HIV risk behaviors in heroin users in a Portuguese district: a qualitative study

Abstracts

OBJECTIVE: To explore heroin users' accounts of risk behavior in relation to the transmission of human immunodeficiency virus (HIV) in the district of Vila Real, northern Portugal, since heroin is the predominant drug in problematic drug use in Portugal and 48% of the total notifications of HIV infection in the country are associated with drug addiction. METHOD: Heroin users in an outpatient addiction treatment public center, randomly selected, were invited to participate. Data collection was via semi-structured qualitative interview designed to explore participants' accounts of health risk behavior associated with heroin use. RESULTS: Twenty-five interviews were conducted. Mean age was 32 years and 92% were men. A mean of 14.7 years of heroin use was reported, and 64% in total referring daily drug use. Two-thirds reported use of heroin and 16% reported intravenous drug use over the previous 30 days. Seventy-five percent reported having shared needles or paraphernalia. Front-loading or back-loading was common and not recognized as risk behavior. Eighty-four percent reported being tested for HIV at least once in their lifetime. CONCLUSIONS: It is essential to design better HIV prevention programs for this high risk group, using information on demographic movements and behavioral patterns of heroin users and addressing their risk behaviors in sexual practices and in sharing injection paraphernalia.

HIV; risk-taking; heroin; Portugal; intravenous substance abuse

OBJETIVO: Explorar relatos de utilizadores de heroína sobre seus comportamentos de risco para transmissão do vírus da imunodeficiência humana (HIV) no distrito de Vila Real, Portugal, já que a heroína é a droga predominante no que se refere ao uso problemático de drogas em Portugal, e 48% de todas as notificações de infecção por HIV no país são associadas à dependência de drogas. MÉTODO: Utilizadores de heroína recebendo tratamento ambulatorial para dependência em clínica pública foram selecionados aleatoriamente e convidados a participar do estudo. A coleta de dados foi realizada através de entrevista qualitativa semiestruturada, desenvolvida para explorar os relatos dos participantes sobre seu comportamento de risco associado ao uso de heroína. RESULTADOS: Vinte e cinco entrevistas foram realizadas. A idade média foi de 32 anos, e 92% eram homens. Os participantes relataram um tempo médio de uso de heroína de 14,7 anos, e 64% deles mencionaram uso diário da droga. Dois terços relataram uso de heroína e 16% referiram uso intravenoso da droga nos 30 dias anteriores à entrevista. 75% referiram compartilhamento de seringas ou parafernália de injeção. Front-loading ou back-loading foram técnicas comuns e não reconhecidas como comportamento de risco. 84% referiram ter sido testados anteriormente para o HIV. CONCLUSÕES: O desenvolvimento de melhores programas de prevenção ao HIV para este grupo de risco é essencial através do uso de informações sobre movimentos demográficos e padrões de comportamento de utilizadores de heroína, abordando seus comportamentos de risco nas práticas sexuais e no compartilhamento de parafernália de injeção.

HIV; comportamento de risco; heroína; Portugal; uso de substância por via intravenosa

REVIEW ARTICLE

HIV risk behaviors in heroin users in a Portuguese district: a qualitative study

Vanessa Fabiane Machado Gomes Marsden

Mestre em Psiquiatria e Saúde Mental, Faculdade de Medicina, Universidade do Porto, Porto, Portugal, Centro de Atendimento à Toxicodependência (CAT) de Vila Real, Vila Real, Portugal, Instituto da Droga e da Toxicodependência (IDT), Delegação Norte, Portugal

This study was carried out at Instituto da Droga e da Toxicodependência, Centro de Respostas Integradas (CRI), Vila Real, Portugal

Correspondence

ABSTRACT

OBJECTIVE: To explore heroin users' accounts of risk behavior in relation to the transmission of human immunodeficiency virus (HIV) in the district of Vila Real, northern Portugal, since heroin is the predominant drug in problematic drug use in Portugal and 48% of the total notifications of HIV infection in the country were associated with drug addiction.

METHOD: Heroin users in an outpatient addiction treatment public center, randomly selected were invited to participate. Data collection was via semi-structured qualitative interview designed to explore participants' accounts of health risk behavior associated with heroin use.

RESULTS: Twenty-five interviews were conducted. Mean age was 32 years and 92% were men. A mean of 14.7 years of heroin use was reported, with 64% in total referring daily drug use. Two-thirds reported use of heroin and 16% reported intravenous drug use over the previous 30 days. Seventy-five percent reported having shared needles or paraphernalia. Front-loading or back-loading was common and not recognized as risk behavior. Eighty-four percent reported being tested for HIV at least once in their lifetime.

CONCLUSIONS: It is essential to tailor better HIV prevention programs for this high risk group, using information on demographic movements and behavioral patterns of heroin users addressing their risk behaviors in sexual practices and in sharing injection paraphernalia.

Keywords: HIV, risk-taking, heroin, Portugal, intravenous substance abuse.

INTRODUCTION

The use of drugs in Portugal has presented, over the last years, changes more or less perceptive, in accordance with world panoramas. The Portuguese people are the second main heroin consumers in Europe and heroin, many times associated with cocaine is the predominant drug in problematic drug use in Portugal.^1-4 In 2004, heroin was referred to as the main drug by 85% patients in outpatient drug treatment clinics and by 75% patients on their first appointments in this network. The predominant route of administration is smoked/inhaled, with intravenous (IV) drug use being preferred by 25 to 52%.⁴

According to data of the Comissão de Vigilância Epidemiológica de Doenças Transmissíveis (CVEDT, Epidemiological Surveillance Committee on Communicable Diseases) in 2005, 48% of the total notifications of human immunodeficiency virus (HIV) infection were associated with drug addiction.^5,6 The European Monitoring Centre for Drugs and Drug Addiction's (EMCDDA) annual reports of the drug situation in each European Unity (EU) country have demonstrated the relative seriousness of the drug problem in Portugal.⁷ There are high levels of HIV/acquired immunodeficiency syndrome (AIDS) infection among drug addicts and high levels of problematic drug use, particularly heroin. In Portugal, signs of advanced modernity and economic, social and cultural development are similar to most developed countries in Europe. At the same time there are indicators comparing unfavorably with other European countries, including education and literacy levels, poverty rates, and rates of early school leaving and educational failure.⁸ Research on the relationship between social deprivation and drug dealing and use shows highly specific configurations in Portugal and within Portugal's districts.

Portugal is not an economic homogeneous country and the northern region is one where the economic and social indicators are less favorable. Economic activity in northern Portugal has diverted from the national average, declining since the 1990's.⁹ The district of Vila Real is a district of northern Portugal, in the region of Trás-os-Montes, with a population of 223,328 inhabitants that has shown negative rates in recent years due to emigration and aging. The population density is sparse and much of this population lives in villages, many of which have fewer than 100 inhabitants. Over 75% of the population live in centers with fewer than 5,000 people, with a rural lifestyle (E. P. Lopes, master's thesis). In a rugged area of low mountains and narrow valleys, where the largest towns are small when compared to provincial capitals in neighboring Spain, Vila Real, the capital city, has roughly 25,000 inhabitants.

This study aimed at exploring Vila Real's heroin users' accounts of risk behavior in relation to HIV transmission.

METHOD

This study was carried out in 2007, during the implementation of HIV voluntary counseling and testing project to increase access to HIV testing and the connection of drug users to assistance. The objectives were to know risk behaviors and drug use patterns in heroin users in follow-up at an addiction treatment public center in the district of Vila Real, Portugal.

Sampling and recruitment

The facility in which the study was conducted is responsible for managing and supplying substance misuse treatment for the entire district, dividing it in subregions, to where methadone maintenance treatment is distributed to subregion's public health clinics. To facilitate management, a smaller center is established in the town of Chaves, the second biggest town (population: 20,000). Nevertheless, specialist consultants (psychiatry and hepatology) are only provided at the facility of Vila Real and patients who are in the subregions must attend regular appointments in the town. There were 1,450 patient's files in the archives, but due to the nature of migratory phenomena and patients who abandoned treatment, only 313 patients were "active" (at least one appointment in the previous 6 months). Ten percent of those active patients were randomly selected to participate in the study. Eligibility criteria included age over 18 years and not be intoxicated or incapable of understanding and supplying the informed consent. Letters inviting for the interview were sent and when patients accepted participation on the project, after being explained the methods, the interviews started. Interviews were conducted by a team of five individuals comprising health professionals who were trained in the methods in a 25-hour course supplied by the Coordenação Nacional para a Infecção VIH/SIDA (National Coordination for the HIV/AIDS infection) and Instituto da Droga e Toxicodependência (IDT, Drug and Drug Addiction Institute), as part of the larger program for Rapid Assessment of HIV/AIDS in Portugal.

Data collection and analysis

Data collection was via semi-structured qualitative interview designed to explore participants' accounts of health risk behavior associated with heroin use. For the topics and to analyze behavioral data we used a version of the Behavioral Surveillance Survey: Guidelines for Repeated Behavioral Surveys in Populations at Risk of HIV for repeated behavior surveys in populations at risk of HIV¹⁰ adapted by the National Coordination for the HIV/AIDS infection.¹¹ The semi-structured interview supplies answers to behavioral practices, profiles of risk and vulnerability of the population. All participants provided written informed consent to participate, noting that the findings were confidential. Interviews took place in Vila Real's addiction treatment center, and lasted between 30 and 60 minutes. Based on a topic guide, interviews sought to encourage conversation on aspects of risk behaviors related to HIV and patterns of drug use. From 31 subjects invited, six did not attend the appointments and 25 qualitative interviews were conducted. The interviews were not audiotaped to instill a sense of security and confidentiality among the heroin users and the data were comprehensively written. Analyses were inductive and thematic. Since this study was conducted during the implementation of a voluntary counseling and testing program, participant sample was chosen and closed when all of those who were invited by randomization had been interviewed or did not respond to the invitation.

Interviews were then analyzed and significant units were identified. Analytical categories were created, allowing to group significant units. Quantitative analyses were initially developed to establish connections and unveil patterns of risk behaviors.

All interviewees were offered free, on site, voluntary HIV counseling and testing by trained professionals using a third-generation immunochromatographic quick test. Confirmatory tests and referrals were provided to HIV care and treatment and other services, if necessary. All interviewees accepted HIV testing.

RESULTS

Sample characteristics

The sample comprised 25 heroin users, who averaged 32 years old (range 18-44 years) and were predominantly male (92%). Average education was 7.8 years (range 4 to 12 years of education). Mean of heroin use was 14.7 years (range 5-29 years), with 64% in total referring daily drug use on the 30 days prior to the interview. The average time of abstinence for those who did not report heroin use over the past month was 16 months (range 2 months to 3 years).

Drug related risk behaviors

In the 30 days prior to the interview, two-thirds (60%) reported use of heroin, 36% cocaine, 16% amphetamines, 8% non-prescribed benzodiazepines, and 28% the use of cannabis. Forty percent reported intravenous drug use (IDU) but not in the previous year, 8% reported IDU but not in the last month and 16% reported IDU over the last month. Among participants who reported IDU, a mean of 7.5 years (range 10 months to 16 years) of history of IDU was obtained. Those who did not report IDU over the past month (48%) reported a mean of abstinence of IDU of 4 years (range 4 months to 13 years). Of those who reported IDU in the prior 30 days, the substances used were heroin (two individuals), cocaine (two individuals), and heroin and cocaine (speedball) (two individuals). Seventy-five percent of participants who reported IDU in the previous 30 days injected 2-3 times a month and one individual injected at least once a week. Only male subjects admitted IDU in the previous 30 days.

Of those who reported IDU, 75% reported having shared needles or paraphernalia, 6.3% could not tell if they ever shared needles or paraphernalia and 18.8% denied ever sharing. Among those who reported sharing, 36.6% lent a needle or syringe after using it and 45% injected drugs with a syringe prepared by someone else. More common was the sharing of materials such as "lemon" or "spoon." Front-loading or back-loading was common and not recognized as risk behavior:

When we prepare it, we cook everything and suck it with a syringe. From there, we can divide it more evenly between me and the other guy. There is no problem, since the syringe we use is always a new one. We use the new syringe to divide it between us, pushing it into our own syringes.

Only one participant reported sharing paraphernalia in the past 30 days, sharing syringes with two other drug users, without cleaning them before use.

Access to new and sterilized syringes

Syringe exchange programs have been in effect in Portugal for the past 16 years. The great majority (92%) of the individuals reported knowing where to go for new and sterilized syringes and no main barriers to obtain them were identified. Pharmacies were the leading places to obtain new and sterilized syringes, according to 92% of the participants, followed by "HIV Street Outreach Workers" (16%) and the "dealer" (4%). The main problem concerning access to new material was related to access afterhours:

I always get syringes at the pharmacy. But the problem is I have to pay for it. It should be distributed at the center for us, like you do with the condoms. And it is difficult to buy it at night. I could get it at the machines, but I don't want anyone to see me.

Participants referred that since sterile syringes were available, they have become more eager to use it but a minority still reported sharing syringes. Most IV drug users reported having tried to disinfect paraphernalia by boiling the syringes or cleaning it with bleach. A minority referred to have cleaned their injecting material with water. The sharing of paraphernalia other than syringes, such as spoon, filters or lemon, is more common and all patients who have had IV drug use reported having shared the last one.

Previous treatments for addiction

Since all individuals were in follow-up for their heroin addiction at an outpatient treatment center, they were asked in which program they were inserted. Forty-four percent were in methadone maintenance program, 28% were in buprenorphine maintenance program, 12% were taking antagonists and 12% were in psychological follow-up with no pharmacological treatment. When asked about previous addiction treatments, 92% have had previous outpatient treatment center appointments, 48% tried home detoxification with medicines, 44% had been in previous maintenance treatment programs with opiate agonists, 36% had previously been committed to a therapeutic community, 28% tried detoxification with opiate agonists, 28% referred trying detoxification without any technical support, 24% had tried detoxification with no medicinal aid and 16% attended self-help groups.

Sexual risk behaviors

Mean age of the first sexual relation was 15.6 years (range 13 to 19 years old). Eighty-eight percent admitted sexual relations in the previous 12 months. The average was two sexual partners per individual (range from one to six sexual partners). We divided sexual partners into three categories: commercial partners (paid sex), occasional partners, and regular partners. Only two individuals admitted having commercial partners in the previous year.

All individuals reported regular use of male preservatives with commercial partners. Seventy-five percent of those who had sex with occasional partners and only 42% of those who had sex with regular partners reported regular use of condoms. All individuals who reported regular use of condoms in the last 12 months (68%) also reported using it during their last sexual encounter. There was no report of homosexual sexual relations in the past 12 months. The prevalent idea over the use of male preservatives in this population is exemplified by the following statement:

I use condoms only in the beginning of the relationship, when we are still getting to know each other. I don't use it anymore. I know her; we've been together for 8 months now. People say we should use it all the time, but that is fantasy! No one can stand to use it for more than a month. Imagine if someone is married, how can you ask that? What if they want to have children? They are going to have to stop using it anyway.

All individuals reported knowing where to easily obtain male preservatives and 96% reported being able to obtain it whenever needed. Reported places to obtain condoms were "pharmacies" (92%); "HIV Outreach Street Workers" (8%); "stores" (20%); "clinics" (16%); "hospitals" (8%); "health clinics" (16%); "Addiction treatment centers" (44%); and "condom machines" (36%). The main problem concerning access to condoms was their price.

Beliefs and attitudes to the HIV/AIDS

HIV education and other harm reduction programs seemed to have influenced beliefs and practices among drug users. Most were aware of the methods of HIV transmission and methods to avoid contamination. Sixty-four percent reported knowing someone who is HIV infected, 60% knew someone who died of AIDS and 24% have a close friend or family member who has HIV or died of AIDS. Ninety percent believe people can protect themselves against HIV by adequate use of condoms during sexual relations. Those who disagreed that condoms protect stated that male preservatives protect during sex, but sharing of needles and paraphernalia should also be avoided. Four percent believe it is possible to get HIV by sharing a meal with an infected person:

I know people say that you can't. But suppose the guy has gingivitis or is bleeding or something. Then you can get it. I wouldn't trust sharing meals.

All patients believed a person can get infected by sharing needles. Eighty percent believed a user of IV drugs can protect himself by avoiding use of IV drugs or by just using sterilized material. Eighty percent believed an infected woman can transmit the HIV virus to her child. This question caused some confusion since it was not specified if the woman in question was pregnant or not. We let them decide how to answer to that and those who replied that a woman can transmit the HIV virus to her child assumed "during pregnancy." Those who said "no" assumed it was not during pregnancy, but when living within a household. Sixty-four percent did not know what to reply to the question "What can a pregnant woman do to reduce the risk of HIV infection of her child?" Of those who answered, 32% believed medication can reduce the risk of perinatal HIV infection.

Previous HIV tests

Eighty-four percent reported having had an HIV test at least once in their lifetime. For those who had being tested, the average of HIV tests was 3.6 tests per person (range from 1 to 20). The reasons for being tested, on their last HIV test were: deciding to do the test voluntarily (38%) and because someone asked them to (62%). Of those who had been tested, 43% had their last HIV test less than a year ago, 33% in the past 2 years, 14% 2 to 4 years ago and 10% reported their last HIV test was more than 4 years ago. All individuals reported knowing the result of the last HIV test and all individuals interviewed were HIV negative. All of those who reported never being tested before were not users of IV drugs.

DISCUSSION

The most well-known prevention strategies for the HIV/AIDS in drug users emphasize not sharing needles and paraphernalia and the correct use of condoms. However, we noted that despite knowing and understanding most prevention strategies, participants still practice HIV risk behaviors. This study was conducted in an outpatient addiction treatment center and even so, it appears there is a need to intervene in this matter.

More than two-thirds of the individuals who had used IV drugs shared material. Many do not seem to understand the dangers of sharing practices such as back-loading or front-loading. The latter is when a single preparation of drug solution is shared equally by loading the solution from one syringe barrel directly from the front of another. Back-loading is this process in reverse, in which the solution from one syringe is injected into the back of another.¹² In a qualitative study, Grund et al. noted that approximately 80% of observed sharing occasions involved these practices.¹³ Ethnographic studies from various countries have demonstrated that such practices increase HIV risks and are significant as independent predictors of HIV transmission.^13-15.

The vast majority of the patients did not state major difficulties in obtaining clean and sterilized material for injections. In Portugal, IV drug users can obtain syringes from machines located in pharmacies, similar to condom machines. Over 21 million syringes have been exchanged in 1,500 pharmacies since 1993.¹⁶ This is the only way to exchange syringes in the district. Other regions such as Porto and Lisbon can also offer syringe exchange through HIV outreach workers. The main problems reported by the participants, however, were not the lack of outreach workers in the district, but that the outpatient treatment clinics would not supply them free syringes. On this matter resides the paradigm of associating treatment centers, which are oriented to recognize the drug problem as a disorder and offer different approaches to treat it; and the political difficulties in accepting the chronic relapsing condition of substance abuse, by also offering injection material. From a political point of view, it could be damaging to offer methadone maintenance program on one end of a facility and syringes on the other end, creating a demand that is not interested in treatment programs. Some studies, however, indicate that syringe exchange programs in treatment facilities did not increase the rate of positive urine drug tests, reduced HIV risks and prevalence, and could work as a means to gather more patients to maintenance programs.^17-21

HIV prevention strategies in Portugal have focused on AIDS education, with billboards and pamphlets alerting to the dangers of unprotected sex and sharing syringes. The problem with mass education and generalization is that groups with specific risk behaviors may be overlooked and details of risk practices are not fully explored. An example of such lack of approach towards drug users is the fact that, despite good knowledge of the virus methods of transmissions through syringes, sharing injection paraphernalia is not understood as dangerous practice. Despite good access to sterilized syringes, at the users' disposal in machines throughout the country, cookers, filters, lemon and even syringes are still shared, illustrating ignorance of the risks of such behaviors.

Specific strategies for influencing behavioral change will only be effective if they reach users and are accepted and adopted by the population. Ways in which to provide specific HIV prevention information to this population, which concerns risk aspects particular to drug users only, are based on personalized interviews and education, elucidating questions and clarifying beliefs.²² One of these strategies is based on outreach programs, in which a team delivers information and services to hard-to-reach populations. Unfortunately, in Portugal, such programs are only available at big centers such as Lisbon and Porto, but there are plans to extend them to all districts.

Another prevention strategy, implemented during the course of this study is HIV voluntary counseling and testing. This strategy focuses on drug users' unique circumstances and risks and aims to help users reach an explicit behavior-change goal, reducing the chance of acquiring HIV.²³ Several models have been developed and evaluated, being efficient in changing behavior and risks.^23-28 For IV users, intervention studies indicate that personalized, interactive prevention counseling might be effective in reducing injections and sexual risks.^24,25 Generally the provider focuses on assessing the user's personal risk or circumstances. In this context, specific sharing techniques such as back- or front-loading and paraphernalia other than syringes can be addressed, enhancing the preventive potential of the program and inciting the clients towards healthier behaviors.

Sexual risks

Individuals interviewed in this study did not appreciate sexual risks, especially when qualifying their sexual partner as "regular partner." Studies show that most drug users perceive unprotected sex to be a normal feature of heterosexual relationships.^26-28 Although prevention strategies encourage safer drug use and sexual practices, perceptions of wider sexual norms may encourage unsafe sexual practices among drug users.^14-16,26 Whereas protected sex is associated with emotional distance, unprotected sex may be associated with the realization of intimacy in relationships.^28-30 The normative social meanings attached to condom use in relationships may have to change before drug users' individual perceptions of sexual risk become malleable.²⁶

Limitations

Behaviors related to the transmission of HIV are particularly sensitive, making it difficult for participants to reveal them and for the researchers to confirm them. A source of bias in this study is the unacceptability bias due to the highly sensitive nature of drug use and HIV.

CONCLUSÃO

This qualitative study provides descriptive evidence of HIV risks associated with heroin use and underscores a need for improvement in HIV prevention in the district of Vila Real. It is essential to tailor better HIV prevention programs for this high-risk group, using information on demographic movements and behavioral patterns of heroin users addressing their risk behaviors in sexual practices and in sharing injection paraphernalia. Greater focus should be given to specific risk behaviors presented by this population. Strategies that personalize the prevention message have the potential to address such risks and potentially increase safer practices.

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Publication Dates

• Publication in this collection
  24 May 2010
• Date of issue
  Dec 2009

History

• Accepted
  24 Feb 2009
• Received
  22 Oct 2008