Injecting and risk - an overview

Injecting drug use is by far the most hazardous way of introducing drugs into the body. A large body of research shows that it creates a serious risk to individual and public health from:

• Blood-borne viruses, particularly HIV, hepatitis C and hepatitis B;

• Bacterial infections;

• Fungal infections;

• Damage to the circulatory system;

• Increased likelihood of overdose;

and that it has a strong association with:

• Increased dependence.

Even though smoking drugs like heroin and crack cocaine is dangerous, and can cause long term, and serious lung damage and other health problems, there is no question that injecting is far more dangerous, associated with higher rates of premature death and illness. The notion that the risk is in any way equivalent is therefore a dangerous one, and one that should be challenged whenever it is heard.

It is obvious to suggest that the best way of reducing the harm associated with injecting is to stop injecting, and workers should not shy away from disucussing this with injectors where necessary or useful. However, many injectors do not want to stop, and for these people there are effective ways to reduce the risks to the injectors themselves, and the risk and costs to the wider community.

The major intervention intended to prevent infection spread is the free provision of sterile injecting equipment. Research from many countries supports the effectiveness of Needle and Syringe Programmes (NSPs) in preventing the spread of HIV. The best evidence comes from cities that have also implemented other interventions such as substitute prescribing, addiction treatment, and outreach. (MacDonald M. 2003)

Because harm reduction interventions act in synergy, it is difficult to disentangle the contributions of the individual elements. Neverthless, NSPs have been shown to be an important – perhaps the most important – contributor.

For the prevention of the spread of hepatitis C, the evidence of the effectiveness is less strong. This is because compared to HIV, hepatitis viruses spread more easily (because the virus is more infectious) and because it is more widespread. The prevelance of hepatitis C in particular was already very high amongst injectors when NSP was introduced in the UK and Australia, so avoiding them required a more comprehensive behaviour change. Sharing occasionally only carried a small risk of contracting HIV – because so few people had it – but a high risk of catching hepatitis C – because so many people had it.

Recent epidemics of injecting in some Russian cities, such as St. Petersburg, have been associated with rapid spread of HCV but not HIV, so it's not just the pre-existing high prevelance that is an issue, it's also the infectious nature of the virus.

Prevention of hepatitis C spread amongst regular injectors of illicit drugs therefore requires the elimination of risk behaviour, rather than just a reduction in it. Although needles and syringes are the cause of blood borne virus transmission, and are the main focus of NSP provision, other drug paraphernalia may also play a role, and efforts to prevent the spread of HCV requires changes across a wider range of behaviours, not just the direct sharing of needles and syringes.

This is a far greater challenge for NSPs. Meeting it will require greater resources and a more active, imaginative approach to equipment distribution because to prevent hepatitis C transmission we need to reach much higher levels of coverage - that is we need to distribute far more syringes, so that the re-use of syringes is cut to a minimum, and efforts will have to address issues such as accidental sharing, and occasional high risk situations in the lives of injectors such the period following release from custody.

In places where there is an open drug scene, this may be best done by stepping up to providing NSP in the context of a health facility which allows injectors to safely inject their drugs on their premises (‘injecting rooms’). In all settings services are likely to need to encourage secondary distribution of equipment - that is give people in contact with services enough equipment so they can give it to their peers, and also organise peer distribution schemes which access peer networks to reach as many injectors as possible.

The fact that hepatitis is still spreading rapidly also raises the concern that enough risk behaviour has persisted to trigger a growth in HIV infections: the main reason that injectors in the UK who have shared injecting equipment haven't contracted HIV is that they are far less likely to come across another injector infected with HIV than one infected with hepatitis. (Ashton 2004).

It is therefore very important that the success of NSPs in slowing the spread of HIV amongst injecting drug users is not allowed to breed complacency. If HIV prevelance continues to rise slowly, it may reach a point where an explosion of infections could occur - not because the frequency of sharing has changed, but because the chances of catching HIV in any one sharing incident have gone up - simply because more people have the virus.

While NSPs are the spearhead of disease prevention, substitute prescribing, syringe cleaning, and BBV awareness campaigns all play an important part. Each can help the other. NSPs can act as a gateway to prescribing and treatment, give credibility to anti-sharing campaigns (‘They are so worried they are giving out needles - it must really be true’), and make it easier to act on their messages.

Substitue prescribing, even where it doesn't completely stop illicit drug use can still have a dramatic protective effect, because it stops some people injecting all together, and reduces the frequency of injecting for the rest. Where injecting continues it is likely to be at a reduced level of risk, with users more able to be able to inject safely.

Having a injecting drug users in treatment can also help exchanges meet the remaining demand for injecting equipment more easily.

UK trends in HIV and hepatitis C
Prevalence of HIV infection amongst injectors in England has been low in comparison to other countries throughout the 1980’s and 1990’s at under 2% in areas outside London. Similarly, hepatitis C prevalence was relatively low when compared with other countries at around 40% in the whole population and 15% in those who had been injecting for under 6 years.(Health Protection Agency 2003).

A study of people who were all 30 years or younger and had been injecting for a maximum of 6 years, (Judd et al. 2004), is a cause for extreme concern as it shows a hepatitis C prevalence rate higher than would have previously been expected in the whole population of 43.7%. Prevalence of HIV was also higher than expected at 4.2%.

HCV rates are also increasing and prevention of the spread of these viruses, which have very serious and expensive long term consequences requires a coordintated combination of high coverage NSP, substitute prescribing and Hepatitis C treatment for HCV+ injectors in order to stop infection rates increasing further.

Not just the UK
Injecting drug use happens all over the world: and has been documented in at least 158 of the world’s countries and territories. UN estimates for 2014 found that 11.7 million people injected drugs worldwide, with 14% living with HIV, 52% living with hepatitis C and 9% living with hepatitis B. The harm reduction response, while in place to some degree in a majority of the world’s countries, falls far short of reaching most people who inject drugs worldwide. In 2016, 90 countries implement needle and syringe programmes (NSPs) to some degree and 80 have at least one opioid substitution programme (OST) in place.


References
MacDonald M. et al. “Effectiveness of needle and syringe programmes for preventing HIV transmission.” International Journal of Drug Policy 2003.
Ashton M. “Hepatitis C and needle exchange: part 2 • case studies.” Drug and Alcohol Findings: 2004, 9, p. 24–32.

Health Protection Agency, Shooting up: Infections among injecting drug users in the United Kingdom 2003.

Ali Judd et al. Incidence of Hepatitis C virus and HIV Among New Injecting Drug Users in London – Prospective Cohort Study. BMJ: 2004