Health: Even drug dealers can show some pity: Edward Platt reports on an agency that has found a way of offering help and treatment to the heroin addicts no one else can reach

On a milk-of-human-kindness scale, drug dealers must score very low. Yet in east London some dealers are introducing addicts to a very unusual agency. One has offered addicts a free pounds 10 bag of heroin as an incentive to go and sign on at HOT, the Healthy Option Team, which was set up to help injecting drug users with HIV, but soon discovered that those at highest risk of infection were homeless.

'People often ask why dealers should want to refer people to us,' says Matthew Southwell, the team manager. 'Well, they're human, and they're users themselves - they're not Colombian drug barons. People have got tied up in their comic-book fantasies of drug dealers. By networking into the right dealers, we were able to access people.'

HOT was established in 1988 and moved to premises in the Mile End Road in 1991, 'bang in the middle of the local drug scene' and within easy reach of a dozen dealers. The team now estimates that 98 per cent of referrals come from other users or dealers.

Lucy (not her real name) is one example. She was thrown out of her home by her partner when she began to take heroin. She started selling drugs to make money.

'If you're a dealer, you get to talk to people. I had regular clients, and I'd know if their habit was going up, and if they were doing a lot of bad things to get their money. Sometimes they'd come to you crying, saying 'God, what am I going to do next?' When people get like that, your heart goes out to them.' After referring others, two-and-a-half years ago she finally referred herself to HOT and has started on a methadone programme, a substitute for her heroin habit.

In 1991, the team started a project working specifically with homeless addicts. They soon discovered that unexpected community systems existed, and no matter how chaotic the lives of addicts with HIV were, their friends and the dealers remained constant. It was these systems they started to tap into.

'We found a whole population that no one else was working with,' says Mr Southwell. Some of HOT's methods are controversial. Traditional methods, such as outreach workers or advertising, had failed to attract this most difficult to help and needy group of people. In many cases, drugs users had found they could not register with more conventional agencies because most require proof of residence.

At the same time, it is held that drug workers should not be users themselves because they need to be at one remove from the people they are counselling. HOT employs users and ex-users at every level of the service, from receptionist upwards. The results have been overwhelming. Now a team of six helps 63 originally homeless users and 27 with HIV or Aids - 90 per cent of clients are homeless when they arrive, but they are rapidly housed.

When HOT was set up with money from North East Thames Regional Health Authority Aids budget (it now receives pounds 165,000 a year and is looking for more) it soon became clear that the most chaotic users, those at highest risk of infection, were homeless. They were part of a growing population of people living on the streets, in hostels and squats who had fallen through the social security net.

'They were the ones that no one knew what to do with, the ones that had been excluded from all the other services,' says Mr Southwell.

As they began to draw their clients in, and study their needs, they discovered that health care was rarely a priority, even for those who were HIV-positive; finding an adequate drug supply, and somewhere to live, were far more important. 'If someone is saying to you, 'I'm about to go to court, I'm likely to go down, I've got no house, no benefits, my life is a mess', then there's no point in us saying 'Come in and detox with us'. For most people, it's the last thing on their list.'

They have devised a 'holistic service', offering help with accommodation, legal advice, welfare and benefits and general health before considering the question of drug use. Then, once their clients' lives are more stable, they pass them on to more traditional agencies. It is a non-judgemental policy designed to deter as few people as possible - even those who tend to be suspicious of medical services. They maintain close links with social services and local GPs. 'It's a question of allowing people to dictate their own care. We say, here are the options, you choose what you're happy with.'

Matthew Southwell came from a background of HIV work, where people expected to be involved in the services provided for them, and he wanted to apply the same principles to drugs work. But he believes that most drug agencies found the idea that users might have something to contribute to their services 'immensely challenging'.

Just as he has exploited the users' own networks to get results, he has used the Patient's Charter to help to present HOT's radical methods in an acceptable light, since patient choice and patients' rights are common to both. 'We're not a bunch of wacky drug workers talking to junkies - we're NHS managers talking to patients about the services we provide.' He can lapse into a bureaucratic jargon - HOT's methods are 'cost-effective' and its services 'consumer evaluated'.

Their success, says Tracy Stein, of Access to Health, an organisation set up to improve health care for the homeless, is due to the fact that they cross the divide between mainstream NHS services and the world of their disadvantaged client group.

Cristina Simionato, who had been using heroin for seven years, is a shining example of HOT in action. When she and her former partner, who was HIV positive, were evicted from their squat in 1989, they were put in touch with the HOT team. Six months later, she moved into her own flat and began an oral methadone programme. Since then her methadone prescription has fallen from 85mg to 20mg a day. Four months ago, Ms Simionato started to work once a week among Italians in east London with drug habits. Last month she took up a full-time job as a drugs and HIV counsellor.

'With my experience of drug use, I know how to help,' she says. 'I can make newcomers feel at home. You get to feel like you're part of a family. For myself, I'm not really interested in taking drugs any more, because I'm busy and I'm doing something I like.'

(Photograph omitted)