Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia

This article provides a critical analysis of existing approaches to the prevention of heroin overdose in Australia. It draws on almost 2 years of ethnographic research with street-based injecting drug users (IDUs), street-based sex workers and service providers in Melbourne, Australia's second largest city, and on recent anthropological and sociological work on governmentality. The substantive sections of the article argue: (1) that heroin overdose prevention in Australia contains implicit or explicit assumptions of rationality and personal autonomy, continues to emphasise individual behaviour change and inscribes a self-disciplined, self-aware, self-regulating subject; and (2) that the social, cultural and economic realities--the 'lived experience'--of street-based IDUs and sex workers may undermine or hinder the successful adoption of overdose prevention strategies. The paper concludes by arguing that the 'chaotic' practices of street-based IDUs and sex workers arise in response to particular 'risk environments', and that individually focused overdose prevention strategies, while an important first step, need to be complemented by measures addressing the macro- and micro-aspects of risk environments.     

The prevalence and risk behaviours associated with the transmission of blood-borne viruses among ethnic-Vietnamese injecting drug users

OBJECTIVE: To measure the prevalence and determinants of blood-borne virus (BBV) transmission in ethnic Vietnamese injecting drug users (IDUs). METHODS:The study was conducted in Melbourne, Australia, in 2003. It was a cross-sectional design with participants recruited from street-based illicit drug markets predominately using a snowball technique. One hundred and twenty-seven participants completed a questionnaire that asked about illicit drug use and participants' blood samples were tested for HIV, HCV and HBV. RESULTS: One hundred and three (81.1%) ethnic Vietnamese IDU study participants were HCV positive and three (2.4%) were HIV positive. More than 60% had evidence of being infected with HBV (either in the past, acute infection or chronic infection). Almost 60% had injected daily over the past 12 months. Fifty-nine participants had recently travelled to Vietnam; 24 (41%) had injected drugs in Vietnam; and three (12.5%) reported sharing injecting equipment in Vietnam. CONCLUSION: The prevalence of BBVs was higher in this study's IDU population compared with IDUs in Australia generally, despite the fact that the injecting risk behaviours were similar to IDUs more generally. IMPLICATIONS: Culturally sensitive drug treatment and education programs need to be developed in Australia for both ethnic Vietnamese IDUs and their families to reduce this group's risk of contracting a BBV.     

Vietnamese-speaking injecting drug users in Melbourne: the need for harm reduction programs

While research on aspects of injecting drug use (IDU), including injecting and sexual risks for HIV transmission, has been progressing in 'mainstream' Australian populations, there has been little among non-English speaking background (NESB) communities in Australia, particularly the South-East Asian communities, of which the Vietnamese is the largest. This exploratory study employed and trained peer workers to recruit and interview IDUs of Vietnamese origin in Melbourne on a wide range of subjects related to risks associated with their drug using, as an initial assessment of risk-taking behaviours for blood-borne viruses among Vietnamese-speaking IDUs. A finger-prick blood sample was taken where possible to measure antibody status to HIV, HBV and HCV.
The profile which emerged was not dissimilar to that of their English-speaking counterparts prior to the benefit of currently available harm-reduction programs. A relatively isolated group whose social world often related only to other Vietnamese-speaking drug users, they were engaging in unsafe sex and unsafe injecting and were unfamiliar with procedures for cleaning injecting equipment and where they could seek out information and services, including needle exchanges. This study has identified an urgent need not only to promote currently available information and services to this group, but also to provide culturally relevant education and other harm-reduction measures needed to prevent transmission of HIV, other BBVs and STDs. The study has highlighted the lack of responsiveness of mainstream health services to the needs of Vietnamese-speaking IDUs.     

Attitudes of Australian Heroin Users to Peer Distribution of Naloxone for Heroin Overdose: Perspectives on Intranasal Administration

Naloxone distribution to injecting drug users (IDUs) for peer administration is a suggested strategy to prevent fatal heroin overdose. The aim of this study was to explore attitudes of IDUs to administration of naloxone to others after heroin overdose, and preferences for method of administration. A sample of 99 IDUs (median age 35 years, 72% male) recruited from needle and syringe programs in Melbourne were administered a questionnaire. Data collected included demographics, attitudes to naloxone distribution, and preferences for method of administration. The primary study outcomes were attitudes of IDUs to use of naloxone for peer administration (categorized on a five-point scale ranging from “very good idea” to “very bad idea”) and preferred mode of administration (intravenous, intramuscular, and intranasal). The majority of the sample reported positive attitudes toward naloxone distribution (good to very good idea: 89%) and 92% said they were willing to participate in a related training program. Some participants raised concerns about peer administration including the competence of IDUs to administer naloxone in an emergency, victim response on wakening and legal implications. Most (74%) preferred intranasal administration in comparison to other administration methods (21%). There was no association with age, sex, or heroin practice. There appears to be strong support among Australian IDU for naloxone distribution to peers. Intranasal spray is the preferred route of administration. Kerr and Kelly are with the Joseph Epstein Centre for Emergency Medicine Research, Sunshine Hospital, St. Albans, Victoria, Australia; Kerr and Kelly are with the The University of Melbourne, Melbourne, Victoria, Australia; Dietze is with the Burnet Institute, Melbourne, Victoria, Australia; Dietze and Jolley are with the Monash Institute of Health Services Research, Melbourne, Victoria, Australia.     

Risk behaviours of young Indo-Chinese injecting drug users in Sydney and Melbourne

OBJECTIVE: To investigate patterns of drug use and injection-related risk behaviours among young Indo-Chinese injecting drug users (IDUs). METHOD: Cross-sectional survey. A structured questionnaire was administered to 184 Indo-Chinese IDUs aged 15 to 24 in Sydney and Melbourne. Participants were recruited using snowball sampling techniques; measures included patterns of heroin and other drug use, injection-related risk behaviours, perceived susceptibility to HIV and HCV infection and access to services. RESULTS: Despite perceived high availability of sterile injecting equipment, 36% had ever shared a needle and syringe and 22% had done so in the preceding month. Lifetime sharing was significantly associated with duration of injecting, history of incarceration and residence in Sydney. Sharing of injecting paraphernalia other than needles and syringes was also common, with young women and Sydney residents significantly more likely to report sharing equipment in the preceding month. CONCLUSIONS: Young Indo-Chinese IDUs are at high risk of infection with hepatitis C and other blood-borne viruses. Results indicate an urgent need for culturally appropriate and sustainable risk reduction programs which specifically target this population. Implications: Health services must respond swiftly to implement effective blood-borne virus prevention programs for young Indo-Chinese IDUs. Failure to do so may sustain the current epidemic of hepatitis C among IDUs.     

Cessation of injecting drug use among street-based youth

Young injecting drug users (IDUs) are at high risk for a number of negative health outcomes such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) infection. However, very little is known about injecting drug-use patterns among this population, particularly with respect to cessation of injection. We sought to identify the factors associated with cessation of injection in a population of young street-based IDUs. A prospective cohort study design was used to assess long-term (≥1 year) cessation of drug injection. Data was collected between January 1995 and September 2000 in Montreal, Québec, Canada. Subjects were originally recruited from various street-based outreach programs in Montreal and, for this study, had to have reported injecting drugs within the prior 6 months at baseline or during follow-up and had to have completed at least two semiannual follow-up questionnaires. Cessation incidence rates stratified by duration of injection and adjusted hazard ratios (AdjHRs) were calculated. A Cox proportional hazards regression model was used to identify risk factors independently associated with cessation of drug injection. Of 502 young IDUs, 305 subjects met the inclusion criteria. Cessation of injection for approximately 1 year or more occurred in 119 (39%) of the young IDUs. The incidence of cessation was 32.6/100 person-years but consistently declined as duration of time spent injecting increased. Independent predictors of cessation of injection were currently injecting on a less than monthly or less than weekly basis (HR=6.4; 95% confidence interval (CI): 3.0–13.6 and HR=2.4; 95% CI=1.1–5.3, respectively); currently injecting two or fewer different types of drug (HR=2.1; 95% CI=1.1–4.0); currently employed (HR=1.7; 95% CI=1.1–2.7); and having at least one parent born outside of Canada (HR=1.4; 95% CI=1.1–1.7). Independent predictors of not ceasing injection were currently attending a needle-exchange program (HR=0.5; 95% CI=0.3–0.8); and current homelessness (HR=0.6; 95% CI=0.4–1.0). The early sharp decline in cessation of drug injection followed by a consistent decrease in this rate suggest difficulties in breaking the habit later on in the drug injecting career. Intensity of drug use and factors which may help to stabilize the social environment of the young IDU may also influence the ability to stop injecting.     

Differences in the social networks of ethnic Vietnamese and non-Vietnamese injecting drug users and their implications for blood-borne virus transmission

The social networks of 49 ethnic Vietnamese injecting drug users (IDUs) and 150 IDUs of other ethnicities recruited in Melbourne, Australia, were examined for ethnic differences in distribution of hepatitis C virus infection risk using social network analysis and molecular epidemiology. Vietnamese IDUs were more highly connected than non-Vietnamese IDUs, and more likely to be members of dense injecting sub-networks. More related infections were detected in IDUs with discordant ethnicities than were captured in the social network data; nonetheless, most dyads and most IDU pairs with related infections had matching ethnicity, confirming that mixing was assortative on that criterion. Mixing was not obviously dissortative by risk; low-risk Vietnamese IDUs injected more frequently than did correspondingly low-risk non-Vietnamese IDUs, but results for other measures were reversed or equivocal. Network measurements suggest that ethnic Vietnamese IDUs are at elevated risk of blood-borne infection, a conclusion supported by their relatively high HIV prevalence.     

Irish injecting drug users and hepatitis C: the importance of the social context of injecting

BACKGROUND: The incidence of hepatitis C (HCV) infection among injecting drug users (IDUs) in Dublin is particularly high by international standards. The most robust predictor of an IDU's HCV status is his or her total number of lifetime injecting episodes. It has been proposed that participation in specific unsafe injecting practices is the principal contributor to this accumulated risk. We sought to test this hypothesis. The relationship between social context of injecting and HCV status was also examined. METHODS: We conducted a cross-sectional survey of IDUs recruited from treatment settings in Dublin. Participants had injected in the preceding six months and had not previously been tested for HCV. A structured interview was conducted. RESULTS: HCV testing was performed on 159 IDUs, and 61% were antibody positive. The three characteristics that were significant independent predictors of a positive test result were increased total number of lifetime injecting episodes, closer social relationships with other IDUs, and injecting in the home of other IDUs. Frequency of recipient syringe sharing (i.e. borrowing used syringes from other IDUs), backloading, and sharing of injecting paraphernalia were not independently associated with infection. CONCLUSIONS: We found that the robust association between HCV infection and number of lifetime injecting episodes was not explained by increased unsafe injecting practices. The socialized nature of heroin injecting in Dublin is contributing to the HCV epidemic in this population. Our findings suggest that accidental and unnoticed sharing of injecting equipment may be an important contributor to an IDU's increasing risk of infection over time.     

Crime, drugs and distress: patterns of drug use and harm among criminally involved injecting drug users in Australia

Objective: Explore demographic characteristics, patterns of drug use and psychological distress among regular injecting drug users (IDUs) in Australia, as a function of recent criminal activity.
Methods: Structured, face-to-face interviews with 909 regular IDUs recruited from every capital city in Australia, between June and August 2007, as part of the annual Illicit Drug Reporting System (IDRS). Criminal activity in the past month was assessed using the Opiate Treatment Index (OTI); psychological distress was assessed using the Kessler psychological distress scale (K10).
Results: Forty-three per cent of IDUs reported recent (past month) criminal activity. Those who had committed crime recently were younger, exhibited riskier patterns of drug use, reported more drug-related problems and were more likely to exhibit significant psychological distress. In a multivariate model the most important correlates of recent criminal activity were use of more than three drug types recently (OR=2.66, 95% CI 1.96-3.61), initiation to injecting before age 18 (OR=1.93, 95% CI 1.42-2.61) and daily drug injection (OR=1.55, 95% CI 1.13-2.13).
Conclusions and Implications: Criminal activity among regular IDUs in Australia is not restricted to a particular demographic group, and is a marker for riskier patterns of drug use, greater drug-related harm and psychological distress. Contact between IDUs and the criminal justice system provides opportunities for the delivery of targeted harm reduction messages, and for screening and diversion into appropriate treatment services.     

Epidemiology of hepatitis C virus infection among injecting drug users in Australia.

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.     

The HIV/AIDS epidemic and changes in injecting drug use in Buenos Aires, Argentina

This article discusses the changes in injecting drug use from 1998 to 2003 in Buenos Aires, Argentina. The Rapid Situation Assessment and Response methodology was used to obtain the information. Quantitative and qualitative techniques were triangulated: 140 current IDUs and 35 sex partners of injection drug users (IDUs) were surveyed; 17 in-depth interviews with the surveyed IDUs and 2 focus groups were held, as well as ethnographic observations. The way in which risk and care practices among injecting drug users changed and the influence of the HIV/ AIDS epidemic on this process are described. In recent years, the frequency of injection practices and sharing of injecting equipment has decreased, while injecting drug use is a more hidden practice in a context of increasing impact of the disease in the injecting drug use social networks and changes in the price and quality of drugs. Knowledge about these changes helps build harm reduction activities oriented to IDUs in their particular social context.     

Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran

Background  

In Iran, there are an estimated 200,000 injecting drug users (IDUs). Injecting drug use is a relatively new phenomenon for this country, where opium smoking was the predominant form of drug use for hundreds of years. As in many countries experiencing a rise in injecting drug use, HIV/AIDS in Iran is associated with the injection of drugs, accounting for transmission of more than two-thirds of HIV infections. This study aimed to: describe the range of characteristics of IDUs in Tehran, Iran's capital city; 2) examine the injecting-related HIV risk behaviors of IDUs, and 3) suggest necessary interventions to prevent HIV transmission among IDUs and their families and sex partners.     

‘Workers’, ‘clients’ and the struggle over needs: Understanding encounters between service providers and injecting drug users in an Australian city

A feature of contemporary Western, neo-liberal democracies is the frequent interaction between representatives of health and social services and the members of stigmatised and ‘unruly’ populations, such as injecting drug users. Previous research on drugs has tended to ignore the power relations and cultural dynamics at work in these encounters, and the ways in which they are framed by the wider neo-liberal context. Drawing on an ethnography of street-based heroin use in Melbourne, Australia's second largest city, I show how the discourses of both service providers and injecting drug users draw on wider neo-liberal values of independence, autonomy, rationality and responsibility. Service providers negotiate a framework of needs interpretation that creates and reproduces professional identities, and maintains boundaries between ‘workers’ and ‘clients’. It also includes tensions around the definition of injecting drug users as ‘chaotic’ (i.e., failed neo-liberal) subjects, and slippage between service philosophies that emphasise a social model of health and forms of service delivery that emphasise the production of responsibilised subjects. For their part, street-based injectors construct an alternative framework of needs interpretation that emphasises their self-reliance, autonomy and independence, attributes and capacities largely denied them in service-provider discourse. In encounters with service providers, street-based injectors respond in various ways that include elements of resistance, strategic accommodation and the incorporation of therapeutic discourse. I conclude by considering the implications of my analysis for the future development of drug policy and practice.     

High HIV testing and low HIV prevalence among injecting drug users attending the Sydney Medically Supervised Injecting Centre

Objective: Measure the self-reported prevalence of HIV, history of HIV testing and associated risk factors among injecting drug users (IDUs) attending the Sydney Medically Supervised Injecting Centre (MSIC).
Methods: Cross-sectional survey of IDUs attending the Sydney MSIC (n=9,778).
Results: The majority of IDUs had been tested for HIV (94%), most within the preceding 12 months. Self-reported prevalence of HIV was only 2% (n=162) and homosexuality (AOR 20.68), bisexuality (AOR 5.30), male gender (AOR 3.33), mainly injecting psychostimulants (AOR 2.02), use of local health service (AOR 1.56) and increasing age (AOR 1.62) were independently associated. Among the 195 homosexual male sample 23% were self-reported being HIV positive. HIV positive homosexual males were more likely to report mainly psychostimulant injecting than other drugs, a finding not replicated among the heterosexual males.
Conclusions: The associations in this sample are consistent with other data indicating Australia has successfully averted an epidemic of HIV among heterosexual IDUs. The absence of any significant associations between HIV positive sero-status and the injecting-related behaviours that increase vulnerability to BBV transmission suggests that HIV infection in this group may be related to sexual behaviours. In particular, the strong associations between homosexual males and psychostimulant injectors with HIV positive sero-status suggests that patterns of infection within this group reflect the epidemiology of HIV in Australia more generally, where men who have sex with men remain most vulnerable to infection.     

Exploring risk perception and behaviour of homeless injecting drug users diagnosed with hepatitis C

Injecting drug users (IDUs) are at the greatest risk of hepatitis C infection by using any item of injecting equipment that has come into contact with contaminated blood. Alongside this, homeless IDUs have been identified as being at increased risk of harm in their illicit drug taking behaviour. This study interviewed 17 hepatitis C positive homeless IDUs about their injecting practices. In-depth interviews explored the impact of a positive hepatitis C diagnosis on their injecting and identified their risk behaviours and perceptions. The interviews were tape-recorded, transcribed and analysed using the framework approach. Homeless IDUs engaged in both high risk and unhygienic injecting practices, such as using drugs outside and in public places, sharing injecting equipment and re-using cleaned needles. Excessive needle reuse whilst in prison was also identified. However, the findings were not universally bleak as a positive diagnosis of hepatitis C did lead to some behaviour change towards safer injecting and some adopted other lifestyle and behaviour changes. It was, however, common for homeless people to devolve responsibility for preventing hepatitis C transmission to their peers, especially when injecting with others. Knowledge regarding possible transmission through injecting paraphernalia appeared to make users more careful to reduce it through these routes. Placing a continuous emphasis on health promotion is therefore important in educating IDUs about the hepatitis C transmission risks associated with injecting drug use. Information regarding safer and hygienic use, including accurate information regarding the most effective methods to clean used equipment, must be re-enforced by people working with homeless injecting drug users.     

High hepatitis C incidence in new injecting drug users: a policy failure?

OBJECTIVE: Evidence of ongoing hepatitis C (HCV) transmission among injecting drug users (IDUs) suggests a need for a better understanding of seroconversion characteristics among new IDUs and other vulnerable subgroups. This study aimed to determine incidence of HCV and associated risk factors among new IDUs in Sydney. METHODS: IDUs who had injected drugs in the past six months and who were unaware of their antibody HCV status or knew their serostatus to be negative were recruited through street-based outreach, methadone clinics and needle and syringe programs in south-western Sydney. Anti-HCV negative IDUs (n = 215) were enrolled and followed-up at 3-6 monthly intervals. New IDUs (n = 204) were defined as aged below 30 years or injecting for < or = 6 years at baseline. RESULTS: A total of 61 seroconversions were observed and incidence was 45.8 per 100 person years. Independent predictors of seroconversion were duration of injecting < 1 year (IRR = 3.10; 95% CI 1.47-6.54), female gender (IRR = 2.0; 95% CI 1.16-3.45), culturally and linguistically diverse background (CALDB) (IRR = 2.03; 95% CI 1.06-3.89) and intravenous cocaine use (IRR = 2.37; 95% CI 1.26-4.44). While new IDUs shared common risk factors, strong associations were observed between HCV seroconversion and sharing syringes, sharing other injecting equipment and backloading in CALDB new IDUs. CONCLUSION: Incidence of HCV infection among new IDUs in Sydney is unacceptably high. IMPLICATIONS: Extremely high rates of incident infection among newly initiated CALDB IDUs indicate an urgent need for enhanced policy and resource commitments to reduce the vulnerability of this group to HCV and other blood-borne infections.     

HIV prevalence and risk behaviours among injecting drug users in six indonesian cities implications for future HIV prevention programs

ABSTRACT: BACKGROUND: The HIV prevalence among injecting drug users (IDUs) in Indonesia reached 50% in 2005. While drug use remains illegal in Indonesia, a needle and syringe program (NSP) was implemented in 2006. METHODS: In 2007, an integrated behavioural and biological surveillance survey was conducted among IDUs in six cities. IDUs were selected via time-location sampling and respondent-driven sampling. A questionnaire was administered face-to-face. IDUs from four cities were tested for HIV, syphilis, gonorrhoea and chlamydia. Factors associated with HIV were assessed using generalized estimating equations. Risk for sexual transmission of HIV was assessed among HIV-positive IDUs. RESULTS: Among 1,404 IDUs, 70% were daily injectors and 31% reported sharing needles in the past week. Most (76%) IDUs received injecting equipment from NSP in the prior week; 26% always carried a needle and those who didn't, feared police arrest. STI prevalence was low (8%). HIV prevalence was 52%; 27% among IDUs injecting less than 1 year, 35% among those injecting for 1-3 years compared to 61% in long term injectors (p < 0.001). IDUs injecting for less than 3 years were more likely to have used clean needles in the past week compared to long term injectors (p < 0.001). HIV-positive status was associated with duration of injecting, ever been imprisoned and injecting in public parks. Among HIV-infected IDUs, consistent condom use last week with steady, casual and commercial sex partners was reported by 13%, 24% and 32%, respectively. CONCLUSIONS: Although NSP uptake has possibly reduced HIV transmission among injectors with shorter injection history, the prevalence of HIV among IDUs in Indonesia remains unacceptably high. Condom use is insufficient, which advocates for strengthening prevention of sexual transmission alongside harm reduction programs.