Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

Background: The practice of injecting drugs in public places (henceforth ‘public injecting’) is associated with higher risk injection practices that may increase the risk of infections (such as HIV) and overdose. To the best of our knowledge, no research has demonstrated recent multiple morbidities among a national sample of people who inject drugs (PWID) in public places, and no detailed analysis of public injecting has been conducted in the UK since 2007. Since then, the landscape of drug injecting and related harms in the UK has changed dramatically with epidemic levels of drug related deaths (DRD) and major outbreaks of anthrax and botulism. More recently, in 2015, the largest recorded outbreak of HIV among PWID in the UK in 30 years has been identified in Glasgow, which is currently ongoing. In response, formal proposals to implement the UK’s first drug consumption room (DCR) in Glasgow were made in 2017, but subsequently rejected by the UK Government.

Aims: In the context of this dynamic and evolving risk environment, we aimed to: 1) Examine the prevalence of public injecting in Scotland and associated individual and environmental risk factors; and 2) Assess the association between public injecting and recent harms; HIV, overdose and skin and soft tissue infections (SSTI)).

Methods: Anonymous, national, cross-sectional, bio-behavioural survey (including dry blood spot (DBS) testing to determine HIV antibody status) of 1478 PWID (who reported injecting in the last six months) conducted in 2017-18. Logistic regression was used to determine factors associated with public injecting and the association between public injecting and harms (HIV, self-reported overdose and SSTI).

Results: During 2017-18 16.2% of respondents reported public injecting. Factors associated with an increased risk of public injecting were being recruited in Greater Glasgow and Clyde (aOR 3.7, 95% CI 2.5 to 5.3), reporting homelessness in the last six months (aOR 4.5, 95% CI 3.2 to 6.3), injecting cocaine in the last six months (aOR 1.7, 95% CI 1.2 to 2.4), excessive alcohol consumption in the last year (>14 units per week) (aOR 2.7, 95% CI 1.8 to 3.8) and high injection frequency in last 6 months (>4 injections per day) (aOR 3.3, 95% CI 1.9 to 5.6). Receiving opiate agonist therapy (OAT) in the last 6 months was associated with lower odds of public injecting (aOR 0.3, 95% CI 0.2 to 0.5). With regard to harms, public injecting was associated with an increased risk of being HIV antibody positive (aOR 2.11, 95% CI 1.13 to 3.92), self-reported overdose in the last year (aOR 1.69, 95% CI 1.18 to 2.41) and SSTI infection in the last year (aOR 1.54, 95% CI 1.12 to 2.12).

Conclusion: This research has demonstrated an increased risk of multiple recent morbidities (HIV, overdose and SSTI) associated with public injecting among a national sample of PWID, in addition to a high national prevalence of public injecting in Scotland. The results of this research provide further weight to proposals to establish the UKs first DCR in Scotland and reinforce the need for new radical harm reduction policies in the UK.