1. Drug Use and Hepatitis C Are we mindful of the gaps? Dave Liddell, SDF

2. Gaps  Scale of the problem – are there still gaps in our knowledge?  Definitely Treatment gaps re current and former injectors with HCV  Prevention issues – key gaps  Policy gaps

3. Total number of current injectors in Scotland  19000* drug injectors(2003 estimate) of whom 8000 HCV positive  19000 likely to be an underestimate as no needle exchange data was used. And treatment data through SMR25 likely to underestimate levels of injecting. Also prevalence figure did not include psycho-stimulant injectors  *Source: Glasgow University Prevalence study 2003

4. HCV Testing, treatment and care issues In Phase 1 of the Action Plan the focus is on raising awareness among professionals because it is evident that there are not sufficient services to cope with the need for treatment. Therefore in Phase 1 a Needs assessment is to be undertaken by October 2007 ‘The Health Department will publish the findings of an in-depth needs assessment undertaken in relation to HCV testing, treatment, care and support services’

5. Its vitally important that this needs assessment also looks at the delivery mechanisms.. The Action Plan states.. ‘Stakeholders from around Scotland have argued for new community-based models of care for Hepatitis C-infected individuals. It has been suggested that these new models of care could take the form of outreach, nurse-led clinics in primary care services, in prisons and / or in drug treatment services.’  Kennedy – HCV treatment outcomes just as good for current injectors  Sharon – small numbers currently getting anti-viral therapy  Kennedy – co-location of services

6. Testing/contact tracing  Clearly to date there has been a reluctance to test or follow up former injectors due to scarce treatment resources. But…  Thought must be given now as to how a campaign could be undertaken to get more people who are current and former injectors into treatment.  25,000 former and 8000 current injectors infected  Sharon – this is cost effective

7. Prevention of HCV – gaps? Prevention of problem drug use Early intervention with drug users to limit progression to injecting Improved access and availability of needle exchanges Swift access to quality treatment to enable sustained move away from injecting Specific services for injectors Service user experiences

8. Early intervention  Re inventing wheels!  Young people – detached youth work models  Young drug users – detached youth work models

9. Early intervention with drug injectors Taking services to injectors. HCV Action Plan…. ‘The Scottish Executive will ask NHS boards to consider whether they have the full range of interventions in place….. These interventions should include: more outreach and mobile needle exchange services; distributing a wide range of paraphernalia (in addition to needles and syringes) in needle exchanges; and labelling or colour- coding of injecting equipment to help drug users identify their own.’

10. Services for drug users  There remain major issues with drug treatment services  Retention rates are poor in a number of areas  Low dose prescribing/punitive approaches  Services delivered in silos  Greater focus on abstinence could lead to injectors being a forgotten population – focus will be on those motivated to come off drugs

11. Specific services for injectors  Outreach Needle Exchange/home delivery/secondary supply/peer projects  Heroin prescribing services  Services for Cocaine injectors  Migrant populations  Prison needle Exchange

12. Service user experiences  Feedback on how best to deliver needle exchanges  Issues of delivery – eg in some areas there is an issue for users re attending needle exchange as part of a treatment service  Dawn – 50% of specialist needle exchanges attached to treatments services

13. Policy gaps  Responses to drug problems and those to HCV/blood borne viruses not sufficiently joined up Within the Scottish Executive  Health – BBVs – Alcohol  Justice – Drugs Local level  BBV Committees/ADATS  CJAs, CHPs, CPPs etc

14. Policy gaps  Potential for responses to be in conflict eg greater focus on abstinence, increased relapse/return to injecting  Planning structures: Need to be clearer lines of responsibility. E.g. Whose responsibility is it to identify levels of injecting and ensure services are available to meet the needs of this population  Under 16’s Needle Exchange  Limits on sets of works(1987 strict 1 for 1 exchange max of 3)  Return rates

15. Conclusion  1000-2000 new infections among drug injectors each year (Sharon suggested a 1000)  Needle Exchange provision and HCV treatment services biggest gaps  Investment in needle exchanges very cost effective –  HIV and HCV treatment savings mean, according to an Australian study that for every £1 invested in needle exchange £50 will be saved in other costs