Publications by authors named "Vivian Hope"

75 Publications

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

J Viral Hepat 2021 Oct 29;28(10):1452-1463. Epub 2021 Jul 29.

National Infection Service, Public Health England, London, UK.

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.
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http://dx.doi.org/10.1111/jvh.13575DOI Listing
October 2021

A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people.

Int J Drug Policy 2021 07 24;93:103187. Epub 2021 Mar 24.

Public Health Institute, Liverpool John Moores University, Exchange Station, Liverpool, L2 2QP, UK.

Introduction: Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM). Although the recent focus on chemsex is a reflection of the associated harms it is important to understand SDU more broadly and its associations with risk behaviours. Additionally, some of the reasons suggested for MSM engagement in SDU are also likely to apply to women who have sex with women (WSW) and trans people. The aim of this review was to investigate SDU, including chemsex, among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual health outcomes (HIV status, STI diagnosis, condom use).

Methods: Papers that were published between January 2010 and June 2020 reporting SDU in MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and Web of Science. Results were synthesised using a narrative approach.

Results: The search identified 2,710 publications, of which 75 were included in the final synthesis. The majority of studies measured SDU among MSM (n = 71), and four studies measured SDU among trans people. Research into SDU had been conducted in 55 countries and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs used to define chemsex varied. Among studies that researched MSM, SDU was most commonly investigated in relation to condomless anal intercourse (n = 42), followed by HIV prevalence (n = 35), and then STI diagnoses (n = 27). Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies.

Conclusions: SDU research is lacking among WSW and trans people, despite trans women having a high HIV prevalence. Among MSM, most drugs were associated with sexual health outcomes, and therefore it is important to include both chemsex drugs and other drugs in SDU research.
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http://dx.doi.org/10.1016/j.drugpo.2021.103187DOI Listing
July 2021

Service provision and barriers to care for men who have sex with men engaging in chemsex and sexualised drug use in England.

Int J Drug Policy 2021 06 26;92:103090. Epub 2021 Jan 26.

Public Health Institute, Liverpool John Moores University, Exchange Station, Liverpool, L2 2QP, UK.

Background: Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU.

Method: Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis.

Results: MSM participants had a median age of 34 years (range 23-66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare.

Conclusion: SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.
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http://dx.doi.org/10.1016/j.drugpo.2020.103090DOI Listing
June 2021

"Belt and braces approach; added benefit and … extra reassurance": a multi-stakeholder examination of the challenges to effective provision of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Northern and Central England.

AIDS Care 2021 06 14;33(6):736-745. Epub 2021 Jan 14.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

Pre-exposure prophylaxis (PrEP) involves HIV negative individuals taking antiretroviral drugs to reduce the probability of infection if exposed and is available through the IMPACT trial in England. This study aimed to explore men who have sex with men (MSM) and service provider (SP) perspectives on provision and accessibility of PrEP in Northern and Central England. Twenty MSM and 25 SPs from four Northern cities and one city in the West Midlands region were recruited for semi-structured interviews (December 2018 to October 2019). Interviews were analysed using Interpretative Phenomenological Analysis (IPA). Three key themes emerged: "Self-sourcing PrEP"; "Service delivery learnings"; and "Impact of using PrEP". Problems with equity of access and accessibility were noted, and recommendations for the future of PrEP programming and equitable service delivery were also presented. The study highlighted divergence in PrEP service experience from patients and providers, with results informing policy, practice and professional training.
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http://dx.doi.org/10.1080/09540121.2021.1871721DOI Listing
June 2021

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

Drug Alcohol Rev 2021 May 8;40(4):586-596. Epub 2020 Nov 8.

Substance Misuse Programme, Public Health Wales, Cardiff, UK.

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.
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http://dx.doi.org/10.1111/dar.13198DOI Listing
May 2021

Image and performance enhancing drug use among men who have sex with men and women who have sex with women in the UK.

Int J Drug Policy 2020 Sep 7:102933. Epub 2020 Sep 7.

Public Health Institute, Liverpool John Moores University, Exchange Station, Liverpool, L2 2QP, United Kingdom.

Background: The use of image and performance enhancing drugs (IPEDs) among men who have sex with men (MSM) and women who have sex with women (WSW) is rarely studied, with most of this research focused on anabolic androgenic steroid use among MSM. To address this gap, the extent of recent IPED use and the associated factors are explored in a community-recruited sample of MSM and WSW METHODS: Data from the UK LGBT Sex and Lifestyles Survey was used, which recruited through social-media advertising and community organisations (April-June 2018). Participants were asked if they had taken any IPEDs (e.g. anabolic steroids, growth hormone, hCG, Melanotan, non-prescribed diet pills) in the past 12 months. Factors associated with recent (in past 12 months) IPED use among MSM and WSW were investigated using stepwise binary logistic regression.

Results: 1,658 MSM and 1,507 WSW were included in the analysis. Among MSM, 3.4% (n = 57) had recently taken IPEDs, 60% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among MSM was associated with psychoactive drug use, Viagra use, higher body dissatisfaction, and lower sexual satisfaction. Among WSW, 4.1% (n = 62) had recently taken IPEDs, and 50% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among WSW was associated with being aged 45 years and over, recent STI diagnosis, recent sexual contact without consent, and higher body dissatisfaction.

Conclusion: IPED use was reported by around 1-in-25 MSM and WSW, and was associated with a number of health and psychological problems. Research to better understand the drivers and impacts of IPED use among MSM and WSW, and how this compares to use among heterosexual people is needed.
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http://dx.doi.org/10.1016/j.drugpo.2020.102933DOI Listing
September 2020

The impact of COVID-19 restrictions on needle and syringe programme provision and coverage in England.

Int J Drug Policy 2020 09 15;83:102851. Epub 2020 Jul 15.

Public Health Institute, Liverpool John Moores University, 3rd Floor Exchange Station, Tithebarn Street, Liverpool L2 2QP. Electronic address:

Background: The restrictions introduced in response to COVID-19 present many challenges, particularly for vulnerable and marginalised populations. These include maintaining access to Needle and Syringe Programmes (NSPs) to reduce the harms associated with injecting drugs. NSPs effectiveness is coverage dependent, but lockdowns and social distancing limit NSP access and availability. The impact on NSP provision in England is explored using enhanced monitoring data.

Method: Data collected through an established comprehensive regional monitoring system from five four-week periods, centred on the implementation of restrictions in the UK in mid-March 2020, are examined. Weekly averages are compared to allow for public holidays and weekly variation in activity.

Results: The restrictions resulted in the number of NSP clients decreasing by 36%, visits by 36%, and needles distributed by 29%. NSP coverage for those injecting psychoactive drugs halved, declining from 14 needles per-week during the 4-weeks to 15 March 2020 to 7 needles per-week by mid-April, and coverage has remained at this level since then.

Conclusions: Though it is currently unclear if there has been a decline in injecting, the decline in NSP coverage is so marked that it almost certainly reflects decreased utilisation among those in need, indicating increased equipment reuse and risk.
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http://dx.doi.org/10.1016/j.drugpo.2020.102851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362866PMC
September 2020

Response to Marsden et al (2020): Mitigation for the impacts on needle and syringe programmes is needed.

Addiction 2021 01 11;116(1):206-207. Epub 2020 Aug 11.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

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http://dx.doi.org/10.1111/add.15193DOI Listing
January 2021

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK.

PLoS One 2020 14;15(7):e0235350. Epub 2020 Jul 14.

Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Background: Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.

Methods: We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.

Results: We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.

Conclusions: Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235350PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360031PMC
September 2020

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.

Drug Alcohol Depend 2020 Jun 3;213:108080. Epub 2020 Jun 3.

National Infection Service, Public Health England, London, United Kingdom.

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.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108080DOI Listing
June 2020

Correction to: Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London.

Harm Reduct J 2020 06 9;17(1):38. Epub 2020 Jun 9.

School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12954-020-00388-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282092PMC
June 2020

Incidence and treatment costs of severe bacterial infections among people who inject heroin: A cohort study in South London, England.

Drug Alcohol Depend 2020 07 6;212:108057. Epub 2020 May 6.

National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 4 Windsor Walk, Camberwell, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, Monks Orchard Road Beckenham, London BR3 3BX, UK; Centre for Epidemiology and Biostatistics, Melbourne School of Global and Population Health, Level 3, 207 Bouverie Street, The University of Melbourne Victoria 3010 Australia; RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK.

Background: People who inject drugs often get bacterial infections. Few longitudinal studies have reported the incidence and treatment costs of these infections.

Methods: For a cohort of 2335 people who inject heroin entering treatment for drug dependence between 2006 and 2017 in London, England, we reported the rates of hospitalisation or death with primary causes of cutaneous abscess, cellulitis, phlebitis, septicaemia, osteomyelitis, septic arthritis, endocarditis, or necrotising fasciitis. We compared these rates to the general population. We also used NHS reference costs to calculate the cost of admissions.

Results: During a median of 8.0 years of follow-up, 24 % of patients (570/2335) had a severe bacterial infection, most commonly presenting with cutaneous abscesses or cellulitis. Bacterial infections accounted for 13 % of all hospital admissions. The rate was 73 per 1000 person-years (95 % CI 69-77); 50 times the general population, and the rate remained high throughout follow-up. The rate of severe bacterial infections for women was 1.50 (95 % CI 1.32-1.69) times the rate for men. The mean cost per admission was £4980, and we estimate that the annual cost of hospital treatment for people who inject heroin in London is £4.5 million.

Conclusions: People who inject heroin have extreme and long-term risk of severe bacterial infections.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301433PMC
July 2020

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London.

Harm Reduct J 2020 04 10;17(1):24. Epub 2020 Apr 10.

School of Medicine, University of California, San Francisco, 513 Parnassus Ave, San Francisco, CA, 94143-0410, USA.

Background: The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms.

Methods: We generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices.

Findings: A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.

Conclusion: Currently, harm reduction equipment and resources for safe injecting are not meeting the needs of people who inject drugs who are street homeless or unstably housed. Preparation of injections with non-sterile water sources could precipitate bacterial and fungal infections, particularly when used without the application of heat. It is crucial that water for injection, also skin cleaning, is made available for the unstably housed and that harm reduction messaging is tailored to speak to the everyday realities of people who prepare and inject drugs in public spaces.
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http://dx.doi.org/10.1186/s12954-020-00369-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145770PMC
April 2020

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming.

AIDS Behav 2020 Nov;24(11):3056-3070

Faculty of Health, Public Health Institute, Liverpool John Moores University, Exchange Station, Liverpool, L32ET, UK.

Pre-exposure prophylaxis (PrEP) is an evidence-based new biomedical HIV prevention intervention, which involves the pre-emptive use of daily (or event-based) antiretroviral drugs, to reduce risk of HIV acquisition if exposed. PrEP has recently been positioned as an integral prevention tool to reduce HIV acquisition risk among men who have sex with men (MSM) at country-level and within global prevention strategies. Given this global scale up of PrEP, we conducted a scoping review of extant international literature documenting service related perspectives, models and lessons learnt in PrEP programming for MSM. A systematic search of literature was conducted, and restricted to English language records in the timeframe 2008 to February 2019. Eligibility criteria centered on whether studies broadly described PrEP programming and service delivery for MSM as well as health communication. Following exclusion of ineligible records and removal of duplicates, 84 records were charted and thematically analysed according to scoping review methods. Four themes emerged from the thematic analysis of data; 'PrEP service aspects, settings and staff'; 'PrEP prescriber experiences, therapeutic alliance and care planning'; 'PrEP adherence within formal service structures'; and 'Multi-disciplinary and innovative PrEP care pathways'. The review highlights the complexities in providing optimal PrEP services for MSM by mapping and illustrating the importance of understanding the informal and formal routes to PrEP use among this HIV risk population; the barriers to uptake; the requirement for the presence of a positive therapeutic alliance between patient and prescriber in supporting patient initiation and adherence to PrEP regimes; and the need for availability in different culturally and ethnically sensitive models of PrEP service delivery according to low to high risk groups within the MSM communities.
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http://dx.doi.org/10.1007/s10461-020-02855-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502438PMC
November 2020

Sexually transmitted infection diagnoses, sexualised drug use and associations with pre-exposure prophylaxis use among men who have sex with men in the UK.

Int J STD AIDS 2020 03 9;31(3):254-263. Epub 2020 Feb 9.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

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http://dx.doi.org/10.1177/0956462419897222DOI Listing
March 2020

Injecting-related health harms and overuse of acidifiers among people who inject heroin and crack cocaine in London: a mixed-methods study.

Harm Reduct J 2019 11 13;16(1):60. Epub 2019 Nov 13.

Public Health Institute, Liverpool John Moores University, Tithebarn Street, Liverpool, L2 2QP, UK.

Background: Venous access is a priority for people who inject drugs (PWID). Damage and scarring of peripheral veins can exacerbate health harms, such as skin and soft tissue infections (SSTI), and promote transitions to femoral and subcutaneous injecting. Brown heroin available in Europe requires acidification for injection preparation. In this paper, we present mixed-methods data to explore our hypothesis of a link between overly acidic injection solutions, venous damage and SSTI risk.

Methods: We present a structured survey (n = 455) and in-depth qualitative interview (n = 31) data generated with PWID in London for the Care & Prevent study. Participants provided life history data and detail on injecting environments and drug preparation practices, including the use of acidifiers. Bivariate and multivariate analyses were conducted using a logistic regression for binary outcomes to explore associations between outcomes and excessive acidifier use. Grounded theory principles informed inductive qualitative analysis. Mixed-methods triangulation was iterative with results comparison informing the direction and questions asked of further analyses.

Results: Of the 455 participants, most (92%) injected heroin and/or crack cocaine, with 84% using citric as their primary acid for drug preparation. Overuse of acidifier was common: of the 418 who provided an estimate, 36% (n = 150) used more than ½ a sachet, with 30% (n = 127) using a whole sachet or more. We found associations between acidifier overuse, femoral injecting and DVT, but not SSTI. Qualitative accounts highlight the role of poor heroin quality, crack cocaine use, information and manufacturing constraints in acidifier overuse. Painful injections and damage to peripheral veins were common and often attributed to the use of citric acid.

Conclusions: To reduce injecting-related injury and associated consequences, it is crucial to understand the interplay of environmental and practice-based risks underpinning venous damage among PWID. Overuse of acidifier is a modifiable risk factor. In the absence of structural supports such as safe injecting facilities or the prescribing of pharmaceutical diamorphine, there is an urgent need to revisit injecting paraphernalia design and distribution in order to alleviate health harms and distress among the most marginalised.
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http://dx.doi.org/10.1186/s12954-019-0330-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854679PMC
November 2019

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis.

Addiction 2020 06 10;115(6):1011-1023. Epub 2020 Feb 10.

National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aims: To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

Design: Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

Setting And Participants: People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

Measurements: Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

Findings: Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

Conclusions: People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.
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http://dx.doi.org/10.1111/add.14892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210080PMC
June 2020

Psychosocial and sexual factors associated with recent sexual health clinic attendance and HIV testing among trans people in the UK.

BMJ Sex Reprod Health 2020 Apr 30;46(2):116-125. Epub 2019 Oct 30.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

Objectives: Trans people remain an understudied population in the UK, with unmet sexual health needs. The aim of this research was to identify possible barriers and facilitators for sexual health clinic attendance and HIV testing among trans people.

Methods: Lesbian, gay, bisexual and transgender (LGBT) participants from across the UK were invited to take part in a cross-sectional online survey through Facebook advertising (April-June 2018). Psychosocial and sexual factors associated with recent sexual health clinic attendance, and ever having an HIV test were examined using multivariate logistic regression.

Results: A total of 3007 cisgender and 500 trans participants completed the survey. Trans participants were less likely to attend a sexual health clinic than cisgender participants (27% vs 36%, p<0.001) and report ever having an HIV test (49% vs 64%, p<0.001). One trans participant reported living with HIV and three reported currently taking pre-exposure prophylaxis. Factors associated with trans sexual health clinic attendance were: living in London, having a relationship with multiple partners, engaging in condomless anal intercourse, greater life satisfaction, and having alcohol and/or drugs before sex. Being a person of colour, aged 25-49 years, in a relationship with multiple partners, condomless anal intercourse, lower body dissatisfaction, and having drugs before sex were associated with ever having an HIV test among trans participants.

Conclusions: Trans people were less likely to attend sexual health services than cisgender people, and half of trans participants who reported condomless anal intercourse had never had an HIV test. Further research is needed to understand and improve uptake of sexual health services among trans people.
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http://dx.doi.org/10.1136/bmjsrh-2019-200375DOI Listing
April 2020

Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol).

BMJ Open 2019 09 24;9(9):e029538. Epub 2019 Sep 24.

Glasgow Caledonian University, Glasgow, UK.

Introduction: Hepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV 'Treatment as Prevention' (TasP) in PWID.

Methods And Analysis: We plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome - chronic HCV prevalence in PWID - is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a 'virtual cohort' of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes.

Ethics And Dissemination: Extending HCV community care pathways is covered by ethics (ERADICATE C, ISRCTN27564683, Super DOT C Trial clinicaltrials.gov: NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.
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http://dx.doi.org/10.1136/bmjopen-2019-029538DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773339PMC
September 2019

Treatment outcomes and antiretroviral uptake in multidrug-resistant tuberculosis and HIV co-infected patients in Sub Saharan Africa: a systematic review and meta-analysis.

BMC Infect Dis 2019 Aug 16;19(1):723. Epub 2019 Aug 16.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

Background: Multidrug-resistant tuberculosis (MDR-TB) in HIV endemic settings is a major threat to public health. MDR-TB is a substantial and underreported problem in Sub-Saharan Africa (SSA), with recognised cases projected to increase with advancement in diagnostic technology. There is paucity of review evidence on treatment outcomes and antiretroviral (ART) uptake among MDR-TB patients with HIV in SSA. To address this gap a review of treatment outcomes in HIV patients co-infected with MDR-TB in the SSA region was undertaken.

Methods: Three databases (Medline, Web of Science, CINHAL), Union on Lung Heath conference proceedings and grey literature were searched for publications between January 2004 and May 2018. Records were assessed for eligibility and data extracted. Random effect meta-analysis was conducted using STATA and Cochrane's review manager.

Results: A total of 271 publications were identified of which nine fulfilled the inclusion criteria. Data was collected from 3368 MDR-TB and HIV co-infected patients from four SSA countries; South Africa (6), Lesotho (1), Botswana (1) and Ethiopia (1). The most common outcome was cure (34.9% cured in the pooled analysis), this was followed by death (18.1% in pooled analysis). ART uptake was high, at 83% in the pooled analysis. Cure ranged from 28.6 to 54.7% among patients on ART and from 22.2 to 57.7%  among those not on ART medication. MDR-TB and HIV co-infected patients were less likely to be successfully treated than HIV negative MDR-TB patients (Risk Ratio = 0.87, 95% CI 0.97, 0.96).

Conclusion: Treatment outcomes for MDR-TB and HIV co-infected patients do not vary widely from those reported globally. However, treatment success was lower among HIV positive MDR-TB patients compared to HIV negative MDR-TB patients. Prompt antiretroviral initiation and interventions to improve treatment adherence are necessary.
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http://dx.doi.org/10.1186/s12879-019-4317-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697933PMC
August 2019

Associations with drug use and sexualised drug use among women who have sex with women (WSW) in the UK: Findings from the LGBT Sex and Lifestyles Survey.

Int J Drug Policy 2019 12 26;74:292-298. Epub 2019 Jul 26.

Public Health Institute, Liverpool John Moores University, Exchange Station, Liverpool, L2 2QP, UK.

Introduction: Studies indicate that women who have sex with women (WSW) report greater levels of drug use than heterosexual women, but globally few studies have looked at sexualised drug use among WSW. This study investigated the factors associated with drug use and sexualised drug use (SDU) among WSW.

Methods: Potential participants across the UK were invited to take part in a cross-sectional anonymous online survey between April-June 2018. The LGBT Sex and Lifestyles Survey recruited participants through Facebook advertising and social media posts from community organisations. Multivariate logistic regression was used to compare WSW who had engaged in any drug use in the past 12 months with those who had not, and those who engaged in sexualised drug use in the past 12 months with those who engaged in other drug use.

Results: 1501 WSW could be included in the analyses (mean age = 28.9, 97% white ethnicity). Any drug use was reported by 39% of WSW (n = 583), 44% of which (17% of total, n = 258) reported SDU. Factors associated with drug use were identifying as queer (aOR = 1.86, 95%CI 1.08, 3.23), younger age (aOR = 0.96, 95%CI 0.95, 0.98), being born outside the UK (aOR = 1.75, 95%CI 1.15, 2.66), recent sexual assault (aOR = 2.35, 95%CI 1.43, 3.86), > = 5 female sexual partners (aOR = 3.81, 95%CI 1.81, 8.01), and psychological distress (aOR = 1.75, 95%CI 1.15, 2.67). SDU was associated with identifying as bisexual (aOR = 2.55, 95%CI 1.69, 3.86), > = 5 female sexual partners (aOR = 4.50, 95%CI 1.91, 10.59), and highest education achieved at 16 or lower (aOR = 2.46, 95%CI 1.24, 4.90).

Conclusions: Some WSW may have negative experiences in relation to drug use and SDU. Harm reduction and health services that provide services for WSW should be aware of potentially compounding factors related to drug use, such as sexual assault and psychological distress, providing a safe and LGBT-friendly environment to discuss these issues.
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http://dx.doi.org/10.1016/j.drugpo.2019.07.034DOI Listing
December 2019

Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK.

Sex Transm Infect 2019 08 12;95(5):342-350. Epub 2019 Apr 12.

Public Health Institute, Liverpool John Moores University, Liverpool, UK.

Objective: To understand how the emerging public health issue of chemsex relates to broader patterns of sexualised drug use (SDU) among men who have sex with men (MSM), which has been understudied.

Methods: Potential participants were invited to take part in an anonymous, cross-sectional online survey through Facebook advertising and community organisations' social media posts (April-June 2018). Multivariable logistic regression was used to compare MSM who engaged in recent SDU (past 12 months) with those who did not, and those who engaged in chemsex (γ-hydroxybutyrate/γ-butyrolactone, crystal methamphetamine, mephedrone, ketamine) with those who engaged in other SDU (eg, poppers, cocaine, cannabis).

Results: Of the 1648 MSM included, 41% reported recent SDU; 15% of these (6% of total, n=99) reported chemsex. Factors associated with SDU were recent STI diagnosis (aOR=2.44, 95% CI 1.58 to 3.76), sexual health clinic attendance (aOR=2.46, 95% CI 1.90 to 3.20), image and performance-enhancing drug use (aOR=3.82, 95% CI 1.87 to 7.82), greater number of condomless anal male partners, lower satisfaction with life and greater sexual satisfaction. Predictors of chemsex compared with other SDU were not being UK-born (aOR=2.02, 95% CI 1.05 to 3.86), living in a densely populated area (aOR=2.69, 95% CI 1.26 to 5.74), low sexual self-efficacy (aOR=4.52, 95% CI 2.18 to 9.40) and greater number of condomless anal male partners. Living with HIV, taking pre-exposure prophylaxis (PrEP), and experiencing or being unsure of experiencing sexual contact without consent were significantly associated with SDU and chemsex in bivariate analyses but not in the multivariable.

Conclusion: Health and behavioural differences were observed between MSM engaging in chemsex, those engaging in SDU and those engaging in neither. While some MSM engaging in chemsex and SDU appeared content with these behaviours, the association with life satisfaction and sexual self-efficacy indicates psychosocial support is needed for some. The association with sexual risk and sexual consent also indicates the importance of promoting harm reduction among this population (eg, condoms, PrEP, drug knowledge).
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http://dx.doi.org/10.1136/sextrans-2018-053933DOI Listing
August 2019

Clonal expansion of community-associated meticillin-resistant Staphylococcus aureus (MRSA) in people who inject drugs (PWID): prevalence, risk factors and molecular epidemiology, Bristol, United Kingdom, 2012 to 2017.

Euro Surveill 2019 Mar;24(13)

Authors contributed equally to the work and share last authorship.

Background: In 2015, Bristol (South West England) experienced a large increase in cases of meticillin-resistant (MRSA) infection in people who inject drugs (PWID).

Aim: We aimed to characterise and estimate the prevalence of MRSA colonisation among PWID in Bristol and test evidence of a clonal outbreak.

Methods: PWID recruited through an unlinked-anonymous community survey during 2016 completed behavioural questionnaires and were screened for MRSA. Univariable logistic regression examined associations with MRSA colonisation. Whole-genome sequencing used lineage-matched MRSA isolates, comparing PWID (screening and retrospective bacteraemia samples from 2012-2017) with non-PWID (Bristol screening) in Bristol and national reference laboratory database samples.

Results: The MRSA colonisation prevalence was 8.7% (13/149) and was associated with frequently injecting in public places (odds ratio (OR): 5.5; 95% confidence interval (CI):1.34-22.70), recent healthcare contact (OR: 4.3; 95% CI: 1.34-13.80) and injecting in groups of three or more (OR: 15.8; 95% CI: 2.51-99.28). People reporting any one of: injecting in public places, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). Phylogenetic analysis identified a dominant clade associated with infection and colonisation among PWID in Bristol belonging to ST5-SCCmecIVg.

Conclusions: MRSA colonisation in Bristol PWID is substantially elevated compared with general population estimates and there is evidence of clonal expansion, community-based transmission and increased infection risk related to the colonising strain. Targeted interventions, including community screening and suppression therapy, education and basic infection control are needed to reduce MRSA infections in PWID.
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http://dx.doi.org/10.2807/1560-7917.ES.2019.24.13.1800124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446509PMC
March 2019

Evaluating the cost-effectiveness of existing needle and syringe programmes in preventing hepatitis C transmission in people who inject drugs.

Addiction 2019 03 23;114(3):560-570. Epub 2019 Jan 23.

Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.

Aim: To evaluate the cost-effectiveness of needle and syringe programmes (NSPs) compared with no NSPs on hepatitis C virus (HCV) transmission in the United Kingdom.

Design: Cost-effectiveness analysis from a National Health Service (NHS)/health-provider perspective, utilizing a dynamic transmission model of HCV infection and disease progression, calibrated using city-specific surveillance and survey data, and primary data collection on NSP costs. The effectiveness of NSPs preventing HCV acquisition was based on empirical evidence.

Setting And Participants: UK settings with different chronic HCV prevalence among people who inject drugs (PWID): Dundee (26%), Walsall (18%) and Bristol (45%) INTERVENTIONS: Current NSP provision is compared with a counterfactual scenario where NSPs are removed for 10 years and then returned to existing levels with effects collected for 40 years.

Measurements: HCV infections and cost per quality-adjusted life year (QALY) gained through NSPs over 50 years.

Findings: Compared with a willingness-to-pay threshold of £20 000 per QALY gained, NSPs were highly cost-effective over a time-horizon of 50 years and decreased the number of HCV incident infections. The mean incremental cost-effectiveness ratio was cost-saving in Dundee and Bristol, and £596 per QALY gained in Walsall, with 78, 46 and 40% of simulations being cost-saving in each city, respectively, with differences driven by coverage of NSP and HCV prevalence (lowest in Walsall). More than 90% of simulations were cost-effective at the willingness-to-pay threshold. Results were robust to sensitivity analyses, including varying the time-horizon, HCV treatment cost and numbers of HCV treatments per year.

Conclusions: Needle and syringe programmes are a highly effective low-cost intervention to reduce hepatitis C virus transmission, and in some settings they are cost-saving. Needle and syringe programmes are likely to remain cost-effective irrespective of changes in hepatitis C virus treatment cost and scale-up.
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http://dx.doi.org/10.1111/add.14519DOI Listing
March 2019

The experiences of people who inject drugs of skin and soft tissue infections and harm reduction: A qualitative study.

Int J Drug Policy 2019 03 18;65:65-72. Epub 2019 Jan 18.

School of Media, Culture and Society, University of the West of Scotland, Paisley, PA1 2BE, Scotland, United Kingdom.

Background: Bacterial skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are considered a public health concern. There is a lack of qualitative research examining the lived experience of PWID who have had SSTI. This paper explores PWID views and experiences of their SSTI, their perceptions on the causes of their SSTI and their harm reduction (HR) behaviours. The implications for HR service delivery and practice will be discussed.

Methods: Between October 2015-January 2016, 22 in-depth interviews were conducted with PWID who had experienced a SSTI within the past year. Interviewees were recruited from an injecting equipment provision service and a drug treatment service in Glasgow and Edinburgh respectively. The interview transcripts were transcribed verbatim and underwent thematic analysis.

Results: We found that the experience of SSTI can cause strong negative feelings, including panic and stigma and that there was limited knowledge of SSTI prior to first hand experience. The awareness of the unacceptable social and physical consequences of SSTI fostered a sense of personal responsibility and agency which led to the introduction or improved HR uptake. However, when PWID were struggling to inject or when their physical and political environments were compromised there was an increased risk for SSTI and reduced effectiveness of HR.

Conclusion: Compared to HCV and HIV, SSTI as an injecting related harm has received less policy attention. Policy makers need to address SSTI HR within enabling environments, such as 'safer environment interventions'. It is recommended that peer based support, improved NSP provision and medically supervised injecting facilities are needed to deliver SSTI HR.
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http://dx.doi.org/10.1016/j.drugpo.2018.09.001DOI Listing
March 2019

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

Drug Alcohol Depend 2019 02 14;195:40-44. Epub 2018 Dec 14.

National Infection Service, Public Health England, London, UK.

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.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.11.021DOI Listing
February 2019

A comparison of two biological markers of recent hepatitis C virus (HCV) infection: implications for the monitoring of interventions and strategies to reduce HCV transmission among people who inject drugs.

Euro Surveill 2018 11;23(47)

Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.

BackgroundMonitoring hepatitis C virus (HCV) incidence is important for assessing intervention impact. Longitudinal studies of people who inject drugs (PWID), using repeated biological tests, are costly; alternatively, incidence can be estimated using biological markers of recent infection in cross-sectional studies.AimWe aimed to compare incidence estimates obtained from two different biological markers of recent infection in a cross-sectional study to inform monitoring approaches for HCV elimination strategies.MethodSamples from an unlinked anonymous bio-behavioural survey of PWID were tested for two recent infection markers: HCV RNA with anti-HCV negative ('RNA') and low-avidity anti-HCV with HCV RNA present ('avidity'). These two markers were used separately and in combination to estimate HCV incidence.ResultsBetween 2011 and 2013, 2,816 anti-HIV-negative PWID (25% female) who had injected during the preceding year were either HCV-negative or had one of the two markers of recent infection: 57 (2.0%) had the RNA marker and 90 (3.2%) the avidity marker. The two markers had similar distributions of risk and demographic factors. Pooled estimated incidence was 12.3 per 100 person-years (pyrs) (95% credible interval: 8.8-17.0) and not significantly different to avidity-only (p = 0.865) and RNA-only (p = 0.691) estimates. However, the RNA marker is limited by its short duration before anti-HCV seroconversion and the avidity marker by uncertainty around its duration.ConclusionBoth markers have utility in monitoring HCV incidence among PWID. When HCV transmission is high, one marker may provide an accurate estimate of incidence; when it is low or decreasing, a combination may be required.
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http://dx.doi.org/10.2807/1560-7917.ES.2018.23.47.1700635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341939PMC
November 2018

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis.

Lancet Infect Dis 2018 12 29;18(12):1397-1409. Epub 2018 Oct 29.

International Charitable Foundation Alliance for Public Health, Kiev, Ukraine.

Background: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I statistic and the P-value for heterogeneity.

Findings: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

Interpretation: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

Funding: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.
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http://dx.doi.org/10.1016/S1473-3099(18)30469-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280039PMC
December 2018

Usage of low dead space syringes and association with hepatitis C prevalence amongst people who inject drugs in the UK.

Drug Alcohol Depend 2018 11 15;192:118-124. Epub 2018 Sep 15.

Population Health Sciences, University of Bristol, Beacon House, Queens Road, Bristol, BS8 1QU, UK; National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU), Evaluation of Interventions, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.

Introduction: Syringes with attached needles (low dead space syringes [LDSS]) retain far less blood following injection than syringes with detachable needles (high dead space syringes [HDSS]). People who inject drugs (PWID) who share needles/syringes may be less likely to acquire Hepatitis C virus (HCV) infection using LDSS, compared with HDSS, but data are limited.

Methods: Utilizing drug behavior and HCV antibody testing data from the UK 2014/2015 Unlinked Anonymous Monitoring Survey of PWID, we calculated the percentage of syringes used in the past month that were LDSS. We investigated which injecting characteristics and demographic factors were associated with 100% LDSS (against 0-99%) usage, and whether 100% LDSS use was associated with antibody HCV-status, after adjusting for confounders.

Result: Of 2174 participants, 55% always used LDSS, 27% always used HDSS, and 17% used both LDSS and HDSS. PWID that had injected into their groin during the past month were unlikely to use LDSS, adjusted odds ratio (aOR) 0.14 (95% confidence interval 0.11-0.17), compared to those not using the groin. Those injecting crack were less likely to use LDSS than those not, aOR 0.79 (0.63-0.98). Polydrug use was negatively associated with LDSS use, aOR 0.88 (0.79-0.98) per additional drug. LDSS use was associated with lower prevalent HCV among all PWID (aOR 0.77, [0.64-0.93]), which was stronger among recent initiates (aOR 0.53 [0.30-0.94]) than among experienced PWID (aOR 0.81 [0.66-0.99]).

Discussion: People who inject into their groin were less likely to use LDSS. Exclusive LDSS use was associated with lower prevalence of HCV amongst PWID that started injecting recently, suggesting LDSS use is protective against HCV.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.07.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541923PMC
November 2018

Sexualised drug use: LGTB communities and beyond.

Int J Drug Policy 2018 05;55:128-130

School of Public Health, Rutgers University, USA.

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http://dx.doi.org/10.1016/j.drugpo.2018.04.015DOI Listing
May 2018
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