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IHRC 2015: Needle Exchanges Must Meet Needs of People Who Inject Steroids and Image-enhancing Drugs


The numbers of people injecting steroids and other image-enhancing drugs has increased significantly in the last decade, and harm reduction services need to develop new skills if they are to help people using these drugs avoid blood-borne viruses, according to presentations at the 24th International Harm Reduction Conference last week in Kuala Lumpur. Surveys in the UK suggest that rates of HIV and viral hepatitis infections are significantly higher among people using these drugs than in the general population.

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Anabolic steroids are by far the most frequently used product, but agencies also report significant numbers of clients injecting peptide hormones, human growth hormone, and melanotan and other skin-tanning agents. Collectively, they are variously referred to as steroids and image-enhancing drugs (SIEDs), performance and image-enhancing drugs (PIEDs), or image and performance-enhancing drugs (IPEDs).

The issue has been best documented in high-income countries (the conference presentations came from the UK and Australia), but some experts believe that this is likely to be a global phenomenon -- for example, some of those using SIEDs in the UK were born in Eastern Europe and South-East Asia.

In both the UK and Australia, people using the substances are typically young men (around half are in their twenties). Most are heterosexual, but between 3% and 7% report sex with other men. Typically, they have limited experience of injecting drugs and tend not to use psychoactive drugs (except for cocaine, taken nasally). Nonetheless, both the UK and Australian surveys suggest that people using SIEDs are conscious of the risks of sharing injection equipment (4% and 2%, respectively, had ever re-used another person’s needle).

People using these drugs were described as being "thirsty for knowledge," but often seek this out in online forums where the information is not always accurate.

A higher than expected rate of HIV among people using SIEDs in the UK was first reported in 2013. In the most recent survey, 2.0% had HIV, 3.0% had antibodies to hepatitis B virus (HBV) and 4.0% had antibodies to hepatitis C virus (HCV). It appears that the proportions with these infections have increased over time, but the numbers of people taking part in surveys are small, so it is hard to be sure.

In contrast, in surveys of people using SIEDs in Queensland and New South Wales in Australia, 0.5% of people using SIEDs were HIV-positive. This is considerably higher than in the rate for the general heterosexual population of Australia (around 0.04%), but lower than the rate among people injecting other drugs (2%) or gay men (8% to 12%). A larger number (5%) had antibodies to HCV.

Given the elevated rate of HIV infection, the UK researchers argue that prevention work with people who use SIEDs needs to address sexual risks as well as injecting practices. In their surveys, around half of people who use SIEDs reporting having multiple sexual partners, but a similar proportion had never used a condom.

John Campbell of NHS Greater Glasgow and Clyde outlined how his needle and syringe program had adapted to the needs of this group. The injecting equipment and techniques are distinct from those used by people who inject heroin, as steroids and image-enhancing drugs are injected into muscle or skin (rather than a vein).

A specialized service one evening a week has been mostly promoted through word of mouth recommendations. Black market steroid dealers have been more helpful in raising awareness of the service than the staff of local gyms.

Last year in the Greater Glasgow area, 3339 individuals who injected SIEDs attended a needle exchange, compared to 7670 who inject heroin. Whereas people who use heroin may attend exchanges several times a week, people who use steroids typically come in much less frequently. They usually pick up large quantities of equipment to cover a cycle of steroid use, and often take material to pass on to friends. The infrequent visits mean that these are relatively rare opportunities for education around safe use.

Advice is not limited to avoiding blood-borne viruses -- many people have limited understanding of how the products work and what side effects and harms they should expect. An important aspect of the service is to offer blood tests and give advice on the often abnormal kidney, liver, cholesterol, testosterone, and estrogen levels that a person taking these drugs may have.

In Australia, Jenny Iversen said that different states have taken different approaches. Queensland’s policy on needle and syringe programs explicitly states that people using SIEDs are a key group that the services must reach, with the aims of preventing new infections and injection-related injuries. Educational materials for people using these products have been created.

In contrast, New South Wales -- where the patterns of use of SIEDs are very similar -- has chosen to limit the supply of equipment to this population, judging them not to be at sufficiently high risk of viral infections to warrant ongoing provision. Costs and a different financial system to Queensland appear to be the main reason for the restrictions.

There is a "need for targeted harm reduction interventions to address the sexual health and drug use risks among those injecting image and performance-enhancing drugs," concluded Vivian Hope of Public Health England.



K Cullen et al. Risk and vulnerability among people who inject image and performance enhancing drugs in England and Wales 2012-2013: where should we focus harm reduction? 24th International Harm Reduction Conference. Kuala Lumpur, October 18-21, 2015.

J Iversen and L Maher. The harm reduction response to an increase in people who inject performance and image-enhancing drugs attending needle and syringe programmes in Australia: a tale of two states. 24th International Harm Reduction Conference. Kuala Lumpur, October 18-21, 2015.

J Campbell and C Hunter. Identifying and reducing harm for steroid and image enhancing drugs (SIEDs) injectors, through innovative approaches. 24th International Harm Reduction Conference. Kuala Lumpur, October 18-21, 2015.

VD Hope et al. An increase in the prevalence of blood-borne infections among men who inject image and performance enhancing drugs in the United Kingdom: 1992-2013. 24th International Harm Reduction Conference. Kuala Lumpur, October 18-21, 2015.


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