The role of the satellite clinic in reaching intravenous drug users at risk from HIV

The arrival of HIV has challenged the traditional services for intravenous drug users providing the im petus to re-examine working practices. Only 10% of intravenous drug users attend hospital based treat ment centres offering out-patient programmes based on reducing doses of oral methadone with an ulti mate goal of abstinence (Hartnoll et al, 1985), yet for public health programmes designed to limit the spread of HIV it is important to increase the contact between high-risk groups and health professionals. Satellite clinics originally introduced to provide low cost help for drug users at a more local level may also be effective as a means of reaching intravenous drug users at high risk of HIV who would otherwise not be exposed to treatment and health education. Strang has described how a satellite clinic may be established with few resources, with staff who can be supervised by more senior workers at a central site (Strang & Creed, 1985). In this study the client groups of a satellite clinic and a conventional drug dependency unit were compared in order to charac terise the clientele of the satellite clinic and to dis cover whether it was indeed fulfilling a useful role in terms of attracting such high-risk individuals for treatment. Drug Indicators Project has already demonstrated that attcndcrs at the satellite clinic are more likely to abuse a variety of drugs and have more drug-related social problems than the drug dependency unit attendcrs (Daviaud, 1987), and Dolans has shown that these two factors are linked with an increased rate of needle-sharing among intravenous drug users (Dolans et al, 1987). Accordingly it might be expected that there would be more needle-sharing among the satellite clinic attenders, and so this and other risk factors for HIV infection were specifically investigated in the two clinic populations. Demo graphic and other variables were also investigated to aid comparison of the two samples with each other and with subjects of other studies.

The arrival of HIV has challenged the traditional services for intravenous drug users providing the im petus to re-examine working practices.Only 10% of intravenous drug users attend hospital based treat ment centres offering out-patient programmes based on reducing doses of oral methadone with an ulti mate goal of abstinence (Hartnoll et al, 1985), yet for public health programmes designed to limit the spread of HIV it is important to increase the contact between high-risk groups and health professionals.Satellite clinics originally introduced to provide low cost help for drug users at a more local level may also be effective as a means of reaching intravenous drug users at high risk of HIV who would otherwise not be exposed to treatment and health education.Strang has described how a satellite clinic may be established with few resources, with staff who can be supervised by more senior workers at a central site (Strang & Creed, 1985).In this study the client groups of a satellite clinic and a conventional drug dependency unit were compared in order to charac terise the clientele of the satellite clinic and to dis cover whether it was indeed fulfilling a useful role in terms of attracting such high-risk individuals for treatment.
Drug Indicators Project has already demonstrated that attcndcrs at the satellite clinic are more likely to abuse a variety of drugs and have more drug-related social problems than the drug dependency unit attendcrs (Daviaud, 1987), and Dolans has shown that these two factors are linked with an increased rate of needle-sharing among intravenous drug users (Dolans et al, 1987).Accordingly it might be expected that there would be more needle-sharing among the satellite clinic attenders, and so this and other risk factors for HIV infection were specifically investigated in the two clinic populations.Demo graphic and other variables were also investigated to aid comparison of the two samples with each other and with subjects of other studies.

Description of the easy access satellite clinic (Rathbone Place)
In 1985 Rathbone Place Clinic was set up in a Pro bation Office.It was hoped it would reach clients who did not not attend hospital based drug treatment centres, in particular the homeless drug users living around the West End for whom no treatment service provision had been made and who lived by theft, prostitution and drug related activities, thus bringing them in frequent contact with the law.The clinic is staffed by an experienced nurse and a psychiatric trainee and is run once a week.The links with pro bation officers (two of whom have a brief to work with drug users) are good and there is close involve ment with Narcotics Anonymous, who provide counselling and a meeting on the same day that the clinic is open.
The clinic is run on a walk-in basis and provides counselling, advice on treatment, methadone reduc tion programmes, health education and condoms.
The philosophy is of harm reduction with nego tiation with the drug user about rate of reduction of the methadone provided within strict limits concern ing adherence to the prescription.Many referrals re flect the intravenous drug users' conflict with the law (e.g.assessment for court reports or advice for those on probation).In the first year the majority cited legal problems as the main reason for seeking help although in the second year (including the study period) drug users also attended on the advice of outreach workers, based in the West End.
Drug Indicators Project has shown that the clien tele at Rathbone Place are different from those attending the drug dependency unit in that they are twice as likely to be in unstable accommodation (66%) and are more likely to be poly-drug users (59% opiate use only, compared with 80% opiate use only, at the drug dependency unit).(Daviaud, 1987).There is evidence of a shorter drug career in those in the "no previous treatment group" at the easy access centre.The profile is similar to those attending voluntary crisis intervention services such as City Roads.

The study
There is a considerable problem in comparing studies in this field due to differences in data collection and sample popu lations.We have therefore described the methodology in some detail.
All injecting drug users making first contact with the sat ellite clinic or the drug dependency unit during the period May to November 1987 were eligible to be included in the study.However interviewing was not carried out on some days because of staff shortages.
At the satellite clinic 75% of new attenders were inter viewed and of them one declined to participate and one could not participate because of an abnormal mental state, leaving a total sample of 63 intravenous drug users, 73% of all clinic attenders.One hundred and eighty five patients attended the drug dependency unit during the study period.The questionnaire was presented to 112 patients injecting drugs, of whom two declined to participate, one was too ill, and 10 did not complete, leaving a total sample of 99, or 54% of all new patients.A previous survey at the latter unit had revealed that 75% of new patients inject drugs and on this basis 139 of the total of 185 would be expected to be injecting so that our sample would represent an estimated 71% of all the injecting drug users attending the drug dependency unit.
Subjects were interviewed by clinic workers experienced in eliciting information from this type of client.A specially designed questionnaire was used as a basis for this inter view, and the information obtained was recorded by the interviewer.Questions were designed to elicit information about risk factors for the spread of HIV infection in this population and were concerned with sexual and needlesharing behaviour, as wellas basic demographic data.In the satellite clinic group the Soho lifestyle includes mobile groups of British and foreign nationals.Whether or not people had shared needles with people from Italy, Scotland and Spain was recorded because of the high HIV prevalence rate in those countries.Needle-sharing with people from Ireland was also recorded because the client group appeared to contain a number of Irish intravenous drug users who had recently arrived in London.The question naire's aim was to investigate HIV risk through the numbers of people each subject had been in contact with rather than through the total number of possibly infective episodes; thus subjects were asked how many people they snared with in a year rather than on how many occasions they had shared needles.
Comparisons were made between the subjects attending the two clinics according to the responses made to the items on the questionnaire.Non-parametric statistics were used: for continuous variables a two-tailed Kendall's S value and for discontinuous variables the Chi squared test.

Thefindings
Out of a total of 63, 39 (62%) were male.The age range was from 19 38 with a mean of 27 and a standard deviation of 4.8 years.The number of years of drug use ranged from less than one to 19years with a mean of 7 years and a standard deviation of 4.9 years.
Of the 63 intravenous drug users, 34 (54%) had shared needles within the last 12 months and only nine (14%) had never shared needles.The number of people shared with in a year ranged from none to 100.although most intravenous drug users had shared with only a few others (mean 4.9).Twenty-two (36%) of the 61 who answered said they had at some time used works supplied by a dealer.Of those who had ever shared needles, 30 (56%) had shared with someone from Scotland (13), Ireland (11), Italy (7) or Spain (3).Fifty-four (86%) had been sexually active within the previous year and of them 29 (54%) had multiple partners and 30 (56%) reported that at least one of their partners also injected drugs.There were four men with male partners in the last year and five women with female partners.No-one reported bisex ual activity.Two of the male homosexuals had large numbers of partners, whereas four of the female homosexuals had only one and the fifth had three.
Seventeen (25%) intravenous drug users admitted to prostitution at some time in their lives, six (15%) of the men and 11(47.8%) of the women.Three (5%) had had large numbers of sexual partners in the pre vious year, suggesting that they were currently ac tively engaged in prostitution: two male homosex uals who had approximately 100 and 700 partners and a woman with at least three to four partners a day, totalling about 1200 partners in the year.
DDU attenders had a mean age of 28 (s.d.5.8) and 64% were male.There were no significant differences between the two groups in age, sex, length of inject ing, sexual activity or number of people shared with in the previous year.However, intravenous drug users at the satellite clinic were more likely than DDU attenders to have shared needles within three months (P < 0.001, see Table I).

Comment
There was a low refusal rate and it was our im pression that the subjects answered questions fairly freely and were cooperative, but future studies may benefit from examination of reliability of the ques tionnaire.By presenting the questionnaire at first contact it was hoped that users would be more candid about their activities than at a later time when anxiety to appear compliant with a treatment pro gramme might lead them to produce misleading answers.Early presentation of the questionnaire also meant that a large proportion of all attenders could be interviewed, including some who might attend on only one occasion.Conversely, it is not possible to say to what extent the samples were representative of clients who actually went on to make good use of the drug treatment facilities, as opposed to those who might have attended only sporadically.
The percentage of intravenous drug users sharing needles within the clinic populations is similar to figures described by previous writers in London in 1985 (Mulleady & Green, 1985).This finding, there fore, does not support reports of changing needle using habits in intravenous drug users.Figures from outside London vary widely.A sample collected of intravenous drug users from Edinburgh had an aver age of 14 contacts in one month, with 42% of them sharing weekly, whereas in the same report intra venous drug users from Glasgow had on average seven contacts in one month (Robertson et al, 1986).German (Harms et al, 1987)and Italian (Tirrelli et al, 1986) figures of 92% and 90% of intravenous drug users sharing needles respectively are probably partly accounted for by differences in the definition of the time period used.Lack of a clear description of samples and methods used in other studies and dif ferences between samples unfortunately prevent detailed comparison with them and may obscure significant findings.
Caution is required in interpreting the data on prostitution.Not all those admitting to exchanging sex for drugs or money at any time will have used prostitution as their main source of revenue.Drug users change their source of revenue according to circumstance (for example one drug user said that while on a suspended sentence prostitution would be less likely to result in being sent to prison than further thieving, and another mentioned prostitution with dealers in return for drugs when "times are hard").
The figures quoted from Germany of 50% of female and 10% of male intravenous drug users prostituting at some time in their lives are similar to those found in this study (Harms et al, 1987).A previous London study reported current prostitution in 6% of intra venous drug users (Mulleady & Green, 1985),and this result would seem fairly close to the present study's finding that three (5%) of intravenous drug users admitted to prostitution at some time and also had a large number of sexual partners in the previous year.
We could find little description of sexual behav iour of drug users in the literature with which to com pare our data.With regard to numbers of sexual partners who are also drug users, in the German study 83% of intravenous drug users had sexual partners who were also intravenous drug users (Harms et al, 1987) and at least 38 (67%) of 57 intra venous drug users in a London study were couples who shared with one another (Mulleady & Green, 1985).The latter figure is close to the figure (56%) in this study.

Comparison of the two clinics
This study shows that as far as risk factors for HIV infection behaviours are concerned, clients at the sat ellite clinic were significantly more likely to have shared needles recently than attenders at the drug dependency unit, but significant differences between the samples were not detected in other areas.This finding is in accordance with Dolans' work showing that a large number of drug-related social problems (as found in the satellite clinic attenders) are associ ated with an increase in HIV risk behaviour (Dolans et al, 1987).It is also interesting to compare this result with Selwyn's finding of increased needle-sharing and reduced knowledge about HIV in intravenous drug users seen at a non-treatment site (Selwyn et al, 1987), since in the present study the differences are observed between clients attending two different types of treatment centre.
Longitudinal studies would be needed to determine whether the samples of drug users remain distinct or if the differences found represent points in a fluctuating career of drug dependence.With this caveat, the find ing of more needle sharing behaviour within three months at the satellite clinic implies that this clinic is bringing intravenous drug users in greater need of health education and counselling into contact with health and treatment services.Probation services probably have a high level of contact with drug users (Tirrelli et al, 1986;Selwyn et al, 1987) yet treatment services have been slow to form therapeutic links.The clinic described here provides a low cost model of a service which is demonstrably effective in reaching a high risk group and so is ideally suited to a major role in countering the HIV epidemic.With the rapid expansion in the number and variety of psychotherapy courses in this country, it is per haps timely to review some of the issues influencing these courses.One purpose of this paper is intended to draw attention to the fact that not only are there interesting conflicts in establishing such courses but also establishments whose power relationships affect the educational effectiveness of these complex teaching ventures.These issues will be discussed with reference to the trainees, trainers, patients, and host organisations.

The trainees
For trainees the conflicts begin as soon as they con template applying for the course.At some level they realise that they may be committing themselves to a great deal of work with less time for family and leisure.There is also the risk for career general psychiatrists that they may be 'branded' psycho therapists and that in some circles that may prejudice their progress in psychiatry.More personally, an in crease in self-knowledge, whether via a 'training' therapy or other aspects of a course, may be at least uncomfortable.
Most applicants for such courses already, at some level, regard themselves as psychotherapists and stand to suffer a considerable narcissistic blow should they be not accepted on a course.This is felt keenly by them and is compounded by any change, real or imagined, in the eyes of colleagues who may also have looked to them as having psychotherapeutic expertise.This leads one to ask what arc the mo tives for seeking a place on such courses.Is it to learn a technique or range of techniques?Is it a disguised C. A. LUND,Consultant Psychotherapist, Claremont House, The Royal Victoria Infirmary, Newcastle upon Tyne (Director of the Newcastle Psychotherapy Course) This paper is based on a lecture given at the AUTP Conference, 'Teaching Dynamic Psychotherapy' College Oxford 14-16 April 1988.