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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Factors associated with risk behaviour among injecting drug users a
a
a
a
H. Klee , J. Faugier , C. Hayes , T. Boulton & J. Morris
b
a
Faculty of Community Studies , Manchester Polytechnic , Elisabeth Gaskell, Hathersage Road, Manchester, M13 OJA b
Department of Medical Statistics , Withington Hospital , Manchester, M20 8LR, U.K. Published online: 25 Sep 2007.
To cite this article: H. Klee , J. Faugier , C. Hayes , T. Boulton & J. Morris (1990) Factors associated with risk behaviour among injecting drug users, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:2, 133-145, DOI: 10.1080/09540129008257724 To link to this article: http://dx.doi.org/10.1080/09540129008257724
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 2,1990
133
Factors associated with risk behaviour among injecting drug users
Downloaded by [University of Glasgow] at 13:14 31 December 2014
H.KLEE’,J. FAUGIER’, C.HA YES^, T.BOULTON’& J. MowsZ ‘Faculty of Community Studies, Munchester Polytechnic, Elizabeth Gaskell, Hathersage Road, Manchester M13 OJA. ’Depamnent of Medical Statistics, Withington Hospital, Munchester M20 8LR, U.K.
Abstract A project which inveaigated the injecting and sexual behaoiour of drug users in
the North West of England revealed several social and behaoioural factors strongly associated with HIV-related risk behaviour. For example, homelessness, crime, ignorance of drug-related health problems and drug use by a regular partner were associated with the shan’ng of injecting equipment. Other variables predicted casual sexual intercourse and intercourse without condoms. Some facton were identijied that were common to both injecting and sexual risk behaviour. Introduction The HIVIAIDS epidemic is now growing faster among injecting drug users than in any other group in Europe and the United States. In Europe the proportion of injecting drug users among AIDS patients rose from 2% in 1983 to 34% in 1988. It was estimated that by the end of 1989 the rate for newly diagnosed cases from this group would overtake that of homosexual men (Hartgers, 1989). Furthermore, reported rates of increase may be underestimates since they take no account of deaths in this group from HIV-related diseases like tuberculosis and pneumonia before they are diagnosed as AIDS. The implications for the health of the wider population have been a source of concern for some time. Injecting drug users have become the predominant source for the ~ a n s m i s sion of HIV infection to non-injecting heterosexuals in Europe and the United States and the course of the epidemic will largely depend on the rate of spread by sexual means from them to their partners. Without sexual risk-reduction among injectors and their non-injecting partners they will “eventually create the potential for self-sustaining heterosexual uansmission” (Des Jarlais, Friedman & Hopkins, 1990). Several reports (e.g. Friedman et al., 1988; Power, et al., 1988) document a trend towards risk reduction among injectors. Increasingly they are using sterile injecting equipment and are reducing the number of people with whom they share. The pattern of sexual risk-reduction is not as encouraging. Almost all studies report little condom use among drug users and little improvement over time (e.g. Donoghoe et al., 1989; Hartgers, 1989). The aim of the project described here was to investigate those aspects of attitudes and behaviour in drug users that would inform predictions concerning the spread of HIV infection by sexual transmission from this group to a wider population. For injecting drug users, the sharing of injecting equipment combined with inadequate injecting hygiene is
Downloaded by [University of Glasgow] at 13:14 31 December 2014
134 H. KLEE ETAL.
regarded by experts and by drug users themselves as the most ldcely risk factor leading to vertical transmission within the group. The collection of information about injecting practices that were likely to lead to the acquisition of the virus by injecting drug users thus formed a large part of the study. It is through unprotected sexual activity that the sexual partners of those who share may become infected themselves. Attitudes towards condoms and the use of condoms by respondents therefore formed another critical pan of the study. The project was located in the North West of England, the area comprising the cities of Liverpool and Manchester, their suburbs and several towns. It is a region with pronounced social problems. The unemployment rate is the fourth highest in the U.K.The proportion of children born outside marriage, at 29% in 1987, and the proportion of single parent households were the highest rates in the U.K.The latest available figures show that between 1981 and 1987 the region had the greatest increase in notified heroin and methadone addicts. Outside the South East it had, in 1988, the highest number of reported AIDS cases (Regional Trends, 1989). Needle-exchange schemes proliferated in the region over the period of data collection, from March 1988 to July 1989, many with a ‘user-friendly’ approach whch &d not impose strict exchange rules, or restrictions on the numbers of needles and syringes handed out. Outreach workers, some carrying packs of injecting equipment, are now employed to make contact with users at street level. Condoms are free and often distributed with injecting equipment. Method
The sample comprised 303 injecting drug users drawn from a variety of sources: drug clinics, inpatient units, the probation service, needle exchanges and through outreach work using exdealers and other drug-users as mediators. Attempts to minimise sampling bias were made. Ideally a balanced, representative study would adopt some form of quota sampling if the characteristics of the population under scrutiny were known. The problematic nature of access to this target group ensures that the ideal is unlikely ever to be achieved. For current researchers, the relative ease of access to those users in treatment has resulted in a data-base that is regarded as rather suspect in terms of its ‘typicality’. Attempts to redress the balance are increasingly made by focusing upon non-treatment groups. Unfortunately the differences between the two groups are far from clear-cut. People move in and out of treatment for a variety of reasons, only some of which are to stop using drugs, and only some of which will influence their risk behaviours. Some of those in treatment continue to use illicit drugs. Several different strategies were used to contact respondents that would yield a sample that would cut across treatment status. The geographical area covered was very large in an attempt to ensure that regional differences could be noted. Sub-cultural norms vary within a few miles of each other and casting the net wide ensured that any factors associated with risk that were common across the whole sample were more likely to be generalizable to the population as a whole. Data collection was through semi-structured interviews which lasted between 50 and 90 minutes and were recorded on tape. They were conducted by two trained Research Assistants. In addition to injecting and sexual risk behaviour, details of drug history and current drug use, the use of services, AIDS beliefs and knowledge, health problems and personal relationships were documented. Between six and nine months after the initial interview, those respondents who could be recontacted were interviewed again. The focus was on changes, if any, in drug use, sharing and sexual behaviour that had occurred in the intervening period. Comparisons over time have been analysed and will be documented elsewhere.
RISK BEHAVIOUR AMONG N DRUG USERS
135
The sample
Downloaded by [University of Glasgow] at 13:14 31 December 2014
Respondents’ ages ranged between 16 and 45 years with 48% under the age of 25. Of the 303 subjects in the study seventy-six (25%) were women. The drug of preference for the majority was heroin (75%) with 13% injecting amphetamine sulphate, 9% methadone and 3% a variety of prescribed drugs illicitly acquired. Despite distinct preferences for one particular drug, the majority (90%) were polydrug users. Sixty percent of the sample were in treatment. They comprised 60 inpatients in residential units and 112 users attending drug clinics. Of those prescribed methadone ( n = 166), 56% were ‘topping up’ with illicit drugs, mostly heroin. Twenty respondents were contacted through the probation service and 14 at needle exchanges. The rest (n =97) were accessed through outreach work using ‘snowballing’ techniques. Two hundred and forty-seven (8 1%) were unemployed.
Analyses Much of the data was categorical in nature and therefore subject only to simple crosstabulation analysis. Cluster and discriminant analyses were also performed to explore potentially informative relationships. Logistic regression analyses were carried out between the variables of sharing and sexual risk and groups of selected variables. Confidence intervals are quoted where groups of respondents are compared that are disparate in size. The conventional 5% level of significance was adopted for all statistical tests.
Result8 Shuring injecting equipment The term ‘sharing’ covers two aspects of joint use of equipment which are quite different in terms of motivation and personal risk-allowing access by others to personally owned needles and syringes, and using needles and syringes belonging to others. In both cases the terms refer to acts in which the equipment has already been used. Such a distinction is important since users are generally more willing to give than receive. Some will never use another’s equipment but give their own away fairly freely. The former act may here be referred to as ‘giving’ for the sake of brevity but it has to be borne in mind that such acts are not always as volitional as the term implies and can take the form of leaving equipment around in the knowledge that it may be picked up by someone else. The injecting environment was conducive to sharing for many respondents-sixty percent of the sample regularly injected in the company of others. Figure 1 shows the extent to which respondents have given and received injecting equipment in the six months prior to intenriew. Asked about changes in sharing, 63% reported that they shared less now than in the past. This is comparable to figures reported by Power et ul. (1988), Selwyn et al. (1988), Friedman et al. (1988). Some of the major variables associated with sharing were identified and are reported below.
Homelessness --five respondents were homeless. Table 1 indicates that homelessness was associated with heavy drug use, daily administration of drugs, not being maintained on methadone, recent involvement in crime, disorganization of daily life and poor knowledge of drug-
136 H. KLEE ETAL.
1496
RECEIVED
GAVE
Downloaded by [University of Glasgow] at 13:14 31 December 2014
< lotimes
FIG.1. The number of occazionr nspadrntr gave
or received used injecting equipment in the six months prior w
inmvicw.
related health problems as well as with a high incidence of giving and receiving injecting equipment.
Table 1. Differences between the homeless and nor-homeless respondem (95% Confidence
Homeless Drug amount-more than 1 g per day Frequency of ux-
W Y Recency of crimeless than 6 months Treatmenton maintenance Organisationdlsorganislxd Knowledge of drugs problems--expcn Giving quipmentmore than 50 times in last 6 months Receiving equipment more than 50 tima in last 6 months
internal)
(95% Confidence
Not homeless
interval)
60%
(42%-76%)
34%
(28%-40%)
94%
(8096-9996)
77%
(72%-82%)
91%
(75%-98%)
66%
(60%-72%)
3%
(0.1%-15%)
30%
(24%-35%)
39%
(22%-58%)
21%
(16%-26%)
26%
( 13%-44%)
50%
(44%-56%)
21%
(9%-39%)
9%
(6%-13%)
15%
(5%-32%)
2%
(0.6%-4%)
In the United States it is reported (Hartgers, 1989) that injecting drug users who are homeless are more likely to be seropositive, and frequency of injection is also associated with seropositivity-the more frequently a drug user was injecting, the more likely he or she was to share with someone infected with the virus (Marmor et al., 1987).
RISK BEHAVIOUR AMONG IV DRUG USERS
137
Knowledge of drug-related heawl problems Respondents were asked about their knowledge of the health problems associated with drug use and on the basis of their responses were allocated to categories of ‘expert’ (16%)) ‘good’ (32%), ‘fair’ (40%) and ‘poor’ (12%). Predictably, older respondents were more expert (x2=41.31, d.f.=9,p
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Factors associated with risk behaviour among injecting drug users a
a
a
a
H. Klee , J. Faugier , C. Hayes , T. Boulton & J. Morris
b
a
Faculty of Community Studies , Manchester Polytechnic , Elisabeth Gaskell, Hathersage Road, Manchester, M13 OJA b
Department of Medical Statistics , Withington Hospital , Manchester, M20 8LR, U.K. Published online: 25 Sep 2007.
To cite this article: H. Klee , J. Faugier , C. Hayes , T. Boulton & J. Morris (1990) Factors associated with risk behaviour among injecting drug users, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:2, 133-145, DOI: 10.1080/09540129008257724 To link to this article: http://dx.doi.org/10.1080/09540129008257724
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 2,1990
133
Factors associated with risk behaviour among injecting drug users
Downloaded by [University of Glasgow] at 13:14 31 December 2014
H.KLEE’,J. FAUGIER’, C.HA YES^, T.BOULTON’& J. MowsZ ‘Faculty of Community Studies, Munchester Polytechnic, Elizabeth Gaskell, Hathersage Road, Manchester M13 OJA. ’Depamnent of Medical Statistics, Withington Hospital, Munchester M20 8LR, U.K.
Abstract A project which inveaigated the injecting and sexual behaoiour of drug users in
the North West of England revealed several social and behaoioural factors strongly associated with HIV-related risk behaviour. For example, homelessness, crime, ignorance of drug-related health problems and drug use by a regular partner were associated with the shan’ng of injecting equipment. Other variables predicted casual sexual intercourse and intercourse without condoms. Some facton were identijied that were common to both injecting and sexual risk behaviour. Introduction The HIVIAIDS epidemic is now growing faster among injecting drug users than in any other group in Europe and the United States. In Europe the proportion of injecting drug users among AIDS patients rose from 2% in 1983 to 34% in 1988. It was estimated that by the end of 1989 the rate for newly diagnosed cases from this group would overtake that of homosexual men (Hartgers, 1989). Furthermore, reported rates of increase may be underestimates since they take no account of deaths in this group from HIV-related diseases like tuberculosis and pneumonia before they are diagnosed as AIDS. The implications for the health of the wider population have been a source of concern for some time. Injecting drug users have become the predominant source for the ~ a n s m i s sion of HIV infection to non-injecting heterosexuals in Europe and the United States and the course of the epidemic will largely depend on the rate of spread by sexual means from them to their partners. Without sexual risk-reduction among injectors and their non-injecting partners they will “eventually create the potential for self-sustaining heterosexual uansmission” (Des Jarlais, Friedman & Hopkins, 1990). Several reports (e.g. Friedman et al., 1988; Power, et al., 1988) document a trend towards risk reduction among injectors. Increasingly they are using sterile injecting equipment and are reducing the number of people with whom they share. The pattern of sexual risk-reduction is not as encouraging. Almost all studies report little condom use among drug users and little improvement over time (e.g. Donoghoe et al., 1989; Hartgers, 1989). The aim of the project described here was to investigate those aspects of attitudes and behaviour in drug users that would inform predictions concerning the spread of HIV infection by sexual transmission from this group to a wider population. For injecting drug users, the sharing of injecting equipment combined with inadequate injecting hygiene is
Downloaded by [University of Glasgow] at 13:14 31 December 2014
134 H. KLEE ETAL.
regarded by experts and by drug users themselves as the most ldcely risk factor leading to vertical transmission within the group. The collection of information about injecting practices that were likely to lead to the acquisition of the virus by injecting drug users thus formed a large part of the study. It is through unprotected sexual activity that the sexual partners of those who share may become infected themselves. Attitudes towards condoms and the use of condoms by respondents therefore formed another critical pan of the study. The project was located in the North West of England, the area comprising the cities of Liverpool and Manchester, their suburbs and several towns. It is a region with pronounced social problems. The unemployment rate is the fourth highest in the U.K.The proportion of children born outside marriage, at 29% in 1987, and the proportion of single parent households were the highest rates in the U.K.The latest available figures show that between 1981 and 1987 the region had the greatest increase in notified heroin and methadone addicts. Outside the South East it had, in 1988, the highest number of reported AIDS cases (Regional Trends, 1989). Needle-exchange schemes proliferated in the region over the period of data collection, from March 1988 to July 1989, many with a ‘user-friendly’ approach whch &d not impose strict exchange rules, or restrictions on the numbers of needles and syringes handed out. Outreach workers, some carrying packs of injecting equipment, are now employed to make contact with users at street level. Condoms are free and often distributed with injecting equipment. Method
The sample comprised 303 injecting drug users drawn from a variety of sources: drug clinics, inpatient units, the probation service, needle exchanges and through outreach work using exdealers and other drug-users as mediators. Attempts to minimise sampling bias were made. Ideally a balanced, representative study would adopt some form of quota sampling if the characteristics of the population under scrutiny were known. The problematic nature of access to this target group ensures that the ideal is unlikely ever to be achieved. For current researchers, the relative ease of access to those users in treatment has resulted in a data-base that is regarded as rather suspect in terms of its ‘typicality’. Attempts to redress the balance are increasingly made by focusing upon non-treatment groups. Unfortunately the differences between the two groups are far from clear-cut. People move in and out of treatment for a variety of reasons, only some of which are to stop using drugs, and only some of which will influence their risk behaviours. Some of those in treatment continue to use illicit drugs. Several different strategies were used to contact respondents that would yield a sample that would cut across treatment status. The geographical area covered was very large in an attempt to ensure that regional differences could be noted. Sub-cultural norms vary within a few miles of each other and casting the net wide ensured that any factors associated with risk that were common across the whole sample were more likely to be generalizable to the population as a whole. Data collection was through semi-structured interviews which lasted between 50 and 90 minutes and were recorded on tape. They were conducted by two trained Research Assistants. In addition to injecting and sexual risk behaviour, details of drug history and current drug use, the use of services, AIDS beliefs and knowledge, health problems and personal relationships were documented. Between six and nine months after the initial interview, those respondents who could be recontacted were interviewed again. The focus was on changes, if any, in drug use, sharing and sexual behaviour that had occurred in the intervening period. Comparisons over time have been analysed and will be documented elsewhere.
RISK BEHAVIOUR AMONG N DRUG USERS
135
The sample
Downloaded by [University of Glasgow] at 13:14 31 December 2014
Respondents’ ages ranged between 16 and 45 years with 48% under the age of 25. Of the 303 subjects in the study seventy-six (25%) were women. The drug of preference for the majority was heroin (75%) with 13% injecting amphetamine sulphate, 9% methadone and 3% a variety of prescribed drugs illicitly acquired. Despite distinct preferences for one particular drug, the majority (90%) were polydrug users. Sixty percent of the sample were in treatment. They comprised 60 inpatients in residential units and 112 users attending drug clinics. Of those prescribed methadone ( n = 166), 56% were ‘topping up’ with illicit drugs, mostly heroin. Twenty respondents were contacted through the probation service and 14 at needle exchanges. The rest (n =97) were accessed through outreach work using ‘snowballing’ techniques. Two hundred and forty-seven (8 1%) were unemployed.
Analyses Much of the data was categorical in nature and therefore subject only to simple crosstabulation analysis. Cluster and discriminant analyses were also performed to explore potentially informative relationships. Logistic regression analyses were carried out between the variables of sharing and sexual risk and groups of selected variables. Confidence intervals are quoted where groups of respondents are compared that are disparate in size. The conventional 5% level of significance was adopted for all statistical tests.
Result8 Shuring injecting equipment The term ‘sharing’ covers two aspects of joint use of equipment which are quite different in terms of motivation and personal risk-allowing access by others to personally owned needles and syringes, and using needles and syringes belonging to others. In both cases the terms refer to acts in which the equipment has already been used. Such a distinction is important since users are generally more willing to give than receive. Some will never use another’s equipment but give their own away fairly freely. The former act may here be referred to as ‘giving’ for the sake of brevity but it has to be borne in mind that such acts are not always as volitional as the term implies and can take the form of leaving equipment around in the knowledge that it may be picked up by someone else. The injecting environment was conducive to sharing for many respondents-sixty percent of the sample regularly injected in the company of others. Figure 1 shows the extent to which respondents have given and received injecting equipment in the six months prior to intenriew. Asked about changes in sharing, 63% reported that they shared less now than in the past. This is comparable to figures reported by Power et ul. (1988), Selwyn et al. (1988), Friedman et al. (1988). Some of the major variables associated with sharing were identified and are reported below.
Homelessness --five respondents were homeless. Table 1 indicates that homelessness was associated with heavy drug use, daily administration of drugs, not being maintained on methadone, recent involvement in crime, disorganization of daily life and poor knowledge of drug-
136 H. KLEE ETAL.
1496
RECEIVED
GAVE
Downloaded by [University of Glasgow] at 13:14 31 December 2014
< lotimes
FIG.1. The number of occazionr nspadrntr gave
or received used injecting equipment in the six months prior w
inmvicw.
related health problems as well as with a high incidence of giving and receiving injecting equipment.
Table 1. Differences between the homeless and nor-homeless respondem (95% Confidence
Homeless Drug amount-more than 1 g per day Frequency of ux-
W Y Recency of crimeless than 6 months Treatmenton maintenance Organisationdlsorganislxd Knowledge of drugs problems--expcn Giving quipmentmore than 50 times in last 6 months Receiving equipment more than 50 tima in last 6 months
internal)
(95% Confidence
Not homeless
interval)
60%
(42%-76%)
34%
(28%-40%)
94%
(8096-9996)
77%
(72%-82%)
91%
(75%-98%)
66%
(60%-72%)
3%
(0.1%-15%)
30%
(24%-35%)
39%
(22%-58%)
21%
(16%-26%)
26%
( 13%-44%)
50%
(44%-56%)
21%
(9%-39%)
9%
(6%-13%)
15%
(5%-32%)
2%
(0.6%-4%)
In the United States it is reported (Hartgers, 1989) that injecting drug users who are homeless are more likely to be seropositive, and frequency of injection is also associated with seropositivity-the more frequently a drug user was injecting, the more likely he or she was to share with someone infected with the virus (Marmor et al., 1987).
RISK BEHAVIOUR AMONG IV DRUG USERS
137
Knowledge of drug-related heawl problems Respondents were asked about their knowledge of the health problems associated with drug use and on the basis of their responses were allocated to categories of ‘expert’ (16%)) ‘good’ (32%), ‘fair’ (40%) and ‘poor’ (12%). Predictably, older respondents were more expert (x2=41.31, d.f.=9,p
