3.4.1. Threats to Self
The fear of over-spending on drugs was a powerful motivator for several participants who had to find ingenious ways to both generate some form of revenue while managing their daily intake and budget. This could include having a job or finding other ways to make ends meet while leveraging on their network. Dealing drugs was however rarely seen as an option, except in one specific case where it ran in the family.
The dangers of trusting and maintaining relationships with fellow users was one of the key issues constantly mentioned by participants. Although the older, more experienced injecting drug users provided some advice and mentoring to their younger peers, the absence of trust towards peers was an aspect of injecting drug use which constantly came up during our interactions. One participant who started using during high school with her friends explained how quickly their bond faded following drug use. She believed that it was impossible to have friends when using. From her perspective, the risk of being infected on purpose by heroin users living with HIV was real: “They’ve got it and their friends don’t, so you also need to get it. I don’t agree with that.” She also referred to a few incidents where she saw people living with HIV sharing needles with others in the woods, knowingly, according to her. She thus kept her distance from fellow users, never shared needles and preferred to inject alone. Such experiential risks were also complemented by anecdotes from other interviews according to which fellow users could interfere with injecting equipment. Although she did not experience it personally, another participant believed that peers could easily exploit the vulnerability of users and that injecting in their presence could be lethal.
“If someone wants to get rid of you without leaving traces, then when you’re injecting, after it’s been cooked, I just need to take one grain of salt and drop it in there. As soon as you inject, you’d die on the spot.”
Other lesser known risks linked to injecting practices include dust getting inside the needle which could lead to serious discomfort referred to as “kongolo”. Some participants mentioned this risk which appeared to be lethal in some cases:
“And when we draw it inside the syringe, we have to use a piece of cotton wool. If the cotton wool is dirty or if there’s dust in the syringe, there’s this thing that’s called kongolo, I think you’ve heard of it? This thing that’s called kongolo, you start shaking, you’re cold and then you have a 40 C fever. Your body starts hurting just because of some dust in the needle, you start having all those complications and people can die from this.”
The participant further explained that one way of avoiding “kongolo” was to dip cotton wool in the substance in a small recipient where it had been cooked and then to place the needle through the cotton to prevent dust from getting in while injecting. She also believed that syringes should always be washed before use because dust might still be found inside, even if they were packaged and had never been used before. Several participants explained how and where they were injecting (arms, legs, genitals, behind, etc.), but few understood the risks of selecting the wrong place to inject. A participant explained that many heroin users encountered were unaware of the risk of amputation following continuous and inappropriate use of injecting equipment.
Most participants interviewed were aware of the dangers of sharing needles and the increased risk of infection: “If the person has AIDS and he’s injected and I use the same syringe, his blood is still in there and when I inject myself, I will also get it”. Quite a few participants reported never sharing a syringe but displayed varying levels of knowledge about different diseases: “Yeah hepatitis is almost like HIV”. A participant also mentioned death and hair loss as risks incurred following long-term heroin use with other substances. Most participants were aware that there were almost no external signs for people living with HIV, that infection could happen sexually and that “it’s not written on people’s foreheads that they’ve got it. Anyone could have it without you knowing”. While most participants were aware of voluntary counselling and testing facilities available at needle service points, and some were even tested on several occasions, others were hesitant to find out their serostatus, despite the increased risks resulting from not receiving adequate care. Such statements indicate that the risk of finding out and its potential implications were greater than not knowing.
“That’s also how it is. That’s why with the life that I’m leading it could either be this or that. I either have it or I don’t, it’s either or. But I’d rather not know.”
Although most participants were aware of the risk of HIV, some male participants still reported not using protection when having sexual intercourse with their wives or girlfriends. One participant initially believed that he could be infected with HIV just by using a needle, even if it had never been used before. Another participant who knew that she was HIV positive initially believed that it was acceptable to share her needle with a fellow person living with HIV. In most cases, participants were not as aware of the risks linked to hepatitis infection and its different forms.
Some users explained how they were conned and exploited by others when they first started to inject as they did not know how to use injecting equipment or where to buy drugs back then. They relied on friends, acquaintances and partners to obtain heroin and related paraphernalia and were often asked to give away their money “But… he was only concerned with my money, he just wanted me to give him money and this became a big problem”.
The gap in knowledge which young women had concerning illicit drugs was sometimes used against them once they were addicted. Once hooked, they were more easily convinced to engage in commercial sex work. The leverage which men had on them included how to inject and where to obtain the heroin, etc. Some participants watched their peers, friends, and even relatives start to inject and gradually becoming sex workers in order to find money to buy their dose and sometimes those of others as well. A few of these cases were shared with us.
“Yeah, I don’t want her to do it, to have to go on the streets. Because people don’t stand on the streets because they like it. They have to do it because of their addiction.”
However, some users mentioned during interviews that they did try to preserve their partners’ dignities by preventing them from engaging in sex work.
Interviewees were aware of the risk of overdose from mixing too many substances. One participant personally overdosed on pills by taking five Tramadol pills after not feeling an immediate effect. It was only a few hours later that he fainted and then eventually woke up in the hospital. Another participant became aware of the risk of overdose following the loss of a friend. Overdose was also likely to occur when someone who had stopped using for some time then suddenly decided to inject again. This was noted among individuals who had just been released from prison or who had just exited a detoxification programme. The risk of polypharmacy was also mentioned by a participant when seeking medical assistance from a public hospital. Medical treatment was seen as potentially hazardous in the context of continuous heroin and polydrug use because of the risk of complex chemical interactions.
“I told him (the Dr) I had taken drugs and whether it would be a problem with the injection they were giving me. if I didn’t tell him… I had to warn him.”
Users often found themselves in situations where they knowingly adopted risky behaviours following intense cravings, despite their better judgment. This included deciding to use needles and syringes which they had previously discarded or using those of other people which they found in open areas where heroin users were known to inject. Under such circumstances users knowingly chose this option because the opportunity cost of finding a clean needle, in this case time spent feeling intense cravings, was deemed too high a cost. Another form of loss of control experienced by participants was the direct effect of living in secrecy and the resulting fear of being caught. This sometimes implied loss of control on one’s thoughts and led to paranoid behaviour where users would become suspicious of their environment.
3.4.3. Threats to Self and Others
Some analytical themes cut across the ‘self and others’ dichotomy. This included stigma and discrimination which could impact both users and their social environment. Injecting drugs was usually done alone in secret or together with fellow injectors. A recurrent theme noted throughout the study was the potential impact which injecting drug use could have on close ones. The primary concern expressed about stigma was its impact on relationships—not wanting one’s immediate family to be aware was one of the main fears expressed and was deemed to be an affective risk as emotions such as fear, worry, and shame played an important role.
“Yeah. And… like people will talk and if your family doesn’t know you’re using and you don’t want them to know. Then you have to hide it.
The desire to hide drug use also extended to the parents of partners, girlfriends and wives given “how society treats people who take drugs, they’ll say if he’s a user then he must be a thief etc.”. The stigma experienced did not always come from close ones, or the community. It was also experienced at the community and societal levels, with multiple negative labels placed on individuals belonging to more than one affected population such as being both a druggie and an SW at the same time. Several users described society’s views about their injecting practices as being extremely negative. The stigma and discriminatory behaviour experienced by participants were also felt when trying to access healthcare. Derogatory treatment was also experienced in the private sector where patients pay for quality and discretion. These issues were only felt after users started injecting. Hence, the fears expressed by participants combined elements of both affective and experiential risks.
Pregnancy was also an issue which impacted the individual and others as explained by four young women during interviews. Two of these participants mentioned the potential health hazard of injecting drug use during pregnancy. One of them decided not to inject while the other believed she had lost a baby partly because of her drug use. She agreed to be interviewed a week after losing her child. Besides being an injecting drug user who mixed heroin with other substances, she was also HIV positive and a sex worker. She was careful during her pregnancy but had been warned by her doctor that the child would be unwell because of the illicit substances that she took. The other participant sought medical advice during her pregnancy to make sure her baby would not be ‘infected’. She stopped using heroin until after she gave birth despite being constantly pressured to use by her partner. A decrease in heroin consumption in their household meant less doses for her partner as well. She only used sleeping pills and painkillers instead during her pregnancy.
PL-P2: “Yes, he’s the one I had a child with. It’s like he did everything to make me use again. “
Interviewer: “He was encouraging you to use even when you were pregnant?”
PL-P2: “Yeah, he tried to but I wasn’t too keen; I was scared something would happen to the baby. That he’d be disabled, that’s what I was scared of. That’s why I didn’t say anything about my drug use. I wasn’t even using. That’s all, I was scared.”
Both participants who used heroin before being pregnant assessed the risks differently after receiving advice on how to minimize harm to the child. While one did choose to stop and the other did not, neither were aware of what to do. The risk was hence assessed experientially. The participant who chose to stop during her pregnancy had a strong emotional reaction triggered by the fear that using drugs would affect her child’s health and future. In her case, the risk was assessed affectively. The addiction of the other participant was too strong to quit.
Getting arrested by the police was a constant fear expressed by participants interviewed during the study. The risk of unwarranted arrests was thus reported as a significant obstacle to obtaining or returning clean paraphernalia from HR service points. Several participants explained that the perceived risk of being caught by the police for syringe possession limited their capacity to fully benefit from HR services, even when they were willing to take the risk to go to a caravan. Some of the implications of that fear included that several users kept using the same syringes. While in some cases the fear of being arrested was triggered by previous experiences, in most cases it came from learning or seeing what had happened to peers. A few arrests were enough to trigger constant anxiety. Young heroin users assessed problems with law enforcement deliberatively, affectively, and experientially, depending on how new they were to using heroin or connected they were to other users.