Harm Reduction Journal BioMed Central

Background Heroin injection is associated with health and social problems including hepatitis C virus (HCV) transmission. Few studies have examined the circumstances surrounding initiation to heroin injecting, especially current users initiating others. The current study aimed to examine the age of first heroin use and injection; administration route of first heroin use; relationship to initiator; the initiation of others among a group of heroin users; and to examine these factors in relation to HCV status and risk. Method Heroin users in Sydney were recruited through needle and syringe programs, a methadone clinic and snowballing. Participants were interviewed about their own initiation to heroin use, blood-borne virus risk and knowledge, and whether they had initiated others to heroin injecting. Information on HCV status was collected via self-report. Data was analysed using univariate and multivariate statistical techniques for Normally distributed continuous and categorical data. Results The study recruited 399 heroin users, with a mean age of 31 years, 63% were male, 77% reported heroin as their primary drug and 59% were HCV positive (self-report). Mean age at first heroin use and injection was 19 and 21 years, respectively. The majority of heroin users commenced heroin use via injecting (65%), younger users (<25 years, 25–30 years) were less likely than older users (>30 years) to commence heroin use parenterally. Participants were initiated to injection mainly by friends (63%). Thirty-seven percent reported initiating others to heroin injection, but few factors were related to this behaviour. Those with longer heroin using careers were more likely to report initiating others to heroin injection, but were no more likely to have done so in the preceding 12 months. Participants who had initiated others were more likely to have shared injecting equipment (12 vs 23%), but were no more likely to be HCV positive (self-report) than those who did not. Conclusion Interventions to prevent heroin users initiating others to injecting are necessary. Peer groups may be well positioned to implement such interventions.


Findings
The Downtown Eastside of Vancouver, Canada is a community characterized by high rates of HIV among injection drug users (IDU), and is also the setting of one of North America's highest volume needle exchange program (NEP) [1]. Recent studies have indicated that injection-related infections, such as abscesses and cellulitis, account for the majority of emergency room visits and acute hospitalizations in local IDU [2,3]. Factors associ-ated with the development of abscesses among IDU have not been well described in settings with widespread access to sterile injecting equipment and high rates of HIV infection. In particular, abscesses are not characterized in Vancouver. However, abscesses can lead to serious complications including but not limited to osteomyelitis [4], endocarditis [5][6][7], and septicemia [8,9]. An ongoing prospective cohort study of IDU in Vancouver allowed for an examination of the prevalence and factors associated having an abscess in this setting.
For these analyses, data was collected through the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort that has been previously described in detail [1]. Data from participants who completed baseline questionnaires between May 1, 1996 and May 31, 2004 were evaluated for the present study. Participants were categorized on the basis of whether or not they reported having an abscess lasting for more than three days during the previous six months. Univariate and multivariable statistics were applied to determine factors associated with developing an abscess in the previous six months. Categorical variables were analyzed using the Pearson's chi-square test, and continuous variables were analyzed using the Wilcoxon signed rank test. Variables associated with having an abscess at p < 0.1 were considered in a subsequent logistic regression analysis.
Socio-demographic and drug-using characteristics considered in these analyses as potential risk factors included: age, gender, HIV status, unstable housing, residing in Vancouver's Downtown Eastside, incarceration in the previous six months, sex trade involvement, borrowing and lending of syringes, frequent heroin and cocaine injec-tion, binge drug use, public drug injection, requiring help with injections, and methadone maintenance therapy use. Unstable housing was defined as living in a single room occupancy hotel, transitional living arrangements, or being homeless. Individuals who reported injecting cocaine or heroin once or more a day were defined as frequent heroin and cocaine injectors. Bingeing was defined as periods in which drugs were injected more often than usual. Variable definitions were consistent with previous analyses [1].
Overall, of the 1 585 baseline VIDUS participants, 341 (21.5%) reported having an abscess in the last six months. The factors associated with having an abscess at p < 0.  Table  1 shows the baseline demographic characteristics of IDU stratified by having an abscess or not in the past six months for significant variables considered in the univariate analysis.
As shown in Our results indicate female gender, recent incarceration, sex trade involvement, frequent cocaine use and HIV serostatus are positively associated with developing an abscess. These results are consistent with results from a study in Amsterdam where female gender and prostitution among women, as well as, frequent cocaine use were identified as independently and positively associated with skin abscesses [10]. In addition, the association between HIV-positive status and having an abscess has been noted elsewhere, and is understandable given that HIV-positive individuals may have a heightened susceptibility to bacterial infections [11,12]. Furthermore, high risk of infectious complications, such as endocarditis from abscesses [10], occur among HIV infected individuals [11].
Abscesses are a common consequence of injection drug use [13][14][15]. The present study demonstrates that widespread access to sterile syringes through high-volume needle exchanges and a medically supervised safer injection facility may not be sufficient to prevent high rates of abscesses among IDU in Vancouver. In addition, our findings demonstrate the need for educational and structural interventions to improve rates of sterile injecting [16,17].
Our study has limitations. First, although previous research has indicated that the VIDUS cohort is represent-ative of Vancouver IDU [18], VIDUS is not a random sample. Second, the study relied on self-report, and therefore, the results could be susceptible to socially desirable reporting although we know of no reason why reporting abscesses would be subject to this concern. Third, the cross-sectional nature of this study precludes any conclusions regarding causal relationships between the variables studied and the outcome of interest. Further prospective study is needed to assess predictors of abscess in this setting.
In summary, 21.5% of IDU participating in this study reported having an abscess in the previous six months. Results from this study indicate female gender, recent incarceration, sex trade involvement, frequent cocaine use and HIV serostatus are independently and positively associated with developing an abscess in injection drug users. Given the potential health complications arising from bacterial infections our findings highlight the need for the expansion of programs to promote safer injection practices.