HPR volume 17 issues 3 and 4: news (28 March 2023)
Updated 28 December 2023
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Infections and other injecting-related harms among people who inject drugs in the UK: annual report in summary
‘Shooting Up’, the annual report on infections and other injecting-related harms among people who inject drugs (PWID) in the UK, has been published by the UK Health Security Agency. The report has been produced in collaboration with Public Health Scotland, Public Health Wales, and Public Health Agency Northern Ireland.
PWID are vulnerable to a wide range of blood-borne viral (BBV) and bacterial infections, which can result in high levels of morbidity and mortality. The Shooting Up report and accompanying data tables describe infections and other injecting-related harms alongside associated risks and behaviours among PWID in the UK to the end of 2021.
As in 2020, the COVID-19 pandemic response continued to impact access to services for PWID in 2021, including BBV testing, treatment and harm reduction. Continued public health monitoring is critical to understanding the impact of COVID-19 on national HIV and viral hepatitis elimination efforts, as well as on the health inequalities experienced by this marginalised group. It is likely that remote interventions will continue to play a key role in the delivery of essential services to PWID.
Main messages from the report
Hepatitis C (HCV) continues to be the most common BBV infection among PWID in the UK with no evidence of a reduction in new HCV infections in recent years. However, there is evidence for a reduction in chronic HCV prevalence, which is likely to be due to better uptake of HCV treatment rather than improved prevention of new and re-infections through harm reduction initiatives. The UK government’s drug strategy outlines significant investment to expand and improve evidence-based harm reduction interventions. People at ongoing risk should be tested regularly to identify re-infection and reduce the risk of transmission.
Fourteen per cent of PWID surveyed in England, Wales and Northern Ireland in 2021 had a chronic HCV infection. The proportion of PWID with chronic HCV has declined, likely due to better uptake of treatment. But there was evidence of both new infections and re-infections. Vaccination against hepatitis B declined in 2021, continuing the downward trend reported in the past decade. Less than two-thirds of PWID surveyed self-reported uptake of at least one dose of the vaccine; uptake was lowest among the under-25s.
Although hepatitis B virus (HBV) vaccination is recommended as high priority for all people who currently inject drugs, nearly 40% report that they have never been vaccinated. HBV infection in this population remains rare, but it is essential that vaccine uptake is improved to ensure high levels of immunity. Vaccination should be particularly promoted among PWID of younger age and recent initiates to injecting, for whom reported uptake is lower. Further work is needed to explore the facilitators and barriers to uptake of HBV vaccination to inform policy and practice.
Overall, HIV infection remains uncommon among PWID in the UK, with prevalence much lower than in many other European countries (1.5% in England, Wales and Northern Ireland in 2021; 3.8% in Scotland in 2019 to 2020). However, HIV outbreaks continue to occur among PWID. The proportion of those aware of their infection has also declined; nearly one fifth of PWID in England, Wales and Northern Ireland were unaware of their infection in 2021. Missed opportunities for testing and prompt diagnosis remain. Care pathways for those with HIV need to be optimised and maintained to ensure outcomes for PWID are equitable.
Cases of bacterial infections among PWID have fallen since 2020, although this is mainly thought to be a consequence of the COVID-19 pandemic response, which resulted in restricted access to healthcare services, reduced testing and reporting delays. To prevent rates of bacterial infections increasing, drug and alcohol services should facilitate easy access to needle and syringe programmes (NSP), embed regular opportunities to discuss safe and hygienic injection practices with clients and provide low threshold and outreach wound care services.
Levels of reported sharing and re-use of injecting equipment remain high, which continues to drive transmission of BBVs and increase the risk of bacterial infections. Around one third of PWID report inadequate provision of needles and syringes. A range of easily accessible harm reduction services for all PWID, including NSP and opioid agonist therapy (OAT), need to be provided.
In 2021, 40% of PWID surveyed in EWNI who had injected drugs in the past month reported sharing of needles, syringes and other injecting equipment such as filters and spoons. 23% of people who injected in the past month reported that they had injected powder cocaine. Cases of fatal and non-fatal overdose were at an all-time high. Increased availability of naloxone (an emergency antidote for opioid overdose) is one way to reduce overdose deaths.
The changing patterns of psychoactive drug injection in the UK remain a concern, as changes in psychoactive drug preferences can lead to riskier injecting practices. The proportion of PWID reporting injection of crack cocaine has remained high in England, Wales and Northern Ireland. Injection of powder cocaine is more common in Scotland but has increased across the UK in recent years and has been linked with ongoing BBV outbreaks in Scotland and Northern Ireland. There is a need for local treatment and harm reduction systems that can respond to both the increasing numbers and the specific needs of people who use crack and powder cocaine.
Reports of both fatal and non-fatal overdose are at an all-time high, with overdose most common among people using and/or injecting opioids. This is in the context of improved availability of naloxone, an emergency antidote for opioid overdose, and increased self-reported carriage of take-home naloxone among PWID. Services working with PWID should provide materials to increase awareness of, and information about, overdose risks and provide training for peers and family members in overdose prevention, recognition, and response.
Infection reports in this issue
Group A streptococcal infections: 11th update on seasonal activity in England
Laboratory confirmed cases of invasive meningococcal infection in England: July to September 2022
Laboratory confirmed cases of measles, rubella and mumps, England: October to December 2022
Laboratory confirmed cases of pertussis in England: April to June 2022
Vaccine coverage reports
Shingles vaccine coverage (England): report for quarter 2 of the financial year 2022 to 2023