Out-patient medical care in Edinburgh for IDU-related HIV

Abstract

Using combined medical and drug clinics, by the end of 1990 we had initiated contact with 511 HIV positive individuals, 75% injection drug use (IDU) related We have previously reported a significant reduction in the number of missed appointments from 1985–89 following the introduction of methadone and an all day clinic, but between 1989 and 1990 the appointment default rate rose from 17 to 25%. A significant percentage increase in missed appointments was, however, only seen in those not attending the all day clinic (x² ₍₃₎ = 121.3, p < 0.001). An analysis of the patients missing appointments during 1989–90 revealed that 36–45% of patients attending each year missed only 1 or 2 appointments, that the majority of missed appointments each year were accounted for by less than 20% of the patients, around 60% of these patients missed appointments in both years and that only 2% of patients attending both years consistently miss 3 or more appointments per year. Laboratory monitoring of HIV, that is at least one sampling episode in a year, was achieved, however, in 92–95% of the patients attending each year. The annual number of patients lost to follow-up varied between 7 and 11% per year, but did not change significantly over time, whilst the cumulative number of HIV infected individuals lost to follow-up after 5 years was only 14%. Between 1986 and 1990 self-reported reduction in IDU was more likely in HIV positive than negative individuals; the number of HIV positive individuals who reported injecting for more than 50% of the year fell from 40 to 5% (x² ₍₄₎ = 15.23, p < 0.01) whilst the number who reported at least one injection per year fell from 51 to 23% (x² ₍₄₎ = 62.06, p < 0.001). By comparison amongst non-HIV-infected patients the percentage who reported opiate use for more than 50% of the visits during a year rose from 54% in 1986 to a peak of 70% in 1989 (x² ₍₄₎ = 10.22, p < 0.05) and those who reported opiate use at least once during the year rose from 57% in 1986 to a peak of 75% in 1989 (x² ₍₄₎ = 14.3, p = 0.006). Combined medical and drug clinics from 1986 to 1990 together with a multi-disciplinary team approach to medical care was successful in delivering health care to HIV-infected injection drug users. We have initiated and maintained contact with HIV infected drug users, undertaken laboratory monitoring of HIV in 95% of patients and noted a decrease in self-reported high risk injection drug use. Whilst such a system is relatively inefficient from the health service's point of view, it may be necessary in order to maintain contact with the most difficult drug users.