In 2009 I arrived in London to work on the Staying Safe project at the London School of Hygiene and Tropical Medicine. This international project was originally devised in New York and I had previously been collecting data for it at the Sydney site. Staying Safe is a HCV prevention project which aims to learn from the experts – people who have been injecting for the long term and have not been exposed to HCV. We take a broad approach, conducting two interviews with each participant, the first being a life history interview from which we construct a computer generated timeline. This is then taken back to the second interview and is used to aid recall when discussing injecting practices, environments and social networks over time.
Before I left Sydney I interviewed 13 participants and to date in London I have interviewed 31. I had also worked on other projects talking to people who injected in Sydney and had a decade 'field experience' in New Zealand injecting drug user networks. What struck me in coming to London was the profound difference between the Sydney and London participants in regard to the state of their veins. True, the Sydney cohort had, on average, a 10 year shorter injecting history than the London participants (11 years as opposed to 21) but the London participants also described losing the use of their veins much quicker in their injecting histories than I had ever heard of in New Zealand and Sydney. So what are the reasons for this? I surmise that it is due to the difference in the heroin injected in Australia and the UK, the overuse of citric and additional injecting of crack which can numb the injecting site and make it easier to miss. However, us New Zealanders use citric in cooking up our gear and, on the whole, retain venous access for years; also many of the London participants who experienced rapid venous collapse only injected heroin (not crack).
Questions about why aside – what relevance has this got for HCV prevention and harm reduction interventions in general? Well, what has been a major finding of the Staying Safe study to date is that the safe injecting practices and other protective factors that helped people to avoid HCV were not necessarily motivated by BBV avoidance, but by more pragmatic concerns such as avoiding track marks (for those early in their injecting careers – particularly the Sydney participants), maintaining venous access (primarily London participants) and facilitating a pleasurable injecting experience.
Avoiding track marks
Used works = blunt works. Blunt works → scars = stigma
The Sydney participants were aged from 25-37 (average 31) and had been injecting for an average of 11 years. All were HCV antibody negative. Significantly, a primary motivator for participants not to share works, or re-use their own, was in order to avoid track marks (injecting-related scars) and associated stigma. This was especially relevant early in their injecting trajectories before many had heard about HCV or even HIV. For example, Lisa, who started injecting 20 years ago in a Sydney street based drug scene, said: "[I didn't share] because I didn't want scars to start off with and blunt needles give you scars ... And that was a massive thing to me 'cause I didn't want to go home and embarrass my family."
Participants were similarly motivated not to reuse their own works in order to reduce track marks. As Phil says: "[I didn't reuse because needles] getting blunt mainly and just leaves scars. Also that picture in the clinics and all that. Once, twice, three, five times used and you see it wear down". Phil refers to a poster depicting magnified pictures of reused needles (see pic). This poster can be seen as an example of health promotion that works, in that it was spontaneously mentioned by a number of participants and appeared to motivate them to reduce the reuse of their needles and syringes. Now, while reusing one's own needles and syringes does not, in itself, constitute a HCV risk, it can lead to the unintended sharing of syringes if, for example, they get mixed up or misplaced.
Avoiding vein damage
Used works = blunt works. Blunt works →vein damage = difficulty injecting
Now, for the London participants, used works were also conceived of as blunt works, but here the implication of using blunt works was vein damage and associated difficulty injecting. The London participants were aged between 30-53 years (average 41) and had been injecting on average for 21 years. They experienced substantial venous damage and being able to maintain their veins and get a (relatively easy) hit was a strong motivator to use new works. As Andy says: "I'm not going to use a pin more than once, once its punctured my skin twice that pin is dead now because it's blunt, therefore I can't share anyone else's because it's blunt already. That was one of the reasons, that was the main reason."
Significantly, as in Sydney, participants also spoke of being motivated to use new works early in their injecting careers before they may have heard of HCV or HIV as they wanted to maintain venous access and the ability to get a quick and easy hit. Avoiding vein damage also lessons HCV transmission risk. A common practice among the London participants, when they couldn't get a vein, was to transfer the mix into another syringe and/or re-cook and filter a mix which has become bloody and congealed. This can lead to increased contamination of spoons, filters and water as well as increase the amount of used works in the injecting environment.
'Building capacity redressing neglect'
A number of the London 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. The inability of the Lambeth based participants to access this help represents valuable missed intervention opportunities. For those who tried, encouragement to cease injecting only caused further alienation and disengagement from services. I asked Tony if he had had any help with vein care or access. He replied "No. You know, for you to ask, no, because they will immediately go, oh well, try smoking. And you know, they don't get it. Fucking hell, you know, smoking!"
Engaging with pleasure
Sterile works = sharp works. Sharp works = less scarring & a quicker hit
Getting a quick hit is pleasurable, and there is often nothing more desperation inducing than poking around for a vein, ever conscious of the risk of the mix coagulating and losing your hit. The pleasure of injecting and drug use in general seems to be somewhat of the elephant in the room in drug services with all speaking the script of 'misuse', 'harm' and 'recovery'. Sure – people who generally come into contact with drug services are often encountering substantial personal, social and economic problems to do with their drug use. This does not negate the pleasurable experience of use for some, and the pragmatic concerns that people who inject have regarding the maintenance of their veins.
This may be controversial, but perhaps it is time for harm reduction interventions to take a leaflet from HIV messages aimed at MSM (men who have sex with men) which actively engage with notions of pleasure in their marketing, and think about the social marketing of syringe use with messages about the capacity for sterile – therefore sharp - works to prolong venous access, minimise unsightly scarring and decrease the need for a transition to groin injecting. These messages have the potential to resonate with injectors who are jaded or confused by HCV prevention messages, and may provide a hook with which to provide other protective interventions.
Yes, using clean works is not completely sufficient in HCV transmission avoidance, as other equipment can be a primary vector of transmission. However, providing non-stigmatising support and advice regarding vein care and venous access can provide an avenue for the dissemination of information about keeping other equipment separate. It was apparent from talking to participants that pragmatic interventions related to facilitating pleasure and ease of injection and avoiding scars and stigma had the potential to be perceived as more appealing and relevant than HCV based messages. For some, HCV was perceived of as inevitable, and/or of little short term consequence. HCV risk could also be difficult to conceptualise when there was no visible evidence of blood or contamination in reused works, for example. This is not to say that the people I spoke to did not care about HCV, however, it was evident that many of their protective practices were motivated by more pragmatic concerns, such as avoiding injecting related scars, and maintaining venous access. By addressing these pragmatic concerns, and not negating the pleasurable aspects of use, harm reduction interventions may engage injectors in a way that a focus on a seemingly nebulous abstract concept as HCV might not.
In this article I've provided a brief summary of a paper I presented at the recent IHRA conference in Beirut (editors note: Magdalena also presented this at the National Conference on Injecting Drug Use where they recorded the audio of her session) . I'd like to acknowledge the co-authors of this paper and Chief Investigators of the Staying Safe project from which the findings are drawn: Professors Tim Rhodes, Carla Treloar and Lisa Maher.
Magdalena Harris is a Research Fellow at the London School of Hygiene and Tropical Medicine. She is currently lead researcher on the qualitative research project: 'Staying Safe: A sociology of how people who inject drugs avoid hepatitis C in the long term'. Magdalena's background is in Health Sociology and she completed her PhD 'Negotiating the pull of the normal: Embodied narratives of living with hepatitis C in New Zealand and Australia' at the University of New South Wales in 2009.