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T
he Staying Safe study is a hepatitis C prevention project with a
difference. Instead of focusing on risk practices and transmission
events, such as the sharing of needles and syringes, we were
interested in how protective practices arose and were maintained over
time. Here, people who had been injecting for the long-term and who
did not have hepatitis C were the experts – or the ‘cases’, with those who had
hepatitis C also interviewed as ‘controls’.
Our 37 participants (ten women, 27 men) were recruited through drug
services and drug user networks in South East and north London. Twenty-two
were hepatitis C negative, and 15 hep C antibody positive. Twenty-five primarily
used heroin, with 12 preferring a crack and heroin mix. All but two were also on
an opiate substitution treatment (OST) programme, with the majority receiving
methadone (31) and four Subutex.
In order to understand the protective factors that helped some people avoid
hepatitis C we chose a broader approach than one that focused purely on
injecting practices, and conducted interviews where we invited participants to talk
about their lives – from birth to the present date – in a way which was meaningful
for them. The process included developing a life history timeline, which helped to
jog people’s memories about significant events, but more importantly allowed us
to explore the interconnection between people’s protective and risk practices and
what was going on in their lives at the time.
We identified a range of protective practices – such as not sharing needles
and syringes – which was unsurprising in itself. What was interesting however,
was that these protective practices were not generally related to hepatitis C or
HIV avoidance, but to more immediate meaningful concerns such as looking after
veins, avoiding withdrawal, having a quiet private place to concentrate on
injecting, and the pleasure of being able to relax and enjoy the hit. They were
also concerned about maintaining social relationships, image management
(presenting as a ‘non-user’ to avoid stigma and police attention), controlling
quality of the drug mix and preventing dirty hits. Hepatitis C and/or HIV
prevention was a concern for some, but for many was not a priority.
For people who inject regularly, veins are precious and minimising the pain
and length of injection time was a primary concern, and one of the main reasons
for using new needles. Half of the participants began injecting before hepatitis C
had been named and when they also knew little about HIV, or did not see it as a
relevant risk. For many, an early motivation to use new works (needle and
syringes) was because they were sharp and would therefore cause less vein
damage.
A number of the participants had transitioned to groin injecting, however many
were fearful of making this move and expressed a desire for help and advice
about maintaining and finding other veins to use. Very little help was forthcoming
however, with participants who had sought advice encouraged to stop injecting.
This only served to increase their frustration and disengagement from services.
It has been well documented that the most risky injecting practices take place
when people are in withdrawal or quickly trying to avoid its onset. It was no
surprise, therefore, to find that strategies participants used to avoid withdrawal also
helped them avoid hepatitis C. The majority of participants were on a methadone
script and, for those who could, stockpiling methadone was key to protecting
against withdrawal, as well as allowing them to help out others in need.
WHAT ABOUT RISK?
Fifteen of our 37 participants were hepatitis C antibody positive, and even those
who were negative did not necessarily maintain protective practices all of the
time. The facilitators of risk that came up ranged from the personal (such as
inability to prepare and administer drugs) to the situational (such as missing an
OST dose or having limited money) to the structural (such as being affected by
policing, or lack of accommodation and benefits).
Misunderstandings about hep C transmission were apparent in many
participants’ narratives and could place them at risk. Most were in long-term
heterosexual relationships and, as with many long-term couples, condoms were
infrequently used. Sharing works and other injecting equipment between couples
was often framed in terms of a ‘risk equivalence’ – ie, the belief that there was
just as much risk catching hep C through unprotected sex as through sharing
injecting equipment.
The risk of heterosexual transmission of hep C is very low, unlike the risk of
transmission through injecting equipment. While there are a number of reasons
that people may choose to share injecting equipment with their sexual partners
(such as an expression of trust and intimacy) participants’ frequent references to
a ‘risk equivalence’ between injecting and sexual practices, indicates that – given
other information – they may have rethought their sharing practices.
While participants had access to services providing free sterile needle and
syringes, there was no or little provision out of hours and no peer-operated
exchanges in the area. The primary providers of needles and syringes for London
users were pharmacies and drug and alcohol services, but participants were
inhibited from using them by fears about confidentiality and being cut off their script.
RECOMMENDATIONS FOR PRACTICE
Interventions advising people on changing their injecting practices have had
limited success in the past. They need to be coupled with interventions that
acknowledge the important social dynamics of injecting and the role of social
networks, environments and services in helping to facilitate protective practices.
Fundamental is the removal of barriers to sterile needle and syringe access.
Peer workers could have an important role in making needle exchange at drug
and alcohol services more accessible, particularly if accompanied by transparent
Participants in the
Staying Safe hepatitis
C prevention project
gave invaluable insight
into life-saving
protective practices.
The findings could be
used to make harm
reduction messages
much more relevant,
say
Magdalena Harris
and
Tim Rhodes
12 |
drinkanddrugsnews
| May 2014
Harm reduction |
Communication
www.drinkanddrugsnews.com
‘
The pleasure of injecting and drug
use in general seems to be the
elephant in the room in drug services,
where the preferred rhetoric is one of
“misuse”, “harm” and “recovery”.
’
Experts