Volume 107, Issue 6, pages 1090–1096, June 2012
Magdalena Harris*, Tim Rhodes
Article first published online: 13 FEB 2012
© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction
Keywords: Harm reduction; hepatitis C; injecting drug use; prevention; vein care
Aim To explore the facilitators of long-term hepatitis C avoidance among people who inject drugs.
Design We employed a qualitative life history design.
Setting Recruitment took place through low-threshold drug services and drug user networks in South East and North London. Participants were interviewed at the recruitment services or in their homes.
Participants The sample comprised 35 people who inject drugs, 20 of whom were hepatitis C antibody-negative. Participants' average injecting trajectory was 19 years (6–33), with 66% primarily injecting heroin, and 34% a crack and heroin mix. Nine (26%) of the sample were female and the average age was 39 years (23–53).
Measurements Two interviews were conducted with each participant, with the second interview incorporating reference to a computer-constructed life history time-line. Interview accounts were audiorecorded, transcribed verbatim and analysed thematically.
Findings Hepatitis C risk awareness was recent and deprioritized by the majority of participants. The facilitation of venous access and care was an initial and enduring rationale for safe injecting practices. Difficult venous access resulted in increased contamination of injecting environments and transitions to femoral injecting. Participants expressed an unmet desire for non-judgemental venous access information and advice.
Conclusions Harm reduction interventions which attend to the immediate priorities of people who inject drugs, such as venous access and care, have the potential to re-engage individuals who are jaded or confused by hepatitis C prevention messages.
Commentary on Harris & Rhodes (2012): Discouraging syringe re-use by
addressing drug injectors’ everyday suffering
By now, the overwhelming seroprevalence and high seroincidence rates of hepatitis C virus (HCV) among people who inject drugs (PWID) should have convinced policy makers to dowhatever they can to increase syringe access. Foremost among health programs aimed at PWID should be to shift the emphasis of prevention messages from discouraging syringe and ancillary paraphernalia sharing to encouraging PWID to use only a new, sterile syringe. The evidence that syringe re-use facilitates HCV transmission even when PWID use their own previously used syringe to inject is overwhelming. Studies have demonstrated the survival of HCV virus in syringes  and shown how the use of a previously used syringe can contaminate shared drugs and/or injection paraphernalia (water, cottons or drug mixing containers) that others may use [2,3].
Finding ways to limit syringe use to a single injection requires interventions capable of reaching PWID who may have grown immune to public health dictates, and become indifferent about a virus that seemingly few avoid. As Harris & Rhodes explain, interventions based on informing PWID about their ‘deficits in risk knowledge and avoidance’ may be seen as condescending and act to further alienate PWID, particularly those already infected with HCV . Such messages reflect a predominant HCV prevention research and intervention model that focuses too narrowly on injection risk behaviours and emphasizes individual behavior change and responsibility while ignoring the complex interplay of situational and relational factors that influence risk [5–11]. Injection risks become decontextualized and ahistorical, resulting in interventions that are ineffective.
Harris & Rhodes challenge this perspective by employing a qualitative research study based on life histories to explore how PWID, the majority of whom were longtime injectors and HCV antibody-negative, avoided HCV. They found that participants were not particularly concerned with HCV; rather, the primary motivation for not re-using syringes reported by the 11 participants who had injected for 20 years or more and were still HCV antibody-negative was that new syringes were sharp, not that they were sterile.
As described in excerpts from participants’ narratives, PWID have good reasons besides the threat of HCV transmission for preferring sterile syringes. Sclerosis of peripheral veins is endemic among long-term injectors, and attempting to inject with a used syringe is often painful and protracted. That PWID may be more motivated to use new sterile syringes to protect their veins and minimize the pain and anguish that comes from repeatedly trying to jab blunt needles into this ever-diminishing venous resource should not surprise researchers who have observed drug injection and listened as PWID describe it. Bourgois & Schoenberg’s recent ethnography of a group of homeless PWID in San Francisco, Righteous Dopefiend  examines graphically the brutal consequences of long-term injection on the body through fieldnotes, photoethnography and analysis. They describe observing men as they stab themselves repeatedly for as long as 45 minutes, searching for a vein in which to deposit their heroin. They also show, visually and through text, the suffering caused by abscesses, an all-too-frequent corollary of skin popping, or injecting into fatty tissue when one’s veins are no longer usable. What is surprising is that this degree of suffering has continued unchecked even though it has been observed and documented for decades.
Harris & Rhodes call attention to this everyday suffering, and suggest making venous care a central theme of interventions, thus shifting the direction of harm reduction research and intervention from ‘a focus on risk and deficit to one that attends to the protective practices and short-term concerns of PWID’ . They suggest countering PWIDs’ apparent lack of interest in messages emphasizing risk behavior mechanics and their avoidance with messages that instead recognize and focus upon more immediate health concerns, in particular PWIDs’ interest in preserving peripheral veins, avoiding painful injections and lessening the need to resort to groin (femoral vein) and neck (jugular vein) injecting. As the authors explain, these goals are best achieved through the use of new sterile needles—an outcome that also addresses the more abstract threat of HCV transmission.
The shift envisioned by these authors builds upon previous work and implies a redirection in current HCV prevention strategies, from risk and its avoidance towards vulnerability and its alleviation. As such, it implies a concomitant commitment to expanding structural level interventions—changes in ‘the context within which health is produced or reproduced’  as well as increased access to health-care services and sterile syringes. As a recent meta-analysis by Turner et al. suggests, high-coverage syringe distribution—where PWID obtain a sufficient number of needles to cover their injection frequency—can reduce HCV transmission . Combining health-affirming messages with the material resources necessary to relieve the immediate and ongoing injuries of injection may prove to be important both for reducing the HCV epidemic among PWID and for demonstrating the utility of a prevention research and intervention approach based on a more comprehensive understanding of their concerns.
Declaration of interests None.
Keywords Harm reduction, HCV, qualitative research, syringe and ancillary paraphernalia sharing, syringe re-use, venous care.
Department of Anthropology, and
Department of Health and Behavioral Sciences,
University of Colorado Denver, Denver, CO, USA.
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