Needle sharing and IDU networks

It is important to emphasize that it is not injection itself that puts users at increased risk for HIV and hepatitis, but rather the sharing of injection devices. Reasons for sharing injection equipment include individual-level factors, such as types and frequency of drugs used, longer duration of drug use, limited awareness, and perceived risk of HIV and hepatitis infection. Furthermore, there are social- or contextual-level factors involved, including cultural norms or practices; gender, ethnic or health inequalities; the political and social economy; scarcity or cost of needles and syringes; imprisonment; paraphernalia laws; and policing or law enforcement (Chaisson et al, 1989; Muller et al, 1995; Deany and Crofts, 2000; Bruneau et al, 2001; Strathdee et al, 2001; Rhodes et al, 2002). For example, injection drug users may fear that while carrying needles and syringes they will be stopped by the police and arrested for a drug-related crime (Deany, 2000). There also exist additional means for disease transmission beyond direct needle sharing. Many injectors report practices where a drug solution is passed from a donor syringe into another, either by removing the plunger ("backloading") or the needle ("front loading") from the receiving syringe (Rhodes et al, 2002). In addition, drug users often share the equipment (including cookers, water cups, filters, spoons, swabs, and other items) used for the preparation, storage and transport of drugs (Rhodes et al, 2002). While sharing of contaminated injection equipment is not as efficient for HIV transmission, it highly facilitates HCV transmission (Hagan et al, 2001).

Sharing often occurs in networks of drug users, in which drug use is not so much an individual act as a group activity, and sharing is part of the culture of injection. These networks can either increase or reduce the likelihood of transmission, depending on prevalence of disease within each network and also on whether the drug users are members of multiple networks (Lovell, 2002). If an injection drug user has only a limited number of partners and does not mix with other networks, then the likelihood of transmission may be reduced (des Jarlais et al., 1995a). However, it is not uncommon for a female user to inject only with her male partner while her male partner may belong to multiple networks, thus putting women at higher risk for disease transmission. In some situations drug users may inject in shooting galleries, where a dealer provides needles and syringes and multiple networks mix. In these locations, drugs may be drawn from a common pot and injections are given in succession, usually without sterilization (Ball et al., 1998). For some individuals, especially in developing countries (e.g. Pakistan, India, Bangladesh, Burma, and Vietnam), professional injectors will administer drugs to clients, and often these injectors will use the same needles for many clients (Ball et al., 1998; Reid and Costigan, 2002).

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