Social context of risk behaviours

Abstract

The global incidence of HIV and other blood-borne viral infections in injecting drug users continues, in varying degrees and at different rates. Yet a problem with the epidemiological characterisation of route of transmission as 'injecting drug use' as a single homogenous category is that it tends to hide major cultural and contextual differences, as these following studies, from Switzerland, France, Brazil, Vietnam, India and Scotland, demonstrate effectively. Thus, whilst Somaini et al. in Zurich can posit a relationship between the provision of harm reduction programmes and reduced HIV incidence, and certainly the protective effects of such programmes on younger drug users, it is unclear why the impact on Hepatits B and C is much less marked. In France, on the other hand, Reynaud-Maurupt et al . indicate that the use of drug maintenance treatment had little impact on risk reduction, and look to other characteristics of IDUs to understand continued risk exposure. This is also evident in Dunn and Laranjeira's account of risk behaviour among IDUs and non-IDUs in Sao Paulo, Brazil. Here, cocaine and multi-drug use in older users was associated with HIV positivity and, as so often with such studies, non-injectors are on a trajectory to greater harm if interventions are not addressed to their needs. In Ho Chi Minh City, Vietnam, Hien et al. find the classic combination of extremely high risk factors (including sharing of needles and syringes in shooting galleries) facilitating HIV transmission not only among drug users, but in relation to their partners and sex workers in the city. In Manipur, India, Eicher et al. demonstrate how quickly new epicentres of HIV can be established when the risk behaviours for HIV are present, with most infections occurring in their study population within two years of commencement of drug injecting. The key to all of these papers is the social context of drug use, and this is explicated by MacRae and Aalto's paper from Scotland, which focuses on the impact of women's sexual relationships on their risk exposure. This finds that male partners injected their female partners, as part of what the women considered to be a loving relationship. Whilst parenteral transmission of HIV can be reduced to its most basic level - in the case of these papers, as a function of the sharing of injecting equipment - it is clear that effective interventions to prevent transmission will not be possible unless the diversity of drug use, the range of people involved and the varied contexts in which it occurs, are placed at the heart of our efforts to stop the spread of HIV and AIDS.