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Aids

Volume 130: debated on Thursday 31 March 1988

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11.29 am

It is hardly possible to exaggerate the seriousness of the threat of AIDS to our society. It is undoubtedly the biggest crisis in public health for over half a century. It is true that, according to Government figures, only 749 people have died of AIDS and only 1,344, at the last count, were identified as suffering or having died from AIDS. However, as we all know, this is only the beginning of this tragedy and many thousands of people are already infected with the AIDS virus and will develop AIDS and, like all AIDS sufferers, will subsequently die from that illness.

The AIDS syndrome was described only in 1981, and it was in 1983 that the human immunodeficiency virus which is responsible for AIDS was identified. Since that time, a great deal has been learnt about the virus, and we certainly know a lot about the methods of transmission. The virus does not survive easily outside the human body; that means in practice that there are three methods of transmission — sexual, blood to blood and maternal/ foetal. It is certainly the case that in England the vast majority of people who have died from AIDS or are suffering from it are homosexuals, but it is wrong to see the problem of AIDS as one that is solely, or even largely, related to the gay community.

I am glad that a Scottish Office Minister is here to reply to the debate, as the position in Scotland is different. Whereas in the coming years the vast majority of AIDS sufferers in England will continue to be homosexual, in Scotland that will not be the case. There is nothing unique about Scotland. The position in Italy and Spain is similar, in that over half the cases of AIDS there are related to drug abuse.

In Scotland the problem is concentrated, to a large extent, in the south-east. It is well known that the situation in Edinburgh is serious. It has been known for a long time that more than half the injected drug misusers are carriers of HIV. It would be helpful if the Minister could confirm the last figures that I have, which show that in Glasgow 5 per cent. of injected drug users were HIV positive.

It is vital that we recognise the enormous importance of tackling the spread of this virus, either within the drug-injecting community or between the drug-injecting community and the rest of society. This is important, first, because there are thousands—in Edinburgh alone there are more than 2,000—of people who misuse drugs and who are HIV positive.

Secondly, it is important to understand that the drug takers are a transient group; they are not a fixed population. People give up drugs and move into general society and, sadly, people, usually younger people, move into that community or habit. It is also the case—again, there has been some misinformation about this, but the research in Edinburgh makes it quite clear—that these drug addicts travel all over the country, so that the infection is spread from major cities, whether Edinburgh or Dundee, to other parts of the country.

Fourthly — this is particlularly important — the infection among the drug-taking community will for some time be the main source of transmission into the heterosexual community. The evidence is clear, but it is unfortunate that we still find people writing in the popular magazines suggesting that the virus cannot be transmitted by normal sexual intercourse. A paper was published recently by a group of Edinburgh workers based on research into partners of HIV-positive drug abusers and one can be fairly confident that the vast majority of these partners have not been injecting drugs themselves. It is clear that a number of them are already infected by HIV as a consequence of a heterosexual relationship with an HIV-positive drug-injecting partner.

Another reason why we attach such great importance to this issue is that the vast majority of the babies who are born HIV positive — of 65 such babies born in the United Kingdom, 40 have been born in the Lothian area —are born to mothers who have contracted AIDS or the HIV virus through the misuse of drugs.

How can we tackle this enormous problem? One approach is to eliminate drug misuse, because if we could do that, we would eliminate this source of infection. We all want to eliminate drug misuse, but we shall not achieve that, certainly not within the time scale that is necessary if we are to avert an enormous increase in the spread of HIV throughout our society. We cannot allow ourselves to get hooked on to that approach. We will want to try to ensure that the measures that are taken to tackle HIV within the drug community are complementary to measures to reduce drug abuse, but one of the mistaken approaches, which I hope that the Minister will reject, is the suggestion that the solution is simply to tackle the problem of drug misuse.

It has been spelt out time and again that the threat of HIV to our society is much greater than the threat of drug misuse. We must fully recognise that fact, which means that we cannot wait until we have tackled the drug problem. We have to persuade drug injectors to alter their habits. How best can we go about doing that? The best information that we have had to date on how to do so is the document of the Government's advisory council on the misuse of drugs, which was published earlier this week. That document represents a valuable statement on how we should go about tackling this problem.

The report emphasises —this is how we see it in Edinburgh on the basis of our experience — the importance of making contact with these drug misusers. We must educate them, and that cannot be done through television or public education programmes. We have to do it by making direct contact with them and, as a consequence, the advisory council has come out strongly in favours of the development of a community-based drug service. We have some experience of this in Edinburgh, where there are a number of drug groups. Historically, partly because of the lack of provision by the public sector, these are voluntary groups which were originally directly funded by the Scottish Home and Health Department but which are now being funded by the local health boards.

These groups are already making a valuable contribution, but they need more resources. The people who are working in the front line are able to relate more effectively to drug injectors than some of the professionals, and they need more resources. They can provide advice and counselling. The most important thing is to make contact, and contact is not made with many drug misusers. The report suggests that so far only a third have been contacted.

The conditions of service of workers in the drug groups should be improved, and this applies to both national and local government funding. Better facilities are needed. To make these workers wait for three years on temporary contracts before telling them that there will be an extension of the programme is wholly unsatisfactory, and I hope that something can be done about that. We need to allow these dedicated people security of employment, because we know that we shall need them for a long time. We also need more provision in the public sector. We need better hospital-based facilities to back up local drug groups and more back-up, in particular, for general practioners who have a high number of HIV-infected individuals within their practice.

It is crucial that we provide additional resources to back up the facility for that kind of contact with injecting drug misusers. Once a dialogue is taking place, we are able to have some influence over them. There is evidence that that influence is already beginning to reduce the risk of their picking up the virus, if they do not already have it, or of transmitting it to other people.

We know that the main method of transmission among drug takers is the sharing of dirty needles. Edinburgh's history in that respect is well summarised in last Session's report of the Select Committee on Social Services into AIDS, which pointed out that during the epidemic of heroin taking—particularly among young people—in Edinburgh in the early 1980s, the practice of sharing dirty needles was very prevalent. That practice was probably contributed to by the police effort to clamp down on the drug problem by virtually eliminating the legal sale of clean syringes. As a consequence, there was a tremendous explosion in the number of people infected over that period.

It is well known that that was the main method of transmission. It was clearly documented in a paper produced by Edinburgh professionals in February 1986. The Scottish Office commissioned a report from a committee chaired by Brian McClelland published in September 1986, which recommended decisively that the Government should bite the bullet and provide clean syringes at an exchange centre, where drug injectors would be able to obtain free needles and syringes.

The Government's response to that call has been so inadequate as to be positively irresponsible. They sat on the McClelland report for months. Eventually, they announced 15 pilot schemes, 12 in England and three in Scotland. Of course such projects involve problems —the Minister may wish to comment on them—but we must make the projects work. It is not sufficient to say that, because there has been a problem in Dundee, such a project will not be possible there. The Edinburgh example shows that the schemes can be made to work. In the long term, the only test of their success is the extent to which they reduce the spread of HIV. But we will not know that for many years. In the short term, the only test can he the number of clients who have been contacted and provided with clean needles, with whom a relationship can be developed and who can be given advice.

Edinburgh has one centre open for half a day a week. We want many more centres throughout the area that are open for much longer. The Government's response to the recommendation in this area in the report by the Advisory Council on the Misuse of Drugs is profoundly disappointing. The Minister for Health states:
"While the evaluation points to some promising features of such schemes, we do not consider that we yet have sufficient evidence to recommend an expansion of schemes in England."
The Scottish Office is marginally more positive in its response. The Under-Secretary of State, who will reply to today's debate, states:
"So far as further needle exchange arrangements by Health Boards are concerned, we are not yet in a position to reach general conclusions on whether any extension of the existing arrangements would be appropriate. However, if any Health Board considers that, notwithstanding possible developments in the pharmacy-based field, there is a need for such facilities in their area, we shall be prepared to consider specific proposals." —[Official Report, 29 March 1988; Vol. 130, c. 406.]
I hope that the Government will think again.

Of course we support the provision of free needles through community-based pharmacists. I welcome the Under-Secretary's statement in his response to the ACMD report that he will enter into discussion with pharmaceutical organisations in Scotland with a view to encouraging them to sell clean syringes. Indeed, there is a good example of how that can work in Glasgow.

In some instances, individual general practitioners may also have an important part to play in the provision of clean needles and syringes. However, they are not a substitute for needle exchange centres. The counselling, advice and education that can be provided in a well-established needle exchange centre, where effective dialogue with drug injectors is possible, may well be more effective than a pharmacist could ever be. That is not to detract from what the Minister is trying to do, but his proposals must not be seen as an alternative to support for such centres.

When we had our only major debate on AIDS, in November 1986, the then Secretary of State made the point that the Government wanted this to be an all-party issue. Of course we are all united on the need to tackle the problem. But, as I said in that debate, if the Government want it to be an all-party issue, that can be sustained only if they are prepared to provide the level of resources that the community—the electorate—considers adequate. We are approaching the point — if we have not already reached it—at which the Government are failing to do that.

In some health authorities and health boards in London —and certainly in Lothian and other parts of Scotland— the provision of facilities to look after AIDS sufferers is already a significant proportion of their budgets. I welcome the Government's specific capital allocation for AIDS units in Edinburgh, Glasgow and Dundee, and I have no criticism of the level of that allocation. I feel, however, that the Government have fallen down on the expansion of resources to tackle the problem before it reaches the stage at which people suffer and die of the disease.

We need a much larger investment in projects to provide counselling and advice for drug users. Of course, some of the money must come from social work departments. The Minister will know of the disappointment, particularly in Lothian, in the Government's response to the joint officers committee of local government and civil servants which reported jointly to COSLA and to Ministers. The Minister accepted the report's recommendations, and said that the increase already provided for social work would cover the requirements. But that is not really adequate, especially in Lothian, which has a special problem. While I welcome the additional money that is being provided, particularly on the capital side, we need additional, specific resources, not only to support the projects to which I have referred, but also for the social work departments' functions in this area.

There was all-party support for the funding of £500,000 by the Lothian regional council, even in its current difficulties. I believe that Lothian may have to make great sacrifices to find money to tackle the problem. The money should come from central Government.

Lothian is lucky—as the Minister, who has taken an interest in the matter, will probably confirm—in that a number of very able people are working on the subject, some highly qualified professionals and other dedicated workers with the voluntary groups. It is striking that so many people have come forward, including senior public sector professionals, to tackle the problem with such commitment, but we need more resources.

Tragically, Lothian is an archetypal authority in that we are having to tackle a problem of major significance to the entire United Kingdom and other European countries. I believe that we can become a model of how best to tackle the problem if the Government give the funding we need, but that will not be done in a few months.

Although it is not only a question of resources, I must stress that we do need more resources, particularly in Lothian, so that we can set an example that will benefit not only Scotland but the rest of the United Kingdom and Europe.

11.50 am

I congratulate the hon. Member for Edinburgh, East (Mr. Strang) on securing this Adjournment debate and on choosing this important subject. I assure him that the Government take the problems of AIDS and drug misuse very seriously. We know that they are of considerable concern in Scotland.

Of those who have chosen to be tested for HIV infection, more than 50 per cent. are intravenous drug misusers, whereas the corresponding figure for the United Kingdom as a whole is only 7 per cent. In Scotland, more than 20 per cent. of those infected are women, the great majority of whom are intravenous drug misusers. In other parts of the United Kingdom, the AIDS epidemic manifests itself in risk groups such as homosexuals, but in Scotland it is predominantly associated with intravenous drug misuse. As the hon. Gentleman rightly emphasised, that carries with it the danger of spreading the infection, through sexual contact, to a wider population.

The hon. Gentleman asked me to confirm figures for the extent of infection among drug misusers in the east, as opposed to the west, of Scotland. He has obviously studied the ACMD report, which in paragraph 7.4 estimates that between 40 and 50 per cent. of intravenous drug misusers in the east of Scotland are infected with the HIV virus, whereas for the west of Scotland the estimate is between 2·5 and 5 per cent.

The hon. Gentleman asked me to acknowledge the imperative that the fight against the spread of AIDS should take precedence over the Government campaign to end drug misuse. I am happy to assure him that it is indeed the predominant priority, and our policies are geared towards that. The main message of the Government's public education campaign is that drugs should not be injected, but that those who persist in doing so should not share needles or other equipment.

If the spread of the virus among those who inject drugs is to be slowed it is vital that they understand the dangers of sharing syringes and needles, and they should act on that knowledge. The evidence is that that message is getting across. Indeed, one reason for the high level of HIV infection in Edinburgh and the east of Scotland was the injecting culture, where people deliberately shared needles. That resulted in a rapid spread of the disease.

The hon. Gentleman suggested that our response on needle exchanges had been inadequate. The experimental needle exchanges have provided a wealth of useful information about the behaviour of drug misusers and about the ways in which they can be encouraged to change to safer practices. The Dundee scheme was closed because of disruption by some of its clients. The Glasgow and Edinburgh schemes were more successful, although, on the basis of the hon. Gentleman's test of take-up, the Glasgow scheme was a little disappointing.

On 29 March I said that we had informed Lothian and Greater Glasgow health boards that, although central funding would not continue after 1 April, they could continue to operate their schemes if they considered that to be appropriate to local circumstances. The two boards have decided to do so. The drug misusers who have availed themselves of the services of those two boards can therefore continue to do so during the foreseeable future.

The hon. Gentleman emphasised the importance of funding local drug misuse services and voluntary groups that are in touch with drug misusers, and I agree with him. I am sure he knows that central Government funds are not intended to finance every worthwhile drugs-related project throughout Scotland. However, our programme makes a substantial contribution to the encouragement and assistance of such services. We announced last year that we were making an additional £300,000 per year available for a further expansion of drug misuse servies in recognition of the additional demands placed upon them by HIV infection and intravenous drug misuse. To encourage the development of local plans, we asked the health boards to co-ordinate proposals and to submit bids for a share of the additional resources.

We have taken on board the hon. Gentleman's plea that we recognise the special problems faced by Lothian and Greater Glasgow. The additional resources were specifically targeted at the three health boards most affected—Lothian, Tayside and Greater Glasgow. In total, £1·1 million has been set aside in the current year's health programme specifically for the support of drug misuse services, and a similar sum will be made available next year.

The hon. Gentleman asked about resources for social work and rightly pointed out the responsibility that falls on local government. A joint working group of Government and local authority officials estimated that in 1988 social work expenditure to deal with the effects of the AIDS virus would be just over £1 million for Scotland as a whole, probably rising to about £3·5 million in 1990. Those are not the Government's estimates; they were made by those involved in the provision of services. We have taken account of that in our rate support grant settlement for 1988–89 through a 1·5 per cent. increase in real terms, which is in excess of £3 million in 1987–88. Therefore, it is difficult to accept that the Government have done anything other than provide the resources required.

Will the Minister provide any additional resources as a result of the report, or is it simply a continuation of existing programmes?

The right hon. Gentleman knows that in answer to a question on Wednesday I made it clear that the Government would take careful cognisance of the report's recommendations. The thinking behind the report has been very much a part of our developing strategy. For example, we said on the same day that we would look to the retail pharmacist as a way to increase the supply of needles, and the hon. Member for Edinburgh, East paid tribute to that decision. It runs very much in line with the thrust of the report's recommendations.

The' report also pointed to the importance of finding informal ways to reach out and make contact with drug misusers so that we could get across to them the necessary information that might encourage them to change their behaviour. That aim has been part of our funding strategy for voluntary organisations and support groups, through the health boards.

The hon. Gentleman said that the number of clients of needle exchanges was a test. I cannot help but observe that when I visited the needle exchange at Ruchill it was dealing with about 65 people, whereas around the corner the pharmacist was selling more than 1,500 sets of injecting equipment every month.

I am grateful to the hon. Gentleman for having raised this subject. I assure him that AIDS and drug misuse have far-reaching social and economic implications which present challenges to the Govermment and the community on several fronts. We intend to meet those challenges. We are grateful to him for the support that he has given us and for the action that he has taken in the House in pursuing the matter.