Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

Abstract

Background Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI). Methods Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017–18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI). Results Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48–8.54, p <0.001), homelessness (aOR=3.68, 95% CI 2.61–5.19, p <0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69–3.44, p <0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93–5.18, p <0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p <0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13–3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01–2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27–2.01, p <0.001) and SSTI (aOR=1.42, 95% CI 1.17–1.73, p <0.001). Conclusions These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.

A rapid review of the impacts of “Big Events ” on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19

“…Additionally, physical distancing measures imposed as a result of the pandemic may reduce the capacity of spaces such as shelters and supervised injection sites, increasing the likelihood of someone using drugs in public or while alone ( Schlosser & Harris, 2020 ). Using drugs in public settings is associated with a range of harms, including elevated risk of BBV infection and overdose ( Trayner et al, 2020 ). People who use drugs in public spaces are also more likely to experience arrest and incarceration ( Ickowicz et al, 2017 ; Trayner et al, 2020 ), which could be exacerbated by increased policing of public spaces during stay-at-home mandates.…”

“…Using drugs in public settings is associated with a range of harms, including elevated risk of BBV infection and overdose ( Trayner et al, 2020 ). People who use drugs in public spaces are also more likely to experience arrest and incarceration ( Ickowicz et al, 2017 ; Trayner et al, 2020 ), which could be exacerbated by increased policing of public spaces during stay-at-home mandates. Reduced access to supervised injection sites may also restrict access to naloxone, a potentially life-saving opioid antagonist ( Chimbar & Moleta, 2018 ).…”

HIV outbreaks among people who inject drugs in Europe, North America, and Israel

“…34,51 The outbreak in Glasgow has multiple similarities to the large HIV outbreak in Vancouver, Canada, in which increased cocaine injection was also followed by a great increase in HIV incidence. 52,53 Lessons Learned I: Overall complacency towards maintaining low HIV incidence among PWID: In all of the sites, the rates of newly diagnosed cases of HIV among PWID were low prior to the outbreak. We have previously used the term "complacency" as a description of the attitude towards HIV prevention in several of the sites prior to the outbreaks, 54 based on the mostly low or declining investments in and coverage of harm reduction (mainly OST and NSP), in what had always been low HIV prevalence settings.…”

Examining the impact of the first wave of COVID-19 and associated control measures on interventions to prevent blood-borne viruses among people who inject drugs in Scotland: an interrupted time series study

“…Pre-pandemic, the coverage of BBV prevention services in Scotland was good (with ‘moderate’ OAT and ‘high’ NSP coverage), compared to other regions globally where less than 1% of PWID live in countries with a high coverage of both NSP and OAT ( Larney et al, 2017 , Wiessing et al, 2017 ). However, despite relatively good access to services, Glasgow, Scotland’s largest city, is currently experiencing an ongoing outbreak of HIV that represents the largest community-based outbreak in the UK since the 1980s ( McAuley et al, 2019 , Trayner et al, 2021 , Trayner et al, 2020 ). The prevalence of hepatitis C virus (HCV) among PWID has also historically been high; however, significant progress in reducing the prevalence of chronic HCV infection (from 39% in 2015/16–19% in 2019/20) has been made as a result of the scale up of direct-acting antivirals ( Health Protection Scotland, 2019a , Palmateer et al, 2021 , Public Health England, 2020a ).…”