Conclusions and Recommendations

Key Issues

1. In all parts of the country, services must have the capacity to respond to increased numbers of ill drug misusers. (1.6)
2. Service providers must recognise the different needs not only of those people who are currently injecting drugs, but also those who became infected through past drug misuse, and those who currently misuse drugs by whatever route who may have acquired HIV-infection through sexual behaviour. (1.7 and 2.7)
3. All services currently caring for, or who may be called upon to care for people with AIDS will soon have drug misusing clients. (1.8)
4. The service offered by specialist drug services today and in the future is radically altered by the advent of HIV-disease. (1.9 and 5.3)
5. The attraction of seropositive drug misusers to services at an early stage is as relevant for individual health as it is important for the prevention of the onward spread of infection. (1.11 and 3.20)
6. For the most part, care for drug misusers with HIV-disease will and should be provided in the community. (1.12 and 4.1)
7. Efforts must be made to provide more reliable epidemiological data on drug misuse, and on HIV-infection among drug misusers. (1.15 and 2.27)
8. Only by planning services in advance will resources be most effectively and rationally used. (1.16 and 7.5)
9. Health and local authorities, the prison and probation services, and non-statutory agencies should all receive sufficient funds to enable them to plan and develop services for drug misusers with HIV-disease. (1.17)

Needs of drug misusers with HIV-disease

10. Whether or not an antibody test is carried out, and regardless of the test result, it is vital that those providing pre and post-test counselling give information and advice on the risks of transmission, and help clients to change behaviour which may put themselves or others at risk. (3.6)
11. Services should formulate policies which recognise the importance of confidentiality and which provide detailed and specific guidance for their staff. The following principles should inform those policies:
i. Information about serostatus should not be passed on without an individual's consent.
ii. The only possible exception is where a specific, named individual is at risk of infection but the infected person cannot be persuaded, through counselling and discussion, to allow this disclosure. Under these circumstances, the person at risk may be informed. This course of action has already been suggested for doctors by the General Medical Council.
iii. Before a confidence is shared — that is, passed on with an individual's consent — clients should be fully aware of the possible consequences. While they should realise that some services may be available as a priority to people with HIV-disease, they should also be informed of the likely number of people who could learn of their HIV-status should they reveal this to gain access to those services.
iv. Services should establish which staff need to know a client's serostatus, and should ensure that this information is strictly confined to those people only. (3.16)
12. All drug misusers with HIV-disease should be examined at least every 6 months by a physician who is experienced in treating HIV-disease. (3.2)
13. All counsellors and staff offering advice to those with HIV-disease must be aware of the range of physical and psychological responses to drug misuse. (3.26)
14. Women-only sessions, and the availability of women doctors and counsellors/advisers can help attract women to services. Where services see significant numbers of women with young children, creches or childcare facilities should be provided, at least at certain times. (3.32)
15. Men and women with HIV-disease, and their partners, require good advice on family planning issues. We are concerned by the reduction in specialist family planning services which has taken place over recent years, and urge Government to reverse this trend. (3.33)
16. Counselling must be available to seropositive women who are pregnant which addresses the implications of HIV-disease for themselves and their children, taking account of the most up-to-date knowledge of the effects of pregnancy upon women with HIV-disease and the likelihood of transmission to the child (3.35)

Care in the Community

17. Support is needed for the "informal" carers of drug misusers with HIV-disease. (4.2)
18. Local authorities, in conjunction with housing associations, non-statutory agencies and health authorities, should now be looking for imaginative solutions in the provision of accommodation for drug misusers with HIV-disease, which might build upon best practice — and learn from worst practice — in providing community care to other groups. Advice should be taken from specialist drug services on the particular needs of those who continue to misuse drugs. Plans should take account of the needs of couples and families as well as single people. (4.7)
19. Social services and housing departments should treat as urgent requests by symptomatic people with HIV-disease when assessing priorities for the provision of equipment and adaptations to people's homes. (4.9)
20. Social services departments, health authorities and non-statutory agencies should collectively consider the provision of day care and respite care for current and ex-drug misusers with HIV-disease. Special attention should be paid to the needs of drug misusers caring for children. (4.12)
21. A working party should be set up to consider urgently how GP involvement with drug misusers can be increased; and in particular to consider the desirability and practicability of offering financial or other incentives to GPs in respect of the treatment of drug misuse following approved training. (4.16)
22. All GPs should accept their responsibility for the ongoing health care of drug misusers with HIV-disease. Where possible, shared care systems should be developed so that GPs and physicians with experience of treating HIV-disease combine to monitor the health of these patients. (4.17)
23. Vigorous efforts should be made to increase the number of community nurses in training, and flexible working practices should be adopted to retain and attract older nurses and those with family commitments. (4.22)
24. All dentists should be prepared to treat people with HIV-infection; simple protective measures are enough to protect the dentist from infection, and instruments used should always be sterilised regardless of whether a patient is known to have an infectious disease. (4.23)
25. In areas with a high prevalence of drug misuse, specialist social worker posts should be established in the field of drug misuse. In the longer term, efforts should be made to disseminate knowledge about drug misuse and HIV-disease throughout Social Services Departments. Secondments of social workers to specialist drug agencies, including non-statutory organisations, can be of great value both for the provision of services and for training purposes. (4.25)
26. Funding agencies should recognise the ancillary costs incurred by support groups which may include travel and telephone costs by participants; overheads for premises; and possible payment to regular "facilitators". Where possible, both statutory and non-statutory agencies should make suitable premises available to such groups on a secure, regular basis. (4.32)

Specialist drug services

27. In general, we do not support the concept of priority treatment for seropositive drug misusers. For prevention purposes, it is essential that services and resources are actively directed towards those drug misusers who are presumed to be seronegative as well as those known to be seropositive. With clients who appear to be exceptionally chaotic, who are likely to be at high risk of acquiring or transmitting HIV disease, special efforts should be made to provide treatment as soon as possible. This should be the case whether their antibody status is known to be positive or not. (5.6)

28. All staff working in drug services should have sufficient knowledge and awareness to be alert to early symptoms of HIV-disease. (5.7)

29. Specialist drug services should aim to provide medical examination facilities and on-site access to a medical practitioner with experience of treating HIV-disease. Those services which are unable to fulfil these aims should establish rapid referral routes to medical practitioners with expertise in HIV-disease. (5.9)

30. As an absolute minimum, all drug services should provide advice and information on HIV-disease regarding both the transmission of the virus and general health care once infected. Those services unable to provide welfare advice, support and personal counselling should arrange for other agencies to meet these needs. (5.11)

31. Staff in specialist drug misuse services should see it as part of their role to advise workers in other disciplines on the care and management of problems associated with drug misuse. (5.12)

32. Drug services should have the capacity to offer home visits, and to provide care for clients in their own homes, and in hospital, where necessary. (5.13)

33. For the purposes of effective hygiene and preventive strategies it should be assumed that all clients attending residential drug services may be seropositive. (5.17)

34. As all residential rehabilitation services are likely to accommodate some clients with HIV-disease, staff should re-examine the service offered to eliminate unnecessary stress and to promote a lifestyle conducive to good health. (5.20)

35. An important task now facing residential drug services will be to prepare residents with HIV-disease for their return to the community, and to ensure that their needs will be met by appropriate services once they leave the residential facility. (5.22)

36. Two or more residential facilities for drug misusers with HIV-disease should be established with the help of central pump-priming funding. One should be for clients who are drug free and the other for people who continue to use prescribed drugs. These facilities should not be dominated by a single regime but should have an eclectic approach. (5.23)

37. Access to prescribing in the treatment of drug dependence should be equally available — in appropriate circumstances — to both presumed seronegative and seropositive drug misusers in every locality. (5.26)

38. We see no reason to depart from the principle that prescribing should never be undertaken without an identified goal. If a drug misuser is known to be seropositive, a range of goals should be considered, including the following:

a. to attract seropositive drug misusers into regular contact with services;
b. to promote behaviour change away from practices which carry a risk of transmitting HIV-infection;
c. to promote behaviour change in such a way as to maximise personal health and stability;
d. to encourage compliance with medical treatment, including regular check-ups, and the regular administration of Zidovudine (AZT).

The first of these goals is not an end in itself, but rather the platform on which, the others are founded. (5.27)

39. Additional ear-marked and continued resources are required if drug services are to implement the recommendations both in our Part 1 Report relating to preventing the spread of HIV-infection, and those which have been outlined here. (5.36)

Hospital Services

40. Hospital managers should ensure that a policy is in place for treating patients who are dependent on drugs and that medical and nursing staff understand, or have access to advice on the implications of drug dependence for the administration of pain relieving drugs. (6.2)

41. Staff in GUM Clinics and HIV-Counselling Clinics should be trained in working with drug misusers; such services should develop rapid two-way routes of referral with specialist drug services; and a specialist drugs worker should spend some time working on-site in areas where significant numbers of clients are drug misusers. (6.3)

42. Out-patient services will need access to expert advice on both drug dependence and psychiatric illness, and should be able to cope with manifestations of either or both in their patients. One of the implications of this is that considerable flexibility in appointment systems will be needed. (6.5)

43. Many staff will have to adopt new attitudes and approaches to manage current drug misusers. (6.6)

44. The advent of HIV-disease demands much greater integration of care between medical and drug services than has happened in the past. Hospital staff should take steps to ensure that expertise on the management of drug misusers is available on the ward. The extent to which integration takes place will depend on local services and the prevalence of HIV-disease among drug misusers in the area. (6.12)

45. Whenever possible, ward staff should be trained and experienced in working with drug misusers. Where this is not possible, specialist drug services should offer advice. (6.14)

46. We acknowledge the strengths of the arguments in favour of segregation of drug misusers from other patients, but we support the concept of integrated care, and believe that segregation should not be a starting point for services. (6.18)

47. Before drug misusers with HIV-disease leave hospital, their needs should be assessed and suitable arrangements made with community-based services. (6.19)

48.    i. In areas of high prevalence of drug misuse, maternity staff should be trained in managing pregnancies in drug misusers. Specialist advice should be available to those areas without this expertise. In all cases there should be good two-way referral systems between obstetric and specialist drug services.

ii. Maternity services should be prepared to operate their appointment system flexibly when seropositive drug misusers present late in their pregnancy, and to see these women quickly.
iii. Health care plans should be in place to ensure that when a seropositive woman and her baby leave hospital, they have access to adequate help from medical and social services in the community. (6.25)

Planning, co-ordination and liaison

49. Health authorities should ensure that the information available to them on the incidence of HIV-infection and illness is made widely available to other service providers through extensive dissemination of the reports they are required to compile annually under the terms of the AIDS (Control) Act 1987. Additionally, District Drug Advisory Committees should annually estimate the scale and nature of drug misuse locally to inform strategies for the prevention of HIV-infection among drug misusers, and the care of those who become infected. (7.4)

50. Statutory and non-statutory services should, based upon the best assessment of the scale of the local problem, address the current and future needs of drug misusers with HIV-disease and identify what future service provision should meet those needs and how. Planning should take place either through existing machinery — ensuring adequate representation of non-statutory services, family practitioner services, and drug specialist expertise — or through specially created fora. AIDS Advisory Committees may be suitable for this purpose, provided that they include members with expertise in the field of drug misuse. (7.5)

51. A nominated individual in a health authority should be held accountable to the District General Manager for ensuring that services are in place to meet medical needs, including help and treatment for drug problems. A nominated individual in a Social Services Department should be held accountable to the Director of Social Services for ensuring that services are in place to meet community care needs. These two service coordinators should also be responsible for ensuring that information on services is available in a readily accessible form to all those who may come into contact with drug misusers. (7.6)

52. When a drug misuser is first diagnosed as seropositive, or first presents to a service, whatever service is involved should take responsibility for ensuring — where appropriate and with the agreement of the client — that the client gains access to specialist counselling; primary health care; specialist drug services; and specialist health monitoring for HIV-disease at regular intervals. (7.8)

53. A specialist drug service, or any other service seeing significant numbers of drug misusers with HIV-disease, may well find it worthwhile to employ a "welfare rights" worker on a full-time or sessional basis. (7.9)

54. The benefits to individual and public health require contact to be maintained with seropositive drug misusers as far as possible, and it is good practice to follow up those who default from services, unless they specifically request otherwise. (7.13)

The Criminal Justice System

55. The police should refer drug misusers with whom they come into contact to local drug services, whether or not they have been charged with a criminal offence. (8.2)

56. All police surgeons should make a conscious effort to look for indications of drug misuse, should be prepared to consider the full range of treatment options — including the prescribing of substitute drugs — as set out in the guidelines sent to all doctors in 1984, and must be fully briefed on how to address issues relating to HIV-disease. (8.4)

57. In encouraging the greater use of existing non-custodial options, and in the development of any new options,it should be recognised that there is a particular value in such disposals for drug misusing offenders. (8.5)

58. Prison medical officers should consider whether a range of treatment options — including the prescription of substitute drugs such as oral methadone — could be utilised to reduce harmful behaviour within the prison setting. (8.18)

59. The use of VIR for known seropositive inmates should be phased out gradually in conjunction with suitable education and reassurance to both prison staff and inmates about the risks of HIV-infection and how to avoid them. (8.30)

60. The Prison Medical Officer should ensure that an inmate with HIV-disease is referred to both primary and specialist medical care on release. The probation service together with any outside agency which has been involved with the inmate's support in custody, should ensure his referral to those community services which will cater for his accommodation and other needs. (8.38)

Training and Support

61. District Health Authorities, local authority Social Services Departments, and the Police, Probation and Prison Services should earmark funding for training on drug misuse and HIV-disease. Non-statutory staff should be involved in these training courses. In the longer term, training should form an integral part of the costing of services, including non-statutory services. (9.2)

62. It is essential that staff are trained to provide pre and post-test counselling and that they receive training to assist them in reducing the likelihood of an individual resorting to high-risk behaviour. (9.12)

63. Staff of all grades in all likely settings must be adequately trained for working with seropositive drug misusers; staffing levels must be adequate; and staff must have access to emotional support, be it through mutual support groups or external agencies, including line management where appropriate. (9.21)