Preliminary bio-behavioural and other surveillance and research data indicates people who inject drugs (PWID) in the UK have been adversely affected by the COVID-19 pandemic in 2020, with access to services severely limited, including access to blood borne virus (BBV) testing and equipment for the safe use and/or injecting of drugs. PWID are particularly vulnerable to infectious diseases due to the extent of poverty, poor physical and mental health and reliance on access to clinical and public health services. It will be crucial to continue to monitor trends in access to services affected by the pandemic, as well as COVID-19 among PWID, to estimate the impact on national HIV and viral hepatitis elimination efforts. Despite a disruption in services for PWID as a result of COVID-19, novel approaches to service delivery have been implemented to ensure continuity of access to interventions. It is important that these innovations are evaluated to assess the impact on outcomes and health inequalities.

Hepatitis C virus (HCV) continues to be the most common infection among PWID in the UK, with bio-behavioural data showing no evidence of a reduction in new HCV infections over recent years. However, there is evidence for a reduction in chronic HCV prevalence, concomitant with the scale-up of direct acting antiviral (DAA) treatment, in this population. Self-reported HCV testing among PWID was high in 2020, in line with HCV elimination activities, yet the significant proportion of individuals not tested recently indicates there is scope for improvement. As an increasing proportion of PWID are successfully treated with DAAs, it is important to continue to test those with ongoing risk regularly to identify re-infection and reduce the risk of transmission early. It is essential that diagnostic services and care and treatment pathways for those with HCV continue and are optimised to meet the needs of PWID, ensuring no-one is left behind.

Although hepatitis B virus (HBV) vaccination is recommended as high priority for all people who currently inject drugs, around a third of PWID have never been vaccinated. Even though HBV infection among this group is currently rare, it is essential that guidelines on vaccination are followed; vaccination should be particularly promoted among PWID of younger age and recent initiates to injecting, for whom uptake is known to be low. Further work is needed to explore the barriers to uptake of HBV vaccination and strategies for increasing vaccine coverage should be developed and evaluated.

HIV infections and outbreaks continue to occur among PWID, although prevalence in this group remains comparatively low. Most of those with HIV are aware of their infection and uptake of treatment and care for HIV among those diagnosed is high. However, missed opportunities remain, with many PWID not tested recently reporting contact with a range of clinical services. It is important that PWID at ongoing risk are offered a diagnostic test regularly. Care pathways for those with HIV need to be optimised and maintained to ensure outcomes for PWID are equitable.

Cases of bacterial infections among PWID dropped in 2020, although this is thought to be due to limited hospital activity as a result of the pandemic. To prevent rates of bacterial infections increasing, drug and alcohol services should facilitate easy access to needle and syringe programmes (NSP), embed regular opportunities to discuss safe and hygienic injection practices with clients and provide low threshold and outreach wound care services. It is also important to provide prompt treatment for injection site infections and tetanus vaccination.

The recent increase in the sharing and re-use of injecting equipment is of concern. A third of PWID in 2020 report inadequate provision of needles and syringes. A range of easily accessible harm reduction services for all PWID, including NSP and opioid substitution therapy (OST), needs to be provided. A better understanding of the range and scope of NSP provision in nondrug service settings is needed. Clients should be supported to use low dead space equipment, including detachable needles and syringes that have lower dead space, to further reduce the risk of BBV transmission. Socially excluded communities, such as PWID experiencing homelessness and those not currently in contact with drug and alcohol services, should be specifically supported to access harm reduction services, regular BBV testing and care.

The changing patterns of psychoactive drug injection in the UK also remain a concern, as changes in psychoactive drug preferences can lead to riskier injecting practices. Injection of crack cocaine has increased in England and Wales, and injection of powder cocaine has increased in Scotland. There is a need for local treatment and harm reduction systems that can respond to both the increasing numbers and the specific needs of people who use crack and powder cocaine.

Reports of both fatal and non-fatal overdose have increased in the UK, with overdose most common among people using and/or injecting opiates. This is in the context of improved availability of naloxone, an emergency antidote for opioid overdose and increased self-reported carriage of take-home naloxone among PWID. Services working with PWID should provide materials to increase awareness of, and information about, overdose risks and provide training for peers and family members in overdose prevention, recognition and response, in addition to providing and encouraging consistent carriage of take-home naloxone and providing OST