INTRODUCTION

We are in the midst of a major transformation in the way we think about and respond to drug problems. Issues that had been pushed to the background, concerned very broadly with our options for the social control of drug problems, are suddenly part of a new and vibrant debate, and underpin whole new ways of working with drug problems. Ideas about risk reduction for HIV prevention, and of minimizing broader health risks for drug users and promoting healthy behaviour, have spilled over into a larger debate about reducing drug-related harm, and in particular a debate about changes in the legal controls over drug use and possession. Many of the issues could not have been discussed even two or three years ago. This debate examines some of the most difficult philosophical, political and practical issues concerning drug use.

Minimizing harm with respect to health can be difficult when there are strong legal controls and penalties for drug use. In the case of the use of some drugs, major personal hazards may come from the legal and penal system itself, rather than from health hazards of the drugs or the way in which they are used. However, it is my view that the issue is not about whether we want to have, or want to abolish, controls over drug use. The evidence is that all societies control drug use in one way or another, ranging from informal controls based in the social etiquette of daily drug use, through to the full panoply of legal and penal deterrence. The issue is rather a matter of choosing what sort of social controls we want.

Social controls both constrain and enable behaviour, both limit and create what is possible, and operate in social interaction and discourse, as well as in institutional sites and material circumstances. For example, at the level of everyday drug use, the social etiquette surrounding drug use (whether of alcohol, tobacco or other drugs) is a system of social control for obtaining drugs, learning to use them, seeking some effects and avoiding others, and for enjoying and discussing drugs in culturally appropriate ways. Consider, for example, the complex social interactions and meanings involved in the nomial drinlcing of alcohol. These include location in space and time — the particular places where drink is consumed and times in the day, week and year when drinking is appropriate. They involve a folk or ethnosdence and history of the drug, for example how to buy, keep, prepare and drink various drinks. And they include how to drink properly — the type of container to be used, the speed of drinking, with whom drink is taken, reciprocal interactions, and accompanying activities. Drug controls can be sensitive to cultural practices and seek to modify them, or can meet them head on and seek to outlaw them.

With regard to the prevention of HIV infection, we have to cons' ider the sort of controls we wish to promote in order to minimize the spread of this disease. HIV disease is a behavioural disease, in that it is transmitted through social, and therefore malleable, behaviours. The social interactions that make possible the transmission of HIV are bound up in mundane practices, which are embedded in social, cultural and material structures. From the point of view of the social scientist, what some people see as 'bad' (or risky) health behaviour, is not irrational or pathological. There are usually good sodal, cultural and economic reasons for risky and other behaviours. Furthermore, in order to influence the transmission of HIV, these everyday practices and health behaviours must change.

A wide variety of innovative practices have been introduced to help prevent the spread of HIV infection among people who inject drugs. These include increasing the supply of syringes through exchange schemes and other outlets, and facilitating access. to condoms; introducing bleach and other means for syringe decontamination; attempting to make services more attractive; improving access to treatment; adopting innovative educative packages and ways of bringing health messages to people; using methadone to help people stop injecting; and reaching out to contact drug users or to encourage conununity changes. They all seek to introduce changes in the ways people inject drugs. In the United ICingdom, as elsewhere, these new approaches are of symbolic as well as practical significance.

ACHIEVEMENTS

Much has been achieved in a short space of time. Among long-standing regular drug injectors the message has got through that sharing syringes is an effective means of transmitting HIV. But knowledge of risks does not automatically lead to changes in health behaviour. This is well known in numerous other fields such as tobacco smoking, heart disease, and obesity: knowledge of the health rislcs is insufficient to cause major changes in health behaviour. In the case of drug injectors, knowledge of the risks does not necessarily lead people to see themselves as personally at risk. Indeed, the personal risk of infection is often assessed as low.

Studies in many cities including San Francisco, Sydney, New York, Bangkok, Edinburgh and Milan show that drug injectors are reporting changes in their risk behaviour. Time trend data from studies by the Monitoring Research Group at The Centre for Research on Drugs and Health Behaviour over the last three years show a steady and consistent decline in self-reported syringe sharing in the UK, both among people who attend syringe exchanges and among injectors recruited in other settings. Tnangulation of data from various locations, using different methods of questioning and different lcinds of interviewers, lends veracity to such claims.

In our qualitative fieldwork, we have found that many drug injectors in the south of Eng,land are no longer tallcing about syringe sharing as normal behaviour. There is considerable evidence that the social etiquette of drug use has changed, much as the etiquette of cigarette smoking has. Injectors tend not to offer syringes to share, just as others tend not to offer cigarettes to others. People we have interviewed have adopted a wide range of protective strategies against the risk of HIV infection and transmission. Not all of these measures make sense in virological terms — but are indicative of attempts to change. This is not to say that syringe sharing has stopped, it certainly has not, but sharing events were usually described as exceptional and occurring for a variety of untoward and unplanned situational or personal reasons (Burt and Stimson, 1990).

The picture is not the same with regard to sexual behaviour. There are some self-reported changes here — but not on the scale of those reported regarding syringe sharing. What of the hard evidence about this epidemic? Are the reported behavioural changes reflected in a changing patter of the spread of this disease? In the case of men who have sex with men we now know that the self-reported behavioural changes that occurred in the mid-1980s have been paralleled by a reduction in sero-incidence of HIV. In the case of injecting drug users it is early to come to definitive conclusions, but there is some evidence that the epidemic is not taking off in most of England in the way it has taken off in many cities throughout the world.

Our studies show that about 50 per cent of injecting drug users have been tested for HIV antibodies. Among those recruited to our studies in London and the south-east last year and tested for HIV using the saliva test, about 4 per cent were positive PoIan et al., 1990). The figure is on a par with data ftom the Public Health Laboratory Service collaborative laboratory study which showed a prevalence of 5.7 per cent in London and 1.5 per cent in the rest of England (Public Health Laboratory Service Working Group, 1989). Earlier studies in England showed rates within the same range. The high prevalence of HIV infection recorded in Edinburgh (of around 50 per cent) and the east of Scotland remains exceptional. There is supporting evidence from Public Health Laboratory Service studies that hepatitis B is declining among injectors — and because hepatitis B is transmitted in a similar way to HIV this is a good proxy indicator that behaviour changes have indeed occurred (Polakoff, 1988).

The known rates of HIV infection are low in most of the UK, apart from the east coast of Scotland. It is too soon to make the link between preventive strategies and the relatively low rates. It may be that mdch of the UK is still at a pre-take-off stage in the epidemic curve — that there are still insufficient people with the virus for the epidemic to gain that frightening dynamic spread that occurred in Edinburgh, New York, in Italian cities and more recently in Bangkok. On the other hand, it may be that there have been effective changes in the behaviour of many people who inject drugs.

Evidence that the epidemic may be levelling also comes from New York, Amsterdam and San Francisco, although in these cities the prevalence rate is much higher than in England. In New York the prevalence rate among injectors has levelled off at around 60 per cent, and in Amsterdam at around 30 per cent. In San Francisco, the prevalence rate has levelled off at around 12 to 15 per cent and the annual seroconversion rate has dropped to around 1 per cent (Moss, 1990). Both cities have had major AIDS risk reduction progranunes.

OBSTACLES

There is reason for some optimism that it might be possible to intervene with beneficial effects. There is no reason for complacency. With HIV there is a Catch 22 situation — if things look good, governments may begin to thinlc that less effort and fewer resources will suffice — if things look bad, resources may be forthcoming but by then it is often too late — and given the mean time between HIV infection and the diagnosis of AIDS this might be eight to ten years too late.

Despite the optimism, there are some real obstacles to future developments. The first phase of the preventive response in the UK was marked by high levels of energy and enthusiasm by many drug workers, and the rapid adoption of many innovative strategies. Moving into the second phase of our preventive response provides the opportunity to refine and develop prograrnmes, and to look critically at what worIcs and at what doesn't.

There are two obstacles that must lead to a review of what is being done in the UK and elsewhere. One is concerned with the resources available for services, and the second with drug injectors' drug-using practices. First the service resource obstacles. In most countries there can never be sufficient resources to offer individual services to all who may be eligible. In the United States of America the Presidential Commission on the HIV epidemic came to the conclusion that the main strategy for preventing HIV was to improve access to drug treatment and to provide treatment on demand. The Commission's own estimates are that this would require 2,500 new treatment agencies and 59,000 new treatment staff (Presidential Commission on the Human Immunodeficiency Virus, 1988). The Advisory Council on the Misuse of Drugs in its first report on AIDS and Drug Misuse (1988) made' the laudable recommendation that drugs services should attract more clients. It is, however, unlikely that these services could be given adequate resources to do this task. In 1986, the Advisory Council estimated the number or injectors of notifiable drugs at between 37,500 and 75,000. On average, English drug agencies see one client per member of staff per day. If each drug injector were to come into a drug agency once every two weeks, we would need between 3,500 and 7,500 agency staff.

Some services are expensive, especially those that employ medical staff. Most drug advice and information agencies are cheaper to run than Drug Dependency Units. But even relatively low-cost pro-grammes such as syringe exchange could not be expanded to provide adequate coverage. In the UK, to meet the needs of the estimated numbers of drug injectors, would require that case loads for the 120 existing exchanges increase to between 149 and 312 per week. Exceptionally, a syringe exchange could see numbers in the lower range. But our surveys show that syringe exchanges only see an average of twenty clients per week for syringe exchange (Lan and Stimson, 1990). The capacity is not there. Neither is it for most services currently operating in the UK. CLASH in London, a classic outreach programme, has about 500 client contacts a year — ten a week — for three or four staff. A Comrnunity Drug Team with, say, eight or ten staff will typically have a case load of 200 a year.

Whatever the programme, it is hard to imagine client-based services ever being expanded to help all the people who potentially need to be reached in an HIV-prevention strategy.

The next obstacles are found in drug injectors' drug-using practices. Among most long-term injectors there is a high level of awareness about the risks of HIV transmission, and the means to change that behaviour exist (or have improved) in many places. Why then do people continue to share syringes? It is a sociological act of faith that there are good reasons for what others view as irrational or stupid behaviour. In our qualitative research we found that syringe sharing occurred for a variety of situational and personal reasons — for example, the failure of syringe supply, the mechanical failure of a syringe, or the intoxicating effects of drugs. In another study we found that people were less likely to share syringes when they were injecting drugs at home. And in a further study, people who injected in prison were highly likely to inject with a shared syringe. Personal and social drcumstances in the realm of everyday drug-using practices are. all important, but the everyday factors that influence syringe sharing are well out of the reach of clinicians and drug workers.

SHARING SYRINGES AND SHARING CULTURE

How can we solve the twin problems of lack of service resources and the factors that influence drug-using practices? What is involved in helping people adopt healthy behaviours? The ability to adopt protective strategies vis-cl-vis HIV has much in common with the ability to adopt other health protective behaviours. There are many health-promoting practices in which people regularly engage and which are integrated into their everyday lives. Personal hygiene practices — such as personal grooming and teeth cleaning — are good examples. Teeth cleaning is done by most of the population — almost without reflection. Promoting safer behaviour and healthy practices requires the knowledge about the desirability of those practices, and the means to adopt them. But it also requires personal resources and routines.

For drug injectors, the relevant knowledge is about the transmission of HIV. The relevant means to promote safer behaviour are sterile syringes, or effective means for syringe decontamination. But avoiding risky injecting practices also requires personal resources — such as a safe place to inject, a place to keep syringes or somewhere to clean syringes.

Harm minimization might therefore indude the need for decent housing — using drugs at home is safer than using them in the street. Such factors also encourage, or inhibit, a life which allows for health planning and the adoption of healthy routines. It is easier to pursue healthy behaviours if they become routinized — that is, if they become part and parcel of everyday practices.

People can be helped to change through having the knowledge, means, resources and personal routines. But for people who inject drugs the routines are not only individual behaviours, but are shared with others.

Preoccupied as we have been with 'sharing' — whether in drug use or sexuality — we have yet to take on the full meaning of the term. We have focused on individual practices — the passing of a syringe from one person to another — without looking at what goes on when things are shared. As I have suggested, sharing is located in particular social and matLal conditions. If we wish to influence individual acts of sharing we have to influence the wider context in which that sharing occurs.

The preventive task is therefore about cultural change — about helping drug cultures to change. It cannot be done by targeting individuals for individual treatment or counselling — even though it may in parrhave to be done through individuals.

TOWARDS PUBLIC HEALTH AND HEALTH BEHAVIOUR

At the risk of caricature, most interventions that are being undertaken to try to help prevent HIV transmission have as their target individuals and individual behaviours. The reasons for this are found at the ideological level, and at the level of institutional sites and workplace practice. For example, in the UK most drug control measures have had an individual focus whether they are educational or treatment, and AIDS prevention has grown out of individually oriented drug advice agencies (which we have discussed elsewhere, Stimson and Lart, 1990). With their existing focus, their success will be limited by the two obstacles I have oudined — the lack  of resources in—d the inability to reach people at the point where drugs are used.

A few interventions take a different focus. First, they are often conceived of and operate on a city- or community-wide basis (rather than at the level of an individual agency). There is a conception how all the elements of the local response fit together as a working totality, rather than existing as a number of disparate elements: the Liverpool and Amsterdam approaches are good examples. Second, they aim to enable changes in shared practices, and not just to change 'sharing behaviour'. The interventions may work through individuals, but there is a conception of how those individuals will in turn influence others. In my view, these approaches can overcome the two obstacles that have been identified.

What this suggests is the need to refocus effort to help behaviour changes within a new public health and health behaviour paradigm, in which public health helps create the conditions under which populations can lead healthy lives.

The focus now would be on enabling community and cultural change. The task would be to change cultural norms around the locus of drug use. It would sometimes be done through individuals, but the target would be other injectors who do not come into agency contact. Drug injectors would be recruited in order to help others change their behaviour.

This would lead to a rethinking of the aims of many of our current practices. For example, in the United Kingdom 'community outreach' has become a new part of the work of many drug agencies. But the term means a variety of things: it can mean agency workers engag).ng in peripatetic work in other agencies — for example, a drug worker going to spend some time each week in a general practitioner's surgery. It can mean reaching out to drug users in the conununity to bring them into contact with services. But there is a lack of a coherent sense of 'community' in much of this work done by community drug teams and other agencies. Drug services have developed on the layer of community services, but the model used is often based on casework with clients rather than being truly community focused. The rhetoric of community work may be correct — but the theory and practice are often vague.

Within a public and community health paradigm, 'outreach' and 'corrununity' work would mean reaching out, using drug injectors or other target groups as agents of change, working through social networks to help communities change. There are some good examples of this in Liverpool, for example, using drug dealers as secondary syringe distributors and health workers. Other examples are the work of ADAPT, the bleach programrnes in San Francisco, and the attempts to organize drug injectors in New York City (Friedman et al., 1990).

Another example is counselling. In a client-centred approach, counselling would seek to help individuals to change their behaviour. In a public and community health approach, the aim would be not just to influence the counselled individuals, but to enthuse those people with the need to influence others. It would entail teaching social skills in resisting risky behaviour — and would also help those people to encourage safer behaviour in others. It would entail asking them not just to refuse to share syringes, but — by offering them dean syringes to give to other people — to take the safer drug use message to others.

CONCLUSION

All drug use — whether of legitimately acquired drugs or otherwise — is, I have argued, subject to social controls that operate at a number of levels. The task for HIV prevention is the encouragement of new types of social control at the informal level of everyday drug-using practices. A public and community health approach is primarily about creating the conditions under which the social etiquette of daily drug use will change and in which new health behaviours will emerge. The airn is to put public health and health behaviour back on the map.

ACKNOWLEDGEMENTS

I arn grateful to colleagues in The Centre for Research on Drugs and Health Behaviour, and in particular to Kate Dolan, Martin Donoghoe, Dr Betsy Ettorre, Dr Robert Power and Dr Brian Wells.

REFERENCES

Advisory Council at the Misuc of Drugs (1988) AIDS and Drug Misuse, Part 1, Lonclon: HMSO.

Burt, J. and Stimson, G. V. (1990) 'Stratcgics for protection: Drug injccting and thc prevention of HIV infcction', Report to thc Health Education Authority, London: Goldsmiths' College.

Dolan, K., Stimson, G. V. and Donoghoc, M. C. (1990) 'Differences in HIV rates and risk behaviour of drug injectors attending, and not attending, syringe-exchanges in England', Sixth International Conference on AIDS, San Francisco, Oral presentation and Abstract no. F.C.108.

Friedman, S. R., Sufian, M., Ncaigus, A., Stcphcrson, B., Manthci, D., Des Jarlais, D. C. et al. (1990) 'Organizing IV drug users against AIDS: a comparison with outreach for producing risk reduction', Sixth International Conference on AIDS, San Francisco, Abstract no. S.C.733.

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Polakoff, S. (1988) 'Decrease in acute hepatitis B continued in 1987', Lancet 540.

Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988) Report, Washington.

Public Health Laboratory Service Working Group (1989) 'Prevalence of HIV antibody in high- and low-risk groups in England', British Medical Journal 298: 422-3.

Stimson, G. V. and Lart, R. (1991) 'HIV, drugs and public health in England: New words, old tuncs', International Journal of the Addidions (forthcoming).