, in this case just prior to or during sexual activity (event-level).

RESULTS

Our search identified 136 publications, of which 28 were included in the final data synthesis. Three of the four surveillance systems assessed provided SDU or CDU data in MSM. Few publications included event-level data for Chemsex (n = 4), with prevalence estimates ranging from 17% among MSM attending sexual health clinics (SHC) to 31% in HIV-positive MSM inpatients. Prevalence estimates for SDU (n = 7 publications) also varied considerably between 4% in MSM receiving HIV care to 41% among MSM attending SHC for HIV post-exposure prophylaxis (PEP). Eighteen publications provided data for CDU.

CONCLUSION

Prevalence estimates varied considerably due to differences in the definition used and population assessed. Standardised definitions and studies with representative national samples of MSM are required to improve our understanding of the extent of Chemsex and its associated risks. Longitudinal event-level data for SDU and Chemsex are needed to monitor impact of interventions.

Non-traumatic lower limb vascular complications in endurance athletes. Review of literature

OBJECTIVES

To review the importance, clinical features, investigations, management and prognosis of non-traumatic vascular injuries, affecting the lower limbs of endurance athletes.

DESIGN

Review of literature.

MATERIALS AND METHODS

A literature search was conducted from Medline, Pubmed, the National Electronic Library for Health, Google and Yahoo search engines for related articles and case reports regarding non-traumatic vascular complications involving the lower limb of endurance athletes.

CONCLUSIONS

Non-traumatic vascular complications affecting the lower limbs include endofibrosis, stenosis/kinking of iliac arteries, dissection of external iliac artery, adductor canal syndrome, popliteal entrapment syndrome, chronic exertional compartment syndrome and effort-induced venous thrombosis. These are important as they affect athletes at the peak of their career and can be confusing to diagnose. The management is relatively well documented and produces good results in short term but the long term results are not known.