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Focus on harm reduction in fight against HIV, says report

BMJ 2016; 352 doi: (Published 10 March 2016) Cite this as: BMJ 2016;352:i1479

Re: Focus on harm reduction in fight against HIV, says report

We welcome the news item on the role of harm reduction in the ‘fight’ against HIV1 and we broadly agree with the findings of the report The Case for a Harm Reduction Decade: Progress, Potential and Paradigm Shifts.2 Clearly harm reduction for people who inject drugs (PWID) is having a positive impact on HIV in places such as the Ukraine, Nepal and parts of China and Kenya. This is supported by evidence of the long term impact of harm reduction approaches in controlling HIV among PWID in the United Kingdom, Switzerland and Australia.

The increased benefits of even a modest proportional shift in resource from the so called ‘War on Drugs’ to evidence based harm reduction policies is a compelling argument. However, in addition to addressing the needs of established drug injecting populations such as heroin and stimulant injectors, we must also get ahead of the curve in relation to emerging patterns of injecting drug use to reduce the number of new cases of HIV. The injection of image and performance enhancing drugs (IPEDs) has been largely overlooked in relation to blood borne virus risks. IPEDs are a collective term for anabolic steroids, growth hormones, other drugs to increase musculature and associated ancillary drugs, together with peptide hormones such as melanotan II (a synthetic melanocortin analogue) and other drugs that are used for enhancement purposes.

A recent meta-analysis and meta-regression of 187 studies on anabolic steroid use indicated a global lifetime prevalence of 3.3%.3 IPED users are growing as a client group in many countries with long standing provision of needle and syringe programmes, such as Australia4 and the United Kingdom where many services now report that over half of their clients inject IPEDs.5 Furthermore, in the United Kingdom there is conclusive evidence of HIV being present within this group of PWID, with an HIV prevalence of 1.5%6 amongst men injecting IPEDs, a level that is comparable to that among those injecting opioids and/or stimulants in the UK. Finally, there is evidence that people using IPED are a very sexually active population with low rates of condom use suggesting a risk of HIV transmission through their sexual networks.6
The use of IPEDs and in particular the injection of anabolic steroids by men, must be viewed as a serious public health concern requiring the attention of policy makers. Addressing the needs of emerging and often hidden populations of PWID should be part of the focus for harm reduction interventions.

1 BMJ 2016;352:i1479
2 Harm Reduction International. The case for a harm reduction decade: progress, potential and paradigm shifts. 2016.
3 Sagoe D, Molde H, Andreassen CS, et al. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol 2014;24:383-98.
4 Iversen J, Topp L, Wand H, et al. Are people who inject performance and image-enhancing drugs an increasing population of Needle and Syringe Program attendees? Drug Alcohol Rev. 2013;32:205-7.
5 Kimergård A, McVeigh J. Variability and dilemmas in harm reduction for anabolic steroid users in the UK: a multi-area interview study. Harm Reduct J 2014;11:19.
6 Hope VD, McVeigh J, Marongiu A, et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 2013;3:e003207.

Competing interests: No competing interests

18 March 2016
Jim McVeigh
Andreas Kimergård, Geoff Bates, Vivian D Hope, Fortune Ncube
Centre for Public Health, Liverpool John Moores University
Henry Cotton Campus, Level 2, 15-21 Webster Street, Liverpool, L3 2ET