Syringe Sharing and the Risk of Viral Transmission Among People Who Inject Drugs in Nigeria: Structural, Relational, and Subjective Influences on Behaviors

• Author: Ediomo-Ubong E. Nelson,Gboyega E. Abikoye
• Date: 01 April 2019
• DOI: 10.1177/0022042618811654
• Published date: 01 April 2019
• Subject Matter: Articles

https://doi.org/10.1177/0022042618811654

Journal of Drug Issues

2019, Vol. 49(2) 387 –404

© The Author(s) 2018

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DOI: 10.1177/0022042618811654

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Article

Syringe Sharing and the Risk

of Viral Transmission Among

People Who Inject Drugs in

Nigeria: Structural, Relational, and

Subjective Influences on Behaviors

Ediomo-Ubong E. Nelson1 and Gboyega E. Abikoye1,2

Abstract

In this article, we report findings of a qualitative study on structural, relational, and subjective

determinants of injecting risks. Forty-one current people who inject drugs (PWIDs) were

recruited through snowball sampling in Uyo, Nigeria. They were interviewed with a loosely

structured interview guide. We employed inductive and thematic analysis of interview

transcripts. PWIDs recognize the risk of viral transmission through sharing of syringes. As

countermeasures, they inject with sterile syringes, refuse to borrow syringes, and disinfect

borrowed syringes. Risk reduction efforts are undermined by withdrawal, pleasure seeking,

public injecting settings, policing, social networks, and intimate relationships. These factors

create a risk environment for viral transmission. Pleasure-seeking and risk reduction practices

show agency and subjectivity, counterbalancing current emphasis on structural determinants of

injecting risks. Findings indicate the need for policy reforms, needle and syringe provision, oral

drug substitution, safe injecting environments, and peer education. Interventions should build

on PWIDs’ agency and risk management practices.

Keywords

HIV, viral hepatitis, people who inject drugs, risk environment, syringe sharing

Introduction

People who inject drugs (PWIDs) are at high risk of infection with blood-borne pathogens such

as HIV and viral hepatitis through the sharing of syringes and other injecting paraphernalia

(Clatts, Heimer, Sotheran, & Goldsant, 1999; Grund et al., 1996). There are about 12 million

PWIDs globally; 1.6 million (13%) live with HIV and 6.1 million (50%) live with hepatitis C

(Joint United Nations Program on HIV/AIDS [UNAIDS], 2017). Injecting drug use is a primary

mode of HIV transmission in high-prevalence settings (UNAIDS, 2017). It is increasingly fuel-

ing the epidemic in the low-prevalence setting of sub-Saharan Africa, where the diffusion of

1Centre for Research and Information on Substance Abuse, Akwa Ibom State, Nigeria

2Department of Psychology, University of Uyo, Nigeria

Corresponding Author:

Ediomo-Ubong E. Nelson, Centre for Research and Information on Substance Abuse, 10 Okon Essien Close, P.O. Box

4230, University Post Office, Uyo, Akwa Ibom State, Nigeria.

Email: degreatnelson@yahoo.com

811654JODXXX10.1177/0022042618811654Journal of Drug IssuesNelson and Abikoye

research-article2018

388 Journal of Drug Issues 49(2)

injecting drug use has been linked to concentrated outbreaks of HIV and hepatitis C (Kurth et al.,

2015; Matiko et al., 2014; Nyandindi et al., 2014).

Injecting risks are shaped by the interplay of individual, interpersonal, and structural–environ-

mental factors. Structural factors manifest in microsocial environments and in patterns of indi-

vidual risk behavior (Rhodes & Quirk, 1998). Existing literature points to withdrawal (Connors,

1992; Power, Jones, Kearns, & Ward, 1996), lack of sterile syringes (Koester, 1994), injecting in

public settings (Carlson, 2000; Deren, Kang, Colon, Andia, & Robles, 2004; Rhodes et al., 2006;

Thorpe, Ouellet, Levy, Williams, & Monteroso, 2000), policing practices (Bluthenthal, Kral,

Lorvick, & Watters, 1997; Cooper, Moore, Gruskin, & Krieger, 2005; Small, Kerr, Charette,

Schechter, & Spittal, 2006), and the social networks of PWIDs (Grund, Kaplan, & Adriaans,

1991; Power et al., 1996) as determinants of injecting risks.

PWIDs share injecting paraphernalia to prevent withdrawal pains, reduce the risk of police

arrest, and maintain social networks (Bourgois, Lettiere, & Quaseda, 1997; Connors, 1992; Power

et al., 1996). The physical settings of injecting also shape risk (Fitzgerald, Dovey, & Dietze, 2004;

Rhodes et al., 2007; Tempalski & McQuie, 2009). Spatially situated policies, which operate as

mechanisms of repression and social exclusion of drug users, undermine safe injecting, and ele-

vate the risk of viral transmission through unsafe injecting practices such as injecting in public,

hurried injecting, and syringe sharing (Bluthenthal et al., 1997; Cooper et al., 2005).

Gender also influences injecting risks. Women are more likely to have a PWID as a sexual

partner (Choi, Cheung, & Chen, 2006). They mostly inject in the context of intimate relation-

ships, characterized by subordination. They have limited control over the circumstances of

injecting, including access to drugs, sharing of syringes, and ability to inject (Barnard, 1993;

Bourgois et al., 1997; Choi et al., 2006; Cruz et al., 2007). Women are at high risk of infection

with blood-borne pathogens through receptive syringe sharing, injecting assistance, and unpro-

tected sex (Barnard, 1993; Lazuardi et al., 2012; Rhodes & Quirk, 1998). A recent study, how-

ever, shows that some women demonstrate agency, and exercise relative control, over the

circumstances of drug injecting (Syvertsen et al., 2014).

HIV prevention is an important harm reduction measure for PWIDs. In most African countries

including Nigeria, key components of the standard package of interventions for preventing dis-

ease transmission among PWIDs such as needle and syringe programs (NSPs) and opioid substi-

tution therapy (OST) are currently not available. HIV prevention interventions mostly rely on

targeted information, education, and communication (IEC) programs that seek to foster the adop-

tion of safe injecting practices by PWIDs (International Drug Policy Consortium, 2016). They

emphasize individual’s perception and management of risks. PWIDs are depicted as “health-

conscious citizen(s) capable of rational decision-making and self-regulation in keeping with risk

avoidance campaigns” (Moore, 2004, p. 1549). As ways of governing drug use, interventions

seek to facilitate informed and rational decision making regarding injecting risks by providing

information and education urging PWIDs not to share injecting paraphernalia. This view over-

simplifies the dynamics of injecting and the context of risk practices, and also ignores the situ-

ated and pragmatic risk management strategies of PWIDs (Duff, 2003; Pilkington, 2007).

Studies emphasizing the social determinants of drug use have been critiqued for downplaying

the personal agency of drug users (Bourgeois & Schonberg, 2009; Duff, 2007). But as Valentine

and Fraser (2008) observe, it is “possible to recognize constraints on agency while also recogniz-

ing people’s inherent capacity for agency” (p. 411). Defined in relation to social structure

(Giddens, 1984), personal agency refers to the capacities or resources that individuals possess to

control the course of their lives, which varies across social stratum, personal experiences, and the

life course (Hitlin & Johnson, 2015; Mirowsky & Ross, 2007). It implies both actual capacities/

resources and individuals’ perceptions of those capacities/resources (Hitlin & Long, 2009),

including self-efficacy (Bandura, Barbaranelli, Caprara, & Pastorelli, 1996) and sense of control

(Mirowsky, 1995). Research on injecting risk needs to capture structure–agency interactions,

where the environment constrains as well as enables personal agency (Rhodes et al., 2012).