In recent years, injecting NPS has become a widespread phenomenon. As injectable drug use is a major risk factor in the transmission of HIV and hepatitis, changes in this population are likely to influence the prevalence of these blood borne diseases. Our survey was conducted as a part of a low threshold HCV, HIV, syphilis screening intervention which allowed to reach the population of people who inject drugs (PWID) otherwise invisible for the healthcare system, and investigate their injecting risk behaviours. The analysis was based on data collected in Hungary at needle and syringe programmes (NSPs) and outreach programmes, between July and November 2015. The questionnaires were completed within the framework of a rapid HIV and HCV screening and counselling intervention. The intervention was provided on site in four cities in Hungary and targeted two risk populations: PWID and sexworkers.

A large proportion of participants of the quick test intervention have never been tested for HIV (44.2%) or HCV (37%). The prevalence of HIV and syphilis was low among the participants, while the prevalence of HCV was alarmingly high: 47.7% (N = 94) was tested positive in total. There were significant differences between the cities (chi-square = 27.798; p = 0.000): Budapest had the highest prevalence, with 64.5% of HCV-positive participants. NPS injecting seems to be a risk factor in itself; HCV prevalence was significantly higher among NPS injectors compared to PWIDs who injected traditional substances (66.7 and 37.5% respectively; chi square = 8.750; p = 0.003). The highest HCV prevalence was observed for NPS injectors from Budapest (79.7%). We found that the engagement in more types of equipment sharing increased the chance of becoming infected (chi-square = 12.844; p = 0.005); those who were engaged in 1-2 injecting risk behaviours had HCV prevalence rates below the average, while participants practicing 3 or more types of equipment sharing had higher HCV prevalence rates. According to the data, there is a relationship between the number of risk behaviours and the number of people one shares their equipment with (chi-square = 16.1; p = 0.003); an increased number of reported risk behaviours translated into an increased number of people sharing their injecting equipment.

According to our findings, Budapest has an intense risk environment; PWID living in Budapest are more likely to become infected with HCV. The most common equipment sharing behaviours were related with group injections and syringe shortage: 46% of participants shared their water, 45% their needle, and 45% their dissolved substance with a friend. A total of 34% shared equipment with 3 or more persons. The social nature of injecting risks has been known for decades in the literature; social determinants (such as group injecting and the practice of injecting together) are indicated by the most prevalent equipment sharing behaviours, all of which are associated with drug preparation. The limited access to needle exchange programmes with the recent rise in HCV prevalence in the injecting drug user (IDU) population in Hungary combined with equipment sharing, could lead to a serious public health problem. Due to the presence of HIV in the population and the common practice of equipment sharing and needle reuse, it seems essential to scale up harm reduction interventions such as NEPs, as well as to provide HCV testing and counselling along with proper access to treatment for the population of PWID.

In recent years, the use of injectable NPS has become a widespread phenomenon. The aim of this paper was to investigate the NPS use-related risk behaviours in the context of infectious diseases. Our survey was conducted as a part of a low threshold HCV, HIV, syphilis screening intervention at different needle exchange programs (NEP) which allowed us to reach people who inject drugs (PWID) otherwise invisible for the healthcare system, and investigate their injecting and sexual risk behaviours.

Injectable drug use is a major risk factor in the transmission of HIV and hepatitis C virus (HCV) (1, 2). There is substantial evidence to support the effectiveness of harm reduction interventions such as NEPs in reducing HIV and HCV transmission among PWID (2-7), although the available scientific evidence suggests that in the case of HCV transmission NEP should be accompanied with other interventions for PWID, such as opiate substitution therapy (3, 7) and testing for HIV and HCV in this population (8). The importance of complex interventions, such as the integration of NEPs, drug treatment, anti-viral treatment and other harm reduction interventions as effective strategies in combating the HIV and HCV epidemic among PWID should not be overemphasised (5, 6, 9-11). The World Health Organization (WHO) underlines the importance of NEPs (12), among other sources of sterile needles and syringes, not only in terms of their role in preventing drug related infectious diseases, but also as important contact with and potential entry points to health services. The European Centre for Disease Prevention and Control (ECDC) and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) joint guidance on the prevention and control of infectious diseases among PWID (8) also underlines the importance of NEPs as well as HIV and HCV testing by listing these services among the seven key interventions to achieve effective prevention of blood borne diseases. Therefore, we can conclude that NEPs along with HIV and HCV testing are key elements of effective HIV and HCV prevention strategies (13).

PWID witnessed a significant change in the past years in Hungary (14-17). Before the emergence of new psychoactive substances (NPS) in 2010, heroin and amphetamine were the two substances used by the overwhelming majority of PWID. Since then NPSs have become the dominant substances in the injectable drug market in Hungary (15-21). When NPSs became available in the Hungarian drug market, the percentage of heroin users was first to drop, followed by a gradual replacement of amphetamines by NPSs. In 2009, the proportion of those who injected amphetamine or heroin was 95% among the PWID in Hungary, while only 13% of them injected those two substances in 2015 (22-27). Unfortunately, drug-related public expenditure has decreased significantly while the NPSs became the most commonly injected substance. The decreased funding had serious consequences for NEPs in Hungary (as the costs of injecting equipment necessary to provide the service are high). As a result, the number of syringes one client can exchange, and the available injecting paraphernalia were limited. In addition to limiting the available injecting equipment, the opening hours and, in many cases, the personnel were reduced as well. As NPSs are injected more frequently (10-15 times a day) than traditional substances, this led to a serious decrease in national coverage of NEPs in Hungary (18). During this period, there have been a significant increase in the health risks associated with injections. The Hungarian National Center for Epidemiology has been studying the prevalence of HIV and HCV among PIWD since 2006. The results of their seroprevalence study showed that the prevalence of HCV doubled between 2011 and 2014. In 2014, the prevalence of HCV was 48.8% in the country (up from 24.1% in 2011), and 60.8% in the capital (up from 34.2% in 2011) (23-27).

The aim of this paper was to investigate the NPS use-related risk behaviours in the context of infectious diseases.

The following analysis was based on the data collected in Hungary as a part of NSPs and outreach programmes between July and November of 2015. The questionnaires were completed within the framework of a rapid HIV and HCV screening and counselling intervention. The intervention was provided on site in four cities in Hungary (Budapest: N = 96, 47.8%, Miskolc: N = 49, 24.4%, Pècs: N = 26, 12.9%, Szeged: N = 30, 14.9%), and covered 2 risk populations: PWID and sexworkers. The personnel providing the screening and counselling assisted every participant during completion of the questionnaire. The primary aim of the questionnaire was to assist the counselling with systematic questions on risk behaviours. The injecting risks were assessed with the injecting risk questionnaire from the EMCDDA’s Evaluation Instruments Bank (http://www.emcdda.europa.eu/html.cfm/index4386EN.html). While the intervention itself was not designed as a scientific study; data collection was parallel to the privileged access interviewer method (28).

Participation was voluntary, although the first 200 screenings were motivated by incentives (a package containing harm reduction equipment, e.g. syringes, alcohol pads, etc.) to reach those who were a part of the risk population but otherwise would not participate in HIV and HCV screening. The sample size was N = 201. The proportion of male participants was 67.7% (males: 136, females: 65); there were no significant differences between the participating cities regarding the proportion of sexes. The mean age of the participants was 32 years, with the youngest participant being 15 years old, and the oldest participant being 50 years old. The majority of respondents were 34 years old or younger (N = 120, 59.7%). Most of the participants had unfavourable labour market position. The majority had low educational attainment (N = 103, 50.3% did not complete secondary education), and did not have any income from employment in the previous 30 days (N = 119, 59.2%).