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, the 24th International Harm
Reduction Conference in Kuala Lumpur was told on Wednesday. Surveys in the United
Kingdom suggest that rates of HIV and hepatitis infections are significantly
higher in people using these drugs than in the general population.
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 may be referred to
as steroids and image-enhancing drugs (SIEDs) or performance and image-enhancing drugs (PIEDs).
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.
The metabolic processes that build new tissues.
In both the UK and Australia, those 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 equipment (4% and
2% respectively had ever re-used another person’s needle).
People using these drugs are described as being ‘thirsty for knowledge’, but
often seek this out on online forums where the information is not always
A higher than expected rate of HIV in 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 and 4.0% had antibodies to hepatitis C. It appears
that the proportions with these infections have increased over time but the
numbers 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 (Australia), 0.5% of people using SIEDs were HIV-positive. This is
considerably higher than in the general heterosexual population of Australia
(around 0.04%) but lower than among people injecting other drugs (2%) or gay men
(8 to 12%). A larger number (5%) had antibodies to hepatitis C.
Given the elevated rate of HIV infection, the researchers
from Public Health England think 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 have multiple sexual partners but a similar proportion has
never used a condom.
John Campbell of NHS Greater Glasgow &
how his needle and syringe programme had adapted to the needs of this
group. The injecting equipment and techniques are distinct from those
people who inject heroin, as steroids and image-enhancing drugs are
muscle or skin (rather than a vein).
A specialised 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
Last year in the Greater Glasgow area, 3339 individuals who
injected SIEDs attended a needle exchange, in contrast to 7670 who inject
heroin. Whereas people who use heroin may attend 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 there 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
blood tests and give advice on the often abnormal kidney, liver,
testosterone and oestrogen levels that a person may have.
In Australia, Jenny Iversen said that different states have
taken different approaches. Queensland’s policy on needle and syringe programmes
explicitly states that people using SIEDs are a key group that the services
must reach, with the aims of preventing new infections and of preventing
injecting-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.