comprehensive harm reduction policies has achieved impressive reductions in
incidence of hepatitis C virus (HCV) infections among people who inject drugs
(PWID) in Scotland, research published in PLOS
In 2008, the
Scottish government expanded access to sterile injecting equipment and also improved
the provision of opioid substitution treatment. HCV incidence among people who inject drugs declined sharply between
2008 and 2012 and the investigators estimated that the harm reduction
interventions averted 1000 new chronic HCV infections in this population.
“We observed a
decline in HCV incidence among PWID during a period of harm reduction services
in Scotland,” comment the authors. “This is the first study to demonstrate that
impressive reductions in HCV incidence can be achieved among PWID over a relatively
short period through high coverage of a combination of interventions.”
Hepatitis C is a
blood-borne virus and people who inject drugs are at high risk of contracting the infection
through the use of non-sterile injecting equipment.
services for people who inject drugs have tended to focus on the provision of clean needles and
syringes and opioid substitution therapy. However, it is known that sharing of
other injecting paraphernalia – spoons, filters and water – is associated with hepatitis C transmission.
In 2008, the
Scottish government introduced a comprehensive programme of harm reduction
interventions to prevent hepatitis C infections among people who inject drugs. The package included the
distribution of sterile injecting packs including filters and spoons as well as
needles and syringes and also improvements in opioid substitution therapy.
A team of
investigators designed a study to examine the impact of these interventions on hepatitis C infection rates among people who inject drugs between 2008 and 2012. They explored changes in
access to harm reduction interventions; associations between uptake of
interventions and injecting risk behaviour; and the number of new hepatitis C
infections averted by the introduction of the interventions and their uptake.
population consisted of 8000 people who inject drugs who were recruited to three separate
cross-sectional studies. Approximately three-quarters (72 to 73%) were male, mean
age was between 34 and 35 and mean time since the onset of injecting was
10.5 to 11.6 years.
There were major
changes in service provision after 2008. Between 2008/9 and 2009/10, provision
of filters and spoons increased sixfold and fourfold, respectively. Distribution
of sterile needles and syringes remained stable, with approximately 4.7 million
distributed each year.
The proportion of people who reported currently receiving opioid substitution therapy increased
from 50% in 2008/9 to 64% in 2011/12. The proportion of people reporting access
to sterile spoons and filters increased from between a fifth and a quarter in
2008/9 to approximately 70% in 2011/12.
declines in the proportion of individuals who reported daily injecting (from
63% to 49%), sharing needles/syringes (15% to 8%), reusing one’s own
needles/syringes (64% to 45%), sharing spoons (42% to 20%), sharing filters
(33% to 17%) and sharing water (31% to 21%). All these reductions were
There were a total
of 53 incident HCV infections. The incidence rate declined from 13.6 per 100
person years in 2008/9 to 7.3 per 100 person years in 2011/12.
needle/syringe and paraphernalia coverage (compared to low coverage) was associated
with a reduced risk of recent HCV infection (AOR = 0.14, 95% CI, 0.04-0.48, p =
0.002; AOR = 0.11, 95% CI, 0.03-0.44, p = 0.002).
People with high
coverage of needle/syringe/paraphernalia who were also on opioid substitution
therapy had a significantly lower risk of recent HCV infection compared to people with the lowest levels of service coverage.
number of new HCV infections declined from 1063 in 2008 to 566 in 2012. The
number of new chronic infections fell from 787 in 2008 to 419 in 2012. The
authors estimate that 1400 new infections and 1000 chronic infections were
averted by the scale-up of harm reduction between 2008 and 2012.
provide evidence of a downward trend in HCV incidence among PWID in Scotland,”
conclude the investigators. “Future monitoring of PWID will be required to
establish whether the downward direction in HCV transmission…is sustained.”