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Effective Interventions Unit
Examining the injecting practices of injecting drug users in Scotland

Chapter 4: Case Studies

The practice of injecting drugs is not a static phenomenon involving fixed types of equipment and techniques. The following case studies illustrate the variation that exists among injectors and highlights the points in the injecting process where risk behaviours for transmission of HCV infection occurs. Names and some demographic details have been changed to protect the identity of participants.

Case study 1

Participants: Alan (102) and Mark (103)

Alan is a 39-year-old who has been injecting predominantly heroin for five years following the death of his mother. Mark is a 23-year-old who has been using heroin intravenously for about a year. Their relationship is based on injecting technique rather than friendship. Mark is not confident in his own ability to inject himself and donates a proportion of his drugs to Alan in return for the latter administering his hit for him.

Mark describes the "panic" that descends on him when blood enters his syringe when he is administering his injection. Blood often congeals within the syringe on these occasions and this scenario introduces time pressure into the injection process; Mark does not handle this pressure well:

"when I get too much blood in it … I end up losing it ( his hit). So when I feel like that I let Alan do it. (Mark, audio footage, p.15)

This lack of confidence in his injecting technique has in the past placed him in certain risky scenarios. Mark has been affected by these experiences and his injecting behaviour now shows a desire to minimise risks. As will be seen, this contrasts with Alan's more openly ambivalent, almost fatalistic view, on safer injecting practices.

The recorded observation of the two men injecting in Alan's flat, which also doubles as a form of local "shooting gallery", highlights two different approaches to injecting. These approaches are, in turn, connected to restrictions in earning potential and social mobility. Mark is able to move freely, without harassment, through the housing scheme in which he lives. He is also a successful shoplifter. Both factors afford him greater choices with regards his drug taking; choices restricted by his lack of confidence in his injecting technique. Alan's notoriety within the housing scheme has effectively restricted his movements and his reliance on under confident self-injectors to donate some of their drugs in exchange for him injecting them has produced an environment (his flat) in which risky injection practices are endemic.

Having been driven to the local needle exchange by the researchers, Mark decides to visit Alan's flat. Mark will supply heroin in return for receiving his hit; he will also supply citric acid and two sterile sets of needles and syringes. Alan is happy to participate. He will supply a fresh filter (a portion of a cigarette); tap water; his flat and his injecting expertise.

Entering the badly lit flat, visitors have to navigate through piles of old newspapers stacked against the wall of the filthy carpet-lined corridor. Alan is not alone; two other IDUs are also present. Neither of these men have been "squared up" (the practice of taking sufficient heroin to remove withdrawal symptoms) today which creates an uneasy atmosphere. Throughout the 30 - 45 minutes that the research team spend in the flat the doorbell and phone ring constantly: the flat evidently has quite a few visitors. The injecting episode takes place in the living room. The room consists of an armchair and settee arranged around a glass topped wooden table covered with previously used syringes (1mls and 2mls); used filters; electrical wiring and parts; overflowing ashtrays and tobacco pouches. The centrepiece of the table is a small plastic 500cl. water bottle two thirds full with a dark crimson liquid similar in appearance to blackcurrant juice. Alan later identifies the crimson liquid as the rinse water of multiple IDU visitors to the flat. The bottle represents an improvement in the hygiene standards in the flat because it encourages users to squirt their rinse water into the bottle rather than on the carpets or curtains. Underneath the glass surface of the table are perhaps half a dozen used needles and syringes and literally hundreds of used filters. Alan claims to usually have:

"about 12 spoons under this table. So if somebody comes up and wants a hit, I gee them a different spoon all the time and a new filter. Basically so that once it's done I'll put the spoons back by again, right? If somebody else wants a hit, I'll gee them a different spoon and a different filter. Basically what it ends up is if I've no got nothing (no drugs) and there's maybe four or five people have had a hit in the house, that will be four or five spoons with filters." (Alan, interview transcript, p.8)

So, in times of drug shortage, Alan will then use these spoons and filters, which contain residue of heroin, to prepare injections for himself until he obtains another supply of heroin.

Mark, in the meantime, conscientiously prepares a hit for two on a space cleared on the table. Having thoroughly cleaned the inside of the spoon with an alcoholic swab, he adds two 10 bags of heroin, the contents of a citric acid sachet and tap water (thirteen units of a 1ml syringe) contained in a glass tumbler and taken from the kitchen. Mark then filters the solution through a new portion of cigarette filter and draws it up into the two sterile needles and syringes. Alan injects Mark first, then himself.

Two occasions of potential transmission risk are observed during the administration and post-administration of this observation. Both place Alan at risk. Firstly, having removed Mark's syringe, Alan wipes Mark's injection site with his hand and then, less than three minutes later, wipes his own visibly reddened groin injection site with the same hand prior to injecting into it. After administering his hit Alan proceeds to rinse out his needle and syringe in the same water that Mark has just used for the same purpose. This water was used in the preparation stage.

Mark later tells the research team that he has recently tested negative for HIV, HBV and HCV but it is unclear whether he has told Alan this.

What is clear is that the way in which Alan supports his drug habit places him in a position of some vulnerability. More often than not Alan surrenders key elements of the preparation process to the IDU who has brought the heroin; despite his seniority in terms of age and injecting experience he watches Mark carefully prepare his hit.

Weeks later during interview Mark responds to a question about him sharing a spoon with Alan on the occasion described above:

"Aye, but did you not see me using the steriles (swabs)? … least I know it's clean that way. I'll use a couple of steriles swabs and they clean it, they will kill everything. I wouldnae just use his spoon. But he gets offended by that. See when I want to use a sterile (swab) he will get offended by that and I say, "**** I'm sorry mate but I have been in a situation". I try to explain to him where I have been stupid before and I shat myself for weeks and weeks and weeks and I'm not wanting to do the same thing again, nae offence tae yae, it's just that I'm no saying you've got it. I've just said I'm no wanting to do that again." (Mark, interview transcript, p.12)

Alan's vulnerability to risk, which arises initially from his social position in the community, is increased further by fluctuations of local drug market. Weeks after the above observation, Mark confirms the research team's suspicions that the dry up of heroin in the city in late March 2003 resulted in the drastic reduction of Alan's visitor numbers. Mark told us that because, "nobody has really had anything and they have no been going to his house when they have been getting some" as a consequence:

"he will let any **** in his hoose for 20ml." (Mark, interview transcript, p.24)

One of the implications of the method by which Alan supports his habit is that it creates an environment in which adherence to safer injecting practices is difficult. Alan is compromised with whom he injects with and how much he injects. Within this wider context one can better understand Alan's more ambivalent, almost fatalistic attitude towards dangerous injecting habits.

When interviewed Alan is the first study participant to vocalise a fairly dominant belief, held by many IDUs, when he responded to a question about HCV:

"I havenae been checked for hepatitis or anything, right? Although I'm aware of the fact that about 90% of users that inject it have probably hepatitis." (Alan and Mark, interview transcript, p.43)

He adds that, in his opinion, even if a group of IDUs were preparing hits with separate spoons:

"…you are still all using the same water, know what I mean? Every body's aware of the fact that if somebody's got hepatitis, there's the chance of you getting it is transferred through the water." (Alan and Mark, interview transcript, p.44)

When prompted about whether sharing injecting paraphernalia was situated in his list of priorities Alan replies:

"Nine times, it depends on when you are needing the stuff. [If] you are choking for it, it kind of throws a lot of the thingmy oot the windy, know what I mean? Because you're needing it, you're wanting it and you are having it there and then **** the carry on of going through all this rigmarole and daeing that and that, know what I mean? You're wanting it and that's it, know?" (Alan and Mark, interview transcript, p.44).

Case study 2

Participants: Sharon (108), Richard (128) and Jackie (129)

Sharon is a 24-year-old injector of six years. She has recently begun a relationship with Richard, ten years her senior with fifteen years of injecting experience. They live together in Sharon's flat.

When the researchers arrive at the flat at noon the couple's arguing could be heard on the stairwell. Upon entering the flat, the research team are introduced to a second woman, Jackie, who is aged 30 years and has been injecting for 8 years. Jackie is acting as a form of buffer between a visibly tense couple neither of whom have slept for days. Both Sharon and Richard estimate that they have spent between 500 and 600 on cocaine in the last 48 hours.

Over the next three hours we observe Richard and then Sharon prepare two separate half grams of cocaine on the same uncleaned spoon. The three participants inject these two prepared amounts of drug over six injection episodes. The drugs for this observation were purchased using pooled resources from the three participants. The events observed in this session are especially risky because both Richard and Jackie are fully aware of Sharon's HCV positive status and unaware of their own serostatus.

• Injecting event 1

Richard prepares the first half-gram. He takes a teaspoon, on which lie traces of residual cocaine powder and a previously used filter, out of a plastic tub placed on the living room table. The tub also contains a set of nail clippers and a small plastic bag containing two used 2ml syringes and some cotton wool. Removing the filter from the spoon, he adds the cocaine powder to the spoon. Once satisfied that the bulk of the powder is on the spoon, he snorts the remainder from the packet. He then asks his partner three times for an insulin needle and syringe before reaching into the cin bin she is holding to select a used set himself. With one exception all of the 1ml insulin needles and syringes that the team observes today are previously used and belong to Sharon. The exception is a set which is used to inject Jackie in this first injecting episode. This set was obtained the day before and had been used on several occasions since then but only by Jackie.

While her partner starts to rinse out the used set of 1mls, Sharon begins to check the sharpness of the needles on multiple sets of insulin syringes which she pulls out of the cin bin. She does this by running the needle tip along the surface of her thumb. Finding a sharp needle is of particular importance at the moment. Her current injecting site is her neck and this has been been extremely sensitive since she asked her partner to inject the contents of some temazepam gel capsules days before this observation.

Richard adds water to the powder on the spoon using the used needle and syringe taken from the cin bin and the water with which he has rinsed these out, thus potentially contaminating the solution. He puts the 2ml syringe, taken earlier from the plastic bag, in his mouth and breaks a portion of cotton wool to use as a filter. Heating the underside of the teaspoon for ten seconds he then stirs the solution for a further 17 seconds with the front end of his used 2ml syringe, another source of potential contamination. Placing the spoon on the table Richard adds a freshly opened blue spike to the used 2ml syringe, thus potentially contaminating the sterile needle.

Richard drops the filter into the cocaine solution and asks Jackie for her syringe. The latter is able to identify her own syringe by at scratch mark on the 1ml barrel. Richard draws up Jackie's share of the potentially contaminated prepared solution and places this on the table beside the spoon. He then measures out his and Sharon's share by drawing up the remainder of the solution on the spoon into the 1ml needle and syringe used in the preparation stage. Richard then squirts half of this solution back onto the spoon and gives Sharon the 1ml syringe containing her share. While Richard draws up his share into his 2ml syringe, Sharon decides that the set her partner has handed her is not sharp enough and backloads the solution it contains into the 1ml syringe that she has been rinsing out.

The administration stage of this first injecting event consists of Richard injecting, firstly, his partner in the neck then Jackie in the wrist and finally himself in the groin.

A quick overview of the journey of each participant's share of cocaine from powder to solution highlights a catalogue of risk events.

The solution that is injected into Sharon has been prepared with water drawn up through a previously used needle and syringe, taken from the cin bin, and stirred with Richard's previously used syringe. The solution was prepared on an unclean spoon previously shared with Richard and drawn up through the same filter previously used by Jackie.

Jackie's share has been prepared with water that has rinsed out Sharon's and Richard's respective syringes and added to the spoon with a needle and syringe previously used by Sharon. Once heated the solution was stirred using the tip of Richard's 2ml syringe. N.B: The hollow hub on which the needle is attached to a two-piece syringe allows a space between the plunger and the needle even when the plunger is fully depressed. As a result this type of syringe represents a significantly greater risk when re-used. Laboratory simulation indicates that 2ml syringes may store up to 55 times the volume of residual blood than diabetic syringes. (Gaughwin, Govan et al quoted in p.694 Grund)

Richard injects his share of solution, which has been prepared with water used to rinse out Sharon's used needle and syringe. He also rinses out his needle and syringe with the rinse water used by Sharon. Finally, his share of the solution is measured by being drawn up into Sharon's used needle and syringe, squirted back onto the spoon and drawn up through the filter previously used for Jackie and Sharon's share.

These events all represent potential opportunities for the introduction of HCV from one IDU to another. Other risky behaviours are observed in the administration of the injections. Having removed the syringe from Sharon's neck Richard applies pressure to the injection site for six seconds with his left forefinger. Less than two minutes later, and without washing his hands in the intervening period, with the same hand he vigorously rubs the area that he intends to inject on Jackie's arm. After her injection, Richard wipes Jackie's injection site with his left thumb. Before injecting himself, Richard removes a plaster from his groin and places it next to the television; he does not clear this up afterwards. The bloodied tissue he uses to stem the blood following his injection is placed in the ashtray on the living room table; again he does not clear this up afterwards. The immediate post-injecting period of this injecting episode consists of a conversation about which dealer might be able to supply the cocaine needed for the participants' next injection. None of the syringes from the first episode are rinsed out or cleaned once they have delivered their solution.

• Injecting event 2

Sharon prepares the half gram of cocaine for the second injecting episode on the same spoon used on the previous occasion; it has not been cleaned. Carefully putting the cocaine powder on the spoon, Sharon mutters: "I cannae really remember the last ten minutes" (tape log 4.5). Sharon then tells Jackie to clean out her syringe. The latter moves towards a jug of water which has been changed since the last episode. Sharon tell her not to use this as she may contaminate it with her used needle and syringe.

Sharon adds the new water to the spoon using one of her used and unrinsed syringes thus again potentially contaminating the water. She then heats the solution and stirs it with the plunger end of her used syringe. The same filter as used in episode one is then dropped into the new solution. Sharon begins again the process of checking the sharpness of various needles. The solution is then drawn up into two of her used needles and syringes to confirm the total amount of solution available. Leaving her share in one of these, she then squirts the other two participants' shares back onto the spoon.

Sharon asks Jackie for her needle and syringe and draws up 30ml (3 units of a 1ml syringe). She then draws up the same amount into her partner's 2ml syringe, announcing that she's taking "40ml" (4 units of a 1ml syringe).

Richard gives Sharon her injection and, afterwards, places his left forefinger on the injection site for two seconds. Sharon attempts to administer Jackie's share and succeeds only in producing a trickle of blood from Jackie's forearm. Sharon tries again but eventually admits defeat. Jackie pulls her arm away and waits for Richard to give her a tissue to mop up the blood. Jackie's needle and syringe have become blocked with congealed blood by this time. Taking over the task of injecting Jackie, Richard tries to clear the blocked needle and syringe by drawing up some water from the jug on the living room table. When it is confirmed that the tools are blocked Sharon says to Jackie:

With this decision made Richard backloads Jackie's share of the solution from the "blocked" needle and syringe into a used set without rinsing out the latter. Meanwhile, one of the researchers speaks to Jackie:

A fortnight later, Jackie is interviewed along with another participant, Eamon. Eamon explained that he had been tested for hepatitis C and other blood borne viruses whilst in prison. To which Jackie responded "I've not got checked".

Richard then takes over and delivers Jackie's injection and, finally, injects himself. Having injected Jackie, Richard places his visibly dirty and possibly blood contaminated left thumb over Jackie's injection site. He then puts the two used syringes and needles, uncapped, next to the television and puts his own uncapped set on a shelf after he self-injects.

Clearing up after the two observed injecting episodes is minimal. Needles and syringes are left lying, uncleaned and uncapped. Bloody tissue paper is left lying on the carpet and in the ashtray. Richard's hands, with visible open wounds, have injected all three participants; the research team do not observe him ever washing his hands at any stage.

Interviewed weeks later, Sharon and Richard discuss how they became aware of blood borne viruses (BBVs) and provide some reasons for their risk behaviours.

Sharon describes herself as a "naïve lassie" (Sharon, interview, p.2) when she started her injecting career. She openly admits to sharing syringes, spoons, filter and water with her first sexual partner, now dead from a drug overdose. She admits to sharing spoons, filter and water with subsequent sexual partners and says she only became aware last year, i.e. 4/5 years into her injecting career, of the dangers of BBV transmission and their association with sharing syringes and other paraphernalia. This discovery arose from an ex-boyfriend revealing his HCV positive status and prompted her to be tested. The test results confirmed that she was HCV positive. Sharon admits that harm reduction advice did not penetrate her thinking during these first 4/5 years of her injecting career because: "well, having been mad with it I never took it on board know what I mean?" (Sharon, interview, p. 5). She continues:

"A year ago, **** came up to me and told me he had hep. I went in and got tested for HIV, everything and the only thing that came back (positive) was hepatitis C. I've no been getting my treatment done for that either. I'll need to cos you see a tinge of yella about ma white bits (of her eyes)? (Sharon, interview transcript, p.5)

She classifies HIV as a BBV with far greater stigma attached to it. Sharon admits that her knowledge of the HCV is still patchy. Recently, Sharon had a scare when she found her son holding a used razor. As a result, she had him tested for BBVs (he tested negative). This fright prompted Sharon to read up about HCV. Despite this, and her fairly recently acquired awareness of BBVs, Sharon admits that this does not consistently translate itself into safer injecting behaviours:

"But there have been times, I mean, I have been that mad with it I canny remember then what I have done. But I am gonny go and get myself tested again." (Sharon, interview transcript, p. 7)

In contrast, Richard's recollection of his injecting career shows an early understanding of BBV transmission risk and the importance of taking precautions. His own initiation into injecting occurred when he was aged 18 and his early injecting career was characterised by occasional injecting of amphetamine and adherence to safer injecting principles. His awareness of injecting risks arose from visiting a needle exchange.

"They had a wee leaflet not to share tools, not to share water, not to share filters and all that … (Richard, interview transcript, p.5)

At that time, Richard was married with a child. He explained his wife's concerns when she discovered that he was injecting:

"She was worried about the AIDS, "what about me, what about the wean?". AIDS this, AIDS that. And I explained to her, I says "listen, that's my stuff up there, naebody uses that apart from me so there is no way I can catch anything, there is no way I can pass anything on to you." (Richard, interview transcript, p. 7)

Following a separation from his wife Richard moved into hostels and it was here that he began injecting heroin at the age of 27 years. Richard insists that he has never shared a set of syringes in his fifteen-year injecting career. He does admit that the combination of moving into hostel life and developing a heroin habit has seen an occasional loosening of his standards with regards the sharing of other paraphernalia. He describes sharing of all injecting paraphernalia in hostels as a common factor:

"You are more likely to share in a hostel because people think when you are in a hostel it's the end of the line know what I mean? You canny go any lower apart from skippering. So you are like that what the ****." (Richard, interview transcript, p. 9)

On one occasion in his room in a hostel Richard recalls sharing a spoon and water with other IDUs:

"I think it was the fact that I was habited up with the kit and I was just pure rattling (withdrawing) and I couldnae be bothered walking away round to West Street to go to the needle exchange to get a new set of tools and walk away back up. I just wanted it there and then and I'd a brand new set of tools. But I never had my ain spoon, I never had my ain water or my ain filter. So I just used theirs." (Richard, interview transcript, p. 7)

It is obvious from Richard's account that he considers his behaviour in the hostel setting as the only time at which he has put himself at risk. His actions with Sharon - sharing water, spoons and filters - are not recollected as risk behaviours.

Case study 3

Participants: Rachel (116) and Margaret (117)

Rachel, aged 28 years, and Margaret, one year younger, have been a couple for three years. Rachel has been injecting drugs for seven years but has recently returned to mainly smoking heroin; she injects if the couple have only a 10 bag between them. Rachel informs us that, despite having been an IDU for so long, she has never learned, or wanted to learn, how to prepare a hit or inject herself. These duties were, for the main part, the responsibility of Rachel's ex-boyfriend and, in the last three years, of Margaret. Despite being a year younger than her partner, Margaret has been injecting for eleven years and describes herself as the dominant half of the relationship.

Whilst Margaret searches the flat frantically for a packet of catering citric acid (which is found under the couch) Rachel prepares her foil for a 'toot'. There is no storage regime in evidence here and this does not change throughout the observation. In response to researcher's question about cin bin use, Margaret states that they do not have a cin bin because it is 'too obvious'. This refers to the fact that the 'woman from housing' who organised their flat five weeks ago has a key to their flat and therefore access. The housing officer believes that they use only methadone.

Margaret prepares her hit on a small living room table. She asks her partner for a cigarette (to use a portion of its filter). She puts the filter onto the spoon first then, having bitten open a 10 bag, adds the heroin to the spoon. It is at this stage that Rachel, having 'tooted' a line of her bag, decides that the heroin is 'jagging kit', i.e. not suitable for smoking, and that she would rather Margaret inject her with what is left of her 10 bag.

Margaret continues preparing her own hit, adding one big pinch of catering citric acid and 1ml of tap water. Having self-administered her hit in the groin, she places the used needle and syringe in the cup of water. Less than five minutes later she uses the same water to prepare Rachel's hit. Thus, Margaret's flush water is Rachel's preparation water. Rachel's hit is drawn up into a sterile needle and syringe on this occasion.

Just after Margaret has had her hit the research team ask whether the couple would ever share needles and syringes? Both reply that they would share with each other but no one else. Rachel adds afterwards that she knows about her partner's HCV+ status (Margaret was diagnosed as HCV a few years ago) but states that 'it doesn't bother her'. She then states that she has only shared tools with Margaret and, on three occasions, with her ex-boyfriend.

At this time in their lives, both Margaret and Rachel place the risk of contracting BBVs low down in a list of multiple concerns that the couple face.

Less than a week prior to our observation, Margaret was attacked and raped near her home. In addition to this, Margaret knows that she is likely to be lifted for multiple arrest warrants anytime she ventures into the city centre. Throughout the next five meetings with the couple, Rachel also reveals herself to be an individual still numbed by the death of her mother amongst other individual tragedies. Recalling this period Rachel told the research team:

"See after ma Ma died I used to go into ma room every single day and O.D… I was pure wrecked with what happened with ma Ma." (Rachel/Margaret, audio footage, p. 46/7)

Case study 4

Participant: Jamie (114)

Jamie is a 27-year-old who has been injecting since he was aged 20 (with some periods of respite and rehabilitation). Over the course of two months we observe Jamie inject four times. Jamie was sleeping rough in the city centre at the time of fieldwork, save for a six-day period in a residential detoxification centre.

The first three events involved Jamie injecting alone and in an outdoor environment. Two of these occasions were in a rarely used city centre backyard near to his begging pitch and the third occasion was in a disused concrete shelter on rail track waste ground near his skipper (regular patch for sleeping rough). The last occasion was in his friend's flat.

Throughout these four observed injecting episodes Jamie shows both a commitment to self-sufficiency in terms of carrying required injecting paraphernalia on his person and a commitment to protect himself against BBVs.

On all four occasions he prepares his hit, a 10 bag of heroin, on the upturned base of an aluminium drinks can. He uses a fresh blue needle on a 2ml syringe on the first and fourth time he is observed. The remainder of occasions he uses a pre-used (by himself) needle and syringe. On two occasions he filters the heroin solution through a freshly ripped portion of cigarette filter and on the other two episodes, the filter has been used previously. The solution is always prepared with catering citric acid stored in a plastic tub.

On the first day of observation, water is not carried on his person; instead, a 500ml bottle of mineral water is hidden inside a black bin bag in the backyard. On that day Jamie explains that the water is almost two weeks old and that this size of bottle usually lasts him for a fortnight. Three days later, injecting in the same backyard, Jamie produces a small brown methadone bottle containing tap water (re-filled in public toilets, etc) to prepare his hit. We see this bottle on his person for the remaining observed events. On our third observation Jamie identifies this water container as, "his friend's old methadone bottle," (Researcher field notes, third session with Jamie). This bottle represents Jamie having all the equipment he needs to prepare and administer his own injections.

After injecting on each of these occasions, Jamie pours some water onto either the aluminium base or the cap of the methadone bottle to rinse out his needle and syringe.

On the fourth occasion, he is observed injecting indoors in his friend's, (Ian (123), flat). Both men prepare with their own individual equipment (they each have a 10 bag of heroin). Jamie uses this opportunity to not only re-fill his portable water bottle but to wash his hands prior to preparing and administering his hit. He is the only participant in the study to do this.

Jamie appeared to be an exception to the rule, as seen in other research, that "roofless" drug users are particularly prone to high-risk behaviours (Neale 2001). Whilst he engages in the acknowledged high-risk behaviour of injecting drugs, the manner in which he does so displays a highly developed understanding of the risks involved.

Jamie explains that his avoidance of the risk of BBVs is centred around AIDS and not hepatitis. The main motivation driving his safer injecting precautions was the fear of contracting HIV at the start of his injecting career. Jamie has never shared needles and syringes because "that's how you catch AIDS and I didn't want to share tools" but he has shared other injecting paraphernalia (Jamie, interview, p.6). Jamie describes how his move into hostel life, "skippering" (sleeping rough) and homelessness in the city centre has resulted in him increasing his knowledge about HCV and how the disease is transmitted through injecting practices, including paraphernalia. He "read things in the jail and leaflets out of West Street." (Jamie, interview, p.7) and through this information began to modify his injecting practices. Jamie explains this evolution in his behaviour:

"…before that I didnae know about hep, that you could get it through injecting and stuff, using filters and that. Because I thought you could only catch it through blood so I was only using (sharing) filters, spoons. I didn't know you could catch it through anything like that until I read a leaflet about it and that's when I stopped, that's when I started carrying my own stuff about with me." (Jamie, interview transcript, p. 8)

Happily, Jamie's approach has resulted in negative results in several tests he has had in the last few years. His last negative result came at the end of March 2003 in between our third and fourth observations with him:

"The guy came and seen us. Took my blood and that. Three days later he was back…. He's like that "there isn't any bad news….you are all clear". I says, "for everything?" and he's like "aye". Had a nice green slip - it's in my bag at my skipper." (Jamie, interview transcript, p. 13)

It seems that Jamie's relatively safe injecting habits result firstly from him absorbing harm reduction messages and, secondly, from his preference of "skippering" (sleeping rough) to hostel life. Jamie's strong dislike of hostel life was made clear to the researchers with him claiming that "**** will use anything in there." (Jamie, interview, p. 16). He adds that one of the benefits of sleeping rough in his eyes is that:

"At least I'm on my own and don't have other people breathing down my neck looking for a bit of kit off me." (Jamie, quoted in field notes)

In Jamie's case sleeping rough has produced a safe injecting practice with regard to BBVs. When asked how he would react to a withdrawal scenario in which he did not have his own injecting paraphernalia he states that he would, "probably go down to West Street" rather than share another IDU's syringes.

Nevertheless, some of his practices (storing and using the same bottle of water for weeks, storing and reusing filters) put him at some risk of acquiring bacterial infections.

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