2 Basic Principles

2.1 We discussed in Chapter 1 the potential threat posed by HIV and we have no hesitation in concluding that the spread of HIV is a greater danger to individual and public health than drug misuse. Accordingly, services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans. We emphasise however, that the goals of minimising HIV risk behaviour and minimising drug misuse are compatible and that reducing injecting drug misuse is one of several strategies which will bear fruit in tackling the spread of the virus.

2.2 At both strategic and individual levels there are a number of approaches which will help to contain the spread of the virus through drug misuse:

— preventing or reducing injecting drug misuse;
— preventing or reducing sharing of injecting equipment;
— preventing or reducing unprotected sexual intercourse (involving injecting drug misusers — but also applicable of course to the population as a whole);
— advising infected women to avoid pregnancy and providing help where needed to reduce the number of births to those women.

Each of these approaches will have different degrees of success with different individuals. We must recognise each of them as a valid goal. In particular, we must recognise that, for the time being, many drug misusers will not be sufficiently motivated to consider abstinence and that many drug injectors will not be sufficiently motivated to change their route of administration. We must therefore be prepared to work with those who continue to misuse drugs to help them reduce the risks involved in doing so, above all the risk of acquiring or spreading HIV. Reaching this less well motivated group will necessitate a more proactive approach and a readiness to work initially towards goals which fall short of abstinence. This is essential if we are to make any significant impact in controlling the spread of HIV. There are however no `master strokes' which will deliver the achievement of these goals. Patterns of drug misuse and sexual behaviour and the personal and situational factors which govern attitudes to risk taking, differ from one individual to another. A range of responses is needed to maximise the reduction in risk behaviour. The greatest benefit is more likely to accrue from the sum of multiple small gains deriving from an integrated and responsive total strategy than from any single approach.

2.3 In order to maximise the achievement of the goals in para 2.2 we need to get health education information to drug misusers, persuade them to change their behaviour, and provide them with the necessary help and support to achieve the required changes. Doing so will be much more difficult than it is proving with the homosexual community. Not only is the homosexual community stronger in its resources and networks of personal support, but the more enlightened social and legal attitudes to homosexuality which have developed over the last two or three decades have undoubtedly made it easier to reach and educate this community. The same cannot be said of attitudes to drug misuse, which remains the subject of great social stigma. As long as drug misusers see that drug misuse per se makes it more difficult to obtain primary health care, and attracts stiffer penalties from the courts, victimisation in prison and penalisation in the policies of public and commercial institutions, many will not come forward for help. The stigma attached to HIV and its association with drug misuse has exacerbated this problem. We conclude that a change in professional and public attitudes to drug misuse is necessary as attitudes and policies which lead to drug misusers remaining hidden will impair the effectiveness of measures to combat the spread of HIV. Ministers and other public figures can play a vital role by giving a strong lead in changing attitudes.

2.4 Turning to immediate practical measures we believe that the most effective way of changing the behaviour of many drug users involves first bringing them into personal contact with a helping agency. This view is supported by substantial evidence that agency contact is associated with more hygienic injecting practices amongst those who continue to inject. Chapter 3 describes the existing helping services and considers their ability to cope with present demand. Chapters 4, 5 and 6 go on to examine ways of bringing more users into contact with helping agencies and ways of changing their behaviour once contact has been established. Inevitably, whatever efforts are made, some drug misusers will remain out of contact with services. Chapter 5 includes discussion of measures that can be taken to influence them away from HIV risk behaviour.

2.5 This urgent report focuses very largely on reaching, and changing the behaviour of, those people who are already misusing drugs. It is right that it should do so since this group, particularly injectors (and their sexual partners), are at the most immediate risk of acquiring and spreading HIV. However, we emphasise that prevention of drug misuse is now more important than ever before and in the longer run the success or failure of efforts to prevent young people from embarking on a career of drug misuse will have a major effect on our ability to contain the spread of HIV.