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

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

Patterns of injecting and non-injecting drug use by sexual behaviour in people who inject drugs attending services in England, Wales and Northern Ireland, 2013-2016.

BACKGROUND: Higher levels of drug use have been reported in lesbian, gay, bisexual and transgender (LGBT) communities, some of which can be explained by sexualised drug use, including 'chemsex'; the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate sex. We explored injecting and non-injecting drug use by sexual behaviour among people who inject drugs (PWID) in England, Wales and Northern Ireland. METHODS: Data were used from an unlinked-anonymous survey of PWID (2013-2016), where participants recruited through services self-completed a questionnaire. We included sexually active participants who had injected in the previous year, and compared injecting and non-injecting drug use between men reporting sex with men (MSM) and heterosexual men, and between women reporting sex with women (WSW) and heterosexual women. The questionnaire did not include GHB/GBL and methamphetamine use. RESULTS: There were 299 MSM, 3215 heterosexual male, 122 WSW and 1336 heterosexual female participants. MSM were more likely than heterosexual men to use drugs associated with chemsex: injected or non-injected mephedrone (adjusted OR (AOR) 2.22, 95%CI 1.54-3.22; AOR 2.15, 95%CI 1.48-3.11) and injected or non-injected ketamine (AOR 1.98, 95%CI 1.29-3.05; AOR 2.57, 95%CI 1.59-4.15). MSM were also more likely to inject methadone, inhale solvents, take ecstasy, cocaine or speed. WSW were more likely than heterosexual women to use non-injected mephedrone (AOR 2.19, 95%CI 1.20-3.99) and use injected or non-injected ketamine (AOR 5.58, 95%CI 2.74-11.4; AOR 3.05, 95%CI 1.30-7.19). WSW were also more likely to inject methadone, inject cocaine, use non-injected cocaine, crack, benzodiazepines or ecstasy, inhale solvents, or smoke cannabis. CONCLUSION: Injecting and non-injecting drug use differed between MSM/WSW and heterosexual men and women. The use of drugs that have been associated with chemsex and sexualised drug use is more common among both MSM and WSW than heterosexual men and women

The Impact of the National HPV Vaccination Program in England Using the Bivalent HPV Vaccine: Surveillance of Type-Specific HPV in Young Females, 2010-2016.

Background: The national human papillomavirus (HPV) immunization program was introduced in England in September 2008 using the bivalent vaccine. Methods: We collected residual vulva-vaginal swab specimens from 16 to 24-year-old women attending for chlamydia screening between 2010 and 2016 and tested for HPV DNA. We compared changes in type-specific (vaccine and nonvaccine) HPV prevalence over time and association with vaccination coverage. For women with known vaccination status, vaccine effectiveness was estimated. Results: HPV DNA testing was completed for 15459 specimens. Prevalence of HPV16/18 decreased between 2010/2011 and 2016 from 8.2% to 1.6% in 16-18 year olds and from 14.0% to 1.6% in 19-21 year olds. Declines were also seen for HPV31/33/45 (6.5% to 0.6% for 16-18 year olds and 8.6% to 2.6% for 19-21 year olds). Vaccine effectiveness for HPV16/18 was 82.0% (95% confidence interval [CI], 60.6%-91.8%) and for HPV31/33/45 was 48.7% (95% CI, 20.8%-66.8%). Prevalence of HPV16/18 was compared to findings in 2007-2008 (prevaccination) and to predictions from Public Health England's mathematical model. Discussion: Eight years after the introduction of a national HPV vaccination program, substantial declines have occurred in HPV16/18 and HPV31/33/45. The prevalence of other high-risk HPV types has not changed

The effectiveness of low dead space syringes for reducing the risk of hepatitis C virus acquisition among people who inject drugs - findings from a national survey in England, Wales, and Northern Ireland.

Syringes with attached needles (termed fixed low dead space syringes [LDSS]) retain less blood following injection than syringes with detachable needles, but evidence on them reducing blood borne virus transmission among people who inject drugs (PWID) is lacking. Utilising the UK Unlinked Anonymous Monitoring cross-sectional bio-behavioural surveys among PWID for 2016/18/19 (n=1429), we showed that always using fixed LDSS was associated with 76% lower likelihood (adjusted Odds Ratio=0.24, 95%CI: 0.08-0.67) of recent hepatitis C virus infection (RNA-positive and antibody-negative) among antibody-negative PWID compared to using any syringes with detachable needles

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

BackgroundIn England, over 80 % of those with hepatitis C virus (HCV) infection have injected drugs. We quantified the HCV cascade of care (CoC) among people who inject drugs (PWID) in England and determined whether this improved after direct-acting antivirals (DAAs) were introduced.MethodsWe analysed data from nine rounds of national annual cross-sectional surveys of PWID recruited from drug services (2011–2019; N = 12,320). Study rounds were grouped as: 'Pre-DAAs’ (2011–2014), ‘Prioritised DAAs’ (2015–2016) and 'Unrestricted DAAs’ (2017–2019). Participants were anonymously tested for HCV antibodies and RNA and completed a short survey. We assessed the proportion of PWID recently (current/previous year) tested for HCV. For participants ever HCV treatment eligible (past chronic infection with history of treatment or current chronic infection), we assessed the CoC as: HCV testing (ever), received a positive test result, seen a specialist nurse/doctor, and ever treated. We used logistic regression to determine if individuals progressed through the CoC differently depending on time-period, whether time-period was associated with recent testing (all participants) and lifetime HCV treatment (ever eligible participants), and predictors of HCV testing and treatment in the Unrestricted DAAs period.ResultsThe proportion of ever HCV treatment eligible PWID reporting lifetime HCV treatment increased from 12.5 % in the Pre-DAAs period to 25.6 % in the Unrestricted DAAs period (aOR:2.40, 95 %CI:1.95–2.96). There were also increases in seeing a specialist nurse/doctor. The largest loss in the CoC was at treatment for all time periods. During the Unrestricted DAAs period, recent (past year) homelessness (vs never, aOR:0.66, 95 %CI:0.45–0.97), duration of injecting (≤3 years vs &gt;3 years; aOR:0.26, 95 %CI:0.12–0.60), never (vs current, aOR:0.31, 95 %CI:0.13–0.75) or previously being prescribed OAT (vs current, aOR:0.67, 95 %CI:0.47-0.95), and never using a NSP (vs past year, aOR:0.27, 95 %CI:0.08–0.89) were negatively associated with lifetime HCV treatment. The proportion of PWID reporting recent HCV testing was higher during Unrestricted DAAs (56 %) compared to Pre-DAAs (48 %; aOR:1.28, 95 %CI:1.06–1.54).ConclusionCOC stages from seeing a specialist onwards improved after DAAs became widely available. Further improvements in HCV testing are needed to eliminate HCV in England

Inadequate needle and syringe coverage among people who inject psychoactive drugs across England and Wales

Aim: Needle and syringe (NS) provision is a proven intervention for reducing harms associated with injecting drug use, such as infections, but impact is coverage-dependent. We characterised people who injected drugs (PWID) in England and Wales who had insufficient NS in the past month to meet their injecting requirements. Methods: This study utilised 2017–2019 data from the annual Unlinked Anonymous Monitoring (UAM) Survey of PWID recruited through specialist services. Logistic regression was used to identify factors associated with inadequate NS coverage. Findings: Of 2,442 PWID surveyed who had injected in the past month, 34% reported inadequate NS coverage (or as high as 51% if including unsuccessful injections). Younger PWID (adjusted odds ratio: 2.18, 95% confidence interval: 1.35–3.52), those who began injecting in the past three years (1.46, 1.09–2.00), and those who reported sharing injecting equipment (1.46, 1.22–1.75) had greater odds of having inadequate NS coverage. PWID currently prescribed Opioid Substitution Treatment (OST) had lower odds of inadequate NS coverage (0.60, 0.49–0.73). Conclusion: Given the poor reported coverage of NS provision in England and Wales, there is urgent need to address inequity in accessing sufficient NS and increase coverage among this vulnerable group to reduce injecting-related harms.</p

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

INTRODUCTION People who inject drugs are at high risk of blood-borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EW&NI) since 1981. METHODS National HIV surveillance data were used to describe trends in diagnoses (1981-2019), prevalence (1990-2019), and behaviours (1990-2019) among people who inject drugs aged ≥15 years in EW&NI. HIV care and treatment uptake were assessed among those attending in 2019. RESULTS Over the past four decades, the prevalence of HIV among people who inject drugs in EW&NI remained low (range: 0.64%-1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4 <350 cells/µl) was common (2010-2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (<200 copies/ml). HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429). CONCLUSION The HIV epidemic among people who inject drugs in EW&NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

OBJECTIVES: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. METHODS: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients &gt;18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. RESULTS: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p&gt;0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p&gt;0.05). CONCLUSION: NOM of grade I-II splenic injuries with CB fails in 20% of patients. LEVEL OF EVIDENCE: IV