PWID - People who inject drugs

Overview

Many risk factors for STIs overlap with risk factors for injecting drugs
Some people who inject drugs (PWID) report high levels of unprotected sex
Recreational drug use among men who have sex with men (MSM) has been associated with HIV, syphilis, lymphogranuloma venereum (LGV) and hepatitis C infection
Testing for STIs should be the same in PWID as those who do not inject.

Testing advice

Infection	Consideration
Chlamydia	Consider Self-collection of samples for NAAT testing Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. self-collection of samples for testing.
Gonorrhoea	Consider Self-collection of samples for NAAT testing Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. self-collection of samples for testing. If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment. Cultures are the preferred test for samples from non-genital sites.
Syphilis	If clinical suspicion of syphilis, refer to the syphilis guideline.
HIV	HIV status should be confirmed in anyone reporting a history of injecting drugs. Annual testing in those with an ongoing history of injecting drugs is recommended. Repeat test if patient exposed within previous 12 weeks (window period).
Hepatitis A	Vaccinate if not immune.
Hepatitis B	PWID are at high risk of hepatitis B acquisition, if not vaccinated and have not been previously exposed to the virus. Vaccinate if not immune. Serological testing after completing vaccination is recommended.
Hepatitis C	Hepatitis C status should be confirmed in all people reporting a history of injecting drugs. Annual testing in those with an ongoing history of injecting drugs is recommended. Hepatitis C is not considered an STI except between HIV infected men having unprotected anal sex. If antibody positive, test for hepatitis C NAAT to determine if patient has chronic hepatitis C.
NAAT – Nucleic Acid Amplification Test

Specimen collection

Clinician collected | Self-collection

Clinical indicators for testing

Testing for HIV, hepatitis C (and hepatitis B if non immune) should be offered to all PWID reporting use of shared injecting equipment (needles/syringes/spoons etc). This should be arranged after the window period for the relevant infection.
It is not recommended to routinely test for herpes and genital warts with serology. Consider testing for herpes and genital warts only if there are clinical signs and symptoms.

Follow up

If test results are positive, refer to STI management section for advice on:

Even if all test results are negative, use the opportunity to:

Educate about condom use and harm minimisation including safer injecting and needle syringe programs
Vaccinate for hepatitis A and B, if susceptible
Refer to drug and alcohol services, if required
Discuss and activate reminders for regular screening tests according to risk, especially if their behaviours indicate the need for more frequent testing.

Auditable outcomes

100% of people reporting a history of ever injecting drugs have a documented hepatitis C test
100% of men who have sex with men (MSM) reporting regular use of recreational drugs are offered 3-6 month STI testing.

References

Centres for Disease Control and Prevention. Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services MMWR 2012 61(5) 1-48 http://www.cdc.gov/mmwr/pdf/rr/rr6105.pdf

Last Updated: Wednesday, 16 March 2016