This presentation draws upon a study recently conducted in Leeds that provides an insight into issues of needle exchange accessibility, risk behaviour, social surveillance and the role of social networks in enabling access to injecting equipment for a hidden population of injecting drug and steroid users. In light of the findings of this study, the implications for harm reduction interventions that target injecting drug users in terms of affording anonymity, convenience and ease of access will be discussed.

1. 
1
National Conference on Injecting Drug Use 2009 The Role of Social Networks in Accessing Injecting
Equipment & the Implications for Harm Reduction Interventions
Lloyd Belcher
drugs: research, education & training

2.  research aims
Capture the role of social networks in
enabling access to injecting equipment
for IDUs and PED users in Leeds.
Explore the experiences of a sample
group of IDUs in accessing injecting
equipment.
Discuss the implications for harm
reduction interventions
Text
National Conference on Injecting Drug Use 2009
Lloyd Belcher

3.  research methods
Qualitative ‘potential to lay bare the
social organisation of hidden group
activities and reveal how interaction
and actors are organised within a
social context’ (Watters & Biernacki,
Text
1989).
In depth, semi-structured interviews
conducted between May - July 2008
at specialist harm reduction service in
West Leeds, City Centre & on needle
exchange van.
Text
National Conference on Injecting Drug Use 2009
Lloyd Belcher

4. 
4
research setting: leeds
Second largest Metropolitan
District in England. Population:
750,250*
6,565 Problematic Drug Users
(University of Glasgow)
50% of IDUs injecting in excess of
13 years have been infected with
Hepatitis C
* (Safer Leeds, 2008)
Text
National Conference on Injecting Drug Use 2009
Lloyd Belcher

5.  participants
Gender Age Ethnicity Substance Location
White
Male 32 Heroin Semi-Rural
British
White
Male 34 Heroin Urban
British
White
Female 24 Heroin Semi-Rural
British
Black
Male 28 Heroin Urban
British
White Steroids
Male 51 Urban
British Supplier
White
Male 18 Heroin Urban
British
White Heroin/
Male 28 Semi-Rural
Text British Crack
National Conference on Injecting Drug Use 2009
Lloyd Belcher

6.  findings:
NX Service Access Issues
Secondary Needle Exchange
Views of Vending Machines
Text
National Conference on Injecting Drug Use 2009
Lloyd Belcher

7. 
risk behaviour: existing literature
Previous studies have shown that the
strongest predictor of needle sharing
and risk behaviour is due to difficulty in
accessing needle exchange services
(Page 1990; Sterk-Elifson 1995;
Carlson, Siegal et al 1996; Des Jarlais
& Friedman 1998)
Accessibility is a critical determinant
of local and micro-environmental risk
and infection patterns among IDUs
(Singer et al. 2000)
National Conference on Injecting Drug Use 2009
Lloyd Belcher

8. 
findings I: access & risk
3 key themes emerged from the data relating to
the difficulties that participants experienced in
terms of accessing NX services:
1. Operating hours of NX services
2. Location of services
3. Social surveillance and stigma
National Conference on Injecting Drug Use 2009
Lloyd Belcher

9.  findings I: access & risk
1. Operating Hours of Services
“I get me pins from the chemist but they’re
not open on Saturdays or Sundays. So if
they’re closed, people are going to use their
old pins innit? People come to me to use my
old pins and that, know what I mean? Cos
they’ve got none.”
[Male, 18 years, heroin injector]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

10. “People are coming from Seacroft
[5 miles away] cos they don’t have
 findings I: access & risk
anywhere” 2. Location of NX Services
[Male, 18 years, heroin injector]
“Don’t know anywhere else to get pins except
here [nx van]. There’s nowhere in this area.
The closest one [nx], I’d have to get two buses
to Bramley”
[Female, 24 years, heroin injector, semi-rural]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

11.  findings I: access & risk
3. Social Surveillance & Stigma
“It’s a small town and a lot of people know I’m
on gear. You can’t get away from that. In the
city centre you’re anonymous, but around here
it’s different. There’s a Boots doing needle
exchange but I prefer it as I am [accessing
weekly NX van]”
[Male, 32 years, heroin injector]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

12.  findings I: access & risk
3. Social Surveillance & Stigma
[Male, 18 years, heroin injector]:
“If there’s people in the chemist you might need
to go without”
Interviewer:
“So you would purposely wait until the chemist
is empty before going in?”
[Male, 18 years, heroin injector]:
“Yeah”
National Conference on Injecting Drug Use 2009
Lloyd Belcher

13.  findings I: access & risk
3. Social Surveillance & Stigma
“Someone might see them walking in
here and think they are not necessarily a
body builder but a drug user. So the
stigma is that they don’t want anyone to
see them coming in here as others might
think I’m a druggie. If their staff see them
coming in here or a friend of a friend then
they’ll tell them”
[Male, 51 years, supplier of steroids and
injecting equipment]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

14. findings 2: 
secondary needle exchange
All except one of the participants
were primary providers of sterile
injecting equipment to other IDUs
who did not access any NX services.
These participants had an
arrangement to provide other IDUs
with injecting equipment which they
obtained when accessing the NX
service.
National Conference on Injecting Drug Use 2009
Lloyd Belcher

15. findings 2: 
secondary needle exchange
“There’s a friend around the corner
[waiting] who takes four or five pins
away once I’ve been on the van”
[Female, 24 years, heroin injector]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

16. findings 2: 
secondary needle exchange
“What I do is when I get to the van, I
give him a ring so he’ll come around to
my house when I’ve finished. I get
enough to keep him going as well.”
[Male, 32 years, heroin injector]
National Conference on Injecting Drug Use 2009
Lloyd Belcher

17. findings 2: 
secondary needle exchange
Interviewer: How many people rely on you for
clean works?
Barry: About four. That’s exactly what my
fifty Myjectors are for [points to
bag] cos I don’t use them.
Interviewer: So this is an agreement you have
with them to sort them out for pins?
Barry: That’s right. They come to my
house to use or they might take the
pins away.
Interviewer: Are they able to get their pins from
anywhere else except you?
Barry: Most of the people who get pins
from me are people who don’t get
their pins from here [NX van]
because they have a full-time job”
National Conference on Injecting Drug Use 2009
Lloyd Belcher

18. findings 2: 
secondary needle exchange
Kevin: “I know about ten other fellas
who would sort me out if I
was short of clean pins.
There’s always someone
who’s got clean pins on
them”
Interviewer: “Do they come to you if they’re
short?”
Kevin: “Yeah, I sort them out”
National Conference on Injecting Drug Use 2009
Lloyd Belcher

19. Structural Issues: Existing Services  implications for
harm reduction services
Operating hours Weekend and late-
night operating hours for both
pharmacy and specialist NX services.
Location more services to be
commissioned
Minimise social surveillance and
potential stigma
Vending Machines (pilot?)
National Conference on Injecting Drug Use 2009
Lloyd Belcher

20. Secondary NX: Findings
from Existing Studies
 implications for
harm reduction services
Peer outreach appears to be effective
in reducing injection-related risk
behaviour among IDUs who engage with
peer educators who they identify with
(Coyle et al., 1998).
National Conference on Injecting Drug Use 2009
Lloyd Belcher

21. Secondary NX: Findings
from Existing Studies
 implications for
harm reduction services
Benefits to peer NX providers (Latkin et al.,
2003). Participants* in a peer-based
intervention providing peer outreach and
harm reduction information to other drug
users were:
almost three times as likely to report
reduction in needle sharing
*compared to IDUs who did not
participate in the peer-based
intervention
more than three times as likely to
report cessation of drug injection
*compared to IDUs who did not participate in the peer-based intervention
National Conference on Injecting Drug Use 2009
Lloyd Belcher

22. Social Networks & Social Capital  implications for
harm reduction services
Social networks have an impact upon a
drug user’s progression to injecting and
risk behaviour (Broadhead, Heckathorn et
al. 1999; Friedman, Curtis et al. 1999;
Hawkins, Latkin et al. 1999; Ksobiech
2004; Best, Manning et al. 2007)
HIV risk and that syringe sharing is
influenced by the size & density of IDU
networks (Latkin et al., 1996 cited in
Rhodes, Singerb et al. 2005; Lovell 2002)
Lack of social capital within IDU
networks can increase the chances of
risk behaviour (Lovell 2002)
National Conference on Injecting Drug Use 2009
Lloyd Belcher

23. 
23
implications for
harm reduction services
Points to consider: Peer Delivered NX
Potentially effective for engaging
certain ‘hidden populations’
where social surveillance & stigma
is a vital issue (cultural groups,
PED users, closed communities,
rural settings)
Model: Peer-led or peer-
delivered?
Links to existing harm reduction
services. How much autonomy?
National Conference on Injecting Drug Use 2009
Lloyd Belcher

24. 
24
implications for
harm reduction services
Points to consider: Peer Delivered NX
Who trains the peer educators?
Payment
Role of service user groups?
National Conference on Injecting Drug Use 2009
Lloyd Belcher

25.  references:
25
Best, D., V. Manning, et al. (2007). "Retrospective recall of heroin initiation and the impact
on peer networks " Addiction Research & Theory 15(4): 397-410.
Broadhead, R., D. Heckathorn, et al. (1998). "Harnessing peer education networks as an
instrument for AIDS prevention." Public Health Reports 113: (Supplement) 42-57.
Carlson, R. G., H. Siegal, et al. (1996). "Attitudes toward needle “sharing” among injection
drug users: combining qualitative and quantitative research methods." Hum Organ 55:
361-369.
Des Jarlais, D. C. and S. R. Friedman (1998). "Fifteen years of research on preventing HIV
infection among injecting drug users: what we have learned, what we have not learned,
what we have done, what we have not done." Public Health Rep 113: 182-188.
Friedman, S., R. Curtis, et al. (1999). Social networks, drug injectors’ lives and HIV/AIDS,
New York: Kluwer/Plenum.
Grund, J. P. (2005). The Eye of the Needle: an Ethno-Epidemiological Analysis of Injecting
Drug Use. Injecting Illicit Drugs. R. Pates, A. McBride and K. Arnold, Blackwell: Oxford.

26. references: 
Hawkins, W., C. Latkin, et al. (1999). "Do actions speak louder than words? Perceived peer
influences on needle sharing and cleaning in a sample of injection drug users." AIDS
Education and Prevention 11(122-131).
Ksobiech, K. (2004). "Assessing and improving needle exchange programs: gaps and
problems in the literature." Harm Reduction Journal 1:4.
Lovell, A. (2002). "Risking risk: the influence of types of social capital and social networks on
the injection practices of drug users." Social Science & Medicine 55: 803-821.
Page, J. B. (1990). "Shooting scenarios and risk of HIV infection." Am Behavioral Scientist
33: 478-490.
Rhodes, T., M. Singer, et al. (2005). "The social structural production of HIV risk among
injecting drug users " Social Science & Medicine 61: 1026-1044.
Safer Leeds (2008). Needs Assessment for Adult Drug Treatment in Leeds.
Sterk-Elifson, C. (1995). Determining drug use patterns among women: the value of
qualitative research methods. Qualitative Methods in Drug Abuse and HIV Research. L.
Lambert, Ashery, R. and Needle, R, Rockville, Md: National Institute on Drug Abuse;
1995:267–281. NIDA Research Monograph 157.

27. contact: 
27
Lloyd Belcher
drugs: research, education & training
e: lloyd.belcher@green.oxon.org
t: (+852) 6579 3006
www.lloydbelcher.org