Hygiene and uncertainty in qualitative accounts of hepatitis C transmission among drug injectors in Serbia

Acceptability of low dead space syringes and implications for their introduction: A qualitative study in the West of England

BACKGROUND

It is recommended that needle and syringe programmes (NSP) distribute low dead space syringes (LDSS) to reduce blood-borne virus transmission. We explored the acceptability of detachable LDSS among people who inject drugs (PWID) and staff who work to support them.

METHODS

Semi-structured interviews were performed with 23 PWID (15 men and 8 women) and 13 NSP staff members (6 men and 7 women) in Bath and Bristol, England. Recruited PWID reflected varying demographic characteristics, drug use and injecting preferences. Interviews explored experiences of different types of injecting equipment, facilitators and barriers of changing this equipment and attitudes towards detachable LDSS. Interviews were audio recorded, transcribed verbatim and analysed using the Framework Method.

RESULTS

Decisions about injecting practices were underpinned by several factors, including early experiences and peer initiation; awareness and availability of alternatives; and the ability to inject successfully. Rinsing and re-using syringes represented a quandary where rinsing could encourage re-use, but not rinsing could result in the re-use of unclean equipment. Most PWID were reluctant to change equipment particularly in the absence of any problems injecting. Prioritising getting a 'hit' over the prevention of potential problems was an important barrier to change. Overall detachable LDSS are likely to be acceptable. Lower risk of transferring infections and reduced drug wastage were valued benefits of detachable LDSS. There was a preference for a gradual introduction of detachable LDSS in which PWID are given an opportunity to try the new equipment alongside their usual equipment.

CONCLUSION

Detachable LDSS are likely to be acceptable and should therefore be offered to those using detachable high dead space syringes and/or fixed 1ml LDSS syringes to inject into deeper femoral veins. An intervention is needed to support their introduction with 'training', 'education', 'persuasion' and eventual 'restriction' components.

Open drug scenes and drug-related public nuisance: a visual rapid assessment research study in Dublin, Ireland

The research was undertaken at a time of increasing public concerns for drug- and alcohol-related public nuisance in the city center of Dublin, Ireland. Rapid Assessment Research was conducted involving qualitative interviewing with drug service users; business, transport, community, voluntary, and statutory stakeholders (n = 61); and an environmental mapping exercise. The interplay between homelessness, loitering, an influx of drug users via city metro systems, transient open drug scenes, street drinking, drug injecting, intimidation, knife crime, and prescribed medication abuse was evident. Potential strategies to address drug and alcohol related public nuisance are advised to include the relocation of treatment services, targeted harm reduction initiatives, urban regeneration, improved community rehabilitation pathways, and heightened policing intensity.

Public injecting drug use and the social production of harmful practice in high-rise tower blocks (London, UK): a Lefebvrian analysis

This paper presents, qualitative findings relating to specific environments hitherto unrecognised as settings used for the injecting-use of illicit drugs in an urban setting. This concerns the temporary appropriation of communal space within high-rise social-housing by injecting drug users (IDU); specifically those settings used by tower-block residents for garbage disposal ('bin chute rooms'). These environments were found to be used on daily, habitual bases by all IDU interviewed during the study. Such settings were found to contribute to a wide range of injecting-related harm and hazard. These findings further debate concerning the negative effect of place on health risk in the context of 'public' injecting drug use. These results are situated within Lefebvre's theoretical framework concerning the 'production of space'. It is contended that the 'representational spaces' shaped by IDU creates a dialectic between wider 'spatial practice' and 'representations of space'. Accordingly, it is further suggested that particular 'spaces' of harm reduction (such as 'safer injecting facilities') should be considered in UK settings in order to address injecting-related harm.

Addiction research ethics and the Belmont principles: do drug users have a different moral voice?

This study used semi-structured interviews and content analysis to examine moral principles that street drug users apply to three hypothetical addiction research ethical dilemmas. Participants (n = 90) were ethnically diverse, economically disadvantaged drug users recruited in New York City in 2009 . Participants applied a wide range of contextually sensitive moral precepts, including respect, beneficence, justice, relationality, professional obligations, rules, and pragmatic self-interest. Limitations and implications for future research and the responsible conduct of addiction research are discussed.

Improving survey methods in sero-epidemiological studies of injecting drug users: a case example of two cross sectional surveys in Serbia and Montenegro

BACKGROUND

Little is known about the prevalence of HIV or HCV in injecting drug users (IDUs) in Serbia and Montenegro. We measured prevalence of antibodies to HIV (anti-HIV) and hepatitis C virus (anti-HCV), and risk factors for anti-HCV, in community-recruited IDUs in Belgrade and Podgorica, and determined the performance of a parallel rapid HIV testing algorithm.

METHODS

Respondent driven sampling and audio-computer assisted survey interviewing (ACASI) methods were employed. Dried blood spots were collected for unlinked anonymous antibody testing. Belgrade IDUs were offered voluntary confidential rapid HIV testing using a parallel testing algorithm, the performance of which was compared with standard laboratory tests. Predictors of anti-HCV positivity and the diagnostic accuracy of the rapid HIV test algorithm were calculated.

RESULTS

Overall population prevalence of anti-HIV and anti-HCV in IDUs were 3% and 63% respectively in Belgrade (n = 433) and 0% and 22% in Podgorica (n = 328). Around a quarter of IDUs in each city had injected with used needles and syringes in the last four weeks. In both cities anti-HCV positivity was associated with increasing number of years injecting (eg Belgrade adjusted odds ratio (AOR) 5.6 (95% CI 3.2-9.7) and Podgorica AOR 2.5 (1.3-5.1) for >or= 10 years v 0-4 years), daily injecting (Belgrade AOR 1.6 (1.0-2.7), Podgorica AOR 2.1 (1.3-5.1)), and having ever shared used needles/syringes (Belgrade AOR 2.3 (1.0-5.4), Podgorica AOR 1.9 (1.4-2.6)). Half (47%) of Belgrade participants accepted rapid HIV testing, and there was complete concordance between rapid test results and subsequent confirmatory laboratory tests (sensitivity 100% (95%CI 59%-100%), specificity 100% (95%CI 98%-100%)).

CONCLUSION

The combination of community recruitment, ACASI, rapid testing and a linked diagnostic accuracy study provide enhanced methods for conducting blood borne virus sero-prevalence studies in IDUs. The relatively high uptake of rapid testing suggests that introducing this method in community settings could increase the number of people tested in high risk populations. The high prevalence of HCV and relatively high prevalence of injecting risk behaviour indicate that further HIV transmission is likely in IDUs in both cities. Urgent scale up of HIV prevention interventions is needed.

Violence, dignity and HIV vulnerability: street sex work in Serbia

Sex work can be contextualized by violence, social and material inequality, and HIV vulnerability. We undertook a qualitative study to explore female and transvestite sex workers' accounts (n = 31) of HIV risk environment in Belgrade and Pancevo, Serbia. Violence emerged as a key theme. Accounts emphasise the ubiquity of multiple forms of everyday violence - physical, emotional, social - in street sex work scenes, linked to police as much as clients. We highlight the salience of emotions in sex work risk management, in which the preservation of dignity is of prime importance. Accounts draw upon narratives of hygiene and responsibility which, we argue, seek to resist portrayals, normative to this setting, of sex workers as contaminated and irresponsible. Findings highlight how the ubiquity of the risk of violence in street sex work scenes reflects institutionalised social inequalities and injustices. Sex workers are inevitably participant in the cycle of symbolic violence they seek to resist. The challenges for HIV prevention are therefore considerable, and require interventions which not only seek to foster safer micro-environments of sex work but structural changes in the welfare, criminal justice and other social institutions which reproduce the cycle of violence faced by sex workers day to day.

The social production of hepatitis C risk among injecting drug users: a qualitative synthesis

BACKGROUND

Intervention impact on reductions in hepatitis C virus (HCV) incidence among injecting drug users (IDUs) are modest. There is a need to explore how drug injectors' interpret HCV risk.

AIMS

To review English-language qualitative empirical studies of HCV risk among IDUs.

METHODS

Qualitative synthesis using a meta-ethnographic approach. Searching of eight electronic databases and reference lists identified manually papers in peer-reviewed journals since 2000. Only studies investigating IDU perspectives on HCV risk were included. Themes across studies were identified systematically and compared, leading to a synthesis of second- and third-order constructs.

FINDINGS

We included 31 papers, representing 24 studies among over 1000 IDUs. Seven themes were generated: risk ubiquity; relative viral risk; knowledge uncertainty; hygiene and the body; trust and intimacy; risk environment; and the individualization of risk responsibility. Evidence supports a perception of HCV as a risk accepted rather than avoided. HCV was perceived largely as socially accommodated and expected, and in relative terms to human immunodeficiency virus (HIV) as the 'master status' of viral dangers. Symbolic knowledge systems, rather than biomedical risk calculus, and especially narratives of hygiene and trust, played a primary role in shaping interpretations of HCV risk. Critical factors in the risk environment included policing, homelessness and gendered risk.

CONCLUSIONS

Appealing to risk calculus alone is insufficient. Interventions should build upon the salience of hygiene and trust narratives in HCV risk rationality, and foster community changes towards the perceived preventability of HCV. Structural interventions in harm reduction should target policing, homelessness and gendered risk.