A nationwide network of needle exchanges has been a feature of drug treatment in England since the late 1980s, when the Advisory Council on the Misuse of Drugs’ (ACMD) 1988 report warned that ‘HIV is a greater threat to public and individual health than drug misuse’.
The Conservative government of the day responded swiftly to the report by establishing needle exchanges, and successive governments have invested in improving the quality and availability of treatment, including harm reduction services. As a result, despite having one of the largest populations of heroin and crack users in the western world, England has one of the lowest rates of HIV among injectors – 1.3 per cent in 2011, compared to 3 per cent in Germany, 12 per cent in Italy, 16 per cent in the USA and 37 per cent in Russia.
We know that drug users come into treatment wanting to overcome addiction, and this is the aim of all drug treatment. At the same time, it is vitally important to keep people safe as they recover. Taking action to minimise the risks that go with drug dependence, such as drug-related death and contracting blood-borne viruses, can be an important first step, especially for those who have been dependent on drugs for some time. Providers of these services are an important link to other treatment and recovery services, such as mutual aid.
Treatment services and needle exchanges work to change individuals’ behaviour via a number of step changes that initially emphasise the importance of using sterile equipment and not sharing, then encourage the shift to non-injecting use and, ultimately, to overcoming addiction.
This approach has not just kept HIV rates low. The number of injectors has also fallen, from 137,000 in 2004-05 to 103,000 in 2009-10, while sharing has declined, almost halving from 33 per cent of injectors in 2001 to 17 per cent in 2011. Fewer people injecting drugs is one of the best protections against drug-related harm.
Drug injectors are vulnerable to a wide range of viral and bacterial infections, which often lead to illness and death. Hepatitis C, which can cause liver disease, poses the biggest risk, and is much more prevalent in England than HIV. Around 45 per cent of injecting drug users currently carry the virus, although this figure has been broadly stable since 2002 and is still lower than in many other European countries (for example, Netherlands at 65 per cent or Sweden at 84 per cent) according to the Health Protection Agency (HPA).
One in six drug injectors has been infected with hepatitis B at some point in their lives, down significantly from 2001 when it was more than one in four. This fall is likely the result of targeted hepatitis B vaccination programmes, including in prisons, which saw vaccination rates among drug injectors leap from 37 per cent in 2001 to 76 per cent in 2011. There is no equivalent hepatitis C vaccination and, of the total 12,642 hepatitis C infections diagnosed in the UK during 2011, around nine in ten were a result of injecting drugs.
Recent UK research estimates that removing substitution treatment and needle exchanges could lead to a 25 per cent rise in hepatitis C among drug injectors. To bring down hepatitis C prevalence, treatment needs continued investment. Evidence shows current injectors can achieve similar treatment outcomes to non-injectors, while NICE guidance says that treating injectors is also cost-effective.
Injectors also run a much higher risk of premature death. Drug-related deaths escalated rapidly in the 1990s, from 1,025 in 1995 to 1,697 in 2001. Since then the number has stabilised at around 1,500 a year, with a spike of 1,800 in 2008 but falling back to 1,461 in 2011. We know that heroin and crack users in treatment are less likely to die than those not receiving treatment – the escalation of drug-related deaths slowed from 2001 as the treatment system expanded.
The current situations in Greece and Romania show that disinvestment threatens public health. Injectors are now the population most affected by HIV in Greece, following significant disinvestment from drug treatment and harm reduction services as a result of the economic crisis. Injectors represented 41 per cent of all new infections in 2012, compared to 2-3 per cent in 2006-2010, while in Romania, significant downsizing of harm reduction services has seen HIV prevalence among injectors increase from 1.1 per cent in 2008 to 52.5 per cent in 2012.
For the moment, blood-borne virus figures for drug injectors remain comparatively low in England, and drug-related deaths have stabilised. But if we are to see these numbers fall further, maintaining needle exchanges and other harm reduction services is vital. Responsibility for commissioning harm reduction services shifts to local authorities from April. The cost-effectiveness of these services is self-evident, the consequences of disinvestment clear.
More positively, harm reduction services integrated within the treatment system provide the entry door to recovery. The more we reduce the harm caused by injecting, the more people will be around to recover.
Michelle Judge is programme officer at the NTA