Twenty years of selective hepatitis B vaccination: is hepatitis B declining among injecting drug users in England and Wales?

Injection drug use is a common route of infection for the hepatitis B virus (HBV) in the UK. The aim of this study was to establish the prevalence and force of infection for HBV among injecting drug users (IDUs) recruited from multiple community and drug agency settings in England and Wales between 1990 and 2004. Cross-sectional studies of IDUs in and out of contact with drug agencies were conducted throughout the 15-year period. Oral fluid samples were tested for antibodies to the hepatitis B core antigen (anti-HBc). Logistic regression was used to investigate associations between risk factors and anti-HBc positivity and force of infection models were explored. In total, 2527 injectors were recruited from community settings, and 29 386 from drug agencies. Anti-HBc prevalence was 31% (95% CI 30.7-31.8%). It declined in the early 1990s from around 50% in 1992 to 25% in 1999, after which it increased slightly. It was also higher in those who had injected for longer, older IDUs, those recruited in London and North West England, and those reporting having a previous voluntary confidential HIV test. The force of infection models suggested that the incidence of infection increased in 1999-2004 compared with 1993-1998, and was higher in new injectors compared with those injecting for > or =1 year. In conclusion, findings suggest ongoing HBV transmission in recent years despite an overall decline in prevalence in the early and mid-1990s, and highlight the importance of targeting vaccination programmes at new IDUs who have high incidence rates of infection.

Pathways into receiving a prescription for diamorphine (heroin) for the treatment of opiate dependence in the United kingdom.

In the UK, few doctors prescribe diamorphine for the treatment of opiate dependence to a small number of patients. A retrospective case note review of patients receiving diamorphine in 2000 was conducted in the UK to determine how and why these patients came to receive a prescription for diamorphine. Patient eligibility criteria were examined together with doctors' stated reasons for initiating a diamorphine (heroin) prescription. Two hundred and ten sets of patients' case notes were reviewed at 27 of the 42 (64%) drug clinics in England and Wales where diamorphine was prescribed by the doctor. There appeared to be a general consensus among the few doctors who had prescribed diamorphine that it was a treatment of last resort, for those with long histories of heroin use and injecting, and those who had not responded sufficiently well to previous other treatments. However, there was also a small number of patients initiated on diamorphine without ever having previously received opiate treatments and some because they were experiencing problems injecting methadone. This reflects the UK history of the individual doctor's clinical autonomy in deciding when diamorphine is appropriate and the previous lack of nationally agreed patient eligibility criteria.

Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution.

OBJECTIVE: To present and update available national and subnational estimates of injecting drug users (IDUs) in developing/transitional countries, and provide indicative estimates of gender and age distribution. METHODS: Literature review of both grey and published literature including updates from previously reported estimates on estimates of IDU population and data sources giving age and gender breakdowns. The scope area was developing/transitional countries and the reference period was 1998-2005. RESULTS: Estimates of IDU numbers were available in 105 countries and 243 subnational areas. The largest IDU populations were reported from Brazil, China, India, and Russia (0.8 m, 1.9 m, 1.1 m, and 1.6 m respectively). Subnational areas with the largest IDU populations (35,000-79,000) are: Warsaw (Poland); Barnadul, Irtkustk, Nizhny-Novgorod, Penza, Voronez, St Petersburg, and Volgograd (Russia); New Delhi and Mumbai (India); Jakarta (Indonesia), and Bangkok (Thailand). By region, Eastern Europe and Central Asia have the largest IDU prevalence (median 0.65%) (min 0.3%; max 2.2%; Q1 0.39%; Q3 1.32%) [corrected] followed by Asia and Pacific: 0.24% (min 0.004%; max 1.47%; Q1 0.14%; Q3 1.47%) [corrected] In the Middle East and Africa the median value equals 0.2% (min 0.0003%; max 0.35%; Q1 0.11%; Q3 0.23%) [corrected] and in Latin America and the Caribbean: 0.12% (min 0.11%; max 0.69%; Q1 0.04%; Q3 0.13%) [corrected] Subnational areas with the highest IDU prevalence among adults (8-14.9%) were Shymkent (Kazakhstan), Balti (Moldova), Astrakhan, Barnadul, Irtkustk, Khabarovsk, Kaliningrad, Naberezhnyje Chelny, Penza, Togliatti, Volgograd, Voronez, and Yaroslavl (Russia), Dushanbe (Tajikistan), Ashgabad (Turkmenistan), Ivano-Frankivsk and Pavlograd (Ukraine) and Imphal, Manipur (India). 66% (297/447) of the IDU estimates were reported without technical information. Data on the IDU age/gender distributions are also scarce or unavailable for many countries. In 11 Eastern European and Central Asian countries the age group 50% of the total. The proportion of IDU men was 70%-90% in Eastern Europe and Central Asia, and there was a marked absence of data on women outside this region. CONCLUSION: Unfortunately data on IDU prevalence available to national and international policymakers is of an unknown and probably yet to be tested quality. This study provide baseline figures but steps need to be taken now to improve the reporting and assessment of these critical data.

Patients receiving a prescription for diamorphine (heroin) in the United Kingdom.

The United Kingdom is unusual internationally in that it is one of few countries able to prescribe diamorphine for the treatment of opiate dependence. Prescribing diamorphine has been part of the UK response to drug problems since the 1920s. Despite this, little is known about who receives diamorphine and how treatment is delivered. This study aims to describe the characteristics and treatment regimes of opiate-dependent drug users receiving a prescription for diamorphine in the United Kingdom in 2000, and report on their status in 2002. A retrospective case-note review was conducted in England and Wales. Two hundred and ten (72%; 210/292) patients' sets of case-notes were reviewed at 27 of the 42 (64%) drug clinics where diamorphine was prescribed by the doctor. Patients had been receiving a prescription for diamorphine for a median length of six years. The majority were unemployed white males, with a median age of 44 years. Illicit drug use and criminal activity, while low, had not been eliminated totally. The majority were prescribed ampoules and few had significant health problems. In some cases patients had been transferred to injectable diamorphine from injectable methadone to reduce injection related problems. There were wide variations in dose. The majority of patients had no serious drug, health or social problems. Diamorphine prescribing was a long-term commitment. The experience from the United Kingdom has been one of long-term prescribing with the aim of retaining patients in treatment and reducing the harms caused by illicit drug use. Prospective studies are needed to determine the long-term consequences of receiving a diamorphine prescription.

Prevalence of, and risk factors for, hepatitis C virus infection among recent initiates to injecting in London and Glasgow: cross sectional analysis.

Our aim was to compare the prevalence of antibody to hepatitis C virus (anti-HCV) among recently initiated injecting drug users (IDUs) in London and Glasgow, and to identify risk factors which could explain differences in prevalence between the cities. Complementary studies of community recruited IDUs who had initiated injection drug use since 1996 were conducted during 2001-2002. Data on HCV risk behaviours were gathered using structured questionnaires with identical core questions and respondents were asked to provide an oral fluid specimen which was tested anonymously for anti-HCV but was linked to the questionnaire. Sensitivities of the anti-HCV assays for oral fluid were 92-96%. Prevalence of anti-HCV was 35% (122/354) in London and 57% (207/366) in Glasgow (P < 0.001). Multifactorially, factors significantly associated with raised odds of anti-HCV positivity were increasing length of injecting career, daily injection, polydrug use, having had a needlestick injury, and having served a prison sentence. In addition lower odds of anti-HCV positivity were associated with non-injection use of crack cocaine and recruitment from drug agencies. After adjustment for these factors, the increased odds of anti-HCV associated with being a Glasgow IDU were diminished but remained significant. HCV continues to be transmitted among the IDU population of both cities at high rates despite the availability of syringe exchange and methadone maintenance. Effectiveness of harm reduction interventions may be compromised by inadequate coverage and failure to reduce sufficiently the frequency of sharing different types of injecting equipment, as well as the high background prevalence of HCV, and its high infectivity. Comprehensive action is urgently required to reduce the incidence of HCV among injectors.

Prevalence of hepatitis C among injection drug users in England and Wales: is harm reduction working?

OBJECTIVES: This study sought to establish the prevalence of hepatitis C antibodies (anti-HCV) and hepatitis B antibodies (anti-HBc) among injection drug users in England and Wales. METHODS: A voluntary cross-sectional survey collected oral fluid samples and behavioral information; 2203 injectors were recruited through drug agencies, and 758 were recruited in the community. RESULTS: Prevalence was 30% for anti-HCV, 21% for anti-HBc, and 0.9% for HIV antibodies. Anti-HCV prevalence rates were significantly greater among those with longer injecting careers, those in older age groups, those residing in London, those recruited in drug agencies, those positive for anti-HBc, and those with a previous voluntary HIV test. CONCLUSIONS: Anti-HCV prevalence rates among injectors in England and Wales, where comprehensive harm reduction programs exist, are lower than rates in other industrialized countries.

Measuring injecting risk behaviour in the second decade of harm reduction: a survey of injecting drug users in England.

AIMS: To measure risk behaviour among injecting drug users (IDUs) using the Injecting Risk Questionnaire (IRQ). METHODS: Data were analysed from the first multi-site survey of injecting risk behaviour among IDUs not in contact with drug services in England. A total of 1214 IDUs were recruited from community settings in seven sites. FINDINGS: Fifty-two per cent reported sharing injecting equipment in the previous 4 weeks in response to a single question on sharing. This rose to 78% when asked more detailed and multiple questions on injecting risk practices. Levels of injecting risk behaviour did not differ substantially by gender, age, length of injecting career, main drug of injection, previous treatment contact or geographical location. However, sharing partners were restricted to a median of two others. CONCLUSION: These data raise questions concerning the extent to which levels of injecting risk behaviour have increased over recent years, or the extent to which previous monitoring systems underestimated levels of risk. None the less, the data confirm that the promotion of safer injecting continues to be an important public health issue with regard to reducing blood-borne infections.

Surveillance of problem drug use in the UK: a review of a Regional Drug Misuse Database.

BACKGROUND: We report detailed findings of the first systematic validation of a Regional Drug Misuse Database (RDMD); such databases constitute the main investment in routine drug statistics in the UK by the Department of Health. METHODS: A retrospective case-finding study in a stratified random sample of one in three specialist drug agencies was carried out. Agency records of clients attending during 1994 were matched with reports (episodes) to the North Thames RDMD to assess the level of under-reporting, and the relationship between RDMD reports (episodes) and the number of problem drug users in contact with agencies. Under-ascertainment of cases was estimated using two-sample capture-recapture. RESULTS: Under-reporting was associated with agency records missing full date of birth or initials (attributers), and agency type. Compared with drug dependency units (DDU) the odds of under-reporting were 3-18 times higher by the other specialist drug agencies. Even after excluding episodes with missing attributers the odds ratio (OR) of not being reported was significantly higher among needle exchanges (OR 2.7), non-statutory community based drug teams (OR 3.2), statutory community based drug teams (OR 4.9) and residential rehabilitation units (OR 8.7) compared with DDUs. Overall database episodes represented 60 per cent of the number of clients attending specialist agencies as a result of a mixture of under-reporting and the proportion of clients retained in treatment, which also varied by agency type. A total of 727 individuals (16 per cent) had never been reported. CONCLUSIONS: Surveillance of drug misuse through RDMDs does not yet fulfil its objectives. It is essential that a system of following up reports is introduced to improve their utility, and to contribute to the monitoring of the UK Government's new drugs strategy, and wider European surveillance.

HIV prevalence and risk behaviour among female injecting drug users in London, 1990 to 1996.

OBJECTIVE: To describe trends in HIV prevalence among female injecting drug users (IDU) in London between 1990 and 1996. DESIGN: HIV prevalence and risk behaviour were measured yearly between 1990 and 1993, and in 1996, in point prevalence HIV surveys of IDU recruited from both drug-treatment and community-based settings within Greater London. Sample sizes were 173 in 1990, 111 in 1991, 128 in 1992, 146 in 1993 and 200 in 1996. METHODS: Each survey used structured questionnaires and common sampling and interview strategies. Oral fluid specimens were collected for testing for antibodies to HIV (anti-HIV). Multiple logistic regression was used to assess the trend in HIV prevalence. RESULTS: The percentage of female IDU testing positive for antibodies to HIV showed a marked decline over the study period, from 15.0% in 1990 to 1.0% in 1996 (P < 0.001). This trend was independent of all other variables examined. Each year, higher HIV prevalences were found among IDU recruited from community settings compared with treatment agencies. CONCLUSIONS: These results concur with those of IDU recruited from treatment sites, although the yearly estimates in this study are higher. London benefits from low prevalence of HIV infection among IDU, coupled with behaviour change facilitated by early intervention. Continued surveillance of injectors recruited from both community and treatment settings is necessary in order properly to assess HIV prevalence among IDU.

HIV infection associated with drug injecting in the newly independent states, eastern Europe: the social and economic context of epidemics.

AIMS: We review recent trends in HIV associated with injecting drug use (IDU) in the Newly Independent States (NIS) in eastern Europe, including Belarus, Moldova, Russia, Ukraine, and Kazakhstan in central Asia. We aim to draw attention to the social and economic "risk environments" in which rapid HIV spread among IDUs has occurred. METHODS: Findings draw on centrally registered HIV surveillance data, published research studies and assessment reports funded by international development agencies. FINDINGS: Since 1995, there is evidence of rapid HIV spread in Belarus, Kazakhstan, Moldova, Russia and Ukraine, with estimates suggesting between 50% and 90% of new HIV infections among IDUs. At the same time, there have been rapid increases in the incidence of syphilis and declines in health and welfare status, including outbreaks of diphtheria, tuberculosis and cholera. Findings emphasize the potential influence of the social and economic context in creating the "risk environments" conducive to HIV and epidemic spread. Key factors include: rapid diffusions in IDU; population migration and mixing; economic transition and decline; increasing unemployment and impoverishment; the growth of informal economies; modes of drug production, distribution and consumption; declines in public health revenue and infrastructure; and political, ideological and cultural transition. CONCLUSIONS: An understanding of the social and economic contexts mediating HIV spread is a prerequiste to identifying the environmental "pre-conditions" of epidemic outbreaks, and thus also, for predicting and preventing HIV transmission. The "risk environment" may influence the efficacy of individual and community-level HIV prevention and highlights the concomitant urgency for interventions targeting social and environmental change.

Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users: associated health gains and harm reductions.

OBJECTIVE: To assess the feasibility of offering the choice of prescribing injectable heroin (diamorphine) or injectable methadone to opiate-dependent injecting drug users and to assess whether there are health and social gains associated with prescribing injectable opiates. DESIGN: A protocol-driven prospective observational study. Type of injectable opiate received was based on self-selection. SETTING: A large west London drug clinic. PATIENTS: Fifty-eight patients admitted to the clinic between 1 June 1995 and 31 December 1996, who were long term opiate-dependent injecting drug users, who had previously tried and failed oral methadone and who were apparently unable or unwilling to give up injecting. MAIN OUTCOME MEASURES: Retention in treatment, illicit drug use, HIV risk behaviour, criminal activity, social functioning, health and psychological status as measured by self-report, urinalysis and doctor's ratings. RESULTS: Thirty-seven patients (64%) chose heroin and 21 (36%) chose injectable methadone. Fifty (86%) were retained in treatment after three months, 40 (69%) after six months and 33 (57%) after 12 months. Among those in treatment at three months, there were significant reductions in illicit drug use, illicit drug-injecting risk behaviour, and criminal activity, and significant improvements in social functioning, health status and psychological adjustment. Generally, these gains were sustained between three, six and 12 months. Doctors' ratings of health and urinalysis results further supported these findings. CONCLUSIONS: Injectable heroin is not always the drug of choice. This intervention retained most patients in treatment with substantial benefits to both patients and the community. Prescribing injectable opiates to long term injecting drug users is a feasible treatment option.

'Unsafe protected sex': qualitative insights on measures of sexual risk.

To describe forms of unsafe protected sex (vaginal or anal intercourse where condoms are used unsafely) among a sample of drug users in London, data are drawn from a qualitative study of the sexual and drug taking lifestyles of opioid and stimulant users. Depth one-to-one interviews (n = 96) elicited detailed descriptions from interviewees of their sexual behaviour, including the last occasions they had protected and unprotected sex. Analysis of these accounts identified the phenomenon of 'unsafe protected sex' (UPS). Three forms of UPS were identified: (1) Condoms for ejaculation only. This is where a condom was used for penetrative sex, but only when ejaculation was imminent. In these situations, the perceived function of the condom related more to the prevention of unwanted pregnancy than the prevention of HIV/STDs. (2) Condoms after limited unprotected penetration. This is where sexual partners commenced unprotected penetration but used a condom soon after. Participants tended to see such unprotected penetration as a coerced or collaborative transgression from their usual safer sexual practices. (3) Condom failure. This is where condoms split or came off during penetration. This was sometimes only discovered after ejaculation and withdrawal, and was invariably perceived by participants to have been unsafe. The likelihood of condom failure may be increased in penetrative sex prolonged through the use of drugs. Findings point to the possibility that surveys of sexual risk behaviour underestimate levels of unprotected and unsafe sex. A broader and more sophisticated definition of 'sexual risk behaviour' is required with regard to condom use, one which incorporates UPS. If some forms of UPS are perceived to be 'safer sex', future interventions need to highlight the STD transmission risks associated with this activity. Also, some people may view UPS as a transgression towards unsafe behaviour, and this may be proffered as a rationalization for not using condoms at all.

A short questionnaire (IRQ) to assess injecting risk behaviour.

AIM: To develop a short injecting risk questionnaire (IRQ) to measure sharing of injecting equipment. DESIGN: Matrix design with quota assignment, designed to compare the questionnaire when used by interview and self-completion, in agency and community settings, by agency staff and fieldworkers, with different injectors (age < 26 vs. 26+; male vs. female, opiate vs stimulant injectors), and in different geographical areas. SETTINGS: Drug treatment and helping agencies, and community settings, in England. PARTICIPANTS: Drug users who had injected in the last 4 weeks. MEASUREMENTS: Questions measured different aspects of equipment sharing. Questionnaire performance assessed by question acceptability, test-retest (parallel forms) reliability, inter-rater reliability, inter-instrument reliability, internal reliability, construct validity and internal collateral validity. Statistical tests included product moment correlation, principal components analysis, and Cronbach's alpha. FINDINGS: The questionnaire was highly acceptable. Test-retest correlations were all high and significant, questions performed well in all conditions, with no differences by site (agency vs. out-of-contact), order (interview or self-completion first), administration (staff vs. fieldworker), elapsed time or subject characteristics. The questionnaire had high internal reliability (Cronbach's alpha > +0.86), and items measured a similar domain with all questions loading highly (> 0.32) on a single factor which accounted for > 42% of the variance. The complete IRQ elicited higher reports of equipment sharing (77%) than a single question (56%). CONCLUSIONS: IRQ performs well in a variety of settings, when administered in different ways to different kinds of IDUs. A single question on 'sharing' elicits fewer positive responses than the use of multiple questions about different sharing practices.