Prevalence of HIV infection in a multi-site sample of injecting drug users not in contact with treatment services in England

Injecting drug use accounts for the largest proportion of AIDS cases in Europe, and this proportion is increasing [1]. In England, relatively low prevalence of HIV (between 1 and 10%) were recorded from injecting drug users (IDU) recruited from both drug agencies and community settings between 1991 and 1998 [2–4]. The swift introduction of preventive interventions in the UK when HIV prevalence among IDU was low has been hailed a public health success [5]. However, in the wake of recent reports of high prevalence and rapid outbreaks of HIV in other parts of Europe [1,6], has the UK's relatively fortunate position been sustained? We recruited the first ever multi-site sample of IDU not in contact with treatment services in England. The methodology of this study has been described elsewhere [7]. Briefly, 753 IDU were recruited from community-based settings in seven sites in England in 1997/1998, and completed a structured interview and provided oral fluid specimens using the EpiScreen device (Epitope Inc., Oregon, USA). All had injected drugs, and had not received treatment for their drug use, in the previous month. Respondents were recruited through social network sampling by trained interviewers [4]. Specimens were anonymously screened for anti-HIV by the Wellcozyme HIV 1+2 GACELISA (VK61; Murex Diagnostics Ltd., Dartford, UK), with confirmatory testing for positive specimens [8]. t-Tests, χ2 tests and exact binomial confidence intervals for proportions were used to describe the data and examine the association between risk factors and prevalence of anti-HIV. The majority of IDU were male (71.1%), and just under a third (30.2%) were under 25 years of age. Over a third (39.8%) had been injecting for less than 5 years, and a third were recruited in London. London injectors had a higher mean duration of injecting career than their counterparts in the rest of England (12 versus 7 years, P < 0.001). The overall prevalence of anti-HIV was 1.9% (95% confidence interval 1.0–3.1%, Table 1). No anti-HIV was detected among those aged 25 years and under, and those injecting for 5 years or less. However, prevalence rose with increasing age and increasing duration of injecting (Table 1). Anti-HIV prevalence was also raised among IDU in London and stimulant injectors. Because there were no cases of HIV among young injectors, and those with short injecting careers, it was not possible to conduct multivariate analysis.Table 1: Prevalence of anti-HIV by key demographic characteristics. These results provide new evidence to suggest that the prevalence of HIV infection among IDU in England continues to be low. Although there are limitations with using prevalence as a marker of disease burden, it is encouraging that in this study no HIV was detected in younger injectors and those with shorter injecting careers, potentially indicating that incidence is low or negligible in this group. This finding adds further support to evidence for the effectiveness of harm reduction measures in England [4,5], and should serve to reassure UK policy makers that prevention activities continue to have an impact on HIV transmission. These results also lead to optimism about the prevention of other blood-borne infections among IDU in the UK. All 15 member states of the European Union provide syringe exchange programmes and substitution therapy for drug users [6], although the scale, nature and year of introduction of these interventions varies. The sheer scale of interventions in the UK, combined with their early introduction, may be the key to continued success in preventing blood-borne virus transmission. For example, in the UK an estimated 28 million syringes were distributed in 1997, from over 2000 outlets (J. Parsons, personal communication). There were also an estimated 150 distinct drug services working in the London area alone, providing a range of harm reduction and specialist treatment interventions [9]. In contrast, the recent rise in HIV prevalence from a low and apparently stable base in Vancouver has been attributed at least partly to the inadequate access to drug treatment, methadone maintenance and counseling services in that city [10]. Recent changes in UK drug policy emphasize a shift in focus from public health approaches towards criminal justice interventions [11,12]. Clearly, policy makers should be warned that such a shift should not be made at the expense of public health interventions, especially as these interventions at the very least have been effective in reducing the harms associated with injecting drug use. Acknowledgements The authors are grateful to the fieldworkers who conducted interviews, those who gave up their time to be interviewed, and the drug agencies that assisted in the recruitment of fieldwork staff and allowed access to outreach clients. The authors would also like to thank Julie Newham at the Virus Reference Division for laboratory support. Ali Judda Gerry V. Stimsona Matthew Hickmana Gillian M. Hunterb Steve Jonesc John V. Parryd Peter Maddena

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