Needle exchange was first introduced in the United Kingdom in 1985 in response to the AIDS epidemic. Most areas within the UK have pharmacy-based needle-exchange services. Mobile, agency-based and automated needle exchange programs also exist.

A new study finds that despite this widespread availability of syringes, there is an increase in HIV infection among injection drug users (IDUs) as well as an increase is the sharing of needles.

These results echo the findings of another study published a year ago in the British Medical Journal which found that HIV and hepatitis C (HCV) rates are increasing among IDUs in the United Kingdom. Nearly half (44%) of injection drug users under the age of 30 are already infected with HCV and 4.2% are infected with HIV– and these rates are increasing, according to the BMJ article.

While the recent study claims that the increase may be a result of an increased focus on crime, it ignores what may be the real cause driving the epidemic which was reported in a university study release last year: Widespread drug abuse. One in 50 young people and adults in London and two other major U.K. cities inject illicit drugs– making drug abuse as common as diabetes. Five million needles are provided to drug addicts in London each year, yet harm reduction advocates claim that this amount is 80% short of the total number “needed.”

All three studies are provided below:

Edwin J. Bernard, Friday, July 15, 2005

New HIV infections via injecting drug use (IDU) appear to be on the increase in England and Wales, according to a collaborative study from the UK’s Health Protection Agency (HPA) and Imperial College London, published in the July 22nd issue of the journal AIDS. The study, which combines anonymous HIV testing data with community surveys for the first time, suggests that recent increases in HIV IDU transmission are most pronounced in younger, recent IDUs, in London. This increase in new infections coincides with a shift in UK drugs policy away from public health concerns towards a stronger focus on crime.

In the UK, harm reduction initiatives such as the provision of clean needles through needle exchange programmes (NEPs) have been relatively effective in limiting the spread of HIV among injecting drug users (IDUs). By the end of 2002, only 7% of the 56,000 diagnosed HIV infections were associated with IDU. However, there has been some recent evidence of an increase in risky injecting practices suggesting that new HIV infections amongst IDUs may be on the increase.

In order to examine trends in HIV prevalence amongst IDUs, researchers from the HPA and Imperial College, London combined data from two voluntary unlinked-anonymous survey programmes that included adults (aged 15-49) who had injected drugs in the previous four weeks.

The first is an annual survey of IDUs via drug agencies in England and Wales (ranging in number over the years between 29-59; providing advice, support, harm-reduction and/or treatment services) has been ongoing since 1990, and includes a brief self-completed questionnaire and oral fluid samples for HIV testing.

The second was a series of community-based surveys in London (1990-1993); London and seven other English cities (1997-1998); and London and Brighton (2001-2002). This was conducted in the field (e.g. street locations, homes and social venues) and included an interviewer-administered questionnaire and oral fluid samples for HIV testing. This provided the researchers with a cross-sectional data set, including almost 28,000 oral fluid samples on which to test anonymously for HIV.

Evidence of increase in HIV prevalence

HIV prevalence among IDUs in England and Wales declined from a peak of 5.9% (67 positive HIV antibody tests out of a total of 1132 samples) in 1990 to a low of 0.6% (14/2270) in 1996. It then remained stable until 2000, after which there was, say the researchers, “some evidence of an increase” to 1.4% (21/1529) in 2003.

Individuals who had been injecting for the shortest period of time (less than three years; 1.2%) and those who had been injecting for the longest period of time (more than twelve years; 2.9%) had the highest HIV prevalence in 2003. In contrast, those who had been injecting drugs between three and five years, or six and eleven years, had lower HIV prevalence (0.3% and 0.7%, respectively).

HIV prevalence was found to be higher in London (5%) compared with elsewhere in England and Wales (0.4%) and similar in women (1.8%) and men (1.6%).

Five factors were included in multivariate modelling after adjustment: survey year; recruitment location; length of injecting career; recruitment setting; and having had a voluntary confidential HIV test.

The odds of being HIV-positive were higher for the survey years 1990-95 and 2001-2003 compared with 1996 (p=0.001); higher for recruitment in London compared with outside London (Adjusted Odds Ratio 7.33; 95% CI, 5.60-9.59); highest for those injecting for 15 years or more (AOR 2.3; 95% CI, 1.61-3.28); higher for those recruited in the community versus those from the agency survey (AOR 1.76; 95% CI, 1.37-2.24); and higher for those who had ever had a voluntary HIV test outside of the survey (AOR 2.49; 95% CI,1.95-3.18).

Younger IDUs in London at highest risk of new HIV infection

The investigators used an adjusted model (adjusted for number of years injecting, recruitment setting and having had a voluntary HIV test outside of the survey) to fit location and survey year together, and the results suggested that the recent increase in HIV prevalence was mainly occuring in London (p=0.025).

To examine this futher, force of infection in and outside of London, defined as the yearly rate at which HIV-negative IDUs become HIV-positive, was estimated by fitting a model to prevalence data by calendar year and injecting career length. The results suggest that force of infection in London is higher amongst novice IDUs (those injecting for less than one year) and has increased over time.

Between 1992-1997, the force of infection amongst novice IDUs in London was 0.008 (95% CI, 0.002-0.02), whereas between 1998-2003 it was 0.028 (95% CI, 0.016-0.045), or almost 3% per year. For IDUs who had been injecting for more than a year, the force of infection was 0.13 lower across all time periods. Since age and length of injecting habit were found to be highly correlated (p=0.001), this suggests younger IDUs in London are acquiring HIV more rapidly than older IDUs in London or elswhere.

This increase in new HIV infections is similar to the 3.4% rate found in a recent London-based cohort study.

Awareness of HIV infection

Overall, 54% of the total cohort had ever taken an HIV antibody test outside of the surveys.

Of those testing HIV-positive, 81%( 371/461) reported ever having taken an HIV antibody test. Of those who reported the results of their last HIV test, 75% (193/259) were aware of their infection.

In 2002-2003, however, only 69% (25/36) of those who were HIV-positive and who reported the results of their HIV antibody test were aware of their infection.

Is UK policy to blame?

Although the combined surveys found that reported needle- and syringe-sharing in the previous month remained uniformly high both in London (31%) and outside London (29%) in 2002, the higher force of infection in London may reflect higher HIV prevalence amongst IDUs in London compared with those outside London, as well as an increased prevalence of injecting drugs, crack cocaine in particular.

However, the authors point out that in 1998, the UK’s national drug strategy changed its focus from harm-reduction and the reduction of blood-borne viruses to “wider social harms, in particular drug-related crime.” They suggest that this “simultaneous shift in the focus of policy and service provisioning for drug users in England and Wales” may have “unintentionally hindered the development and re-invigoration of harm reduction measures in response to evolving patterns of drug use and risk behaviours.”

In addition, younger IDUs would not have been exposed to either national or targeted HIV prevention campaigns that took place earlier in the HIV epidemic.

It also appears that many of the recently-infected IDUs are foreign nationals. “Data on country of birth from clinicians’ reports of newly diagnosed HIV infections indicate that two-thirds of HIV-infected IDUs diagnosed in the UK in 2003 were born in another country,” the authors write. Thus the recent increase in HIV prevalence in London may reflect recent patterns of emigration to London, particularly from south-western and eastern Europe where the prevalence of HIV is higher among IDUs than in other risk groups.

Reference

Hope VD et al. HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years. AIDS 19:1207-14, 2005.

HEPATITIS C ‘EPIDEMIC AMONG LONDON DRUG USERS’

By Lyndsay Moss, PA Health Correspondent

Cases of hepatitis C among young drug users in London are reaching epidemic levels, researchers warned today. The number of people who inject drugs who now have HIV is also worryingly high, according to a study published in the British Medical Journal. The researchers blamed the Government’s current drug policy for failing to protect this high risk group from bloodborne viruses like hepatitis C.

The team, from Imperial College London, the Health Protection Agency and the London School of Hygiene and Tropical Medicine, estimated that four in 10 new drug users in London now had hepatitis C, which can cause fatal liver damage.

They also estimated that 3% of injecting drug users was now infected with HIV. The results were based on tests involving 428 drug users who had been injecting for six years or less. Hepatitis C and HIV can be spread by sharing needles and the researchers found high levels of syringe-sharing during their study. One in four reported injecting with needles and syringes used by someone else in the past four weeks.

Researcher Dr Ali Judd, based at Charing Cross Hospital, west London, said: “Hepatitis C is now spreading at epidemic levels across London and HIV incidence is worryingly high, which if unchecked will lead to an increase in the total number of HIV infections.

“There is an urgent need for new and comprehensive programmes to tackle this growing number.”

Dr Matthew Hickman, from Imperial College London, added: “For the past six or seven years Government drug policy has focused on drugs and crime, and has been successful in expanding specialist drug treatment, especially through referral from criminal justice. “However there is a need now to reinvigorate harm reduction policies that prevent transmission of hepatitis C and HIV.”

A Department of Health spokeswoman said the Government was committed to driving down cases of hepatitis C and other blood-borne infections like HIV.

“Almost £500 million will be spent on drug treatment in 2004-05 and we recently announced that all Drug Action Teams will get a 55% increase in their allocations between 2006 and 2008. “The extra funding in the last few years has led to many more drug users engaging in treatment and an increase in the numbers successfully completing treatment.

“This is good news as there is clearly a link between getting people into treatment and substantially reducing the rate of blood-borne diseases.” The spokeswoman added: “A Hepatitis C Action Plan for England was launched by the Department of Health in June 2004 calling for a review of harm reduction services to prevent hepatitis C transmission. “Such services include provision of needle exchange services in the community, safe disposal of used needles and syringes and provision of specialist drug treatment services.”

One in 50 injects drugs, research finds

The government has been urged to step up its efforts to tackle drug use after research showed levels of use in English cities to be higher than previously thought.

A study published today revealed that as many as one in 50 young people and adults in three major English cities were injecting drugs.

This statistic is higher than previous Home Office figures, which estimated that in 2001, 0.3% of the population between 15 and 64 years old were injecting drug users.

Using information from sources including drug treatment centres and syringe exchange schemes between 2000-01, researchers from Imperial College London and Liverpool John Moores University studied levels of drug use in London, Liverpool and Brighton.

They discovered that the proportion of adults and young people between 15 and 44 who were injecting drugs was 2% in Brighton, 1.5% in Liverpool and 1.2% in London.

Based on the rates for each city, the researchers said that these figures equated to between 10 and 18 patients in a typical general practice list of 2,000 patients, with 900 aged 15 to 44.

“Thus, in Brighton, Liverpool and London the prevalence of injecting drug use among young adults is as common as diabetes and greater than many other chronic conditions such as epilepsy or psychosis,” the researchers said.

The study also found injecting drug-users (IDUs) were more likely to die of their habit in Brighton. Overall, around 1% of IDUs die from an overdose each year, but in Brighton this rate was twice as high.

The government wants to increase the number of problem drug users in treatment programmes in coming years, but researchers said the figures on which the target was based were flawed and more effort was needed to reach the targets.

“The government aims to double the number of problem drug users in treatment,” the authors said. “In the three sites [looked at in the study], there is ample opportunity for this [drug treatment], given that less than one in four IDUs are in receipt of treatment at any one time. Unfortunately, the data on the numbers in treatment were of poor quality and requires urgent improvement.”

The research also revealed a shortage of sterile needles in each of the cities studied. Around 5 million syringes were distributed each year in London, 400,000 in Brighton and 560,000 in Liverpool.

This works out at 190 syringes per person in Brighton and Liverpool – one used every two days – and slightly less in London at about one used every 2.5 days.

“Given that users inject on average twice a day, this would suggest that current levels of activity provide sterile equipment for approximately 27% of all injections by users in Brighton and Liverpool and 20% in London,” the researchers said, adding that this low take-up increased the risk of diseases being spread.

 

These studies show that the harm reduction strategies of providing needles do not result in decreased HIV infection….. More emphasis on drug prevention is indicated.  The research shows that two thirds of those testing positive are not British born nationals…..the social costs of the spreading of HIV and HEP C plus the costs to the over-burdened NHS surely indicate the need for health testing of all people taking up residence in this country?