Addressing a topic that has received remarkably little research attention over the years, Dr Vivian Hope of Public Health England told the British HIV Association conference yesterday that injection of image- and performance-enhancing drugs is rising in England and Wales. Moreover, his research suggests that men may be acquiring bloodborne viruses through this route – 1.5% had antibodies to HIV, 8.8% had antibodies to hepatitis B and 5.5% to hepatitis C.
Dr Hope said that across the world, only three previous studies have been conducted on HIV prevalence among people who inject drugs which are taken to enhance body image, physical strength or performance. One of these three was conducted in the UK in the mid-1990s and did not find any HIV infections in those surveyed.
There are reports of increased numbers of people injecting these drugs who present to needle and syringe exchanges. However, not all syringe exchanges have the skills and experience to meet their needs. The injecting process is different to that of opiates – these drugs are normally delivered in a sealed vial, and are not usually injected into a vein, but into a muscle or beneath the skin.
Moreover, the social profile of injectors of image- and performance-enhancing drugs is different to that of opiate injectors – younger, more likely to be employed, less likely to have had problems with the criminal justice system.
Data from the 2012 British Crime Survey suggest that 70,000 people have used anabolic steroids in the previous year – greater than the 47,000 who have used heroin.
As part of the established unlinked anonymous survey of drug injectors, a sub-survey was conducted with people who inject image- and performance-enhancing drugs. However, as recruitment was through 19 needle and syringe exchange programmes, the characteristics of those recruited may be different to those of users who do not attend these services.
The survey recruited 395 men (a further five women reported use of these drugs, but were excluded from the analysis). Oral fluid samples were taken for antibody testing.
Men in the sample had an average age of 28 and were predominantly heterosexual. Half had been injecting for less than five years; one third used multiple drugs of this class; 5% had ever injected a psychoactive drug; half had also snorted cocaine in the past year.
Most of the men injected anabolic steroids (86%) or growth hormones (32%), with fewer men injecting human chorionic gonadotropin (hCG), insulin or melanotan I/II.
Nine per cent reported ever sharing a needle, syringe or vial; 17% reported being injected by another person in the past year. These rates are lower than in users of opiates.
As well as injecting, the men’s sexual behaviour could be linked to viral infections. Only one in five always used a condom; 20% had five or more female partners in the past year; 8% had ten or more female partners; 7% used Viagra or a similar drug; 3% were men who have sex with men.
Despite these numerous risk factors, engagement with health services was limited. Only 23% had been vaccinated for hepatitis B, 22% had ever been tested for hepatitis C and 31% had ever been tested for HIV. In the past year, 17% had visited a sexual health clinic. (And health service use may be even lower in injectors not using drugs services.)
Whereas prevalence of hepatitis B antibodies (8.8%) or hepatitis C antibodies (5.5%) was lower than in injectors of psychoactive drugs in the UK, 1.5% of the injectors had HIV, which is around the same as the figure in psychoactive injectors. These figures are considerably higher than in the general population.
Half the HIV infections were in heterosexual men. Nonetheless HIV was associated with having sex with men, use of sexual health services and older age.
Concluding, Hope said that the results should be interpreted with caution. Nonetheless his results do point to injecting behaviours, sexual behaviours, and psychoactive drug use that are putting the participants at risk of infections.
Providers of HIV testing and HIV treatment services need to be aware of the possibility of this behaviour in people in their care, although it may not be readily disclosed, he said.
Hope V et al. Prevalence of, and risk factors for, human immunodeficiency virus, hepatitis B and hepatitis C infections among men who inject image and performance enhancing drugs in England & Wales. 19th British HIV Association conference, Manchester, abstract O4, April 2013.