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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
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• No conflicts of interest
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• 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
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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
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New diagnoses of HIV by transmission
category, NHS GGC (Glasgow), 1982-2015
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New diagnoses of HIV among PWID,
NHS GGC (Glasgow), 2009-2018
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Indiana
Athens
Dublin
Russia
Glasgow
Luxembourg
VancouverTelAviv
Saskatchewan
Recent outbreaks of HIV among PWID
internationally
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Laboratory
NSP
ClinicalNESI
Phylogenetics
Surveillance/InvestigationSurveillance and outbreak investigation
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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
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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
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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
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• 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
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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
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• Add andy title paper slide
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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
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-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.)
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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.
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• 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
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- Risk management
- Communication
- Harm reduction
- Treatment and Care
Outbreak response...
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HIV Awareness & Education
Significant gaps - clients and staff
HIV essentially not seen as a risk
Risk Management: Communication
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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
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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:
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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
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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
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Broader context: risk environment
...Anthrax, botulism, Staph aureus bacteraemia, drug deaths........
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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
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Thank you
@arjmcauley
Acknowledgments:
Catriona Milosevic, Louise Carroll, Rebecca Metcalfe, Lyndsay Boyd, Kirsten Trayner
and all members of the outbreak Incident Management Team