Harm reduction should address the specific needs of couples who inject drugs

The sharing of drug injecting equipment most often occurs between sexual partners, but the ways in which couples manage risks and care for each other have been largely ignored by harm reduction services, say Australian researchers.

In-depth interviews showed that drug users’ relationships were based on mutual trust, honesty and care. Couples tried to avoid sharing their equipment but when they did, they took into account what they knew about each other’s hepatitis C status and genotype to minimise risks. This could be described as a form of ‘negotiated safety’, say the researchers.

Jake Rance, Tim Rhodes, Carla Treloar and colleagues have published the findings in articles published online ahead of print in Health and Social Science & Medicine. The programmatic implications are summarised in a document from the University of New South Wales.

The study

The researchers recruited heterosexual couples in which both partners injected drugs. Both partners were interviewed separately, but the unit of analysis was the couple – the researchers considered the male partner’s account in the light of the female partner’s interview, and vice versa.

Of the 80 people who took part in in-depth interviews, 68 were members of couples in which both partners were interviewed, while the last 12 interviewees spoke about their current or past experience with a partner who did not take part in the study.

Participants, who were mostly heroin users, were recruited through drug services in Sydney and Melbourne. Nine had some form of employment and nearly all received some form of social welfare. Of 41 relationships described, 17 had mixed hepatitis C status, in 13 both partners had hepatitis C, and in 11 neither had hepatitis C.

Twenty-nine couples reported sometimes sharing injecting equipment within the partnership.

The relationships

The duration of partnerships ranged from two months to 20 years, with most interviewees having been together several years. They often described each other as ‘best friends’ and said that they did ‘everything together’. They described all-encompassing relationships of care and protection. This man had been in a relationship for eight months:

“We’ve been injecting together since, almost since we started seeing each other. We’re very much obsessed with each other, and so spend 90% of our time together. We look after each other, you know, financially, emotionally.”

Frequently, the relationship functioned as an emotional refuge and social protection against the stigma, hostility and uncertainty of the outside world, as these interviewees explained:

“When you’re normal it’s different. But when you’re using, I think because you need somebody, it’s better than being on your own, it helps you help each other. You know what I mean, kind of thing, with money, and this, and the emotional support.”

“If one is sick [in withdrawal], the other is sick. If one goes out to make money, the other goes out to make money as well. It’s always 100% together. That’s the commitment we made from the beginning, and I’ll stick to that until I die.”

However, the way in which the relationship served as a refuge from the hostile outside world could also serve to entrench each person’s social isolation. Interviewees often used the language of ‘co-dependency’ and reflected on how drugs being a fundamental part of their relationship could make it hard for either person to move on.

“If one person wants to stop and the other doesn’t, how do you fucking deal with that?”

Several interviewees emphasised how ‘normal’ their relationship was, describing activities like watching a movie, cooking dinner or going to the beach. But this could sometimes be more of an aspiration than a reality as this woman in an eight-year long relationship explained:

“Our lifestyle has been a lot more of just chasing, surviving, in terms of not being sick, because that is survival for most of us… Our lives are so consumed by the lifestyle.” 

Injecting together

When talking about using drugs together with their partners, many interviewees emphasised trust, honesty, safety and security. Almost all described codes of conduct they had negotiated with their partner around using drugs with other people. Following these ‘rules’ was key to maintaining trust and intimacy within the relationship.

“I know [Fred], I love him, it’s different. We’ve been together for so long, we know so much about each other and we’re just so close. Whereas other people, I don’t trust, I don’t know their life. I know his life.”

Safety and security was not just about avoiding blood borne viruses. By only injecting with their partners, participants avoided other risks and dangers – a disagreement about how drugs should be shared or someone having an overdose. Using drugs with others required vigilance, so many preferred to do so with a partner where things followed a familiar routine.

Almost all interviewees said that while they had shared needles with their partner, they would not contemplate doing so with anyone else. In doing so, many attempted to reduce viral risks, based on their shared knowledge of each other’s hepatitis C status and even genotype.

“Every now and then when we have been stuck and we’ve only got one fit [needle] between us… [He] will make sure that I use it… then he’ll rinse it and use it… Because he has [hepatitis C] and I don’t… And he wants to keep it like that.”

“We found out we’ve both got the same strain, and we know we both don’t have anything else. We always have blood tests… he’s the only person I’ll share with.”

One couple, who both had hepatitis C, based decisions on their knowledge of the interferon-based treatments that were available at the time of the interview. Their decision for the female partner to inject first was based on their understanding that treatment for her genotype 3 was of shorter duration and more effective than the male partner’s genotype 1a. They reasoned that it was better to risk transmission from her to him, than vice versa.

But hepatitis C was not the only consideration in deciding who would inject first when only one needle was available. Other risks to be managed included overdose (a greater risk for the first person) and being able to find a vein (reused needles are less sharp).

"I always went [injected] first I suppose... If the gear was too strong, or something like that, I would be the one to overdose first... If Cath goes first, I don’t want anything to happen to her."

Similarly, caring for a partner could sometimes result in decisions about injecting that would run counter to advice on avoiding blood borne viruses. For example, it could mean reusing injecting equipment to cope with the immediate demands of drug dependence and withdrawal.

While some previous studies have described women having diminished power and agency in relation to injecting with their partners, only two of the female participants explicitly described this. Both were unhappy with their partner’s strong insistence on the couple injecting in public spaces, immediately after purchasing drugs, despite the associated risks. There were no accounts of violence.

Negotiated safety

The term ‘negotiated safety’ was coined to describe how gay male couples use their knowledge of each other’s HIV status and of transmission routes to create HIV prevention strategies that go beyond consistent condom use. Specifically, many couples have agreements about not using condoms within the primary relationship, but using them with casual partners.

The researchers think that their interviewees’ use of knowledge about hepatitis C status and genotype could be described as negotiated safety. “For both gay men and couples who inject drugs, negotiated safety as a form of viral risk reduction relies on the coming together of the biomedical and the intimate: on sharing and incorporating knowledge of each other’s serostatus within a relational context of honesty and trust,” they say.

They note a crucial difference, however. Whereas gay men’s agreements are about findings ways to safely include other men in their sexual dynamic, the agreements of the couples who inject drugs are about excluding other people.

The interviewees saw sometimes sharing equipment with their partner (but never with outsiders) as a way to protect the couple from unknown or less trustworthy outsiders. The ways in which couples managed risks was not just a rational calculation, but also a way of demonstrating intimacy and mutual care.

Recommendations

“Failing to recognise the unique issues that face couples who inject drugs, and disregarding their partnerships, means missed opportunities for understanding decision making around injecting drug use and HCV prevention,” say the researchers.

Harm reduction workers are not equipped to engage effectively with couples who inject drugs, they say. Services focus on individual behaviours and self-care, rather than considering social relationships and any protection within a couple. Harm reduction needs to develop skills and competencies for working with couples, the researchers believe.

Harm reduction workers should acknowledge the care couples provide for each other, not only in relation to hepatitis C, but in all aspects of their lives. They should provide realistic and relevant advice that acknowledges the restrictions and complexities couples who inject drugs deal with.

The researchers also suggest that there could be a potential for couples-orientated programmes for detoxification, opioid substitution therapy and hepatitis C treatment. For example, the latter could help couples jointly address the challenges involved in taking treatment, offer support to the partner not taking treatment, and address reinfection concerns. Couples should be engaged in programmes to provide naloxone for overdose management.