G Model DRUPOL-1337; No. of Pages 4
ARTICLE IN PRESS International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short Report
Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? V.D. Hope a,b,∗ , K.J. Cullen a , S. Croxford a , J.V. Parry b,c , F. Ncube a a
Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK Centre for Research on Drugs & Health Behaviour, London School of Hygiene & Tropical Medicine, London, UK c Microbiology Services, Public Health England, London, UK b
a r t i c l e
i n f o
Article history: Received 3 December 2013 Received in revised form 15 February 2014 Accepted 18 February 2014 Keywords: People who injecting drugs Infections Cleaning of needles/syringes Risk behaviours
a b s t r a c t Background: The sharing and reuse of injecting equipment are associated with acquiring infections. Even in countries with large-scale needle and syringe programmes (NSP), injections using cleaned needles/syringes continue. Method: People who inject drugs recruited through services completed a short questionnaire and provided a dried blood spot sample. Factors associated with injecting using cleaned needles/syringes in 2011–2012 were explored using logistic regression. Results: Of the 2283 participants who had injected during the preceding 28 days (mean age 34.5 years, 23% women), 71% had ever been imprisoned and 37% had recently been homeless. Overall during the preceding 28 days, 34% reported injecting with a needle/syringe that had been cleaned, and 36% had shared any injecting equipment. Of those who had shared, 51% reported injecting with cleaned needles/syringes, compared with 24% of those not sharing. In the multi-variable analysis, injecting using a cleaned needle/syringe was associated with: sharing injecting equipment, injecting more frequently, injecting into hands, injecting crack-cocaine, recent abscess/open wound, homelessness, and poor NSP coverage. Conclusion: The associations suggest that sub-groups are at particular risk. Using a cleaned needle/syringe could be due to issues with managing injecting equipment supply. Policy should promote good injecting equipment management and use of appropriate cleaning methods. Crown Copyright © 2014 Published by Elsevier B.V. All rights reserved.
Introduction The main factors in the transmission of blood borne viruses (BBVs) and acquisition of injection-related bacterial infections among people who inject drugs, are the ‘sharing’ of injecting equipment (i.e. using the same equipment as someone else) or the reuse of needles/syringes (Donoghoe & Wodak, 1998). People who inject drugs may share needles/syringes knowingly; however, some may share unknowingly when they reuse needles/syringes, due to problems with identifying injecting equipment that only they had previously used (Taylor, Fleming, Rutherford, & Goldberg, 2004). The sharing of needles/syringes is a risk for the transmission of
∗ Corresponding author at: Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK. E-mail addresses: [email protected], [email protected] (V.D. Hope).
BBVs and bacterial infections, whilst bacteria can also be introduced in to the body by someone reusing their own needles/syringes. The cleaning of injecting equipment by washing it with water and bleach will, if done correctly, reduce the risk of these infections (Abdala, Gleghorn, Carney, & Heimerm, 2001; Kapadia et al., 2002), and appropriate cleaning strategies for needles/syringes – such as flushing them with water before treating with bleach and then rising out – have been advocated (Academy for Educational Development; CDC, 2004). The main public health intervention to reduce the use of unsterile injecting equipment in the United Kingdom (UK), and many other countries, is the provision of needle and syringe programmes (NSP) to distribute new sterile equipment and to collect used needles/syringes (Craine et al., 2010). However, even in settings where NSP provision is extensive and coverage is high, such as in the UK, there may be situations that necessitate the reuse (Taylor et al., 2004) and cleaning (Nathani, Iversen, Shying, Byrne, & Maher, 2010) of needles/syringes. For example, reuse might be the result
http://dx.doi.org/10.1016/j.drugpo.2014.02.008 0955-3959/Crown Copyright © 2014 Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Hope, V. D., et al. Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.008
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2
of having used more equipment than expected (for example, due to problems with accessing veins), issues with accessing NSPs when needed, or limited options for storing equipment (due to homelessness for example). Thus NSPs and other services provide advice on appropriate cleaning strategies for when this is the only option. However, these cleaning strategies are often poorly applied (Nathani et al., 2010). Factors associated with the sharing of injecting equipment have been widely studied (McKegany, Friedman, & Mesquita, 1998); however, very few studies have looked at the factors associated with the use of cleaned needles/syringes. Those studies that have examined the use of cleaned equipment have looked at this in the context of reported sharing events – even though much sharing is probably inadvertent and so unknown – rather than looking at any injections using cleaned needles/syringes. We explore the factors associated with having injected using cleaned needles/syringes among a large sample of people who inject drugs recruited in the UK. The aim of this analysis was to identify those sub-groups who are most likely to inject using cleaned needles/syringes so that interventions can be appropriately targeted. Methods People who inject drugs have been recruited into a voluntary annual unlinked-anonymous monitoring survey since 1990; methodological details of this survey have been published previously (Hope et al., 2005). Briefly, agencies providing services to people who inject drugs (e.g. NSPs and addiction treatment) at sentinel locations throughout England, Wales and Northern Ireland invite clients who have ever injected to participate. Sentinel sites are selected so as to reflect both the geographic distribution and range of services offered to people who inject drugs. Those who consent to participate provide a dried blood spot (DBS) sample and self-complete a brief questionnaire focused on the injection of psychoactive drugs. The DBS samples were tested for antibodies to HIV (anti-HIV), hepatitis C (anti-HCV) and the hepatitis B core antigen (anti-HBc) using published methods. The survey has multi-site ethics approval. In 2011, a question on injecting with needles/syringes that had been cleaned was added to the survey questionnaire: “In the last 28 days, did you inject with a needle or syringe after it had been cleaned (e.g. with water, bleach or detergent)?”. Data from the first participations in the survey during 2011 and 2012 were used in this study (i.e. those taking part in 2012 who reported having previously taking part in 2011 were excluded). Those who reported injecting during the preceding 28 days and who had completed the survey questionnaire were included in the analyses. Firstly, bivariate associations (p < 0.05) between the outcome variable (i.e. having injected with cleaned needles/syringes) and covariates (demographics, injecting practices, the drugs injected, sexual practice, current or past infections, and health service use) were examined using Pearson’s Chi-square test. Where possible associations were found (p < 0.10), these were then further examined via logistic regression using a forward stepwise procedure to select variables for inclusion in the model, with selection based on the likelihood ratio test (p < 0.05). All analyses were undertaken using SPSS 19. Results During 2011–2012, the survey recruited 2283 individuals who had injected during the preceding 28 days. Almost half (48%, 1088) were aged 35 years or older (mean age 34.5 years, median 34 years), 23% (528) were women, and 6.7% (152) had been born outside of the UK. These included 1625 (71%) individuals who had ever been imprisoned, and 840 (37%) who had been homeless
during the preceding year. At the time of participation, 66% (1510) were receiving a detox or maintenance drug regime, and 97% (2194) reported having used a NSP during the preceding year. The majority were sexually active, with almost three-quarters (74%, 1683) reporting that they had anal or vaginal sex in the preceding year. Testing of the biological samples collected in the survey found that 0.96% (22) had anti-HIV, 16% (365) anti-HBc, and 48% (1097) had anti-HCV. Overall, 76% (1734) had taken up vaccine against hepatitis B, 74% (1680) reported ever having a voluntary confidential test for HIV and 78% (1792) for hepatitis C. The most commonly injected drug during the preceding 28 days was heroin (2005, 88%); with a third reporting that they had injected crack-cocaine (807, 35%), almost a quarter amphetamines (514, 23%) and 9% (200) powder cocaine. The most commonly used injection sites on the body were the arms (1381, 60%) and the groin (781, 34%), other sites used included the hands (26%, 585), legs (21%, 477) and feet (12%, 264); with 47% having injected on at least 28 occasions during the preceding 28 days (mean 53 times, median 38 times). The sharing of mixing containers in the preceding 28 days was reported by 29% (673), filters by 25% (572), and needles or syringes by 16% (354). Injecting during the preceding 28 days, with a needle or syringe that had been cleaned, was reported by 34% (772). Overall, 825 (36%) had shared needles, syringes, spoons or filters during the preceding 28 days, of these 51% (417) reported cleaning needles or syringes; this compares with 24% (355/1458) of those who did not report any sharing. The factors associated with having injected using cleaned needles/syringes during the preceding 28 days in the bivariate and multivariate analyses are given in the table. In the multivariate analyses, having injected using cleaned needles/syringes was associated with: having shared either needles/syringes, spoons or filters; the number of times injected during the preceding 28 days; having injected into the hands; injecting crack-cocaine; reporting having had an injection site abscess/open wound during the preceding year; being homeless during preceding year; and poor NSP coverage (Table 1).
Discussion One third of people who inject drugs sampled reported injecting with needles/syringes that they had ‘cleaned’, this is more than twice the proportion that reported sharing. Those who shared were more likely to report having injected with cleaned needles/syringes; however, one third of those who reported sharing did not report using cleaned needles/syringes. This suggests that they had injected with needles or syringes previously used by someone else without attempting to clean them. Furthermore, as more than a quarter of those who had not shared reported that they had injected with cleaned needles/syringes, it is probable that some of these individuals may have shared unknowingly – albeit with needles/syringes that they had tried to clean – as a result of mixing-up their injecting equipment with that of others. Firstly, it is important to consider the limitations of this study. The behavioural data used here is based on self-report, the accuracy of which may be subject to recall bias; however, the reliability of self-report risk behaviours among people who inject drugs has been previously shown (Latkin, Vlahov, & Anthony, 1993). A further limitation is that the illicit and marginalised nature of injecting drug use makes the recruitment of a representative sample problematic. To maximise representativeness, this survey used the extensive provision of targeted services for people who inject drugs as a sampling frame. In the UK, the uptake and use of such targeted services is high, with very few of the people who inject drugs recruited through community based studies found not to be in contact with such services (Craine et al., 2010; Hickman et al., 2007).
Please cite this article in press as: Hope, V. D., et al. Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.008
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Table 1 Factors associated with having injected with cleaned needles and syringes among people who inject drugs in England, Wales and Northern Ireland: 2011–12. N
Yes
p
Shared needles or syringes during preceding 28 days
No Yes
1929 354
548 224
28% 63%
Shared spoons during preceding 28 days
No Yes
1610 673
429 343
27% 51%
Shared filters during preceding 28 days
No Yes
1711 572
465 307
27% 54%
714 318 477 594 180
184 107 167 254 60
No Yes
1698 585
No Yes
Adjusted Odds Ratio, with 95% confidence interval
ARTICLE IN PRESS International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short Report
Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? V.D. Hope a,b,∗ , K.J. Cullen a , S. Croxford a , J.V. Parry b,c , F. Ncube a a
Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK Centre for Research on Drugs & Health Behaviour, London School of Hygiene & Tropical Medicine, London, UK c Microbiology Services, Public Health England, London, UK b
a r t i c l e
i n f o
Article history: Received 3 December 2013 Received in revised form 15 February 2014 Accepted 18 February 2014 Keywords: People who injecting drugs Infections Cleaning of needles/syringes Risk behaviours
a b s t r a c t Background: The sharing and reuse of injecting equipment are associated with acquiring infections. Even in countries with large-scale needle and syringe programmes (NSP), injections using cleaned needles/syringes continue. Method: People who inject drugs recruited through services completed a short questionnaire and provided a dried blood spot sample. Factors associated with injecting using cleaned needles/syringes in 2011–2012 were explored using logistic regression. Results: Of the 2283 participants who had injected during the preceding 28 days (mean age 34.5 years, 23% women), 71% had ever been imprisoned and 37% had recently been homeless. Overall during the preceding 28 days, 34% reported injecting with a needle/syringe that had been cleaned, and 36% had shared any injecting equipment. Of those who had shared, 51% reported injecting with cleaned needles/syringes, compared with 24% of those not sharing. In the multi-variable analysis, injecting using a cleaned needle/syringe was associated with: sharing injecting equipment, injecting more frequently, injecting into hands, injecting crack-cocaine, recent abscess/open wound, homelessness, and poor NSP coverage. Conclusion: The associations suggest that sub-groups are at particular risk. Using a cleaned needle/syringe could be due to issues with managing injecting equipment supply. Policy should promote good injecting equipment management and use of appropriate cleaning methods. Crown Copyright © 2014 Published by Elsevier B.V. All rights reserved.
Introduction The main factors in the transmission of blood borne viruses (BBVs) and acquisition of injection-related bacterial infections among people who inject drugs, are the ‘sharing’ of injecting equipment (i.e. using the same equipment as someone else) or the reuse of needles/syringes (Donoghoe & Wodak, 1998). People who inject drugs may share needles/syringes knowingly; however, some may share unknowingly when they reuse needles/syringes, due to problems with identifying injecting equipment that only they had previously used (Taylor, Fleming, Rutherford, & Goldberg, 2004). The sharing of needles/syringes is a risk for the transmission of
∗ Corresponding author at: Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK. E-mail addresses: [email protected], [email protected] (V.D. Hope).
BBVs and bacterial infections, whilst bacteria can also be introduced in to the body by someone reusing their own needles/syringes. The cleaning of injecting equipment by washing it with water and bleach will, if done correctly, reduce the risk of these infections (Abdala, Gleghorn, Carney, & Heimerm, 2001; Kapadia et al., 2002), and appropriate cleaning strategies for needles/syringes – such as flushing them with water before treating with bleach and then rising out – have been advocated (Academy for Educational Development; CDC, 2004). The main public health intervention to reduce the use of unsterile injecting equipment in the United Kingdom (UK), and many other countries, is the provision of needle and syringe programmes (NSP) to distribute new sterile equipment and to collect used needles/syringes (Craine et al., 2010). However, even in settings where NSP provision is extensive and coverage is high, such as in the UK, there may be situations that necessitate the reuse (Taylor et al., 2004) and cleaning (Nathani, Iversen, Shying, Byrne, & Maher, 2010) of needles/syringes. For example, reuse might be the result
http://dx.doi.org/10.1016/j.drugpo.2014.02.008 0955-3959/Crown Copyright © 2014 Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Hope, V. D., et al. Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.008
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ARTICLE IN PRESS V.D. Hope et al. / International Journal of Drug Policy xxx (2014) xxx–xxx
2
of having used more equipment than expected (for example, due to problems with accessing veins), issues with accessing NSPs when needed, or limited options for storing equipment (due to homelessness for example). Thus NSPs and other services provide advice on appropriate cleaning strategies for when this is the only option. However, these cleaning strategies are often poorly applied (Nathani et al., 2010). Factors associated with the sharing of injecting equipment have been widely studied (McKegany, Friedman, & Mesquita, 1998); however, very few studies have looked at the factors associated with the use of cleaned needles/syringes. Those studies that have examined the use of cleaned equipment have looked at this in the context of reported sharing events – even though much sharing is probably inadvertent and so unknown – rather than looking at any injections using cleaned needles/syringes. We explore the factors associated with having injected using cleaned needles/syringes among a large sample of people who inject drugs recruited in the UK. The aim of this analysis was to identify those sub-groups who are most likely to inject using cleaned needles/syringes so that interventions can be appropriately targeted. Methods People who inject drugs have been recruited into a voluntary annual unlinked-anonymous monitoring survey since 1990; methodological details of this survey have been published previously (Hope et al., 2005). Briefly, agencies providing services to people who inject drugs (e.g. NSPs and addiction treatment) at sentinel locations throughout England, Wales and Northern Ireland invite clients who have ever injected to participate. Sentinel sites are selected so as to reflect both the geographic distribution and range of services offered to people who inject drugs. Those who consent to participate provide a dried blood spot (DBS) sample and self-complete a brief questionnaire focused on the injection of psychoactive drugs. The DBS samples were tested for antibodies to HIV (anti-HIV), hepatitis C (anti-HCV) and the hepatitis B core antigen (anti-HBc) using published methods. The survey has multi-site ethics approval. In 2011, a question on injecting with needles/syringes that had been cleaned was added to the survey questionnaire: “In the last 28 days, did you inject with a needle or syringe after it had been cleaned (e.g. with water, bleach or detergent)?”. Data from the first participations in the survey during 2011 and 2012 were used in this study (i.e. those taking part in 2012 who reported having previously taking part in 2011 were excluded). Those who reported injecting during the preceding 28 days and who had completed the survey questionnaire were included in the analyses. Firstly, bivariate associations (p < 0.05) between the outcome variable (i.e. having injected with cleaned needles/syringes) and covariates (demographics, injecting practices, the drugs injected, sexual practice, current or past infections, and health service use) were examined using Pearson’s Chi-square test. Where possible associations were found (p < 0.10), these were then further examined via logistic regression using a forward stepwise procedure to select variables for inclusion in the model, with selection based on the likelihood ratio test (p < 0.05). All analyses were undertaken using SPSS 19. Results During 2011–2012, the survey recruited 2283 individuals who had injected during the preceding 28 days. Almost half (48%, 1088) were aged 35 years or older (mean age 34.5 years, median 34 years), 23% (528) were women, and 6.7% (152) had been born outside of the UK. These included 1625 (71%) individuals who had ever been imprisoned, and 840 (37%) who had been homeless
during the preceding year. At the time of participation, 66% (1510) were receiving a detox or maintenance drug regime, and 97% (2194) reported having used a NSP during the preceding year. The majority were sexually active, with almost three-quarters (74%, 1683) reporting that they had anal or vaginal sex in the preceding year. Testing of the biological samples collected in the survey found that 0.96% (22) had anti-HIV, 16% (365) anti-HBc, and 48% (1097) had anti-HCV. Overall, 76% (1734) had taken up vaccine against hepatitis B, 74% (1680) reported ever having a voluntary confidential test for HIV and 78% (1792) for hepatitis C. The most commonly injected drug during the preceding 28 days was heroin (2005, 88%); with a third reporting that they had injected crack-cocaine (807, 35%), almost a quarter amphetamines (514, 23%) and 9% (200) powder cocaine. The most commonly used injection sites on the body were the arms (1381, 60%) and the groin (781, 34%), other sites used included the hands (26%, 585), legs (21%, 477) and feet (12%, 264); with 47% having injected on at least 28 occasions during the preceding 28 days (mean 53 times, median 38 times). The sharing of mixing containers in the preceding 28 days was reported by 29% (673), filters by 25% (572), and needles or syringes by 16% (354). Injecting during the preceding 28 days, with a needle or syringe that had been cleaned, was reported by 34% (772). Overall, 825 (36%) had shared needles, syringes, spoons or filters during the preceding 28 days, of these 51% (417) reported cleaning needles or syringes; this compares with 24% (355/1458) of those who did not report any sharing. The factors associated with having injected using cleaned needles/syringes during the preceding 28 days in the bivariate and multivariate analyses are given in the table. In the multivariate analyses, having injected using cleaned needles/syringes was associated with: having shared either needles/syringes, spoons or filters; the number of times injected during the preceding 28 days; having injected into the hands; injecting crack-cocaine; reporting having had an injection site abscess/open wound during the preceding year; being homeless during preceding year; and poor NSP coverage (Table 1).
Discussion One third of people who inject drugs sampled reported injecting with needles/syringes that they had ‘cleaned’, this is more than twice the proportion that reported sharing. Those who shared were more likely to report having injected with cleaned needles/syringes; however, one third of those who reported sharing did not report using cleaned needles/syringes. This suggests that they had injected with needles or syringes previously used by someone else without attempting to clean them. Furthermore, as more than a quarter of those who had not shared reported that they had injected with cleaned needles/syringes, it is probable that some of these individuals may have shared unknowingly – albeit with needles/syringes that they had tried to clean – as a result of mixing-up their injecting equipment with that of others. Firstly, it is important to consider the limitations of this study. The behavioural data used here is based on self-report, the accuracy of which may be subject to recall bias; however, the reliability of self-report risk behaviours among people who inject drugs has been previously shown (Latkin, Vlahov, & Anthony, 1993). A further limitation is that the illicit and marginalised nature of injecting drug use makes the recruitment of a representative sample problematic. To maximise representativeness, this survey used the extensive provision of targeted services for people who inject drugs as a sampling frame. In the UK, the uptake and use of such targeted services is high, with very few of the people who inject drugs recruited through community based studies found not to be in contact with such services (Craine et al., 2010; Hickman et al., 2007).
Please cite this article in press as: Hope, V. D., et al. Factors associated with the use of cleaned needles and syringes among people who inject drugs in the UK: Who should we target to minimise the risks? International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.008
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3
Table 1 Factors associated with having injected with cleaned needles and syringes among people who inject drugs in England, Wales and Northern Ireland: 2011–12. N
Yes
p
Shared needles or syringes during preceding 28 days
No Yes
1929 354
548 224
28% 63%
Shared spoons during preceding 28 days
No Yes
1610 673
429 343
27% 51%
Shared filters during preceding 28 days
No Yes
1711 572
465 307
27% 54%
714 318 477 594 180
184 107 167 254 60
No Yes
1698 585
No Yes
Adjusted Odds Ratio, with 95% confidence interval
