This section includes the main findings from the Unlinked Anonymous Monitoring (UAM) Survey of HIV and viral hepatitis among people who inject drugs (PWID) in England, Wales, and Northern Ireland (EWNI) for the period 2014 to 2023. HIV prevalence among UAM Survey participants has remained low and stable over the past decade and was 1% in 2023.

Overall, the proportion of UAM Survey participants with hepatitis C virus (HCV) antibodies (a marker of ever HCV infection) has remained relatively stable over the past decade (from 49% in 2014 to 53% in 2023) and is higher among those aged 35 years and above. This suggests continued exposure to HCV and a treatment effect, with increased uptake of HCV treatment resulting in those recruited to the UAM who are ever-infected living longer.

Chronic hepatitis C (hepatitis C ribonucleic acid (RNA) and antibody positive) prevalence continues to decline from 26% in 2017  to 7.8% in 2023 among all PWID. This decline is noted alongside the scale-up of direct-acting antiviral (DAA) treatment for HCV infection in this population.

The prevalence of HCV antibodies among people who began injecting within the last 3 years (an indication of new infections) has declined in recent years. However, the small (and declining) sample size has resulted in imprecise 95% confidence intervals (CIs) and there is not yet clear evidence of a decline.

In 2023, 27% of UAM Survey participants with chronic HCV infection reported that they were aware of their infection status, a decline in reported awareness from 51% in 2017. This decline in awareness is expected, as the proportion of persons aware of their infection decreases over time as those previously diagnosed and aware of their status are successfully treated and cured. Among those unaware of their infection in 2023, 39% reported receiving an HCV or bloodborne virus (BBV) diagnostic test during the Survey, similar to 38% in 2022. After accounting for participants who either had a test or were awaiting results, 40% were potentially unaware of their chronic infection in 2023. Of this group:

• 63% had injected drugs in the past 4 weeks, among whom 55% reported never being tested or having their last HCV test more than 2 years ago
• 77% had experienced homelessness
• 77% had been in prison

This highlights opportunities for testing and prompt diagnosis among this population.

The proportion of participants who self-reported ever being tested for HIV and HCV remains high. In 2023, 81% of PWID reported ever being tested for HIV, an increase from 77% in 2014, and 88% reported ever being tested for HCV, compared to 84% in 2014. Uptake of HCV and HIV testing in the current or previous year have increased over the last decade at 49% and 39% in 2023, respectively.

The prevalence of antibodies to hepatitis B virus (HBV) core antigen (anti-HBc) a marker of ever infection declined from 14% in 2014 to 7.7% in 2023, indicating fewer people have ever been infected with HBV. However, the prevalence of current HBV infection (HBV surface antigen (HBsAg)) positive among those with antibodies to HBc antigen has remained relatively stable, at 5.8% in 2023 compared to 4.2% in 2014. Among all UAM Survey participants in 2023, the proportion currently living with HBV was 0.44%.

Over the same period, self-reported HBV vaccination uptake has declined, with only 62% of participants in 2023 reporting receipt of at least one dose, compared to 73% in 2014. The decline was observed across all age groups and was particularly low among people aged 25 years and under and in people who started injecting drugs in the past 3 years (33% and 40% respectively in 2023). The decline suggests that PWID remain at risk of HBV infection and is of concern as vaccination is the cornerstone of HBV prevention and control.

Sharing and re-use of injecting equipment reached its highest levels in a decade in 2023. Direct needle and syringe sharing rose to 25%, up from 17% in 2014, while sharing of needles, syringes, and other paraphernalia increased to 44% from 38% in 2014.

Direct sharing remained consistently higher among female participants and notably increased in the aged 25 to 34 years group over the past decade.

In 2023, heroin remained the most injected drug among PWID, with 90% reporting its use in the past month. Crack cocaine was the second most common at 53%, down from a peak of 60% in 2018 but up from 40% in 2014. Other forms of cocaine injection rose to 33% in 2023, compared to 7.6% in 2014. In contrast, amphetamine injection continued to decline, from 24% in 2014 to 7.7% in 2023.

In 2023, nearly a quarter of those who had injected drugs in the past year reported a non-fatal overdose, up from 17% in 2014. Naloxone carriage among participants increased to 66% in 2023 from 54% in 2017. Among those who overdosed, 60% reported naloxone administration, up from 45% in 2014 and similar to 2022....

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2023 report (January 2024):

Main messages from the Unlinked Anonymous Monitoring (UAM) survey of people who inject drugs (PWID) in England, Wales, and Northern Ireland (EWNI) for the period 2013 to 2022 are listed below.

• Recruitment to the UAM survey in 2022 has recovered to pre-pandemic levels.
• From 2013 to 2022, the median age of UAM participants increased from 36 to 43 years, indicating an ageing group of PWID. Concurrently, the proportion of young injectors (under 25 years) decreased from 6% in 2013 to 1.5% in 2022. While this is reflective of the changing demographics of the wider injecting population, further work needs to be done to compare the UAM survey participants to other behavioural and risk factor data from the wider injecting population.
• HIV prevalence among UAM survey participants has remained low and stable over the past decade ranging from 0.8% to 1.5%. However, prevalence varies by nation and region of England.
• Overall, chronic hepatitis C (hepatitis C ribonucleic acid (RNA) and antibody positive) prevalence continues to decline from 49% in 2017 to 23% in 2022. This decline is noted alongside the scale-up of direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) in this population. However, decreases in chronic HCV prevalence are not similar across all nations and regions of England.
• There is no evidence to suggest a decline in chronic HCV prevalence among people who have recently started injecting drugs (up to 3 years prior to survey participation), which implies prevention of new and re-infections remains a challenge.
• Overall, the proportion of UAM survey participants with HCV antibodies (a marker of ever HCV infection) has increased significantly over the past decade (from 49% in 2013 to 54% in 2022) and is higher in the older cohort. This suggests continued exposure to HCV and a treatment effect, with increased uptake of HCV treatment resulting in those recruited to the UAM who are ever-infected living longer.
• Among UAM survey participants recruited in Northern Ireland, HIV and HCV antibody prevalence has increased during 2020 to 2022, to 3.8% and 48% respectively in 2022, which is reflective of an ongoing outbreak in the country.
• The proportion of participants testing positive for HCV antibodies who were aware of their infection, had seen a specialist nurse or doctor (hepatologist) for their HCV and reported having been offered and accepted treatment, increased from 30% in 2017 to 70% in 2022. Among those who were aware of their infection and had been treated, 14% reported having been infected with HCV more than once.
• Over the past decade, the percentage of participants reporting a recent (current or past year) HCV diagnostic test rose from 35% in 2013 to 48% in 2022. However, awareness of infection among those who remain infected remains low.
• The prevalence of antibodies to hepatitis B virus (HBV) core antigen (anti-HBc) (a marker of ever infection) declined significantly from 16% in 2013 to 7.8% in 2022, indicating fewer people have ever been infected with HBV. However, self-reported HBV vaccination uptake has declined over the past decade from 72% in 2013 to 61% in 2022, suggesting that PWID remain at risk of HBV infection. In 2022, HBV vaccine uptake was particularly low among those aged under 25 years (27%) and people who have recently started injecting drugs (39%).
• Significant increases in injecting risk behaviours were noted in 2022 when compared to a decade ago. Direct sharing of injecting equipment has increased from 16% in 2013 to 19% in 2022. Although 82% of all PWID in the UAM survey reported that they had accessed a needle exchange in 2022, this is a notable decline from the 90% reported pre COVID-19 pandemic.
• In 2022, nearly a quarter of those who had injected drugs in the past year reported experiencing a non-fatal overdose during that year, an increase from 16% in 2013. The increase in non-fatal overdose was noted particularly in people aged 25 and over and was similar among participants regardless of whether they had been in drug treatment previously.
• The percentage of participants carrying naloxone in the past year rose significantly, from 54% in 2017 to 68% in 2022. Moreover, 59% of those who reported overdosing in the previous year had naloxone administered, an increase from 46% in 2013.
• In 2022, heroin was the most commonly injected drug, at 92% among people who had injected in the preceding 4 weeks, followed by crack cocaine at 55%, a figure that is similar to the 2018 peak at 60% and an increase from 37% in 2013.
• The injection of other forms of cocaine significantly increased from 6.9% in 2013 to 29% in 2022 among people who had injected in the preceding 4 weeks. In Northern Ireland, reported recent injection of powdered cocaine surged from 5.9% in 2018 to a remarkable 84% in 2022.