Injecting practices in sexual partnerships: Hepatitis C transmission potentials in a ‘risk equivalence’ framework
Introduction
The hepatitis C virus (HCV) is a growing cause of morbidity and mortality worldwide (Lavanchy, 2011). In the West transmission primarily occurs through illicit drug injecting practices and, prior to blood screening in the early 1990s, via medical blood products (Shepard et al., 2005). Other, less common, modes of transmission include: occupational needle sticks, unsterile tattooing or piercing equipment, shared toothbrushes/razors and vertical transmission (Orlando and Lirussi, 2007). Though there is variation, most evidence reports minimal transmission risk between monogamous heterosexual partners, with increased risk for men who have sex with men (MSM), particularly if they are living with HIV (Rauch et al., 2005). Sexual transmission risk is also increased for women living with HIV and individuals with genital ulceration (Tohme and Holmberg, 2010).
The weak likelihood of HCV sexual transmission among HIV negative heterosexuals is well evidenced (Azeem et al., 2011, Neumayr et al., 1999, Shepard et al., 2005, Vandelli et al., 2004). In a 10-year cohort following 895 heterosexual HCV serodiscordent couples who were monogamous, regularly sexually active, and did not use barrier protection, none seroconverted (Vandelli et al., 2004). Clustering of HCV within heterosexual couples has largely been accounted for by drug injecting practices (McMahon et al., 2007) or other parenteral exposures (Neumayr et al., 1999). Neumayr et al. (1999) calculate the risk of heterosexual HCV transmission among monogamous partners at 1.25%, noting that higher reported sexual transmission rates are likely to be due to missing or inadequate information about additional parenteral exposure.
Suggestions of increased sexual transmission risk among heterosexuals with multiple partners (Feldman et al., 2000, Salleras et al., 1997) may likewise by confounded by a history of drug injecting (Klevens et al., 2010, Tohme and Holmberg, 2010). The social stigma linked to drug injecting may lead to under-reporting, potentially resulting in unfounded attributions of HCV sexual transmission (Hahn, 2007, Tohme and Holmberg, 2010). The weight of evidence indicates that there is minimal risk of HCV heterosexual transmission, with no evidence of transmission risk increasing with duration of exposure (McMahon et al., 2007, Neumayr et al., 1999, Orlando and Lirussi, 2007). Accordingly, organisations such as the United States Centre for Disease Control do not recommend condom use for HCV transmission prevention among serodiscordant long-term heterosexual couples (Klevens et al., 2010).
Where there is evidence of HCV sexual transmission, reviews link this to the presence of HIV, especially unprotected sex between HIV-positive MSM (Tohme and Holmberg, 2010). Studies show that HCV risk significantly increases for MSM with HIV who engage in practices that involve higher levels of trauma to the anogenital mucosa, such as fisting (Urbanus et al., 2009) and the use of sex toys (Danta et al., 2007). However, the sexual transmission of HCV between MSM may also be attributable to under ascertainment of potential nonsexual risk factors (Alary et al., 2005).
There is a dearth of evidence investigating how people who inject drugs (PWID), those most affected by HCV transmission, perceive sexual transmission risk. HCV literacy among PWID is variable, with a number of studies reporting confusion among PWID about HCV symptoms, test results and transmission (O’Brien et al., 2008, Canfield et al., 2010, Rhodes et al., 2008, Treloar and Holt, 2008). PWID report low levels of condom use (Kapadia et al., 2011) particularly when in long-term heterosexual partnerships (Deren et al., 2008). Drawing on qualitative evidence, we report on perceptions of HCV heterosexual transmission among PWID, and how such perceptions may perpetuate risk practices.
Section snippets
Methods
This study explored the social conditions of long term HCV avoidance among PWID. Study design (Friedman et al., 2008) and methods (Harris and Rhodes, 2012a) have been described in full elsewhere.
Results
The majority of participants who were, or had been, in long term heterosexual relationships referred to needle and syringe [N&S] sharing with their regular sexual partner. This was referenced in a context of ‘discriminative sharing’ whereby only the N&S of known others, such as sexual partners or those in close friendship networks, were used (Rhodes et al., 2008). Prior studies have noted that discriminative N&S sharing is rationalised in terms of trust and intimacy (Rhodes et al., 2008,
Discussion
Needle sharing is not a random practice without situated meaning but is shaped by social relations in specific cultural and material contexts. Accounts of N&S sharing specifically are generated in a social context of meaning regarding risk acceptability and moral responsibility (Rhodes et al., 2008, Zule, 1992). In the UK, HCV messaging arose within a HIV focused harm reduction framework of ‘risk hierarchy’ interventions which encouraged PWID to prioritise practices in terms of their risk
Role of funding source
Funding for this study was provided by the Economic and Social Research Council (ESRC) Grant RES-062-23-1766. The ESRC had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Tim Rhodes conceived of the study and wrote the protocol. Magdalena Harris took a lead role in data collection, analysis and manuscript drafting. Tim Rhodes contributed to final manuscript drafts. Both authors have contributed to and approved the final manuscript.
Conflict of interest
Both authors declare that they have no conflicts of interest.
Acknowledgements
The authors would like to thank the participants of this study, fieldworker Greg Holloway and recruiting services Lorraine Hewitt House, Islington Primary Care Practice and Cedar's Road Hostel. Also to acknowledge international collaborators Samuel Friedman, Carla Treloar and Lisa Maher. The study was funded by the Economic and Social Research Council.
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