This article is part of Telescope: The New AIDS Epidemic, a deep-dive investigation into the modern face of a disease that transformed the world.

GLASGOW, Scotland — When someone in Glasgow complains about a nearby needle-exchange program, John Campbell is the man sent in to explain why it's necessary. Now, as Scotland’s largest city struggles with a resurgent HIV epidemic, he finds himself explaining why these exchanges aren’t enough.

Just as an outbreak of the virus in Edinburgh in the mid-1980s required the radical rethink of drug policy that led to needle exchanges, today’s epidemic necessitates an equally bold initiative, he argues: Glasgow should set up so-called drug-consumption rooms, in which people can inject their own cocaine and heroin under medical supervision.

“If this would have been implemented 20 years ago ... this outbreak would not have happened or would have been under control much faster," said Campbell, the NHS's needle-exchange coordinator.

It’s not an easy sell, especially to the British government in London, whose approval would be required. Unlike in the 1980s, when HIV and AIDS were seen as a dire threat to public health, medical advances in treatment and prevention mean the epidemic has been largely confined to marginalized communities — in Glasgow’s case, a small group of less than 200 injecting drug users.

“Anything that’s perceived as a threat to the general population gets much higher up in the political agenda” — Andy McAuley, researcher

That makes controversial programs, such as a government-run facility in which drug users can shoot up, a difficult sell.

Andy McAuley, a researcher at Glasgow Caledonian University and one of the first to investigate the epidemic, believes that the national response would be “much more emphatic” if another group were hit by an infectious disease of this magnitude — such as Zika or Ebola.

“Anything that’s perceived as a threat to the general population gets much higher up in the political agenda,” McAuley said. “But that’s not happened in Glasgow.”

Perfect storm

Campbell points to a housing complex in Glasgow's East End. When a nearby needle exchange recently shut down, people began breaking into the apartments to shoot up. They left blood on the walls and peed on the carpets.

Policies that focus only on stopping people from doing drugs simply don’t work, he said. Shut down a needle-exchange program and people just inject elsewhere.

“The drugs have never been cheaper; the drugs have never been more available; the drugs have never been stronger,” he said. “That’s what we’re fighting against.”

It’s not the first time Scotland has grappled with an HIV epidemic driven by injectable drugs.

Roy Robertson was a clinician in Edinburgh when the city’s heroin problem hit in the 1980s. At the time, the city’s public health workers had their eyes fixed on an ongoing hepatitis B outbreak. AIDS was seen as something happening overseas, affecting mostly gay men in New York and San Francisco.

But soon after HIV tests became available in 1985, Robertson realized Edinburgh had a problem of its own: Within a year of the rollout, more than 50 percent of the drug-using population had tested positive for HIV — an epidemic famously depicted in the hit book and movie "Trainspotting."

“It was a perfect storm,” Robertson said. People were sitting around in a flat with one set of needles and injecting 20 to 30 people. “If you wanted to transmit a virus, this is how you would do it."

The solutions that Robertson and public health workers advocated were radical for their time — needle exchanges and methadone treatments. The Conservative government in London, led by Margaret Thatcher, was skeptical.

By contrast, across the North Sea, a group called the "Junkiebond" in the Netherlands set up needle exchanges in 1984 to fight hepatitis B and, later on, AIDS. In Edinburgh, Robertson and a small number of other doctors controversially began writing methadone prescriptions for drug users.

The public wasn't happy. Some patients refused to attend their clinics. Police started hanging around outside them. One local politician said that all HIV-infected people should be sent away to an island off the coast; others said they should be locked up.

The change came when the virus came to be seen as a threat to the general public. "It became irresistible" for politicians to ignore, Robertson said. “That’s when the tide turned.”

In 1986, the U.K. became one of the first countries to introduce government-run needle exchanges, a move credited with halting the spread of HIV and keeping it at bay for decades.

Resurgence

The Abbey Chemist in Glasgow's East End is home to the busiest needle exchange in the U.K. One pharmacist employed there estimates she spends most of the day exchanging needles and distributing methadone. A million needles are exchanged in Glasgow every year.

Campbell is working behind the counter when a young man walks in asking for “an exchange.” He doesn’t have needles to return, but he wants a few to take with him.

Campbell reaches for three blue one-hit kits and asks if he’s still using heroin. The man says he is but adds that he’s injecting cocaine, too. He stuffs the kits inside his sweatpants and walks out the door. The interaction takes 33 seconds.

Meanwhile, another man is leaning against another pharmacist in the corner, his eyes rolled back. He just overdosed outside on benzodiazepines — after probably taking the street stuff on top of the methadone prescription he had just picked up. A pharmacist found him on the corner and brought him inside, where Jackie Rolland, an NHS harm reduction nurse, gave him naloxone — an overdose treatment — and called the ambulance.

Thirty years after Edinburgh was hit, Glasgow is facing a perfect storm of its own. As recently as 2015, health workers believed that HIV had receded as a major threat — so much so that when they tested a drug user's blood, they checked the box for hepatitis C but skipped the one for HIV, according to McAuley, the researcher at Glasgow Caledonian University.

Before the spike, Glasgow registered usually around 10 HIV cases among drug users a year. In 2015, however, there were 47. By the beginning of 2020, that total was more than 160. While still far fewer than the thousands infected in Edinburgh in 1986, this marks a 10-fold increase in five years.

Researchers believe this specific strain of HIV originated around 2005 with one infected individual and spread to a small number of people over the years.

Then Glasgow's drug users started injecting cocaine. The drug had become a lot cheaper and more available than ever. Among a drug-using population that's often homeless, there were many who liked the sense of warmth it provided on the cold streets.

Cocaine brought with it a more chaotic injecting behavior. The high from cocaine doesn’t last as long as heroin, so users inject more frequently, which increases the likelihood that they'll grab a dirty needle off the ground or share one. Cocaine also increases libido, which increases the chances HIV will also spread through unprotected sex.

Again, a “perfect storm,” McAuley said.

‘Political football’

McAuley and others working to stop the HIV epidemic point to a lack of alarm about AIDS as one of the factors holding back new interventions like drug-consumption rooms.

With the widespread availability of antiretroviral medications, HIV is no longer perceived as a terrifying death sentence. Across the U.K., the number of people infected with HIV (mostly men who have sex with men) has been decreasing. But the outbreak in Glasgow among drug users is raising alarm bells, with the National AIDS Trust warning that "a larger outbreak in England is possible if investment and coverage of harm reduction initiatives are not increased."

Seen from Glasgow, the case for drug-consumption rooms isn't hard to make. In the absence of a sanctioned place to shoot up, people who use drugs use public toilets, bushes, car parks and abandoned buildings — "nooks and crannies," according to Kirsten Horsburgh, the drug death prevention strategy coordinator at the Scottish Drugs Forum, a group advocating harm reduction policies. She has even seen people shooting up from the office window.

By contrast, publicly run drug consumption rooms have been introduced in seven EU countries, as well as Switzerland, Norway and Canada, to address public injecting and the blood-borne viruses like HIV that come with it.

"The safer injection facilities become a bit of a political football" — Andy McAuley

Drug users that visit these rooms are given sterile needles and are monitored for safe injecting. They’re also connected with social services who try to get them off the streets. The centers have been shown to decrease risky injecting behavior that increases the chances of contracting HIV, according to self-reported data — though information on how well these centers decrease HIV incidents is less conclusive, according to a summary from the European Monitoring Centre for Drugs and Drug Addiction.

One 2010 study in Vancouver, for example, showed that a safe injection room prevented 35 new HIV cases in the city each year. A more conservative study in 2011 reported an estimate of five to six a year.

Drug-consumption rooms have the support of Scottish Health Minister Joe FitzPatrick and the rest of the Scottish National Party, but the U.K.'s Home Office has declined to put in place a pilot program, arguing that drug-consumption rooms would "condone" drug availability and imply "acceptance" of criminal activity.

The battle over the rooms has become part of a larger political fight between the SNP and Tories, even as the epidemic continues to grow.

Scotland's Lord Advocate could technically write an exemption so drug users won't be prosecuted, but he argues it's not within his power, and that the introduction of a drug consumption room would require a legislative change.

"The safer injection facilities become a bit of a political football," McAuley said. "We have this kind of toing and froing happening at the moment, and nobody's really kind of driving things forward."

Eye of the hurricane

In the meantime, Glasgow’s health workers are doing their best to brave the storm.

Pharmacists at Abbey Chemist pharmacy are still filling prescriptions and exchanging needles as the paramedics arrive and take the man who'd just overdosed out of the pharmacy. A string of drool hangs from his mouth.

Even after administering naloxone to the man, Jackie Rolland, the NHS harm reduction nurse, continues drinking her coffee and walking around with her chipper charm.

She walks around the neighborhood poking anyone nodding off on street corners. Annoying people doesn’t bother her. “I have thick skin,” Rolland said and shrugs. “I’m Glaswegian.”

It’s taken her years to build trust with the people who use drugs in Glasgow, a population that often doesn’t use mainstream health services but urgently needs help. Rolland estimates that 70 to 80 percent of her time is spent addressing leg ulcers from poor injecting that breaks the vein.

Rolland also convinces hundreds of people to take a quick dried blood spot test. This is difficult because when users come in asking for needles, they're in a hurry — the drugs are burning a hole in their pocket.

More recently, there's hope that the view in London could be changing. In January, the British government unexpectedly announced it'll host a drug summit in Glasgow; previously, it had refused an invitation to a similar event the Scottish government had planned in March.

Some see this as an indication that Prime Minister Boris Johnson will be more willing than his predecessors to consider drug-consumption centers. Others are less optimistic.

Meanwhile, a heroin assisted-treatment facility opened in Glasgow in December. People who come to the facility, which resembles a small doctor’s office, may sit in one of the four booths to inject pharmaceutical-grade heroin they have a prescription for, while a staff member watches them. They can then sit in the waiting room. It smells like fresh paint.

The facility targets "complex, high-risk" users, said Saket Priyadarshi, the service's medical doctor. Almost all of the nearly 10 people enrolled in the pilot are also injecting street drugs in addition to the prescribed methadone treatment. The facility hopes to get 20 enrolled by the end of the first year; 40 by the end of the second. The goal is to get people off the street drugs.

The truth is that a lot more people in Glasgow fit this profile. The facility is only reaching the tip of the iceberg: There are more than 4,600 injecting drugs users in the city, according to Priyadarshi.

Still, it’s a start. And if it succeeds, it could help make the case for a drug consumption room, where users may bring their own drugs. That would allow health care workers to reach more of the at-risk population and help minimize the public impact of injecting in Glasgow, Priyadarshi said.

Such a center would be a long time coming, he said.

"Better late than never," he added.

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