BACKGROUNDWith improvements in test sensitivity and testing frequency, more people in Europe are diagnosed during the HIV acute/seroconversion phase, when their CD4+ T-cell count can be temporarily low.AIMWe piloted a revised definition of late HIV diagnosis for surveillance which considers laboratory markers, evidence of HIV test negativity in the past year and clinical evidence of recent HIV acquisition, to better distinguish between people diagnosed late and those diagnosed during the acute/seroconversion phase.METHODSWe collected pseudonymised HIV diagnosis records for 2022 and 2023 from nine European countries (Belgium, Czechia, Denmark, Germany, Greece, Italy, the Netherlands, Portugal and Sweden). We applied the revised definition to reclassify those with evidence of recently acquired HIV as 'not late' and calculated the corresponding correction factor by country and demographic group. Individuals with a previous diagnosis were excluded from the analysis.RESULTSAmong 10,220 individuals with a CD4+ T-cell count at diagnosis, 56% (5,689/10,220) had a CD4+ T-cell count < 350 cells/µL or an AIDS-defining event at diagnosis. Applying the revised definition reduced the late diagnosis proportion from 56% to 50%, a correction factor of 9% (535/5,689). The correction factor ranged between 3% and 25% across countries and was higher for younger ages and for gay, bisexual and other men who have sex with men, compared with other groups.CONCLUSIONSWithout reclassification, late HIV diagnosis proportions are overestimated. We provide recommendations and validity considerations for countries intending to use the revised definition.

BACKGROUND:Mental health professionals play a crucial role in promoting the physical well-being of people with mental illness. Awareness of HIV status can enable professionals in mental health services to provide more comprehensive care. However, it remains uncertain whether mental health professionals consistently document HIV status in mental health records. AIMS:To investigate the extent to which mental health professionals document previously established HIV diagnoses of people with mental illness in mental health records, and to identify the clinical and demographic factors associated with documentation or lack thereof. METHODS:A retrospective cohort study was conducted using an established data linkage between routinely collected clinical data from secondary mental health services in South London, UK, and national HIV surveillance data from the UK Health Security Agency. Individuals with an HIV diagnosis prior to their last mental health service contact were included. Documented HIV diagnosis in mental health records was assessed. RESULTS:Among the 4,032 individuals identified as living with HIV, 1,281 (31.8%) did not have their diagnosis recorded in their mental health records. Factors associated with the absence of an HIV diagnosis included being of Asian ethnicity, having certain primary mental health diagnoses including schizophrenia, being older, being with a mental health service for longer, having more clinical mental health appointments, and living in a less deprived area. CONCLUSIONS:A significant number of individuals living with HIV who are receiving mental healthcare in secondary mental health services did not have their HIV diagnosis documented in their mental health records. Addressing this gap could allow mental healthcare providers to support those living with HIV and severe mental illness to manage the complexity of comorbidities and psychosocial impacts of HIV. Mental health services should explore strategies to increase dialogue around HIV in mental health settings.

Background:The risk of onward HIV transmission is strongly influenced by the interval between HIV infection and its diagnosis. The SELPHI trial examined whether this interval could be reduced by offering free HIV self-testing kits to men who have sex with men (MSM).Setting:Internet-based RCT of MSM aged >= 16 years, resident in England/Wales, recruited through sexual and social networking sites.Methods:The second-stage randomization of SELPHI was open to participants who used an initial free HIV self-test kit, were HIV seronegative, and reported recent condomless anal sex. They were randomized to receive a free HIV self-test kit every 3 months (repeat testing [RT] group) versus no such offer (nRT group). The primary outcome was time from randomization to a confirmed HIV diagnosis, determined from linkage to national HIV surveillance databases. The key secondary outcome was the frequency of HIV testing regardless of test modality.Results:In total, 2308 eligible participants (1161 RT, 1147 nRT) were randomized between April 2017 and June 2018, and followed for 15-27 months. The proportion of participants reporting an HIV test in the previous 3 months was much higher in the RT group (86%) than in the nRT group (39%). Overall, 16 (9 RT, 7 nRT) confirmed HIV diagnoses were observed (0.35/100 person-years), with no difference between the groups (hazard ratio = 1.27 [95% CI: 0.47 to 3.41], P = 0.63).Conclusions:Providing regular free self-testing kits to sexually active MSM was highly acceptable and markedly increased HIV testing. However, in this low incidence cohort, it did not result in a demonstrably more rapid diagnosis of incident infections.

Aim: Needle and syringe (NS) provision is a proven intervention for reducing harms associated with injecting drug use, such as infections, but impact is coverage-dependent. We characterised people who injected drugs (PWID) in England and Wales who had insufficient NS in the past month to meet their injecting requirements.Methods: This study utilised 2017-2019 data from the annual Unlinked Anonymous Monitoring (UAM) Survey of PWID recruited through specialist services. Logistic regression was used to identify factors associated with inadequate NS coverage.Findings: Of 2,442 PWID surveyed who had injected in the past month, 34% reported inadequate NS coverage (or as high as 51% if including unsuccessful injections). Younger PWID (adjusted odds ratio: 2.18, 95% confidence interval: 1.35-3.52), those who began injecting in the past three years (1.46, 1.09-2.00), and those who reported sharing injecting equipment (1.46, 1.22-1.75) had greater odds of having inadequate NS coverage. PWID currently prescribed Opioid Substitution Treatment (OST) had lower odds of inadequate NS coverage (0.60, 0.49-0.73).Conclusion: Given the poor reported coverage of NS provision in England and Wales, there is urgent need to address inequity in accessing sufficient NS and increase coverage among this vulnerable group to reduce injecting-related harms.

BACKGROUND:In England, over 80 % of those with hepatitis C virus (HCV) infection have injected drugs. We quantified the HCV cascade of care (CoC) among people who inject drugs (PWID) in England and determined whether this improved after direct-acting antivirals (DAAs) were introduced. METHODS:We analysed data from nine rounds of national annual cross-sectional surveys of PWID recruited from drug services (2011-2019; N = 12,320). Study rounds were grouped as: 'Pre-DAAs' (2011-2014), 'Prioritised DAAs' (2015-2016) and 'Unrestricted DAAs' (2017-2019). Participants were anonymously tested for HCV antibodies and RNA and completed a short survey. We assessed the proportion of PWID recently (current/previous year) tested for HCV. For participants ever HCV treatment eligible (past chronic infection with history of treatment or current chronic infection), we assessed the CoC as: HCV testing (ever), received a positive test result, seen a specialist nurse/doctor, and ever treated. We used logistic regression to determine if individuals progressed through the CoC differently depending on time-period, whether time-period was associated with recent testing (all participants) and lifetime HCV treatment (ever eligible participants), and predictors of HCV testing and treatment in the Unrestricted DAAs period. RESULTS:The proportion of ever HCV treatment eligible PWID reporting lifetime HCV treatment increased from 12.5 % in the Pre-DAAs period to 25.6 % in the Unrestricted DAAs period (aOR:2.40, 95 %CI:1.95-2.96). There were also increases in seeing a specialist nurse/doctor. The largest loss in the CoC was at treatment for all time periods. During the Unrestricted DAAs period, recent (past year) homelessness (vs never, aOR:0.66, 95 %CI:0.45-0.97), duration of injecting (≤3 years vs >3 years; aOR:0.26, 95 %CI:0.12-0.60), never (vs current, aOR:0.31, 95 %CI:0.13-0.75) or previously being prescribed OAT (vs current, aOR:0.67, 95 %CI:0.47-0.95), and never using a NSP (vs past year, aOR:0.27, 95 %CI:0.08-0.89) were negatively associated with lifetime HCV treatment. The proportion of PWID reporting recent HCV testing was higher during Unrestricted DAAs (56 %) compared to Pre-DAAs (48 %; aOR:1.28, 95 %CI:1.06-1.54). CONCLUSION:COC stages from seeing a specialist onwards improved after DAAs became widely available. Further improvements in HCV testing are needed to eliminate HCV in England.

Abstract Background Bacterial infections cause substantial pain and disability among people who inject drugs. We described time trends in hospital admissions for injecting-related infections in England. Methods We analyzed hospital admissions in England between January 2002 and December 2021. We included patients with infections commonly caused by drug injection, including cutaneous abscesses, cellulitis, endocarditis, or osteomyelitis, and a diagnosis of opioid use disorder. We used Poisson regression to estimate seasonal variation and changes associated with coronavirus disease 2019 (COVID-19) response. Results There were 92 303 hospital admissions for injection-associated infections between 2002 and 2021. Eighty-seven percent were skin, soft-tissue, or vascular infections; 72% of patients were male; and the median age increased from 31 years in 2002 to 42 years in 2021. The rate of admissions reduced from 13.97 per day (95% confidence interval [CI], 13.59–14.36) in 2003 to 8.94 (95% CI, 8.64–9.25) in 2011, then increased to 18.91 (95% CI, 18.46–19.36) in 2019. At the introduction of COVID-19 response in March 2020, the rate of injection-associated infections reduced by 35.3% (95% CI, 32.1–38.4). Injection-associated infections were also seasonal; the rate was 1.21 (95% CI, 1.18–1.24) times higher in July than in February. Conclusions This incidence of opioid injection-associated infections varies within years and reduced following COVID-19 response measures. This suggests that social and structural factors such as housing and the degree of social mixing may contribute to the risk of infection, supporting investment in improved social conditions for this population as a means to reduce the burden of injecting-related infections.

BACKGROUND:Measuring the incidence of HIV and hepatitis C virus (HCV) infection among people who inject drugs (PWID) is key to track progress towards elimination. We aimed to summarise global data on HIV and primary HCV incidence among PWID and associations with age and sex or gender. METHODS:In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies among PWID by searching MEDLINE, Embase, and PsycINFO, capturing studies published between Jan 1, 2000, and Dec 12, 2022, with no language or study design restrictions. We contacted authors of identified studies for unpublished or updated data. We included studies that estimated incidence by longitudinally re-testing people at risk of infection or by using assays for recent infection. We pooled incidence and relative risk (RR; young [generally defined as ≤25 years] vs older PWID; women vs men) estimates using random-effects meta-analysis and assessed risk of bias with a modified Newcastle-Ottawa scale. This study is registered with PROSPERO, CRD42020220884. FINDINGS:Our updated search identified 9493 publications, of which 211 were eligible for full-text review. An additional 377 full-text records from our existing database and five records identified through cross-referencing were assessed. Including 28 unpublished records, 125 records met the inclusion criteria. We identified 64 estimates of HIV incidence (30 from high-income countries [HICs] and 34 from low-income or middle-income countries [LMICs]) and 66 estimates of HCV incidence (52 from HICs and 14 from LMICs). 41 (64%) of 64 HIV and 42 (64%) of 66 HCV estimates were from single cities rather than being multi-city or nationwide. Estimates were measured over 1987-2021 for HIV and 1992-2021 for HCV. Pooled HIV incidence was 1·7 per 100 person-years (95% CI 1·3-2·3; I2=98·4%) and pooled HCV incidence was 12·1 per 100 person-years (10·0-14·6; I2=97·2%). Young PWID had a greater risk of HIV (RR 1·5, 95% CI 1·2-1·8; I2=66·9%) and HCV (1·5, 1·3-1·8; I2=70·6%) acquisition than older PWID. Women had a greater risk of HIV (RR 1·4, 95% CI 1·1-1·6; I2=55·3%) and HCV (1·2, 1·1-1·3; I2=43·3%) acquisition than men. For both HIV and HCV, the median risk-of-bias score was 6 (IQR 6-7), indicating moderate risk. INTERPRETATION:Although sparse, available HIV and HCV incidence estimates offer insights into global levels of HIV and HCV transmission among PWID. Intensified efforts are needed to keep track of the HIV and HCV epidemics among PWID and to expand access to age-appropriate and gender-appropriate prevention services that serve young PWID and women who inject drugs. FUNDING:Canadian Institutes of Health Research, Fonds de recherche du Québec-Santé, Canadian Network on Hepatitis C, UK National Institute for Health and Care Research, and WHO.

BackgroundThere is increasing interest in the use of electronic health records (EHRs) to improve the efficiency and cost-effectiveness of clinical trials, including the capture of outcome measures.Main textWe describe our experience of using EHRs to capture the primary outcome measure - HIV infection or the diagnosis of HIV infection - in two randomised HIV prevention trials conducted in the UK. PROUD was a clinic-based trial evaluating pre-exposure prophylaxis (PrEP), and SELPHI was an internet-based trial evaluating HIV self-testing kits. The EHR was the national database of HIV diagnoses in the UK, curated by the UK Health Security Agency (UKHSA). In PROUD, linkage to the UKHSA database was performed at the end of the trial and identified five primary outcomes in addition to the 30 outcomes diagnosed by the participating clinics. Linkage also produced an additional 345 person-years follow-up, an increase of 27% over clinic-based follow-up. In SELPHI, new HIV diagnoses were primarily identified via UKHSA linkage, complemented by participant self-report through internet surveys. Rates of survey completion were low, and only 14 of the 33 new diagnoses recorded in the UKHSA database were also self-reported. Thus UKHSA linkage was essential for capturing HIV diagnoses and the successful conduct of the trial.ConclusionsOur experience of using the UKHSA database of HIV diagnoses as a source of primary outcomes in two randomised trials in the field of HIV prevention was highly favourable and encourages the use of a similar approach in future trials in this disease area.

IntroductionSex workers, who provide sexual or erotic acts in exchange for payment, often experience multiple disadvantages, including mental ill health and substance misuse. Mainstream healthcare services are generally not configured to facilitate engagement with sex workers and therefore, services are needed that are accessible to this population. The aim of this scoping review is to understand the evidence base for approaches, services and interventions that are aimed at addressing sex workers' health needs. Methods and analysisNine databases, CINAHL, Embase, EThOS, Google Scholar, Health Management Information Consortium, MEDLINE, ProQuest Dissertations and Theses, PsycINFO and Web of Science (Core Collection), will be searched, with results limited to English language publications and those published from 2003 onwards. De-duplication, study selection and data extraction will be conducted using Covidence software. Included studies will describe or evaluate approaches, services or interventions that address the health needs of sex workers who offer services that involve physical contact with a client. Ethics and disseminationNo ethical review is needed. The final report will be shared with Birmingham City Council as part of ongoing work and will be disseminated by peer-reviewed publication. Study registrationOpen Science Framework (doi: 10.17605/OSF.IO/N7WSX).

The London HIV Mortality Review Group has been conducting annual reviews of deaths among people with HIV since 2013. In 2020, the National HIV Mortality Review was introduced, formed of a collaboration between the UK Health Security Agency (UKHSA) and the British HIV Association (BHIVA), to extend the review to the whole of the UK. In 2017, Brighton and Hove became the first Fast Track City in the UK, committing to reaching zero HIVrelated deaths by 2030. We thus set out to measure how many deaths in people with HIV were potentially preventable in the city. We included all patients who resided in and received their routine care in Brighton and Hove between 2017 and 2020. Data were collected from clinical records, laboratory results and coroner reports, and were entered into the UKHSA/BHIVA National HIV Mortality Review online tool. Cause of death was classified following an independent review of each death by an HIV epidemiologist and two HIV clinicians (as previously described). Deaths were described as potentially preventable, based on most recent consensus recommendations. Potentially preventable, directly HIVrelated deaths included those due to AIDSdefining illnesses, those that were HIVrelated and occurred within one year of diagnosis and those where the patient was not virally suppressed at death. Potentially preventable, but not directly HIVrelated, deaths included those due to lifestyle risk factors, suicide, a vaccinepreventable disease; or those that may have benefitted from earlier hepatits C treatment. A total of 75 deaths among people with HIV were included; a cause was determined for 74 of these. Five deaths were considered to be directly HIVrelated and potentially preventable, four of which were from AIDS causes. One patient died from progressive multifocal leucoencephalopathy with poor adherence to antiretroviral therapy (ART); one presented with advanced HIV disease and severe pneumocystis pneumonia, and died within 24 hours despite prompt treatment; two died from complications of HIVrelated lymphomas despite good adherence to ART; and one patient died from pneumonia having declined ART. The reasons for poor adherence and declining ART were complex and included specific health beliefs about ART and mental ill health. An additional 23 deaths were considered not directly HIVrelated but potentially preventable. Of these, 20 were likely to be attributable to lifestyle risk factors. Eight died from smokingrelated diseases (four from lung cancer and four from chronic obstructive pulmonary disease) and were smokers in the year before death, although a causative relationship cannot be confirmed. A further eight were related to alcohol (seven had chronic alcoholic liver disease and one had acute alcohol poisoning). Four deaths were due to accidental drug overdoses. Two people died due to suicide. One person died from hepatitis Crelated liver cirrhosis. Another significant group of deaths we identified were those due to cardiovascular disease, which accounted for eight deaths. This is in keeping with previous findings that those living with HIV are at increased risk of cardiovascular disease both as a direct result of HIV infection and a higher prevalence of risk factors. In the year before death, smoking was the highest reported risk factor, reported in 52% of the cohort. Regarding other risk factors, alcohol excess was reported among 27% of people and nonintravenous drug use was reported by 24%, of which 27% also used drugs intravenously. There are potential limitations regarding how deaths were classified. In this study, deaths from cardiovascular disease were not classed as preventable, despite many of the risk factors and comorbidities being modifiable (namely smoking, dyslipidaemia and hypertension). A further limitation of describing all the deaths in Brighton and Hove residents with HIV is that not all access their care locally. As we only looked at people who attended the HIV clinic in Brighton and Hove, there will be an unknown number of people with HIV who died elsewhere and were not included, and we may also have missed deaths in the community that we were not aware of. Our study highlights the importance of monitoring lifestyle risk factors and comorbidities including cardiovascular risk, mental ill health, smoking, and alcohol and drug use in routine HIV management. It is encouraging that only five deaths among people with HIV over 4 years were directly attributable to HIV. However, the high number of potentially preventable deaths that were not directly related to HIV highlights the importance of addressing holistic health promotion in routine HIV care.

Objectives: This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections.Study design: The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland.Methods: Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi(2) tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression.Results: Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03 -11.33], P 1/4 0.043).Conclusions: Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.Crown Copyright (c) 2023 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY license.

Background: Crack use is higher in the United Kingdom (UK) than other European countries. Crack is a stimulant with a short half-life, requiring frequent injection to maintain its euphoric effects, thus increasing the risk of blood borne viruses (BBVs) and skin and soft tissue infections (SSTIs). We assessed trends in the prevalence of current crack injection among people who inject drugs (PWID) and investigated harms and other factors associated with its use. Methods: We used data from the annual Unlinked Anonymous Monitoring Survey of PWID, which recruits people who have ever injected psychoactive drugs through specialist services. Participants provide a biological sample and self-complete a questionnaire. We included participants from England and Wales who had injected in the past month. We examined trends in crack injection over time (2011-2021) and factors associated with crack injection using multivariable logistic regression (2019-2021). Results: The proportion of people self-reporting crack injection in the past month almost doubled between 2011-2020/21, from 34 % (416/1237) to 57 % (483/850). Crack injection was more frequently reported by males than females (adjusted odds ratio 1.46, 95% confidence interval: 1.15-1.87) and injected alongside heroin (6.67, 4.06-10.97) more frequently than alone. Crack injection was independently associated with injecting equipment sharing (1.64, 1.30-2.07), groin injection (2.03, 1.60-2.56) in the past month, overdosing in the past year (1.90, 1.42-2.53), homelessness in the past year (1.42, 1.14-1.77) and ever having hepatitis C infection (1.64, 1.31-2.06). Conclusion: Crack injection has increased significantly over the past decade in England and Wales. People injecting crack are more likely to engage in behaviours that increase the risk of BBV and SSTI acquisition, such as needle/syringe sharing, groin injection and polydrug use. Harm reduction and drug treatment services should adapt to support the needs of this growing population of people injecting stimulants.

Objective To examine the prevalence of HIV in a cohort of people who have used secondary mental health services in the UK. Design Retrospective cohort study. Setting Routinely collected clinical data from secondary mental health services in South London, UK available for research through the Clinical Record Interactive Search tool at the National Institute for Health and Care Research Maudsley Biomedical Research Centre were matched with pseudonymised national HIV surveillance data held by the UK Health Security Agency using a deterministic matching algorithm. Participants All adults aged 16+ who presented for the first time to mental health services in the South London and Maudsley (SLaM) National Health Service Trust between 1 January 2007 and 31 December 2018 were included. Primary outcome Point prevalence of HIV. Results There were 181 177 people who had contact with mental health services for the first time between 2007 and 2018 in SLaM. Overall, 2.47% (n=4481) of those had a recorded HIV diagnosis in national HIV surveillance data at any time (before, during or after contact with mental health services), 24.73 people per 1000. HIV point prevalence was highest in people with a diagnosed substance use disorder at 3.77% (n=784). A substantial percentage of the sample did not have a formal mental health diagnosis (27%), but even with those excluded, the point prevalence remained high at 2.31%. Around two-thirds of people had their diagnosis of HIV before contact with mental health services (67%; n=1495). Conclusions The prevalence of HIV in people who have had contact with mental health services was approximately 2.5 times higher than the general population in the same geographical area. Future work should investigate risk factors and disparities in HIV outcomes between those with and without mental health service contact.

Getting to Zero is a commonly cited strategic aim to reduce mortality due to both HIV and avoidable deaths among people with HIV. However, no clear definitions are attached to these aims with regard to what constitutes HIV-related or preventable mortality, and their ambition is limited. This Position Paper presents consensus recommendations to define preventable HIV-related mortality for a pragmatic approach to public health monitoring by use of national HIV surveillance data. These recommendations were informed by a comprehensive literature review and agreed by 42 international experts, including clinicians, public health professionals, researchers, commissioners, and community representatives. By applying the recommendations to 2019 national HIV surveillance data from the UK, we show that 30% of deaths among people with HIV were HIV-related or possibly HIV-related, and at least 63% of these deaths were preventable or potentially preventable. The application of these recommendations by health authorities will ensure consistent monitoring of HIV elimination targets and allow for the identification of inequalities and areas for intervention.

BACKGROUND:In 2019-2020, record-high numbers of overdoses have been reported across the UK. We estimated perceived availability to and carriage of naloxone and explored factors associated with carriage among people who inject drugs (PWID) engaged with services in England, Wales, and Northern Ireland. METHODS:Participants were PWID enrolled in the Unlinked Anonymous Monitoring Survey in 2019 who reported past-year injection drug use (n = 2,139). Recruitment occurred through specialist and community drug agencies located across the UK, excluding Scotland. Socio-demographic, behavioural and service use characteristics were self-reported. Participants were asked whether they carry naloxone (timeframe unspecified). If they answered "no", they were further asked whether it is available in their area. Perceived naloxone availability and carriage were estimated by requirement region, classified using the Nomenclature of Territorial Units for Statistics 1. We used the Gelberg-Andersen Model of healthcare access to explore predisposing, enabling and need factors associated with regionally-aggregated naloxone carriage. RESULTS:Perceived naloxone availability was ≥95% in all 11 regions; naloxone carriage varied (mean: 61.1; range: 48%-71%; P<0.01). Among predisposing factors, female gender (adjusted odds ratio (AOR): 1.52; 95% confidence interval (CI): 1.21-1.91) was positively associated with naloxone carriage, whilst recruitment in Yorkshire and the Humber-relative to London-was negatively associated (AOR: 0.55; 95%CI: 0.37-0.82). Among enabling factors, past-year contact with needle and syringe programmes (AOR: 1.74; 95%CI: 1.39-2.18) and currently receiving treatment for drug use (AOR: 1.75; 95%CI: 1.24-2.46) were positively associated with naloxone carriage. Among need characteristics, past-month heroin injection, with or without past-month high-risk drinking or benzodiazepine use, was positively associated with carriage relative to no heroin injection (range of AORs: 1.71-2.58). CONCLUSION:Perceived naloxone availability is very high among PWID attending services in England, Wales, and Northern Ireland. Naloxone carriage is moderately high and varying across regions, and appears improved through recent engagement with harm-reduction programs.

Syringes with attached needles (termed fixed low dead space syringes [LDSS]) retain less blood following injection than syringes with detachable needles, but evidence on them reducing blood-borne virus transmission among people who inject drugs (PWID) is lacking. Utilizing the UK Unlinked Anonymous Monitoring cross-sectional bio-behavioral surveys among PWID for 2016/18/19 (n = 1429), we showed that always using fixed LDSS was associated with 76% lower likelihood (adjusted odds ratio = 0.24, 95% confidence interval [CI]: .08-.67) of recent hepatitis C virus infection (RNA-positive and antibody-negative) among antibody-negative PWID compared to using any syringes with detachable needles.

Background: Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year). Methods: We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression. Results: Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration >= 3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67). Conclusion: Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

Abstract Background and aims Mortality and drug treatment data suggest that the median age of people who inject drugs is increasing. We aimed to describe changes in the characteristics of people injecting drugs in the United Kingdom (UK). Design Repeat cross‐sectional surveys and modelling. Setting Low‐threshold services in the United Kingdom such as needle and syringe programmes. Participants A total of 79 900 people who recently injected psychoactive drugs in the United Kingdom, recruited as part of the Unlinked Anonymous Monitoring Survey (England, Wales, Northern Ireland, 1990–2019) and Needle Exchange Surveillance Initiative (Scotland, 2008–2019). Measurements Age of people currently injecting, age at first injection, duration of injecting (each 1990–2019) and estimates of new people who started injecting (1980–2019). Findings In England, Wales and Northern Ireland between 1990 and 2019, the median age of people injecting increased from 27 (interquartile range [IQR], 24–31) to 40 (IQR, 34–46); median age at first injection increased from 22 (IQR, 19–25) to 33 (IQR, 28–39); and median years of injecting increased from 7 (IQR, 3–11) to 18 (IQR, 9–23). Values in Scotland and England were similar after 2008. The estimated number that started injecting annually in England increased from 5470 (95% prediction interval [PrI] 3120‐6940) in 1980 to a peak of 10 270 (95% PrI, 8980‐12 780) in 1998, and then decreased to 2420 (95% PrI, 1320‐5580) in 2019. The number in Scotland followed a similar pattern, increasing from 1220 (95% PrI, 740–2430) in 1980 to a peak of 3080 (95% PrI, 2160–3350) in 1998, then decreased to a 270 (95% PrI, 130–600) in 2018. The timing of the peak differed between regions, with earlier peaks in London and the North West of England. Conclusions In the United Kingdom, large cohorts started injecting psychoactive drugs in the 1980s and 1990s and many still inject today. Relatively few people started in more recent years. This has led to changes in the population injecting drugs, including an older average age and longer injecting histories.

Late HIV diagnosis (CD4 <350 cells/mm3) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re‐assessed 1‐year mortality following late diagnosis.