More than just someone to inject drugs with: Injecting within primary injection partnerships
Introduction
According to the United Nations (UN) reference group on HIV and injection drug use, more than 16 million people currently inject drugs globally (Mathers et al., 2008). In most high- and middle-income countries, hepatitis C virus (HCV) transmission occurs primarily through the direct and indirect sharing of contaminated needles/syringes and ancillary drug injecting equipment (Hagan et al., 2010, Nelson et al., 2011, Thorpe et al., 2002). Many structural and social constraints impact access to sterile injecting equipment, resulting in injection equipment sharing rates between 30 and 70% among people who inject drugs (PWID) (Bruneau et al., 2008, Munoz et al., 2015, Pouget et al., 2012).
Injection drug use is a highly social activity. Drug procurement processes often necessitate resource pooling, and peer networks provide an important resource for securing drugs and connecting with dealers. The drug preparation process often occurs in social settings and can include mixing or heating drugs, filtering drug and dividing drug solution into multiple syringes. The physical action of injecting drugs may require another person's help to find a vein, tie the tourniquet, or administer the injection itself. These activities lend to a social environment where relationships may develop and conversely, relationships may influence the social environment where drugs are used (Grund et al., 1996). There is a value in recognizing the injecting partnership as a unit of study and intervention (Rhodes and Quirk, 1998) given the social nature of injection drug use and that risk for infection to occur when contaminated equipment is shared between at least two people. However, much of the literature on the social nature of injection drug use focuses on the risk of sharing syringes (Davey-Rothwell et al., 2010, Hahn et al., 2010, Harris and Rhodes, 2013).
Interpersonal dynamics have been acknowledged as factors fueling syringe and ancillary equipment sharing. Several studies have shown an elevated risk of sharing behaviors when injecting with someone who is also a close friend, family member, or sexual partner (Bryant and Hopwood, 2009, Costenbader et al., 2006, Hahn et al., 2010, Morris et al., 2014, Neaigus et al., 1994, Rhodes and Treloar, 2008, Shaw et al., 2007), acknowledging the powerful role trust can exert on individual risk profiles (Harris and Rhodes, 2013, Unger et al., 2006). Understanding the motivations underlying the development of intimate injection partnerships can improve our understanding of why such partnerships are at higher risk of both sharing behaviors and HCV infection (Tracy et al., 2014). People who use drugs have been shown to be active agents in their own individual and collective protection from social and drug related harms (Friedman et al., 2007, Sirikantraporn et al., 2012). People inject with others for various reasons and while some injection partnerships only endure for short periods, others become more established. The heterogeneity in injection partnership type and related drug using contexts has previously been discussed (Costenbader et al., 2006, Gyarmathy et al., 2010, Lakon et al., 2006). However, little attention has been given to the development of primary injection partnerships and the risks and benefits associated.
The current study aimed to look beyond injection related risks within an established and/or intimate injecting partnership (e.g., close friend, family member, or sexual partner) in order to examine the other side of the coin – perceived benefits. The objectives were two-fold. Qualitative data collected from both members of injection partnerships were used to identify key domains related to the reasons for injecting with a primary injection partner and development of drug injection patterns within such partnerships. This study adds to the literature on injection partnership typologies and the social context of drug use behaviors (Mathers et al., 2008, Nelson et al., 2011).
Section snippets
Methods
Qualitative in-depth interviews using a semi-structured interview guide were conducted with nine pairs of individuals who injected drugs together (n = 18) in Sydney, Australia during August 2012. Participants were drawn from the HITS-c Study – an epidemiological study of hepatitis C virus seroconversion and associated risk behaviors among PWID (Maher et al., 2010, White et al., 2014a, White et al., 2014b). Purposive sampling targeted current HITS-c participants in various injection partnership
Sample description
Of the nine injection partnerships interviewed, the plurality (44%) were male–female partnerships who also identified themselves as intimate sexual partners, one (11%) partnership was male–male and engaged in a casual sexual relationship. Three (34%) partnerships were family members; one was a father–daughter and two were sibling partnerships. Table 1 provides both individual and partnership characteristics. The majority (55%) were HCV negative, 8 (44%) were HCV positive, and one was unaware of
Discussion
Using qualitative data from both members of an injecting dyad, we were able to describe the contexts and individual motivations leading to the selection and development of primary injection partnerships. Our findings build on the field by furthering our understanding of the social context of drug use behaviors as a function of closeness. Our data indicate that given the opportunity, people preferred to inject with a primary injection partner. Primary injection partners offered protection from
Role of funding source
This study was funded by an NHMRC grant (#630483 Hepatitis C Vaccine Preparedness Studies) and University of California San Francisco (UCSF) Center for AIDS Research (CFAR) pilot grant (P30AI027763). Dr. Meghan Morris is supported through a NIH Mentored Scientist Career Development Award (K01DA037802) and receives support through a NIH Clinical and Translational Sciences Institute program (KL2TR000143), and Professor Lisa Maher is supported by a NHMRC Senior Research Fellowship.
Contributors
M. Morris conceived, designed, and implemented the study and subsequent analyses and wrote the study findings. A. Bates, E. Andrew, K. Page, and L. Maher contributed to the study implementation and/or analysis and conceptualization of the findings, and preparation of the article.
Conflict of interest
No conflict declared.
Acknowledgements
The authors thank the participants of this study, the HITS-c (Hepatitis C vaccine preparedness studies) field staff: Anna Bates, Jarliene Enriquez, Sammy Chow and Bethany White for their support and assistance during data collection.
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