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Considerations for educators working with people who inject drugs

Considerations for working with populations at risk of hepatitis C

People with or at risk of hepatitis C come from all sectors of the Australian community and their experience of hepatitis C varies according to individual and community circumstances. This section contains information on some of the basic considerations educators should be aware of when providing education to particular communities to ensure both relevant and language appropriate hepatitis C messages are delivered.

Information in this section been adapted from the Hepatitis Council of Queensland Box Project Workshop manual (2003).

People who choose to inject drugs should have access to information about safer injecting practices so they can reduce the risk of contracting hepatitis C. Educators have an important role in dispelling the myths and misconceptions that surround hepatitis C transmission and injecting for  people who inject, health care workers and the general community.

Hepatitis C epidemiology in people who inject drugs

It is estimated that in 2006 there were 271,000 Australians with hepatitis C antibodies, of which 202,400 people had chronic hepatitis C infection. People who inject drugs are at greatest risk of contracting hepatitis C. Approximately, 82% people had been exposed to hepatitis C through unsafe injecting drug use (IDU) and 90% of new infections were attributable to unsafe injecting practices which include sharing needles, syringes, spoons, filters and tourniquets. Of the hepatitis C notifications received up to 2005, 65% occurred in people aged 20 to 39 years, of whom 35% are women.

The 2004 National Drug Strategy Household Survey established that 1.9% (over 313,500 people) of the Australian population had injected illicit drugs at some time in their lives and that more than 73,800 (0.4%) had done so at least once in the preceding 12 months. Research indicates that the median age at which Australian youth are initiated into IDU is 18 years; and there is a high incidence of IDU among people from culturally and linguistically diverse (CALD) communities and people living in rural and remote areas. Aboriginal and Torres Straight Islander people are also at risk of hepatitis C infection through IDU, injecting while incarcerated and because they have poor access to health and related services such as needle and syringe programs (NSP).

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Considerations when working with people who inject drugs

The role of peer education programs

People who inject drugs are a valuable resource for each other. In Australia, peer education and support is the essence of educating people who inject drugs about safer injecting and preventing transmission of hepatitis C and other blood borne viruses (BBVs). The aim of peer education is to provide relevant information using appropriate education strategies for people who inject drugs so they can minimise harm to themselves. Peer education programs are delivered by current and/or past injectors who have been trained in adult education principles and hepatitis C. Peer education acknowledges the expertise and cultural awareness of people who inject. The State and Territory Drug User groups administer many of the peer support and education programs and are an important source of advice and support for educators.

Acknowledge the impact of stigma and discrimination

There is considerable evidence that people who inject drugs face discrimination on the basis of their drug use, particularly in health care settings. Hepatitis C related discrimination is often associated with the wider problem of discrimination towards people who use drugs. People with hepatitis C who inject, or have a history of injecting drug use often face a double burden of societal discrimination.

Encouraging an understanding of the stigma that injecting drug users experience is crucial to targeting preventative messages and minimising the spread of hepatitis C. A powerful education strategy is to incorporate quotes and stories of people who inject into training sessions as it provides a voice for people who inject but also humanises the problem of discrimination. It is crucial to address the discrimination facing IDU communities because stigma and internalised discrimination affect individual’s ability to control their own health and access essential health services.

Educate people who inject drugs about preventing hepatitis C transmission

Hepatitis C education targeting people who inject drugs needs to address all the potential ways that blood to blood contact could occur and subsequently the modes of hepatitis C transmission. Specific information about hepatitis C transmission in the context of re-infection with another genotype of hepatitis C needs to be provided for people who have either cleared the virus or people with existing chronic infection.

While the success of NSPs has been crucial in minimising the spread of BBVs, all equipment used for the preparation of drug use can pose a possible risk for hepatitis C transmission. Equipment such as tourniquets, water, spoons, swabs, filters, contaminated hands and the environment where drugs are mixed for preparation and administered, all pose a high risk of transmission of hepatitis C among people who inject drugs.

Educators are encouraged to work collaborative with the national and state and territory drug user organisations when delivering hepatitis C training. User organisations produce resources and information on topics relevant to the health and well being of people who inject, they also have expertise in administering and managing peer education programs and are therefore an excellent resource for educators.

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Barriers to safer injecting practices

With appropriate education and health promotion messages people who inject drugs are able to make informed decisions based on accurate information and perceptions of risk. However, perception of risk does not necessarily translate into effective risk management behaviours and can itself be a barrier to safer injecting practices. Hepatitis C educators need to have an awareness of the barriers to safer injecting so they can advocate for change to reduce the barriers and assist health services, government agencies and individual community members to assist people who inject drugs to navigate the barriers.

Structural barriers to safer injecting

Structural barriers encompass the availability of equipment at the time and place of injecting and a range of geographic barriers. Structural barriers may include:

• people who inject drugs require access to sterile syringes and clean injecting equipment outside of regular business hours
• people who inject drugs who live or work in outlying areas have to travel significant distance to an NSP outlet
• discrimination by primary and secondary NSP staff including workers where operation of an NSP is not their core work role, for example, pharmacies, accident and emergency departments and administration staff
• fear of being identified as a drug user by social service staff and police
• lack of access to the equipment or the amount of equipment they need to inject safely
• lack of privacy and confidentiality for people who inject drugs particularly in rural areas.

Situational barriers to safer injecting

Many unforeseen circumstances can impact on an individual’s intention and their ability to inject safely. For example, an individual may need to use quickly without considering the risks, especially if they are experiencing physical withdrawal from a drug. In addition, the effects of other drugs such as alcohol may override the adoption of safer injecting behaviour, in turn affecting the level of equipment hygiene. Other situation barriers to safe injecting include:

• fear of being caught by the police and subsequent police detention
• the risk of attracting moral outrage
• outing and shaming by community members, family and friends
• the risk of overdose, and dirty hits (for example from bacteria or toxicity).

These barriers all contribute to hepatitis C being a low priority for some people who inject.

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Cultural barriers to safer injecting

Cultural values and norms can create both perceived and real barriers to safer injecting, for example:

• the way a person is initiated into injecting drug use is likely to influence their subsequent behaviour in relation to the risk of hepatitis C transmission
• people who inject drugs may adopt the cultural behaviours and values of the people who initiated and taught then to inject
• other cultural beliefs and values including language and concepts of health and illness, infection and blood, also influence barriers toward safer injecting.

Social barriers to safer injecting

Social barriers to safer injecting may include:

• sharing drugs may be viewed as being socially important in a network of IDUs
• patterns of sharing may reflect patterns of affiliation in social networks
• sharing between sexual partners may be based on the belief that sexual partners will not pass on disease and that refusing to share may imply that they are dirty or untrustworthy
• peer pressure from other users not to adopt safer injecting practices.

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Gender related barriers to safer injecting

Gender is an important influence on the patterns of sharing among people who inject. There are differences between males and females with respect to initiation to injecting, the way they are initiated and their reasons for beginning injecting drug use. Women have been found to be more likely to share and place more importance on the social aspects of sharing than men, thus placing them in a vulnerable position with regard to hepatitis C infection.

Success of needle and syringe programs (NSPs)

Educators should be mindful that the general community may not understand the purpose or the success of NSPs in Australia in terms of preventing hepatitis C transmission. Therefore, consider addressing the role of NSPs in hepatitis C education programs.

Needle and syringe programs distribute needles, syringes and other injecting equipment either free or with minimal charge. Between 1991 and 2000 an estimated $141 million was spent on NSPs by the Australian government.

In terms of the effectiveness of NSPs in preventing hepatitis C infection, it is estimated that between 1988 and 2001, 21,000 hepatitis C infections were prevented across Australia among people who inject. Consequently it is estimated that 16,000 cases of hepatitis C will have been prevented and 90 hepatitis C-related deaths avoided by 2010.