Trust, disruption and responsibility in accounts of injecting equipment sharing and hepatitis C risk

Maintaining the healthy body: Blood management and hepatitis C prevention among men who inject performance and image-enhancing drugs

Australia's ambitious aim to 'eliminate' hepatitis C as a public health concern by 2030 requires researchers, policy makers and health practitioners to engage with populations rarely identified as a priority. Men who inject performance and image-enhancing drugs (PIEDs) are one such population, yet research suggests they have low rates of knowledge about hepatitis C. Although rates of needle-sharing in this group are thought to be low, other risks of blood-to-blood contact exist due to the use of large-gauge needles, intramuscular injecting, hard-to-reach injection sites, repeated injecting and peer-to-peer injecting. How should health initiatives engage people who might not customarily consider themselves vulnerable to hepatitis C? Drawing on the work of body theorist Margrit Shildrick, this article considers how men who inject PIEDs understand their bodies, with a particular focus on injecting practices, blood awareness and infection control, in order to inform hepatitis C prevention efforts. In our analysis, we draw on qualitative interviews with 60 men who inject PIEDs, which we conducted for an Australian Research Council-funded project focused on better understanding PIED injecting to improve health and minimise hepatitis C transmission. The interviews suggest that men who inject PIEDs closely monitor potential external infection risks, such as dirt and bacteria that might intrude upon the 'purity and security' of the body. However, less attention appears to be paid to what might be transferred out of the body and potentially to others, such as blood. Notions of trust and cleanliness, and normative perceptions of intravenous drug use, also shaped injecting practices and cursory attention to blood management. While environmental transmission poses a smaller transmission risk than needle-sharing, educating PIED consumers about it is nevertheless warranted. Focusing targeted health promotion materials on environmental blood as a potential route of hepatitis C transmission may help engage this population in prevention, and encourage more frequent hepatitis C testing.

Silence Surrounding Hepatitis C Status in Risk Relationships Among Rural People Who Use Drugs

Hepatitis C virus (HCV) has reached epidemic proportions in rural Central Appalachia in recent years. We sought to identify demographic, behavioral, and interpersonal characteristics associated with HCV serostatus disclosure among high risk people who use drugs (PWUD) in Appalachian Kentucky. HCV antibody-positive participants (n = 243), drawn from the fifth follow-up assessment of a longitudinal study of rural PWUD, completed interviewer-administered questionnaires eliciting demographic and interpersonal characteristics, risk behaviors, and information about HCV disclosure. We assessed correlates of HCV disclosure using gender-stratified multivariate logistic regression. Participants reported having disclosed their HCV-positive status to a current sex partner (44.0%), family member (35.8%), close friend (9.5%), or past sex partner (6.6%). Of those reporting current (n = 72) or past (n = 215) injection drug use (IDU), only 2.8% disclosed to current and 0.9% disclosed to past IDU partners, respectively. Female participants were more likely than male participants to disclose to current sex partners and family member(s). In multivariate analyses, adjusting for time since testing HCV positive, older age and lifetime history of drug treatment were associated with decreased odds of HCV disclosure among females, while only lifetime history of drug treatment was associated with decreased odds of HCV disclosure among males. In summary, the almost complete absence of disclosure to current or former injection drug use partners was concerning. However, most participants (69.1%) reported disclosing their HCV status to at least one of their social referents, suggesting that family members, partners, and friends of people living with HCV could play a critical role in encouraging uptake of treatment. Although further research is warranted, it is clear that interventions are needed to encourage HCV disclosure among those most at risk of transmitting HCV.

Harm Reduction and Tensions in Trust and Distrust in a Mental Health Service: A Qualitative Approach

BACKGROUND

People seeking care for substance use (PSCSU) experience deep social and health inequities. Harm reduction can be a moral imperative to approach these persons. The purpose of this study was to explore relationships among users, health care providers, relatives, and society regarding harm reduction in mental health care, using a trust approach rooted in feminist ethics.

METHODS

A qualitative study was conducted in a mental health service for PSCSU, and included fifteen participants who were health care providers, users, and their relatives. Individual in-depth and group interviews, participant observation, and a review of patients' records and service reports were conducted.

RESULTS

Three nested levels of (dis)trust were identified: (dis)trust in the treatment, (dis)trust in the user, and self-(dis)trust of the user, revealing the interconnections among different layers of trust. (Dis)trust at each level can amplify or decrease the potential for a positive therapeutic response in users, their relatives' support, and how professionals act and build innovations in care. Distrust was more abundant than trust in participants' reports, revealing the fragility of trust and the focus on abstinence within this setting.

CONCLUSION

The mismatch between wants and needs of users and the expectations and requirements of a society and mental health care system based on a logic of "fixing" has contributed to distrust and stigma. Therefore, we recommend policies that increase the investment in harm reduction education and practice that target service providers, PSCSU, and society to change the context of distrust identified.

Hepatitis C virus genotype 3A in a population of injecting drug users in Montenegro: Bayesian and evolutionary analysis

Few reports are available on HCV molecular epidemiology among IDUs in Eastern Europe, and none in Montenegro. The aim of this study was to investigate the HCV genotype distribution in Montenegro among IDUs and to perform Bayesian and evolutionary analysis of the most prevalent HCV genotype circulating in this population. Sixty-four HCV-positive IDUs in Montenegro were enrolled between 2013 and 2014, and the NS5B gene was sequenced. The Bayesian analysis showed that the most prevalent subtype was HCV-3a. Phylogenetic data showed that HCV-3a reached Montenegro in the late 1990s, causing an epidemic that exponentially grew between the 1995 and 2005. In the dated tree, four different entries, from 1990 (clade D), 1994 (clade A) to 1999 (clade B) and 2001 (clade C), were identified. In the NS5B protein model, the amino acids variations were located mainly in the palm domain, which contains most of the conserved structural elements of the active site. This study provides an analysis of the virus transmission pathway and the evolution of HCV genotype 3a among IDUs in Montenegro. These data could represent the basis for further strategies aimed to improve disease management and surveillance program development in high-risk populations.

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.

Love, Trust, and HIV Risk Among Female Sex Workers and Their Intimate Male Partners

OBJECTIVES

We examined correlates of love and trust among female sex workers and their noncommercial male partners along the Mexico-US border.

METHODS

From 2011 to 2012, 322 partners in Tijuana and Ciudad Juárez, Mexico, completed assessments of love and trust. Cross-sectional dyadic regression analyses identified associations of relationship characteristics and HIV risk behaviors with love and trust.

RESULTS

Within 161 couples, love and trust scores were moderately high (median 70/95 and 29/40 points, respectively) and correlated with relationship satisfaction. In regression analyses of HIV risk factors, men and women who used methamphetamine reported lower love scores, whereas women who used heroin reported slightly higher love. In an alternate model, men with concurrent sexual partners had lower love scores. For both partners, relationship conflict was associated with lower trust.

CONCLUSIONS

Love and trust are associated with relationship quality, sexual risk, and drug use patterns that shape intimate partners' HIV risk. HIV interventions should consider the emotional quality of sex workers' intimate relationships.

Embodied accounts of HIV and hope: using audio diaries with interviews

Capturing the complexity of the experience of chronic illness over time presents significant methodological and ethical challenges. In this article, we present methodological and substantive insights from a longitudinal qualitative study with 20 people living with HIV in Serbia. We used both repeated in-depth interviews and audio diaries to explore the role of hope in coping with and managing HIV. Using thematic longitudinal analysis, we found that the audio diaries produced distinctive, embodied accounts that straddled the public/private divide and engaged with alternative social scripts of illness experience. We suggest that this enabled less socially anticipated accounts of coping, hoping, and distress to be spoken and shared. We argue that examining the influence of different methods on accounting not only illustrates the value of qualitative mixed-method study designs but also provides crucial insights to better understand the lived experience of chronic illness.

Hepatitis C avoidance in injection drug users: a typology of possible protective practices

Introduction

Hepatitis C virus (HCV) represents a serious public health concern. People who inject drugs (PWID) are at particular risk and nearly half (45%) of PWID in England may be infected. HCV prevention interventions have only had moderate impact on the prevalence of HCV in this population. Using qualitative methods, we sought to detail the protective practices potentially linked to HCV avoidance among PWID, and explore the motivations for these.

Methods

The study used a life history approach allowing participants to detail their lived experience both before and during the course of their injecting careers. Thirty-seven participants were recruited from drug services in London, and from referrals within local injecting networks. A baseline and follow-up in-depth qualitative interview was carried out with each participant, and for half, a third interview was also undertaken. All underwent testing for HCV antibody. Analyses focused on developing a descriptive typology of protective practices potentially linked to HCV avoidance.

Results

Practices were deemed to be protective against HCV if they could be expected a priori to reduce the number of overall injections and/or the number of injections using shared injecting equipment. Participants reported engaging in various protective practices which fell into three categories identified through thematic analysis: principles about injecting, preparedness, and flexibility.

Conclusions

All participants engaged in protective practices irrespective of serostatus. It is important to consider the relative importance of different motivations framing protective practices in order to formulate harm reduction interventions which appeal to the situated concerns of PWID, especially given that these protective practices may also help protect against HIV and other blood borne infections.

Injecting practices in sexual partnerships: hepatitis C transmission potentials in a 'risk equivalence' framework

BACKGROUND

Evidence indicates minimal hepatitis C (HCV) sexual transmission risk among HIV negative heterosexual partners. Limited HCV literacy has been demonstrated among people who inject drugs, yet there is a dearth of research exploring perceptions of HCV heterosexual transmission risk among this high risk population.

METHODS

We conducted a qualitative life history study with people who had been injecting drugs for over six years, to explore the social practices and conditions of long-term HCV avoidance. Participants were recruited through London drug services and drug user networks. The sample comprised 10 women and 27 men (n=37), of whom 22 were HCV antibody negative. Participants were aged from 23 to 57 years and had been injecting for 6 to 33 years. Twenty participants were in long term heterosexual partnerships.

FINDINGS

The majority of participants in relationships reported 'discriminate' needle and syringe sharing with their primary sexual partner. Significantly, and in tension with biomedical evidence, participants commonly rationalised syringe sharing with sexual partners in terms of 'risk equivalence' with sexual practices in regard to HCV transmission. Participants' uncertain knowledge regarding HCV transmission, coupled with unprotected sexual practices perceived as being normative were found to foster 'risk equivalence' beliefs and associated HCV transmission potential.

CONCLUSION

HCV prevention messages that 'add on' safe sex information can do more harm than good, perpetuating risk equivalence beliefs and an associated dismissal of safe injecting recommendations among those already practicing unprotected sex.

Structural factors that promote stigmatization of drug users with hepatitis C in hospital emergency departments

BACKGROUND

Interventions to mediate the stigmatization of people affected with HCV, particularly those who use illicit drugs, have been largely focused on changing health care practitioners' attitudes and knowledge regarding Hepatitis C and illicit drug use and these have had disappointing results. There is a need for research that examines factors beyond individual practitioners that explains why and how stigmatization of the population occurs within health care and informs interventions to mitigate these factors.

METHODS

The research was intended to identify structural factors that contribute to the structural stigmatization of people within hospital Emergency Departments who are current users of illicit drugs and are HCV positive. The research had an interpretive description design and occurred in Nova Scotia, Canada. The year-long qualitative study entailed individual interviews of 50 service providers in hospital EDs or community organizations that served this population.

RESULTS

The research findings generated a model of structural stigmatization that greatly expands the current understanding of stigmatization beyond individual practitioners' attitudes and knowledge and internal structures to incorporate structures external to hospitals, such as physician shortages within the community and the mandate of EDs to reduce wait times.

CONCLUSIONS

The research reported herein has conceptualized stigmatization beyond an individualistic approach to incorporate the multifaceted ways that such stigmatization is fostered and supported by internal and external structures.

Taming systems to create enabling environments for HCV treatment: negotiating trust in the drug and alcohol setting

HCV (hepatitis C) treatment uptake among the population most affected - people who inject drugs - is suboptimal. Hospital based treatment provision is one evidenced barrier to HCV treatment uptake. In response, HCV treatment is increasingly located in treatment settings seen as more amenable to people who inject drugs, such as drug and alcohol services. We explored the accessibility of HCV treatment provision at two such partnerships. Data collection comprised qualitative interviews collected in 2011 and 2012 with 35 service users and 14 service providers of HCV treatment in London, United Kingdom. We draw here primarily on thematic analyses of service provider accounts, yet narratives relating to trust and environment emerged unsolicited in both user and provider accounts of negotiated HCV treatment access. A key theme in service provider accounts were strategies they deployed to 'tame' the treatment system so as to create an 'enabling environment' of care, in which trust was a critical feature. This 'taming' of the system was enacted through practices of 'negotiated flexibility', including in relation to appointments, eligibility, and phlebotomy. Service user accounts accentuated familiar environments and known health providers as those most trusted, and the potentially stigmatising effects of negotiating treatment in unfamiliar territory, especially hospital settings. Whilst noting the effects of provider strategies to negotiate flexibility on behalf of would-be patients seeking treatment, we conclude by noting the limits of trust relations in settings of constrained choice.

The lived experience of hepatitis C and its treatment among injecting drug users: qualitative synthesis

Hepatitis C virus infection is a stigmatized condition because of its close association with injecting drug use. There is a need to explore how people who inject drugs (IDUs) perceive hepatitis C, including in relation to treatment experience. We undertook a review, using a qualitative synthesis approach, of English-language qualitative research focusing on the lived experience of hepatitis C among IDUs. The review included 25 published articles representing 20 unique studies. A synthesis of this literature generated three interplaying themes: social stigma, biographical adaptation, and medical and treatment encounters. Interactions with health systems can reproduce stigma linked to drug injecting and hepatitis C, as well as trivialize the lived experience of diagnosis and illness. Hepatitis C can be biographically reinforcing of socially accommodated risk and spoiled identity, as well as disruptive to everyday life. We hypothesize hepatitis C as a liminal illness experience, oscillating between trivial and serious, normalized and stigmatized, public and personal. We conclude by emphasizing the disconnects between the lived experience of hepatitis C among IDUs and Western health care system responses.

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.

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.