For World AIDS Day on 1st December, Scottish Drugs Forum (SDF) re-commit their support for those currently living with HIV and also want to commemorate those who have died. We also launch a call to action so as to prevent a return to the time in recent Scottish history when the greatest risk of HIV infection was through injecting drug use.
To keep our members and the wider public up to date with the current status of HIV amongst people who inject drugs in Scotland, SDF have created a briefing which contains information on keys issues, such as the continuing HIV outbreak in Glasgow, the importance of regular testing, treatment accessibility, risk of infection spread and preparation and prevention.
There is currently an ongoing outbreak of HIV infection in people who inject drugs in Glasgow. Injecting drug use (IDU) has become the most common route of infection in new diagnoses of HIV in Glasgow for the first time since 1987. The outbreak was first identified around 18 months ago with 72 new diagnoses now identified (as at October 2016). Across the previous 20 years the health board area saw less than 10 new HIV cases annually acquired via injecting drug use.
This is an emerging and serious issue which demands attention because of the human and resource costs and the public health implications involved.
In the mid 1980s, around 45% of Edinburgh and 40% of Dundee injecting drug users were HIV positive. The course of this epidemic was however significantly altered by the emergence of harm reduction measures, championed by visionary staff and now internationally validated.1 These measures included the introduction of needle exchange, opioid replacement treatment (methadone) and information for drug users that promoted behavioural changes2.
There are several issues emerging from the Glasgow outbreak which should be cause for serious concern and interest among elected representatives across Scotland.
Early diagnosis and treatment are key both in improving health and saving lives as well as preventing transmission. Co-infection with hepatitis B and hepatitis C infections can cause rapid progression of liver disease so early diagnosis and access to treatment is vital in intravenous drug users, around 60% of whom have hepatitis C.
SDF’s work around the Glasgow outbreak has uncovered several important issues which should be noted nationally –
Importance of regular testing
It seems that low prevalence of HIV has meant that there has been inadequate testing of people who inject drugs. When blood samples have been taken, they have been tested for hepatitis C but sometimes not for HIV. Testing has been focussed on those in drug treatment rather than other injecting drug users who are at greater risk.
User and staff perceptions of risk, treatment and disease
HIV has a low profile in terms of the perceived risks of injecting drugs amongst both service staff and people who inject drugs. Both groups have poor understanding generally of infection risks and transmission of the virus and exactly how this may be avoided. Likewise both groups have poor understanding of treatment and prognosis for people with HIV which tend to be based on perceptions from the 1980s. These may lead to fatalism and reluctance to engage in testing or treatment.
Treatment accessibility for this group
HIV services are designed and appropriate for men who have sex with men and, to a lesser extent, Sub-Saharan Africans. It has proved difficult to engage and retain injecting drug users in treatment. Staff training and service reconfiguration are required.
Risk of spread to other areas
There is a significant risk of the outbreak spreading into other populations. Although the affected population is not particularly mobile there are patterns of imprisonment across Scotland, involvement in prostitution and homeless resettlement that are possible means by which it could move to other groups and areas.
Risk of similar outbreaks elsewhere in Scotland
Even without direct spread as described above, there is a significant risk of similar outbreaks in other areas of Scotland. The introduction of an HIV vector into a community of injecting drug users will result in rapid spread through that group, this is an ongoing risk for which we may be currently underprepared
Preparation and prevention
Local areas should take action now, ensuring testing of injecting drug users is adequate and that treatment services are appropriate. An education campaign for users and staff in frontline services is required. New ways of delivering services in the community should be considered. Glasgow Health and Social Care services are currently considering a range of interventions that include harm reduction measures such as a drug consumption room, drug treatment options such as heroin assisted treatment and outreach access to anti-retroviral treatment.
Stigma is often directed at substance users and may lead to their care needs being given less weight when balancing health and social care budgets. SDF urge the members of the Scottish Parliament to continue to highlight that although HIV affects many across society, those who need care the most are often those who are most uncared for.
SDF’s activity in response to the outbreak has been carried out in partnership with colleagues in NHS Greater Glasgow and Clyde and includes –
- Design, development and distribution of a staff booklet – Click here to download this
- We are currently developing a resource for people at risk which is being peer reviewed.
- 65 face to face briefings to 692 staff, peers and users of substance use and other services to raise awareness of the outbreak and update and improve knowledge around HIV
- Delivering briefings and the staff booklet to other areas of Scotland
- Delivering training to peers to support peer education and support
- Hosting and inputting at various conferences and other events
- Working with health and Scottish Prisons Service staff to improve HIV awareness in HMP Low Moss
- Attendance and contribution to the work of the Incident Management Team established by the Health Board