SECTION 4 - SOME ISSUES IN THE REDUCTION OF RISK: EDUCATION AND POLICY IMPLICATIONS

In this section and the next two sections, 5 and Appendix 1, we draw out a number of implications for education and policy. First, we do this with reference to issues surrounding personal use--knowledge of risk, planning behaviour, needle procurement, that is, with an emphasis on use from the point of view of the user. In section 5 we examine implications for policy with reference to broader societal and structural issues. In Appendix 1 we examine some specific issues--prisons, gender, young people, and dealers.

Knowledge about HIV Transmission:
Drug use and Needle Sharing

The people I've had casual sex with - they are very sort of clean people.   They don't use.    I don't have sex with a drug user .... not that I can remember, anyway.    It was, usually ... like... businessmen. We always use clean needles, but that's as far as it goes.

Well, you know, all this hype about fucking - you get it from fucking and needles ... but there's a lot of things that they just aren't telling you. You know, people look upon the government, I mean, my generation and my friends and things like that, and you don't believe a word they're telling you. I mean, as far as we're concerned, it's all bullshit, all this AIDS fucking shit ... withholding things from you ... they cannot seriously expect you...you know, you've got to use clean fits and condoms and you've got to do this and you've got to do that ... when they are not telling you all the facts about it ...I read somewhere there's only been one recorded case in Australia where a woman got AIDS from sexual intercourse ... the junkies are getting it ... the gays are getting it ... but not many of the straight people are actually getting it.

We have discussed in section 3 above the incidence of unsafe sexual and drug infecting practices. Here we will comment on the distribution of knowledge about processes of HIV transmission. We will highlight gaps in this knowledge which education strategies need to address. With respect to knowledge about safe injecting practices, no one in the sample was ignorant of the prohibition about sharing needles. We need to stress, however, the way in which injecting drug use is frequently a social activity. It often takes place with partners or groups of friends. On such occasions more than one hit may be taken perhaps by several of the participants. New needles may run out, or the task of cleaning needles disrupt the social flow, just as at a boozy party friends may drink from others' glasses, something unlikely to occur in the early stages.

More information needs to be given, too, about the dangers of other aspects of sharing: the fact that other elements can come into contact with potentially infected blood. Some respondents volunteered information that indicated that they also used their own spoon or container etc., but most did not. Indeed, the interview data contained much direct and indirect evidence that respondents thought that if they were using clean/new needles, and not sharing syringes that this was all they needed to do.

This information was confirmed by those few who were HIV positive. They claimed always to shoot up last, in order to avoid others being placed in a dangerous situation, but they never volunteered caution with respect to the other implements used.

Successful intervention to change practices regarding the way injection of the drug is usually administered will not be easy. Many respondents referred to the routines and rituals surrounding injection, indicating longstanding institutionalised practices. Several referred to the methodical way in which the drug injection scenarios take place. Others who had been injecting for some time, pre-AIDS, provided information about how the shift to the prohibition against needle sharing has occurred. However, there were few indications that more individualised methods of preparing the drugs for injection were emerging. Indeed, given one typical way in which access to the drug is procured--where a group will be waiting in a social situation, dependent on obtaining supply from a dealer--it is hardly surprising that once the drug arrives, it is collectively prepared and consumed. This is especially likely, given that the costs of acquiring the drugs are also being collectively shared. It may be easier to transform practices if knowledge of the dangers of sharing were extended to include all the physical elements of the drug injection administration routines. This needs to be done sensitively, given the ample evidence of sharing as having symbolic meaning: providing social bonding, commitment to a socially mediated common identity, as well as having aspects of egalitarianism which may in some typical using scenarios cut across other divisions of class, gender and ethnicity etc. Again the question of the norm of responsibility to self and to others needs to be built upon. The ethos of sharing itself is a good starting point. Responsibility can be shared, but needles, not.

Another aspect which needs strengthening concerns knowledge about methods of cleaning needles. About half were aware of the 2x2x2 method and the use of bleach or alcohol as cleaning agents but this knowledge was not as widespread as it needs be, given the more than occasional absence of new fits. A number still claimed to be cleaning used needles with just tap water, a practice which is not adequate. Furthermore, some respondents admitted that in situations where more than one hit was being taken, the needles could get mixed up, despite good intentions. This would be likely especially given respondents reports that in such a situation, they probably would be under the influence of the drug and less careful than they might otherwise be.

Whilst respondents' knowledge about safe and unsafe drug injecting practices is probably more extensive than would be the case among the non drug-using population and tends to focus on practices rather than the drug taker, per se, as the transmission agent, there is some evidence that this concern for safe practice becomes dissipated where the drugs are being injected solely with regular partners rather than in group situations. Sharing of needles, when coupled with the trust that one's partner is 'clean', i.e. not an HIV carrier, may occur. This aspect also needs to be a focus in future intervention strategies, because it is a diversion from an emphasis on risk practices.

Safe sex
My attempt at safe sex is 'not to' when I am bleeding, or any other person who is bleeding.

With oral sex, we always use dental guards, a couple of times I've had bleeding gums and it is - like - I'm not sucking you off ... if I've got my period we don't have penetrative sex at all ... we don't use condoms.

It fluctuates ... there is no clear definition and sometimes ... because there are things that are not safe and there are things ... in terms of penetration ... and there are things that are really safe and there is a grey area between which is - sort of safeish and we tend to float around in the grey area.

I have condoms here and I suggest it but if the blokes not all that interested or if they don't want to then I cannot do anything about it. I haven't come across anyone that's interested. They know I use ... asked me if I have had tests and that seems to settle their minds....

I suppose oral sex does carry some sort of risk .... But   I've never really thought about it - my partners have been quite clean.

Oral sex could be dangerous if there were lesions around, cuts or something like that.

When compared with knowledge about the risks of drug related practices, knowledge about safe and unsafe sexual practices is far less extensive. As we have seen in the section on sexual practices and from the quotes above, much unsafe practice is occurring. There is still the assumption among some respondents that appearance is a means of identifying whether one is an HIV carrier, and that the danger is from members of risk groups such as injecting drug users, sex workers, or gay people rather than from risk practices themselves. The respondents indicated the full range of misconceptions about sexual processes of transmission identified in other studies.

1.    Only gay people, sex workers and IDU's are at risk of being HIV carriers.

2.    HIV tests proving negative are a reliable indication of a 'clean' status.

3.    Unprotected penetrative sex is safe unless sores or lesions are present.

4.   A woman is only at risk of transmitting the virus or becoming infected when she is menstruating.

5.    Lesbians do not have to worry about safe sex since lesbian sex is, ipso facto, safe.

6.    Oral sex is safe if dental guards are used.

7.    Monogamy is a defence.

8.    If a partner tells you they are clean, one can trust them.

9.    You can tell if someone is a carrier by their appearance.

All claimed to be aware of the advisability of condom use, especially for casual sexual encounters, but this knowledge tended to be discounted in regular sexual partnerships. Even in casual relationships, the knowledge was frequently not operation alised, there still seems to be great resistance, especially by heterosexual men, to condom use. The only participants in the study who seemed to be scrupulous in the practice of safe sex were those who were HIV infected. The latter emphasised the importance of responsibility to others, both in terms of sexual partners' having the right to know about one's HIV status such that a choice could be exercised, and in terms of the care being taken not to transmit the virus when a sexual encounter was proceeded with. The only occasion where this did not occur was when both sexual partners were HIV positive, knew of each other's status and decided not to engage in safe sex since both were already infected. Gay men in the sample did not stand out as more likely to engage in safe sex in regular partnerships, but they did so in casual sexual encounters.

The implications of the above for AIDS prevention strategies seems to be clear: targeting risk groups about either unsafe injecting drug use or sexual practices runs the risk of leading to complacency with respect to the one or the other kind of risk practices. In this sample, it seems that there is a higher danger that transmission will occur via sexual encounters, given the knowledge gaps in this area, rather than through unsafe injecting practices. Consequently, there is a need to emphasise the need for safe practices in both areas. This is particularly the case because the drug injecting experience is frequently associated with sex. Indeed, aspects of it are often spoken about as themselves suffused with sexuality-such as the act of injection, the experience of the rush and the feeling of a lowering of sexual inhibitions when under the influence of the drug. Nearly all the respondents were sexually active, even those who claimed to have reduced libido as a result of the drugs, thereby pointing to the need to strengthen intervention work in this area.

An aspect identified in other studies (Kippax et al., 1990) is the difficulty of negotiating safe sex. Several women recounted feeble attempts to require condom use which were not proceeded with in the face of partner resistance. We already know the extent to which negotiating practices are underpinned by deeper assymetrical gender divisions in society. This seems to suggest the need for intensified effort, especially with younger heterosexual men and women in sex education, focusing on negotiation strategies and assertiveness training in the light of knowledge about AIDS transmission processes. A much more intensive effort is needed in this area.

Rules and Planning Behaviour:
The syringe has got to be discarded properly.   I've got control.   I can shoot up - I'm a tidy junkie. When I have a hit, I like to clean everything up and put it away, 'cause a lot of people freak out about needles, you know .... I wouldn't throw my rubbish out of my car window either.

My rent, and feeding the cats are my first priority. I never let my drug use interfere with my job.

If I've got bills to pay, I put money away for bills, I pay me rent, I buy me food, all the essentials are done first; then if I go out and waste it ...I waste it. I've got no money for another week. I don't care, my rents paid, my bills are paid and I've got food in the cupboard ... all my responsibilities are taken care of.

I usually get new needles before I run out of the others.

If I'm getting down to my last 2 or 3 needles, then its time to get some more before I use the last one; because I might also find myself in a situation where 4 or 5 people might arrive here to inject. There is always a condom .... I say 'You will be wearing a condom or you can go and find someone else; it doesn't matter how clean you tell me you are!' With a casual partner, I am the one who is establishing the whole practices so I am more in control.

The person who would be thinking about sharing a cleaned fit with me would obviously have to use it first ... they'd have to be made aware of the fact that I'm HIV positive.

Respondents in the sample provided a great deal of evidence of rule following and planning behaviour, especially concerning their drug use. A central theme coming through the data was the desire to remain in control and not to allow the drug use to get out of hand or take over the user's life. Those who seemed to have most control were applying a wide variety of rules and control strategies, both about drug use and about other aspects of their lives. Users' rules and planning behaviour centred around such general issues as ensuring that financial obligations could be met, that one's recreational patterns did not interfere with the time schedules demanded by work involvements, that relationships with friends, partners and, less frequently, family members were being sustained.   This rule following with respect to more specific aspects of using expressed itself in a variety of ways. Many respondents were following rules with respect to the frequency of use, the physical location of use, concerning with whom to use, ways of approaching dealers and whether to deal oneself, the procurement of syringes, the actual administration of the drugs and the disposal of used equipment. As we have noted, these rules are sometimes broken. This depends on a variety of factors: the spontaneity of the moment or an excessive desire for the drugs once they have been obtained; an atmosphere of light-hearted social conviviality, polydrug use and its effect on dropping one's guard, or some chance happening which prohibits forward precautions. But the many confessions of occasional rule breaking do not detract from an obvious desire to adhere to rules and the recognition that not to do so is foolish and likely to precipitate a downward slide into drug dependency, or other kinds of harm to oneself or to others. The data provide ample evidence of renewed resolve and remorsefulness after episodes of rule breaking. Respondents reaffirm a desire not to break the rules in future.

This planning behaviour and rule following is very frequently coupled with a strong sense of personal responsibility for one's own and others' well being. Frequently, respondents claimed that one could not rely on others to take responsibility for oneself.   It was up to oneself to make the kind of decisions for one's life which would avoid harm, and one could not abrogate responsibility. This was especially noticeable among those who were HIV positive. There was little evidence that others were to be blamed for having transmitted the virus.   It was rather seen as the result of the respondent not having been aware at the time of what would constitute unsafe practices, or as the product of foolish behaviour where sensible rules were not being followed. There was almost no evidence of any bitterness among those with HIV.

The evidence cited in section 3 regarding unsafe sexual practice detracts from the positive evidence of rule following with respect to drug injecting practices. Educational strategies with respect to both drug use and sexual practices need to gear into this pattern of rule following and planning behaviour to strengthen the resolve and widen the sphere of application of rules and planning behaviours.   It is especially important to enhance caution as an inoculant against the sometimes spontaneous desire for immediate effects. If successful scoring has transpired in contexts where supply is difficult to obtain, and where functional use is only precariously being maintained, then these are critical danger points. But it will be difficult to bring about a wider observance of rule following and planning behaviour if the dominant message coming through is one of negativity regarding injecting drug use per se. We will expand on this below in our discussion of harm minimisation as an ideological theme in a prevention strategy.

The ideology of Trust:
One day she said - guess what, I've got some heroin, do you want to try it?   I said 'yes, you bet'.   They had previously injected ... it didn't occur to me that anything could possibly go wrong ... there was an enormous amount of trust involved .... she injected both the boy and myself and it was a new bonding experience.

If I have substantial reason to believe someone is negative ... then I have engaged in unprotected penetrative sex in both directions! Sharing needles didn't come into it. I mean, we shared needles and that was it. We thought it was safe to do that in a relationship. There have been very, very occasional situations where I have shared syringes-you want to inject, there is one syringe - so people, who goes first? Normally the girls because they are not poofters, are they, and they don't have bum sex.

We live together we spent a lot of time together. An awful lot of time ... we don't go out a lot and it's not often that he goes out by himself or I go out by myself. I don't see the opportunity for it to happen.   He tells me that he doesn't.   I believe it ...I   don't think there is any room for that to happen ... if he's had an AIDS test and he is clear ... that, to me, is safe sex.

It's not something that is really big on my mind because I know my sexual partners. I know that my first boyfriend had four AIDS tests and they were all clear. M. has had a lot of AIDS tests.   I haven't. I suppose I should but I can, sort of, trace back my partners and they are not positive so I consider myself not to be in danger!

All the respondents were asked to recount their first injecting experience. Almost all of them were initiated into injecting drug use after a prior history of other drug taking involving considerable experimentation with a range of drugs. None was initiated into injecting use via strangers or pushers, and no one related that they had been forced to inject against their will. With all, it occurred as a result of social contacts with other users, with friends, or known acquaintances, family siblings or partners. With some, it transpired after a period of regular interaction with a known user or users where the respondent had been invited on previous occasions to share the experience but had refused. This refusal may have been the result of anxiety, fear or lack of interest or desire to make what all recognised was a crucial transition. Expressed motives for not continuing to refuse such invitations ranged from curiosity about what the experience might produce, excitement, a spontaneous decision just to go along with what others were doing, or an urge to get properly inside a situation which had previously only been known from the outside. Some admitted to a burning desire to participate in an illicit activity and experience the thrills of breaking the taboo. Others said that they had asked, or begged to be allowed, to make the transition. Those who had previously declined to be injected sometimes continued to resist for some time before eventually changing their minds. Others, who decided to participate on the first occasion injecting became a possibility, expressed similar motives. A few others experimented on their own with drugs acquired from others. These latter related how this proved, frequently, to be a clumsy experience, resort then being made to others to teach one how to inject properly.

Injecting drugs successfully requires tuition from others already experienced in the rituals of drug preparation and the use of the syringe to administer the drug. Respondents related how this tuition took place and recounted the experience which followed. All but a few were initially injected by others, some making soon the transition to self injection, others continuing to be injected by others as the preferred mode.

What needs to be emphasised is the degree of trust placed by the initiate in those carrying out the tuition. Those whose first experience predates knowledge of the HIV epidemic recount much information about the role of such teachers in finding the vein, teaching how to use the syringe, mix the drugs, avoid transmitting hepatitis or scarring, as well as how to deal with and interpret the effects of the drug. Preferences for a 'safe' environment, injecting at home, or the homes of friends, with only friends or partners being present were frequently expressed, indicating the continued importance of trust in recurrent use. Those injecting for the first time after knowledge of the HIV epidemic relate, too, how they were initiated into the key rules of 'safe' injection post-AIDS--never share needles--and needle cleaning methods via the 2x2x2 bleach and water method figuring most prominently.

Injecting drug use, like other illicit activities, necessitates a display of trust in a number of key areas: access to the drugs via dealers and not being ripped off with cut supplies; respect for personal privacy and not having one's cover 'blown' if one is trying to pass as straight with significant others; trust that one will not be betrayed to law enforcement agencies; trust in the network of petty users and dealers in the informal economy which many of the respondents were involved in at some level.

The need for trust, once the choice regarding continued drug use has been taken, does not, however, detract from the common theme of the need for responsibility for oneself and for others which many respondents kept emphasising. This emphasis centres on what is now well known: the dangers of sharing needles and the risks associated with re-using uncleaned needles if new ones are in short supply. Knowledge about these issues is well implanted, if not always acted upon, as we have seen. This knowledge is not, however, necessarily there in the minds of new initiates. The latter's knowledge of safe injecting and safe sexual practices may be limited, leaving the initiate open to risk behaviours which, if less trust had been displayed, might have been avoided. The implications of this for intervention strategies is to underline the importance of targeting those who are likely to be experimenting with drugs and hence in a position where the transition to injecting becomes a possibility if not a probability. Harm minimisation strategies have tended at times to work to discourage injecting drug use. This we feel is a shortsighted strategy and one which does not do justice to the many injecting drug users who are doing so unproblematically without harmful effects. More important is for the transmission of accurate, reliable information about safe using and cleaning practices such that those deciding to make the transition to injection do so in the full knowledge of what is required, rather than placing their trust in others.   This is even more important given the number of occasions where respondents admitted that needle sharing sometimes takes place. We also need to re-emphasise that self reports of safe practices are likely to overlook instances of unsafe using which may occur in practice. Knowledge is not necessarily translated always into safe practice.

Building on the claimed responsibility to self and to others especially as regards teaching initiates the rules of safe drug use is a wise strategy. It should also be linked with an emphasis on the need for safe sex. Again, the data reveals a high degree of trust substituting for safe sexual practices in our sample. Knowledge about safe sex is less evident in our sample than knowledge about safe using practices. Having a regular partner and assuming that the relationship is monogamous is frequently seen as the defence against HIV transmission, especially if the partner has a negative result on an HIV test. A number of people in the sample have had a number of HIV tests indicating a concern about one's own or one's partners' HIV status and the risks of acquiring the virus. Yet trusting in the apparently 'clean' status of one's partner, or relying on good luck, or perceiving the risks to be low unless sleeping with gay people or prostitutes still, as we have seen are too prevalent for complacency. Delegitimising misplaced trust in one's own or one's partner's monogamy, the expert's judgement via HIV tests and perceived low risk attached to unprotected sex seems an important priority.   So also is the need to correct the impression that it is still gay people who are the main group at risk.

Needle Procurement:
I don't like going into chemists, I don't like giving them my money.... They are basically retailers and very greedy people who are making a lot of money under the guise that they were actually providing for the health of the people and they weren't at all and their attitude towards people coming in to buy syringes was absolutely atrocious.

I don't like it if I'm going to score, and I'm going to pick up a packet [of fits] at the same time, then I won't take a pack back because ... just for the cops, you know.

I don't normally share with people unless I particularly have to, you know .... If its 5.00 in the morning or something and I'm not prepared to walk all the way up to the - to find a bus to - to get myself a disposable syringe and I don't have one in the house, well I'll share one with someone else...

If I don't have any drugs, [I] don't usually have syringes lying around because to have syringes lying around makes me feel like I'm going out to buy drugs - so I prefer to just sort of get everything at once.

I just go to the pharmacist now they've brought in the fit packs, you don't pay for them, just swap them over ... it's easier to get to a pharmacist than the - drug clinic.

We've got a friend who is on the needle exchange so she brings boxes of syringes over and that is not a problem at all with the needles. They go back into the little yellow box ... you fill up the box and give it back to her.

Needle exchanges ... it's the best thing that has ever happened to this country, you know ... before you could get needles someone would come out to your house to score ... and if they didn't have their own fit you know you would lend them your own fit. That was just the way it was.

I usually get new needles before I've run out of my other needles ... to be able to just go in and buy a package of syringes is civilised ... Chemists, yeh, chemists. Needle exchanges? No, never N0. I wouldn't even know where one was. I don't even know how they operate. It's my use, and it is a private thing in that I don't particularly want the world to know ... we just have the one chemist. Our sample divides into roughly two equal sized groups. Half of the sample always buy their fits from a chemist and do not know of the location of needle exchanges or would not use one. The other half regularly use needle exchanges and sometimes use pharmacists or obtain fit supplies from drug clinics. There is some evidence that it is the heavier, more regular users who use needle exchanges more regularly and that there are income factors also at work. The more functional users also tend to use pharmacists. Use of a pharmacist is seen as more anonymous, less stigmatising than the needle exchanges. Some never obtain their own syringes personally, relying on friends or partners to keep them supplied with fits, indicating fear of the stigma attached to having personally to front up to the supplier. Some complain of what they see as too many gatekeepers at the needle exchanges. They do not want to talk; they just want to obtain their fits quickly and leave. A few complained of the hassle of getting fits if a pharmacist or needle exchange was not nearby and a number mentioned the difficult of procuring clean needles at night time.

The general ease of procuring clean needles is undoubtedly one of the key factors contributing to safer patterns of drug injection. Care should be exercised to ensure that every area is covered by both needle exchanges and pharmacists and that access to very late in the evening is possible. It is important, too, that fit supplies are accompanied by pamphlet information reinforcing the messages about safe using and cleaning practices and safe sex. This is important, too, for syringe packets obtained from pharmacists. More pharmacists should be encouraged to participate in the needle purchase and exchange schemes and encouraged to display free literature or distribute free information with the packs.

Several respondents spoke of fear that needle exchanges were watched by police. There needs to be an intensified effort to deter law enforcement agencies from undertaking surveillance of places where fits can be obtained or disposed of.

Another issue of concern is the question of large social gatherings such as dance parties or musical events in pubs etc., where some spontaneous drug taking sometimes occurs.   It is at these occasions rather than in private houses that sharing of needles is more likely to occur if the drug taking happens in an unplanned manner. Consideration should be given to the installation of automatic syringe dispensing machines in all pubs and buildings where such events are likely to occur. The need for less conspicuous but secure needle disposal bins was also mentioned by some of our respondents. Those using at home claimed to be careful about needle disposal, placing them in plastic bottles or cartons and wrapping them up in paper or plastic bags before using the garbage bins. others claimed to keep a special bin for needle disposal, but a number of users, especially those indicating a greater dependency on drugs would admit to using public toilets or pub toilets soon after scoring. This raises the question of the provision of needle disposal devices in such places; to do so would require a change of attitude on the part of publicans, many of whom would be reluctant to appear to concede that their pubs are being frequented by users. Some respondents in the sample mentioned specific pubs as being the source of their usual supplies from dealers. What prevents adherence to the rule about safe needle disposal is, of course, the stigma attached to injecting drug use itself and the desire to avoid disclosure: hence the emphasis placed above on the need for a change of public attitudes regarding drug use.