Learning from HIV and drug policy failures: reflections from clinical practice and research in Edinburgh

Purpose:
The purpose of this study is to review the evolution of drug use in South East Scotland over the period since 1980 and from the clinical experience and to consider the implications of early and evolving clinical practice and related policy on outcomes for individual cases. Also, this study derives conclusions about the success or failure of practice and policy on the medical and social outcomes for individuals, families and communities.

Design/methodology/approach:
This paper is a mixed method review of cases in clinical practice and publications carried out over the time period. The authors have published extensively in clinical journals and public health publications and draw on these experiences to describe a series of scenarios and observations which are a unique combination in the more general global pandemic of HIV/AIDS and the evolution of a modern substance use environment.

Findings:
Clinical practice in the community and in specialist services was unprepared for a rapidly rising number of people using injectable heroin. The introduction of the HIV agent into this community was also met with medical, social and criminal justice systems which had to react rapidly to a situation which, at the time, was seen as a threat to the whole population. So many unknowns required a national (and international) response. What has been learned from what is now seen as a historical disaster is considered in the current policy and political framework.

Research limitations/implications:
The events described energized the academic and research communities. To say that we now live in a different environment is an underestimate of the impact of HIV/AIDS and substance use on how we conduct research and the ethical framework which has evolved compared to earlier times. The need for involvement of lived experience and the independence of research from political or ideological control and influence is self-evident from the paper that is presented.

Practical implications:
Interpretation of clinical experience needs to be an integral part of planning projects. Structural changes allow early implementation of projects which link frontline services with specialist care and academic institutions. Unfortunately, silos still exist, and in a time of economic restraint, cooperation is curtailed by lack of interdisciplinary working. Learning from the events described in this paper should be helpful for clinicians, policymakers and funding agencies.

Social implications:
The social implications are enormous and almost too wide ranging to encapsulate in a few words. Since the 1980s, patient management and relationships have changed beyond recognition. Social norms have seen a revolution in attitudes to sexuality, drugs and relationships. Political and management practice has had to adjust and modernize to accommodate these changes. Unfortunately, these changes have not always penetrated the disadvantaged communities, and the lessons from the past have to be revisited. Hopefully, this paper will draw attention to ongoing inequalities.

Originality/value:
Although it is in some ways relating to events past, it is strangely contemporary in its message and the implications for policy and research communities. While dramatic improvements have been made, there are forces which still need to be overcome and warnings of the dangers of not learning from past mistakes should be highlighted. The recent COVID pandemic was a global shock which again suggested changes outlined in this paper from the HIV/AID pandemic (which is still a threat).