Re-emergence of injecting drug use-related HIV …...Nov-18 Dec-18 New cases of HIV in PWID 2015-2018 by month and subtype Subtype B Subtype C Unknown New diagnoses of HIV by subtype,

Re-emergence of injecting drug use-related HIV

despite a ‘comprehensive’ harm reduction

environment

Dr Andrew McAuley

Principal Scientist, Health Protection Scotland

Senior Research Fellow, Glasgow Caledonian University

• No conflicts of interest

• Population ~ 5 million

• 14 Health Boards

--------------------------------------

• ~ 60,000 ‘Problem Drug Users’

• ~ 20,000 PWID

• ~ 25,000 Px OST

• Widespread availability of NSP

--------------------------------------

• 15 Prisons

– 1/3 prisoners test +ve for opiates

– 1/3 prisoners has history of

injecting

--------------------------------------

• Drugs law is reserved for UK

Parliament

Background

HIV prevention

• Needle and syringe provision (NSP)

• Opiate substitution therapy (OST)

• Testing and treatment (treatment as prevention)

• Social and structural interventions

o drug consumption rooms (DCRs), peer driven

interventions

HIV Prevention

New diagnoses of HIV by transmission

category, NHS GGC (Glasgow), 1982-2015

New diagnoses of HIV among PWID,

NHS GGC (Glasgow), 2009-2018

Indiana

Athens

Dublin

Russia

Glasgow

Luxembourg

VancouverTelAviv

Saskatchewan

Recent outbreaks of HIV among PWID

internationally

Laboratory

NSP

ClinicalNESI

Phylogenetics

Surveillance/InvestigationSurveillance and outbreak investigation

0 2 4 6 8

10

12

Feb-15

Mar-15

Apr-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Ne

w ca

ses o

f HIV

in P

WID

20

15

-20

18

by

mo

nth

an

d su

bty

pe

Su

bty

pe

BS

ub

typ

e C

Un

kn

ow

n

Ne

w d

iag

no

ses o

f HIV

by

sub

typ

e,

NH

S G

GC

(Gla

sgo

w), 2

01

5-2

01

8

0

10

20

30

40

50

60

70

80

90

100

2015 2016 2017 2018

% o

f ca

ses

% female

% male

New diagnoses of HIV by gender,

NHS GGC, 2015-2018

0

5

10

15

20

25

30

2015 2016 2017 2018

No

. o

f n

ew

ca

ses

seroconversion

low

high

unknown

2015-2018: over 130 new diagnoses, 28-40% recent infection

New diagnoses of HIV by recency of infection,

NHS GGC, 2015-2018

• First sequence detected

in 2005

• Outbreak originated in

Scotland, unique strain

• Rapid transmission

intervals

• Three main

transmission chains

Source: Ragonnet Cronin et al, JID, 2018

Phylogenetics

Addictions

• Primarily opiate Injectors (heroin) but also cocaine use

• Predominantly male and older injectors - average age 44

• Majority known to Addictions services

• Extensive use of IEP Services

• Two-thirds report injecting in a public place

Social

• Homeless within the last year

• High contact with criminal justice system – many been/are in prison

• Links to City Centre/East End

Outbreak cohort: key characteristics

• Add andy title paper slide

Pre- HIV outbreak

HIV outbreak

NHS GGC HIV prevalence = <1%

City centre HIV prevalence = 1%NHS GGC HIV prevalence = 1%

City centre HIV prevalence = 1%

NHS GGC HIV prevalence = 3%

City centre HIV prevalence = 6%

NHS GGC HIV prevalence = 5%

City centre HIV prevalence = 11%

Change in HIV prevalence among PWID in Glasgow city centre

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Adjusted odd ratio

Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for individual and environmental

factors associated with HIV infection among PWID in Greater Glasgow and Clyde, 2011-2018.

Survey year

Age

Female gender

Homelessness

High number of

incarcerations

Cocaine injecting

High injecting

frequency

Factors associated with the HIV outbreak in Glasgow*

“Re-emergence of injecting

drug use-related HIV despite

a comprehensive harm

reduction environment: a

cross sectional analysis”.

McAuley A, Palmateer NE,

Goldberg DJ, Trayner KMA,

Shepherd SJ, Gunson RN,

Metcalfe R, Milosevic C,

Taylor A, Munro A and

Hutchinson SJ. (The Lancet

HIV, 2019.)

Location Size and population Main factors associated

with outbreak

Athens, Greece (2011-2013) Homeless migrant PWID; 1110

cases

• Limited access to harm

reduction

• Homelessness

• Economic recession

Bucharest, Romania (2011) MSM PWID; 1195 cases • Limited access to harm

reduction

• Stimulant injecting

Dublin, Ireland (2014-2015) Homeless PWID; 57 cases • Homelessness

• Stimulant injecting

Glasgow, Scotland (2015-

ongoing)

Homeless PWID; 140 cases • Homelessness

• Public injecting

• Stimulant injecting

Indiana, USA (2014) Small community; 200 cases • Deprived community

• Limited access to harm

reduction (IEP illegal)

• Addiction to prescription

opiates

Des Jarlais, D. et al. (2018) ‘Complacency is the new problem: comparative analysis of recent outbreaks of HIV among persons

who inject drugs in Europe and North America’, in. Amsterdam: International AIDS Conference 2018.

• Lack of awareness of HIV risk (patients and staff)

•Injecting risk behaviours (sharing / re-use)

•Ineffective HIV care pathway for PWID

•Low levels HIV testing

•Limited out of hours harm reduction provision

Other factors associated with the outbreak

- Risk management

- Communication

- Harm reduction

- Treatment and Care

Outbreak response...

HIV Awareness & Education

Significant gaps - clients and staff

HIV essentially not seen as a risk

Risk Management: Communication

Risk Management: Harm Reduction

• Increased testing including promotion of DBST

– CATs

– Acute

– Pharmacy

– Primary care

– Criminal Justice

– Outreach

• City Centre NSP extended

• Low dead space syringes (LDSS)

• Proposals for HAT and SCF

• Treatment as prevention (PreP)?

Continued work needed

to keep HIV testing on the agenda to

ensure high coverage and regular HIV testing

among the at-risk population

Safer drug consumption facility /

Heroin-Assisted Treatment

• June 2016: Needs Assessment

on public injecting in Glasgow

City recommends SCDF/HAT

• Oct 2016: IJB approve

development of full business

case for SDCF/HAT

• Feb 2017: Draft business case

for SDCF/HAT approved in

principle by IJB

• June 2017: Business case for

SDCF/HAT formally approved by

IJB

• Nov 2017:

HIV Treatment and Care

• HAT HIV Treatment clinic

• One-stop clinics

• Community pharmacy dispensing

• HIV care focused on those who attend

• Variation in practice and service not designed for this

population

Risk Management: Treatment & Care

As of October 2019…

�100% of cohort EVER been on ART

� 98% (122/124) CURRENLTY on ART

� 83% (103/124) UNDETECTABLE VL in last 6 months

Risk Management: Treatment & Care

0

200

400

600

800

1000

1200

2014 2015 2016 2017 2018 2019

Da

ys

fro

m d

iag

no

sis

to i

nit

iati

on

of

AR

T

(me

dia

n a

nd

in

terq

ua

rtil

e r

an

ge

)

Year of HIV Diagnosis

Broader context: risk environment

...Anthrax, botulism, Staph aureus bacteraemia, drug deaths........

Summary

• Largest HIV outbreak among PWID in Scotland in 30 years

• Originated in Glasgow ~ 15 years ago

•Highlights prevention needs in PWID

•Importance of engaging and retaining in:

oAddictions

oHIV care and treatment

• Complex control measures; new relationships

• Risk now, risk later

• One of a number of (health, social) issues in this population

Thank you

andrew.mcauley@nhs.net

@arjmcauley

Acknowledgments:

Catriona Milosevic, Louise Carroll, Rebecca Metcalfe, Lyndsay Boyd, Kirsten Trayner

and all members of the outbreak Incident Management Team