The Social Geography of AIDS and Hepatitis Risk: Qualitative Approaches for Assessing Local Differences in Sterile-Syringe Access Among Injection Drug Users
Merrill Singer, PhD, Tom Stopka, MHS, Cara Siano, MPH, Kristen Springer, MPH, George Barton, BA, Kaveh Khoshnood, PhD, April Gorry de Puga, PhD, and Robert Heimer, PhD
American Journal of Public Health -July 2000, Vol. 90, No. 7- P P 1049 - 1056:
ABSTRACT
While significant gains have been achieved in understanding and reducing AIDS and hepatitis risks among injection drug users (IDUs), it is necessary to move beyond individual-level characteristics to gain a fuller understanding of the impact of social context on risk. In this study, 6 qualitative methods were used in combination with more traditional epidemiologic survey approaches and laboratory bioassay procedures to examine neighborhood differences in access to sterile syringes among IDUs in 3 northeastern cities. These methods consisted of (1) neighborhood-based IDU focus groups to construct social maps of local equipment acquisition and drug use sites; (2) ethnographic descriptions of target neighborhoods; (3) IDU diary keeping on drug use and injection equipment acquisition; (4) ethnographic day visits with IDUs in natural settings; (5) interviews with IDUs about syringe acquisition and collection of syringes for laboratory analysis; and (6) focused field observation and processual interviewing during drug injection. Preliminary findings from each of these methods are reported to illustrate the methods’ value in elucidating the impact of local and regional social factors on sterile syringe access. (Am J Public Health. 2000;90:1049–1056).
Field Observation and Processual Interviewing During Drug Injection
Rigorous analysis of intersite and intrasite variation in injection practices, associated risk, and key context variables that shape local and microenvironmental IDU risk behavior remains an important arena of HIV prevention research. Despite a number of field studies in recent years,41 as McCoy et al.42 stress, we need to investigate local variation in “the potential populations [at risk] and their injection practices, patterns, and cultures.” Socioenvironmental differences across regions and even across neighborhoods appear to be associated with behavior differences in drug injection practices and risk levels.43,44 In addition, it is important to note that drug use is never a static behavior.45,46 Injection practices change over time as new drugs, new drug combinations, and new routes of consumption are introduced (e.g., the initiation in recent years of crack cocaine injection). Emergent behaviors often create new risks. Sustained direct ethnographic field monitoring of injection and other drug use practices, consequently, has emerged as a critical tool for HIV prevention research.
In our study, ethnographic observation and recording of natural syringe-use behaviors is conducted with a subsample of the individuals recruited for participation in the epidemiologic survey component of the study. In each of the 24 neighborhoods under study, project outreach workers and ethnographers select 2 participants (a man and a woman) for our ethnographic subsample (n= 48). Selection is also guided by an attempt to include individuals who represent the range of ethnic identities found among IDUs in the target cities. In addition, participants are selected who are known to inject different drugs (heroin, cocaine, speedball). Selected individuals are asked if they are willing to be observed injecting, a request that some IDUs decline because they do not feel comfortable being observed in this way but that others readily accept. Project ethnographers accompany consenting participants to their regular injection sites.
Following and expanding on the methodology developed in the Needle Hygiene Study,47,48 beginning with the drug mixing process (and focusing on previously identified potential direct and indirect sharing behaviors), the ethnographers record the drug use sequence (chronology of events): who mixes the drugs, how they mix, equipment used, drawing of drug solution into the syringe, quantities of drugs consumed, arguments over amounts of drugs taken, squirting back, back loading (injecting drugs into the back end of the syringe) and front loading (removing the needle and injecting drugs into the front end of the syringe), cotton sharing, drawing up previously used rinse water, syringe cleaning behaviors, where rinse water is squirted, “booting” (moving the drug mixture and blood back and forth between a user’s syringe and the vein), transfer of syringes to other injectors, bleaching or use of other cleaning agents, duration of syringe cleaning, body injection location, injecting of others, duration of injection process, and postinjection behaviors. For each syringe that is loaded or reloaded in the scenario during the observation period, this process of data collection is repeated.
Other drug use (e.g., smoking of marijuana, cocaine, or heroin) or alcohol consumption during the observation is also recorded. The ethnographers record any other behaviors that appear to hold potential HIV transmission risk, as well as the topics of conversation of participants while they inject. Finally, the ethnographers ask and record the answers to questions that help clarify observed behaviors (e.g., What determines injection order when several individuals inject together? Why do some people share syringes here while others do not?). Ideally, these questions are asked processually, during the course of the injection scenario, as the behaviors in question are being performed. If necessary, they are asked at a later time.
Observations and note taking on drug use practices in our study are guided by the Drug Use Observational Frame, an instrument developed in this project. The frame directs researchers’ observations and record keeping during each observational event toward the following: (1) demographic information on the identified project participant and all others present at the injection scenario; (2) nature and characteristics of the physical setting, including detailed descriptions of the setting, ownership and organization of the setting, and time of day and week of year of the injection event; (3) the drug(s) being consumed; (4) the social roles and behaviors of all who are present at any time during the event; (5) injection equipment present (syringes, cookers, cotton, rinse water, etc.) and who brings and controls the equipment; (6) details of the preparation and handling of the drug solution; (7) interaction and relations among coinjectors, and proxemics (spatial arrangement) of event participants; (8) specific drug injection practices, injection behaviors, and all uses of injection equipment; (9) transfer of equipment between participants; and (10) disposition of syringes following injection event, including specific rinsing, sterilization, hiding, and discarding behaviors. This information, as well as all other qualitative data collected in the project, is computer entered as textual data and coded (following a project coding scheme developed around the key issues of concern for the study) for qualitative analysis by means of the NUD*IST (Qualitative Solutions and Research Pty Ltd, Victoria, Australia) text management and analysis software program.
The value of direct observation of injection behavior and processual interviewing during injection is seen in the following account recorded by a project ethnographer:
The spot Don has picked to inject strikes me as very open. I can see people walking by a grocery store on the other side of the street (and they can see us if they choose to). . . . But Don says he’s fast. He puts his back to the wall and crouches down. I crouch with him. There is debris around us, plastic bottle caps, bottles, and the part that you pull to open them, condom wrappers (Don explains that prostitutes bring their tricks here), dope bags, all in a heap at the other end of the landing. Someone it seems has tried to do some tidying up here and pushed “everything” into a corner. Don pulls out his syringe from a back pocket of his jeans. He cleans it a little with the water he scooped up from the mound of snow on his way here. He can’t use much because it was only a capful.
He picks up another bottle cap from the floor and wipes the inside out with his shirt sleeve. I ask if it looks like it’s been used before, he says yes, because it had the residue still in it. He tears open the dope bag and pours the powder in the cap. First he just pours it straight, then he tilts the bag to make sure he’s gotten all of the powder. . . . Once it’s all in, he draws up a small amount of water. He says he likes to use 10 [units of water] and adds it to the dope. He tells me he got the syringe from a street seller, a guy who gets them from the [syringe exchange] van and resells them for three bucks.
Don crushes the heroin with the other end of the syringe. This takes a few seconds, as the stuff doesn’t dissolve immediately. Then he quickly snaps a piece of cigarette off of the one he has laying next to him. I hadn’t noticed until this point that he has placed the box and cigarette at his side. Again, it’s a very rapid motion, too quick for most people to notice. He places the sliver of filter in the mixture and moves the syringe around to various places in the cooker in order to get every part of the mix. By the time he places the cooker back down it is clean. Don flicks at the syringe a couple of times, presses slightly on the plunger and a few drops of water fly out, then he rolls up his sleeve. . . . Don just presses the needle in, notices blood enter the syringe, pushes down the plunger and pulls out. Then he puts his hand to the spot, a little pressure to try to stop bleeding and he is done.
Described in this account are several risk behaviors, including use of a previously used cooker picked up from the floor of a shooting gallery (a behavior that could transmit hepatitis), use of a syringe purchased on the street (said to be from the syringe exchange, which may or may not be true), and use of a finger to stem the flow of blood at the injection site (which, if the IDU is infected with hepatitis, would make even shaking hands with him potentially risky).
Conclusions
Individually, none of the qualitative methods described above can confer a complete picture of the life and risk behavior of IDUs. Consequently, we have incorporated all of these approaches simultaneously, with the goal of triangulating findings across methods (i.e., matching and contrasting finding from one method with those of other methods and using various methods to increase the reliability of any particular finding). Together, this set of qualitative strategies offers a rigorous methodology for directing attention to the importance of local context on IDU risk behavior; disentangling the complex set of local context factors that promote transmission of HIV and other bloodborne diseases; comparing and contrasting risk-influencing features across microenvironments; and improving the targeting of interventions to the precise configuration of risk-enhancing characteristics of specific local settings.
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