Overview

1 This is our first report on the implications of AIDS and HIV for services for drug misusers. It concentrates on measures which can be taken to tackle the spread of HIV through injecting drug misuse. Except in some parts of Scotland, the prevalence of HIV amongst injecting drug misusers appears to be low in the UK. But the speed with which the virus can spread in this way has been dramatically illustrated in Edinburgh and elsewhere. The opportunity to take preventive action must be seized now if the tragedy of Edinburgh is not to be repeated throughout the UK.

2 The report's first conclusion is that HIV is a greater threat to public and individual health than drug misuse. The first goal of work with drug misusers must therefore be to prevent them from acquiring or transmitting the virus. In some cases this will be achieved through abstinence. In others, abstinence will not be achievable for the time being and efforts will have to focus on risk-reduction. Abstinence remains the ultimate goal but efforts to bring it about in individual cases must not jeopardize any reduction in HIV risk behaviour which has already been achieved.

3 The most effective way of educating drug misusers about HIV, and changing their behaviour so as to minimise the risks, involves first bringing them into contact with a helping agency. At present, only a small minority of drug misusers are in touch with such services. The report discusses how larger numbers can be brought into contact with services. It concludes that community-based services for drug misusers provide the best opportunity and that considerable development and expansion is needed to ensure that accessible and attractive services are available throughout the country. It makes practical suggestions about ways in which these, and other services should attract more drug misusers. The role of general practitioners and other generic professions is also emphasised and suggestions are made to promote greater GP involvement with drug misusers. The need for specialist psychiatric services to back up these front-line services, providing help and support and accepting referrals in difficult cases, is highlighted.
Without this support, the ability of front-line services to make contact with more drug misusers and help them move away from HIV risk behaviour is seriously impaired.

4 Having established contact with drug misusers the next step is to educate them about HIV and how to avoid acquiring or transmitting it. The report recommends that all services for drug misusers should give practical and explicit advice on risk-reduction. This advice must recognise that some will carry on misusing drugs, by injection in some cases. It must also cover sexual transmission. If education is to succeed it is essential that drug misusers who cannot be persuaded to stop injecting should have access to sterile needles and syringes. The report considers this issue in some depth and concludes that a combination of syringe exchange schemes and over-the-counter sales from community pharmacies offers the best solution.

5 The role of prescribing in attracting drug misusers to services and helping them move away from HIV risk behaviour is discussed. The report concludes that prescribing is one of a number of tools which can help achieve this in some cases but stresses that it is not a panacea. It emphasises the need for treatment to be tailored to the individual drug misuser if it is to be effective in inducing a change away from HIV risk behaviour. This means that a full range of treatment options must be available in each district so that those providing services to drug misusers can select the most appropriate treatment package in each case.

6 The report considers the use of HIV antibody testing of drug misusers. The policy of testing individual clients only with informed consent is endorsed and the report urges that very full pre- and post-test counselling should be provided. The need for intensive efforts to achieve behaviour change with seropositive drug misusers is emphasised.

7 The measures recommended should enable services to make contact with a much larger proportion of drug misusers and work with them to change their behaviour. However, many drug misusers will remain `hidden'; for them there will be a continued need for national and local education and publicity about HIV and how to avoid it.

8 The report looks at the special problems posed by the link between HIV and drug misuse in prisons and recommends urgent action to improve prisoners' education about HIV and AIDS. It stresses the importance of identifying drug misusers when they enter prison and seizing the opportunity presented to educate them away from HIV risk practices and, where possible, towards sustained behaviour change.

9 Although the report covers the UK as a whole, special mention is made of the situation in Scotland which is a cause of grave concern. Prevalence of HIV amongst injecting drug users is high, particularly in the East where, in those tested, seroprevalence rates of around 50 per cent have been reported. Yet services north of the border are ill-equipped to play an effective role in combating the spread of the virus. The lack of psychiatric input to drug services and the lack of treatment options are worrying. So too is the continued shortage of injecting equipment in places and the lack of access to already overstretched counselling and advice services. Additional recommendations are made for immediate action in Scotland.

10 The measures recommended have not been costed in detail but it is clear that a substantial increase in funding for services for drug misusers will be needed. Investing now in these measures to prevent the spread of HIV will bring much greater future savings and benefits in both human and financial terms.