Mortality and increasing drug use in Edinburgh: implications for HIV epidemic.

Mortality among a group of known drug users shows small numbers of deaths from AIDS so far but increasing deaths from overdose, especially in young women. Steadily rising numbers of drug injectors are observed. The need for a distinctly different educational approach in areas of very high seroprevalence is discussed and the requirement for close co-operation between prescribing sources identified.

After the epidemic: follow up study of HIV seroprevalence and changing patterns of drug use.

OBJECTIVE: To follow up known intravenous drug users to determine current health state and drug use, compare characteristics with those of recent drug users, and examine HIV exposure and serostate. DESIGN: Subjects were identified from conventional general practice records and recruited from 1980 to the end of 1985; they were followed up during 1987 and 1988 and compared with drug users identified in the same way but recruited after 1985. SETTING: General practice and community in north west Edinburgh. Follow up conducted throughout the United Kingdom. SUBJECTS: Subjects known to have injected illegal drugs before 1986 (n = 203) and since that time. MAIN OUTCOME MEASURES: Mortality from and prevalence of HIV seropositivity and various parameters indicative of abstinence. RESULTS: Of the 203 subjects in the follow up group, 189 (93%) were traced; 16 (8%) had died and the remaining 173 (85%) were interviewed. In all, 146 (72% of the follow up cohort) had been tested for HIV antibodies, 94 (64%) having positive and 52 (36%) negative results; 57 (28%) had not been tested. Of the 65 subjects in the recently recruited group, 51 (79%) had been tested for HIV, 15 (29%) having positive results. A further 21 (43%) were currently negative for HIV antibody but still at risk. Thirty three (19%) of those followed up were confirmed abstinent, although more (about half) showed evidence of diminished drug injecting. Age correlated strongly with abstinence (p less than 0.001). One third of the group currently used cannabis, buprenorphine, dihydrocodeine, or diazepam. When the two groups were analysed together there was a strong association between the date of starting injecting and HIV seropositivity (chi 3 = 23.81, df = 2, p less than 0.001), with a peak around 1980-3. CONCLUSIONS: Although only a fifth of the followed up group were convincingly abstinent, a much larger group showed evidence of prolonged periods of remission. Overall, much use of oral drugs was confirmed and worrying trends towards taking buprenorphine and benzodiazepines were evident. The peak incidence of starting drug use and the comparatively low seroprevalence of HIV in the newer drug users probably explain the anomalous high seroprevalence in Edinburgh drug users during 1980-5. The epidemic of HIV during the first half of the 1980s in the group suggests that the virus was probably being transmitted because of a pattern of behaviour. Changing patterns of HIV transmission suggest a need to concentrate on heterosexual transmission as the main problem in the future.

Human immunodeficiency virus in drug misusers and increased consultation in general practice.

The use of general practitioner services by a group of intravenous drug users was recorded over two two-year time periods 1984-85 and 1986-87. This was felt to represent the period of maximum change in awareness of human immunodeficiency virus (HIV) infection by patients and medical staff. Fifty patients were randomly selected: 25 who were HIV positive and 25 who were HIV negative. Between the two time periods a dramatic increase in consultation rate for both high risk and infected patients attending their general practitioner was recorded (318% and 172% increase, respectively). A small increase in attendance at the accident and emergency department (30% and 34% increase, respectively) was recorded for high risk and infected patients, and there was a large increase in attendance at the infectious diseases unit for infected patients but there was little effect on use of other hospital services. The implications for resource needs in the community are discussed.

Remission and relapse in heroin users and implications for management: treatment control or risk reduction.

A general practice based study of 117 heroin users receiving minimal intervention for their drug use examines the patterns and frequency of use from onset to last medical contact. Patterns of abstinence and relapse, and episodes of dependent and nondependent use are defined and quantified, demonstrating variations between and within individuals over time. This evidence of both controlled heroin use and remission and relapse not related to intervention is discussed and contrasted with the continued fixed belief of the public and professionals that heroin use is continuous, incurable, and permanent. Implications for therapy, especially in a "post-AIDS" era, are discussed.

Heterosexual spread of human immunodeficiency virus in Edinburgh.

Heterosexual transmission of human immunodeficiency virus (HIV) was investigated in 123 subjects with no apparent risk factor for infection other than having had heterosexual intercourse with a person who was either infected with HIV or at high risk of being infected with it. Seven subjects were found to be infected with the virus. Risk factors for transmission included being the regular sexual partner of an abuser of intravenous drugs and having a sexual relationship of more than 18 months' duration. Anal intercourse was not a risk factor in the three subjects who admitted to it. There were 41 regular partnerships with abusers of intravenous drugs in which the antibody state and history were fully known for both partners. In these partnerships male to female transmission of the virus occurred in five out of 34 (15%) and female to male in one out of seven. In 30 couples in whom one partner was known to be positive for HIV and an abuser of intravenous drugs four female partners were found to be seropositive at first testing, but there were no new positive results on subsequent serial testing. In six of these 30 couples both partners abused intravenous drugs but the partner who was negative for HIV remained so. Few of the partnerships always practised safe sexual techniques, even after a partner was known to be positive for HIV. Heterosexual transmission of HIV occurred but was incomplete and may be related to the timing of the relationship with the infection.

Toxicological screening in heroin users: implications for management of drug misuse.

The toxicological screening of 200 urine samples from 55 known heroin users claiming to be abstinent revealed that in 18% of samples (24% of users tested) opiates were unexpectedly detected. Other substances, many of which were psychoactive drugs, were identified in 35% of samples. Cocaine was not detected in any samples. In addition, nicotine was found in 91% of users and caffeine in 44%. The data showed the presence of polydrug abuse in 29% of subjects and suggested there is an illegal supply of drugs originating from doctors' prescriptions. The requirement for more general use of toxicological screening and the implications of the results for management of drug takers in general practices are discussed.