HIV and Injecting Drug Users

1. HIV and Injecting Drug Users Sophie Strachan sstrachan@positivelyuk.org Project lead for prisons and family & children

2. Our History Started in 1987 by 2 HIV+ former drug users using their front rooms as a place for meetings. Registered as a charity in 1992 Our Ethos has always been peer led support. All frontline staff and volunteers are living with HIV themselves. Some with direct experience of former drug use and being in prison. We have been delivering peer led support in Holloway prison since 1993.

3. HIV in Prison • We currently provide outreach in 5 London prisons • HMP: • Holloway • Downview • Bronzefield • Pentonville • Brixton and provided advocacy for people detained in detention centres. • Outreach in London Hospitals • Royal free, Royal London, Newham, St. Marys, Ealing, Northwick Park, Chelsea & Westminster, Homerton.

4. Issues for HIV+ drug users • Multiple identities • Trauma of active addiction and diagnosis • Cross addicted: including sex addiction • Denial of problematic drug use and denial of status • Lack of engagement to providers of support • Multiple discrimination (society and institutions) • Stigma (drug user, HIV status, sex worker, gay, gender) • Co infection with Hep B and Hep C, managing treatment • Poverty, homelessness, social isolation, children in care, high income, peer pressure • HIV,ARV’s and interaction with drugs (methadone, ecstasy, cocaine) • Drug mules (both men & women)

5. The London Gay Scene • High risk practices amongst MSM, Lesbians and heterosexual male and female friends • Injecting crystal meth, Tina, mephedrone, annihilation very common practice (known as slamming, common practice at chill out parties/sex parties) • Statistics in recent Lancet report state 80% service users are injecting drug users, 70% sharing needles. CODE clinic + Club Drug clinic. • Antidote statistics: Of crystal meth, GBL and Mephedrone users: • 95% are using to facilitate sex • 80% are injecting (Meth and Meph

6. The London Gay Scene • Statutory services expert at Opiate injecting advice, but ignorant of safer injecting advice for meth and meph. • 75% are HIV positive • 60% report non compliant with ARV’s while ‘High’ • 90% attribute diagnosis to use of drugs and alcohol • Of the HIV negative clients, more than half have had one or more courses of PEP in the last year. • Thank you Antidote for sharing.

7. What we see • Unable to negotiate condom use • Practising unsafe sex knowing status and potential consequences • No self worth/esteem, looks for validation through sex • Rape occurring but client feels unable to report as states ‘put myself in situation’ or in black out. • Frequent drug use, injecting crystal meth, GBL, cocaine, mephedrone, and using annihilation. • Very poor mental health, increased isolation. • High income fuels cross addicted addicts (can only engage in sex if high, preferring escorts and privacy/ isolation within home or sex parties. • Blasé approach to re infection and almost non existent knowledge of developing resistance (meds/different strain) • Non adherence to ARV’s

8. Findings in prisons • Illegal drug use by needles or other use takes place throughout prison system, practice is prolific and taking place within knowledge of prison staff. • One prison stated it felt they had gone backwards by 10 years regarding level of stigma/discrimination from inmates and staff, and in other area’s no progression at all, lack of commitment to improve HIV care from Governing bodies. • Stigma a barrier to people testing, disclosing, and engaging with healthcare and peer support. • Prison officers remaining in room with prisoner breaches confidentiality and freedom to talk, known fact they will not disclose drug use so appropriate/effective clinical care compromised. Also highlights issues of authority This was also reported by clinicians in hospital setting when seeing prisoner.

9. Findings in Prison • Inconsistent practice across prison system regarding prison officers duty to remain present in the consultation. More senior officers more flexible in being able to facilitate psychological intervention. • Drug services unaware of interaction of ARV’s –OST, Methadone and recreational drugs, ecstasy and cocaine. • Prison is a time when people living with HIV access health care, quite a few re-offending clients only engage with us when back in prison. • Good practice was evidenced within some prisons regarding confidentiality, as people do not want to be seen going down to healthcare escorted by prison officers as it raises questions from inmates and potential breach of confidentiality. • Presentations of depression and other mental and physical health problems not being dealt with (assessed or referred quickly enough)

10. Findings in prisons • Some prisoners found little support when on probation or guidance for reintegration in to society, increased drinking patterns, increasing sense of isolation and loneliness. Financially very difficult as had to rely on benefits. • While imprisoned some prisoners have found new direction and motivation but once released they have been left to their own devices and found it very difficult to re integrate and find employment and career, leading to boredom, social isolation, substance abuse, increase in depressive features and depressive episodes. • Quote from previous prisoner: Prison does not cater for the health needs of people living with HIV, peer support was a vital lifeline and having that weekly visit helped me massively, and they were there to help me as I was preparing to leave prison, they have continued to support me ever since.

11. Findings in prisons • Every stakeholder in a clinician role expressed lack of awareness regarding ARV’s from the nurses and the importance of adherence. In action by nurses. • Access to treatment sporadic. • Confidentiality compromised by having to get medication at the hatch. • Private prison had opted out from having specialist HIV clinician attend. On our first outreach day 7 women presented themselves wanting peer support, bullying was rife, as was access to treatment, one women waited 6 months from being detained before receiving treatment, she had been on ARV’s prior to being sentenced. • Another prison now engaging with us providing peer led support since research project

12. Insight to the bigger picture • Policy issues working against people living with HIV in prisons: • Low clarity around HIV in prison orders • Lack of implementation of existing policies • Lack of popular support for prison reform • Lack of awareness of needs of people living with HIV, including emotional and psychological needs • Systemic challenges within prisons: • Lack of understanding of prison practices around confidentiality and disclosure. • Poor adherence support • Information within the prison out of date • Guidelines on HIV are too flimsy