Journal of Psychoactive Drugs
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Risk and Reciprocity: HIV and the Injection Drug User William A. Zule To cite this article: William A. Zule (1992) Risk and Reciprocity: HIV and the Injection Drug User, Journal of Psychoactive Drugs, 24:3, 243-249, DOI: 10.1080/02791072.1992.10471644 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471644
Published online: 20 Jan 2012.
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Citing articles: 34 View citing articles
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Date: 05 November 2015, At: 23:14
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Injection Drug Usert William A. Zule, MPH* Abstract- Injecting practices of illicit drug users in San Antonio, Texas, were studied by means of informal field interviews and participant observation. The methods injection drug users (IDUs) employed to obtain drugs seemed to affect their HIV risk behaviors. Many of the methods involve reciprocal exchanges between a person who has drugs and a person who wants drugs. The exchanges frequently occur in the context of asynunetrical social interactions. The person with the drugs usually occupies the dominant role in the interaction and determines the needle hygiene for both parties. Analysis of the decision-making process of IDUs indicates that the party in the dominant role may choose not to disinfect a syringe for a variety of reasons. An understanding of the subcultural rules that govern these interactions may provide valuable clues to researchers or educators who are designing interventions aimed at reducing HIV risk behaviors among IDUs. This research suggests that for IDUs in subordinate roles, education alone may be insufficient to produce behavior changes necessary to eliminate risk of HIV infection. Keywords- asynunetrical social interaction, high-risk behavior, human immunodeficiency virus, injection drug user, sharing drug paraphernalia
The link between injection drug users (IDUs) and human immunodeficiency virus (HIV) infection has been the subject of considerable research (Turner, Miller & Moses 1989). Sharing contaminated hypodermic syringes and needles appears to be the primary mode of HIV transmission within this group (Newmeyer et al. 1989). Quantitative studies (Chaisson et al. 1989; Schoenbaum et al. 1989) have identified demographic and drug use variables associated with HIV infection. Recently, ethnographic studies have noted the potential for HIV transmission associated with sharing other injection equipment, such as spoons, cookers, and cottons (Koester, Booth & Wiebel1991; Loirner, Werner & Presslich 1991) as well as the liquified drug solution itself (Grund et al. 1991). Other ethnographic studies have noted that an IDU's HIV risk behaviors are influenced by a wide variety of factors (Grund, Kaplan & Adriaans 1991; Murphy 1987). This article examines how the roles that IDUs assume when they interact to obtain drugs affect their HIV risk behaviors. Illicit drug-related activities- buying, selling, and using drugs- usually occur in the context of inter-
actions between people who know each other. Many of these interactions involve low-status hustles and their analysis is facilitated by the use of the sociological concept of reciprocity. Much of human social intercourse rests on the principle of returning the equivalent of what one receives. Sociologists refer to this principle as the "norm of reciprocity" and have noted its importance in all societies (Gouldner 1960). The analysis of reciprocity in this report draws on the work of Sahlins (1965) as a general frame of reference. Sahlins delineated a continuum of reciprocities. He idealized negative reciprocity as an attempt to get something for nothing, balanced reciprocity as an equal exchange, and generalized reciprocity as a pure gift Spradley (1970) applied this framework to analyze the hustling behavior of transient alcoholics in his ethnographic study You Owe Yourself a Drunk. Data presented in the present report were collected as part of the San Antonio AIDS Community Outreach Demonstration Project. Similar projects were funded by the National Institute on Drug Abuse (NIDA) at multiple sites to test interventions aimed at reducing HIV risk behaviors among IDUs and their sexual partners. The San Antonio Project included an ethnographic component, which collected qualitative data to complement quantitative data derived from standardized NIDA research instruments,
t1bis study was supported in part by Public Health Service Grant No. DA 05741 from the National Institute on Drug Abuse. •The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7792.
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such as the AIDS Initial Assessment (AlA) questionnaire. The IOU population in San Antonio differs from that of many large cities in the United States in three respects: the preponderance of Hispanics, the relatively low number of African-Americans, and the preeminence of heroin as the drug of choice. San AnLonio has one of the lowest HIV seroprevalence rates among large metropolitan areas, with less than two percent of both treatment and non treatment samples testing positive for HIV antibodies (Vogtsberger 1992; Battjes, Pickens & Amsell991).
were recorded verbatim, others were paraphrased. Respondent's key words were retained whenever possible. Later, a narrative summary of each interview was prepared from field notes. A majority of subsequent interviews were recorded on audiotape and transcribed verbatim. Participant observation (Spradley 1980) was used to corroborate interview data and to understand the context in which behaviors of interest occurred. One of the locations chosen for participant observation provided access to a racially mixed group of heroin users. This site was an old house in the heart of a barrio on the West side of San Antonio, where heroin use is endemic. The house was owned by a small church whose elders allowed the residents, an African-American couple and their two-year-old son, to live there rent free. Throughout the four-month period of observation, the residents operated an informal shooting gallery in the house, which was similar to those described by Murphy and Waldorf (1991). Participant observation was discontinued after the residents were arrested and charged with delivery of heroin. The other si te was an apartment where a group of non-Hispanic White amphetamine users congregated. Involvement in these settings ranged from passive observation of injection episodes to active participation in barbecues and other social activities. Observational periods usually ranged from one to four hours. Several attempts were made to record observations as events occurred, but this strategy seemed to inhibit actors so it was abandoned. A condensed account of observations was prepared in the investigator's car shortly after he left the site. These accounts included key phrases, major events, and incidental material. The investigator prepared an expanded account of the observations as soon afterward as possible.
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METHODS T his study differs from most published ethnographic reports in that it was designed, conducted, and written by a person with an 18-year personal history of illicit drug injection. The author, in his role as project ethnographer, accompanied indigenous outreach workers into the field, where he was introduced into social networks of active IDUs . Outreach workers briefly described the nature of the research and role of the ethnographer to prospective interview participants. Interested IDUs were referred to the ethnographer, who provided a more detailed description of the study that contained all of the elements for informed consent. After verbal consent was obtained, an anonymous interview was conducted. Following each interview, the participant was paid $10 for his or her time. As the ethnographer developed rapport with some of the IDUs at each s ite , the y assisted him in recruiting and screening additional interview participants. Eligibility was restricted to persons who reported injecting a drug within the two month s preceding the interview. The ethnographer made the final determination regarding a participant's eligibility following each interview based on observations during the interview. The number of subjects interviewed at most sites ranged from five to 15. Referrals from participants at these sites led to interviews with IDUs at other sites. Two of these were selected for intensive investigation . Approximately 30 to 40 interviews were conducted at each of these sites. The strategy for selecting interview participants combined snowball sampling (Biernacki & Waldorf 1981),elements of targeted sampling (Watters & Biernacki 1989), and theoretical sampling (Glaser & Strauss 1967). Data collection and analysis proceeded concurrently. The present study employed semistructured field interviews that contained a series of open-ended questions. The interview outline was revised periodically as data analysis suggested new topics of theoretical interest. The final outline obtained information regarding demographics, illicit drug use, alcohol use, needle use, drug abuse treatment, criminal history, AIDS, and sexual behavior. Pencil and paper were used to record responses and note observations in the first 100 interviews. Some responses Journal of Psychoactive Drugs
FINDINGS Two hundred thirty-four (234) field interviews were conducted and 15 injection episodes were observed between July 1989 and September 1991. The mean age of the interview participants was 35 years. Seventy-six percent were male. The racial-ethnic composition of the sample was 48% Hispanic, 32% non-Hispanic White, 19% African-American, and 1% other. Only 15% claimed fulltime employment, while 68% were unemployed . Sixtyfour percent were high-school dropouts. Sixty-six percent were primary heroin users, 19% were primary methamphetamine users, 10% were primary cocaine users, and 4% were primary speedball (cocaine and heroin in combination) users. Seventy-five percent reported sharing needles. Seventy-four percent reported using potentially contam inated syringes to add water to powdered drugs or measure and divide the solution between two people after it was dissolved. Data were sufficient to classify the needle use of 222 interview participants as safe or unsafe. Of these, 244
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66% (146 subjects) reported unsafe needle use- sharing needles without disinfecting them. However, of the 34% (76 subjects) who reported safe needle use- either never sharing needles or always disinfecting when they did49% (37 subjects) reported using potentially contaminated syringes to prepare and divide drug solutions. Thus only 18% (39 subjects) practiced safe needle use. illicit drug users may utilize a wide variety of methods to acquire drugs, many of which are beyond the scope of this article. This analysis focuses on situations where IDUs obtain drugs by pooling their resources (money or essential prerequisite), providing a service or receiving a gift, either solicited or unsolicited.
solution is observed. The division is made by squirting a portion back into the cooker or into the barrel of another syringe from which the plunger has been removed. A syringe is almost always used to add water to the heroin. If the syringe contains HIV, the cooker, cotton, and heroin-water solution may be contaminated as soon as the water is added. If the syringe used to pick up the solution and measure its volume contains HIV, the solution may be contaminated. Because the pick up is usually performed with the same syringe used to add the water, this step is not the initial source of risk. The step is necessary because it is virtually impossible to estimate the volume of the heroin-water solution before dissolving the heroin. The liquid increases in volume when the heroin is dissolved, and the solution's volume is decreased through heating and absorption in the cotton. After the solution is picked up, a drop of water may be added to the cooker by sticking a finger, needle guard, or other convenient object in some water and flicking it over the cooker to recover residual solution. This additional solution is then picked up with the syringe, which contains the bulk of the solution, and then the division is made. One heroin user described the process as follows :
The Exchange When drug users buy drugs, they may contribute all of the money, most of the money, half of the money, or less than half. Alternatively, they may obtain drugs in exchange for an essential prerequisite or service. The prerequisites of drug injection include the drug, injection equipment, the skill to inject, and a place to inject. Criminal penalties for illegal possession of drugs and injection paraphernalia deter many users from carrying these items. Therefore it is not uncommon for an IDU to find himself or herself with some, but not all, of the essential prerequisites. Under these circumstances, each prerequisite assumes some value. Many of the injection episodes in which IDUs participate involve exchanges of one or more prerequisites. Services observed or reported in San Antonio include scoring (purchasing drugs) for another person, transporting others to and from the connection (drug dealer), and injecting a person who was unable to inject himself or herself. When IDUs pool their resources, the division of the drug almost always takes place after the drug has been dissolved in water. This practice, as described later, may increase the IDU's risk for exposure to HIV. The following descriptions of how and why the drug is divided after it has been dissolved are specific to heroin, but most of the steps in the process also apply to injectable cocaine and methamphetamine. Illicit drugs are expensive and highly valued by IDUs, so equitable division is extremely important. But it is often impractical to divide a small quantity of powder accurately. The drug may not be evenly distributed in the powder, or the drug and cut (adulterant) may be inadequately mixed or separated slightly if particles of drug and adulterant are of different size or density. Therefore, when IDUs divide a quantity of drug among themselves, according to the resources each has contributed, the division occurs after the drug has been dissolved. The process typically goes as follows: heroin is placed in a cooker ( usually a metal bottle cap), water is added with a syringe, and the mixture is heated and stirred. A small piece of cotton is placed in the solution, the liquid is "picked up" (sucked through the cotton into a syringe), and the volume of the Journal of Psychoactive Drugs
Ethnographer: Tell me about the last time you shared a needle. How did you do it? Respondent: Threw the dope in a cooker. I bought the dope myself but didn't have a syringe, so I borrowed a friend's and gave him about ten Wlits for lending me his syringe.
The following scene, from field notes recorded in an informal shooting gallery, depicts the ethnographer's perception of the process: A tecata (Hispanic female junkie) entered the house and asked the resident (R) if he had a rig (needle/syringe combination) she could use. He retrieved one from his stash (hiding place) and handed it to her along with a cooker (bottle cap). She tore a dime ($10 worth of heroin packaged in a balloon) open with her teeth and dumped the contents into the cooker. By this time, R had filled an aluminum salt shaker with water from a five gallon bucket. She drew water from the salt shaker and squirted it into the cooker. R handed her a disposable lighter, which she used to heat the solution and dissolve the heroin . She needed some couon for a filter, so R tore a thread from a cotton dish toweL She balled up the thread, dropped it in the cooker, and drew up the solution. When this was completed, the syringe contained about 40 units (.40 ml) of liquid. She squirted I 0 Wliu back into the cooker and injected the other 30 units . Then she rinsed the syringe twice with water from the salt shaker and picked up (drew into the syringe) the 10 Wliu in the cooker and handed the syringe toR. He stuck his finger into the salt shaker and flicked a drop of water into the cooker. He drew this up too and injected the contents of the syringe, which now contained almost 15 units.
The preceding observation describes an episode where the use of a syringe and a place to inject were exchanged for a small amount of heroin. The ethnographer had been 245
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acquainted with the resident for almost three months when this episode occurred. During that time, the resident had been educated in the use of bleach for cleaning needles. He had even begun to assist the ethnographer by distributing bleach to IDUs who dropped by the house. But in this instance he never had an opportunity to disinfect the syringe because the teeata drew his dose into the syringe before she handed it to him. In both of these instances, the preparation and division of the drug were controlled by the person who had purchased the drug, not by the person who provided the syringe. This procedure is standard; it is described again in the following interview excerpt:
with permanently affixed needles, once the needle is broken it cannot be repaired. As the syringe can never be used to inject, it is used exclusively as a "draw fit." A draw fit is any syringe that is used to add water to powdered drugs, measure the volume of the solution produced, and then divide the solution. Most IDUs use the injection syringe as a draw fit. From the IDU's perspective, designating a single syringe as a draw fit provides a secondary benefit by eliminating the possibility of dulling or barbing the point of the needle by accidentally jamming it into the bottom of the cooker. Thus the practice serves to reduce the pain caused by injecting with a dull needle and prolongs the usefulli ves of the other syringes.
Ethnographer: When you go halves (pool resources) with scmebody, do you draw yours up and they draw theirs up or do you draw it all up into one rig and see how many units there are or what do you do? Respondent: Yeah, we piclc it all up at once and see how many units we get and then we go halves on it. Whoever buys it goes first. Or whoever pays more goes first and the other has to wait.
Tbe Gift Although true giving of drugs is probably a rare occurrence, scenes similar to the one described in the following observation are relatively common. In this episode, there were no formal negotiations regarding a specific form and time of repayment Still, if the situation were reversed in the future and the recipient failed to reciprocate, he would be violating a cultural norm.
In more technical language, unequal contributions produce asymmetrical interactions. Control in asymmetrical interactions is determined by the relative value of the contributions. As a general rule, the person who contributes all or most of the money controls the preparation and division of the drug. Whether to disinfect injection equipment first is his or her prerogative. He or she may choose to forego disinfecting for a variety of reasons, which are discussed below. Exceptions to this rule may occur when other factors override the monetary contribution. An asymmetrical relationship also exists when one person offers to lend his or her rig (needle and syringe) in exchange for some heroin. Although the person with the heroin still controls the exchange, the person providing the equipment usually has the option of disinfecting the rig before it is used. In contrast to unequal contributions, equal contributions produce symmetrical interactions. When people contribute equally to the purchase of a drug, they prepare and divide the drug in the manner described previously, but the relationship approaches symmetry. In this situation, it becomes easier for either party to insist on the use of bleach or other disinfectant, such as rubbing alcohol or hydrogen peroxide. An interesting solution to the problem of how to eliminate the risk of HIV transmission while still dividing the drug accurately was reported by three IDUs. Each one, independently, adopted the same strategy for eliminating the risks that arise from dividing drug solutions. Each reported buying at least ten syringes at a time, and then breaking the needle of one syringe before any are used. Because IDUs in San Antonio use lee insulin syringes Journal of Psychoactive Drugs
Jim and the ethnographer dropped by Harry's house to visit him about one o'cloclc on a Sunday afternoon . When they arrived,
they found Harry and his brother Jody watching a football game and drinking beer. Jody, who appeared highly intoxicated , and Jim were old friends who had not seen each other in several years . When they saw each other, they exchanged greetings and immediately started to fill each other in on events in their lives since they had last seen each other. About an hour later, Jody asked Jim if he wanted to "do aD" (inject a Dilaudid). Jim indicated he would and Jody went into the bathroom. Several minutes later, Jody returned and handed Jim a syringe containing approximately .5 ml of liquid. When Jim asked Jody if the syringe had been cleaned, Jody replied, "with water." Jim shrugged his shoulders, took the syringe, and injected the contents.
In a subsequent discussion, Jim indicated that he was aware of how HIV is transmitted and that he usually tried to avoid sharing needles. He explained that when he accepted the offer, he assumed that either a new syringe would be available or he would have an opportunity to disinfect a used one. When Jody brought him the prepared injection, Jim was faced with the unanticipated choice of either turning it down or using a potentially contaminated syringe. According to Jim, by this time he was so eager to do the D that his anticipation of the rush and subsequent euphoria momentarily overrode his fear of HIV infection. In this episode, the unsolicited gift of an injection precipitated high-risk behavior. In discussions with IDUs during participant observation, no one reported turning down a free injection because the syringe had not been disinfected. An important factor here may be the low HIV seroprevalence rates (Hill Hill
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
Risk and Reciprocity: HIV and the Injection Drug User William A. Zule To cite this article: William A. Zule (1992) Risk and Reciprocity: HIV and the Injection Drug User, Journal of Psychoactive Drugs, 24:3, 243-249, DOI: 10.1080/02791072.1992.10471644 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471644
Published online: 20 Jan 2012.
Submit your article to this journal
Article views: 15
View related articles
Citing articles: 34 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujpd20 Download by: [NUS National University of Singapore]
Date: 05 November 2015, At: 23:14
Risk and Reciprocity: HIV and the Downloaded by [NUS National University of Singapore] at 23:14 05 November 2015
Injection Drug Usert William A. Zule, MPH* Abstract- Injecting practices of illicit drug users in San Antonio, Texas, were studied by means of informal field interviews and participant observation. The methods injection drug users (IDUs) employed to obtain drugs seemed to affect their HIV risk behaviors. Many of the methods involve reciprocal exchanges between a person who has drugs and a person who wants drugs. The exchanges frequently occur in the context of asynunetrical social interactions. The person with the drugs usually occupies the dominant role in the interaction and determines the needle hygiene for both parties. Analysis of the decision-making process of IDUs indicates that the party in the dominant role may choose not to disinfect a syringe for a variety of reasons. An understanding of the subcultural rules that govern these interactions may provide valuable clues to researchers or educators who are designing interventions aimed at reducing HIV risk behaviors among IDUs. This research suggests that for IDUs in subordinate roles, education alone may be insufficient to produce behavior changes necessary to eliminate risk of HIV infection. Keywords- asynunetrical social interaction, high-risk behavior, human immunodeficiency virus, injection drug user, sharing drug paraphernalia
The link between injection drug users (IDUs) and human immunodeficiency virus (HIV) infection has been the subject of considerable research (Turner, Miller & Moses 1989). Sharing contaminated hypodermic syringes and needles appears to be the primary mode of HIV transmission within this group (Newmeyer et al. 1989). Quantitative studies (Chaisson et al. 1989; Schoenbaum et al. 1989) have identified demographic and drug use variables associated with HIV infection. Recently, ethnographic studies have noted the potential for HIV transmission associated with sharing other injection equipment, such as spoons, cookers, and cottons (Koester, Booth & Wiebel1991; Loirner, Werner & Presslich 1991) as well as the liquified drug solution itself (Grund et al. 1991). Other ethnographic studies have noted that an IDU's HIV risk behaviors are influenced by a wide variety of factors (Grund, Kaplan & Adriaans 1991; Murphy 1987). This article examines how the roles that IDUs assume when they interact to obtain drugs affect their HIV risk behaviors. Illicit drug-related activities- buying, selling, and using drugs- usually occur in the context of inter-
actions between people who know each other. Many of these interactions involve low-status hustles and their analysis is facilitated by the use of the sociological concept of reciprocity. Much of human social intercourse rests on the principle of returning the equivalent of what one receives. Sociologists refer to this principle as the "norm of reciprocity" and have noted its importance in all societies (Gouldner 1960). The analysis of reciprocity in this report draws on the work of Sahlins (1965) as a general frame of reference. Sahlins delineated a continuum of reciprocities. He idealized negative reciprocity as an attempt to get something for nothing, balanced reciprocity as an equal exchange, and generalized reciprocity as a pure gift Spradley (1970) applied this framework to analyze the hustling behavior of transient alcoholics in his ethnographic study You Owe Yourself a Drunk. Data presented in the present report were collected as part of the San Antonio AIDS Community Outreach Demonstration Project. Similar projects were funded by the National Institute on Drug Abuse (NIDA) at multiple sites to test interventions aimed at reducing HIV risk behaviors among IDUs and their sexual partners. The San Antonio Project included an ethnographic component, which collected qualitative data to complement quantitative data derived from standardized NIDA research instruments,
t1bis study was supported in part by Public Health Service Grant No. DA 05741 from the National Institute on Drug Abuse. •The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7792.
JourNJl of Psychoactive Drugs
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such as the AIDS Initial Assessment (AlA) questionnaire. The IOU population in San Antonio differs from that of many large cities in the United States in three respects: the preponderance of Hispanics, the relatively low number of African-Americans, and the preeminence of heroin as the drug of choice. San AnLonio has one of the lowest HIV seroprevalence rates among large metropolitan areas, with less than two percent of both treatment and non treatment samples testing positive for HIV antibodies (Vogtsberger 1992; Battjes, Pickens & Amsell991).
were recorded verbatim, others were paraphrased. Respondent's key words were retained whenever possible. Later, a narrative summary of each interview was prepared from field notes. A majority of subsequent interviews were recorded on audiotape and transcribed verbatim. Participant observation (Spradley 1980) was used to corroborate interview data and to understand the context in which behaviors of interest occurred. One of the locations chosen for participant observation provided access to a racially mixed group of heroin users. This site was an old house in the heart of a barrio on the West side of San Antonio, where heroin use is endemic. The house was owned by a small church whose elders allowed the residents, an African-American couple and their two-year-old son, to live there rent free. Throughout the four-month period of observation, the residents operated an informal shooting gallery in the house, which was similar to those described by Murphy and Waldorf (1991). Participant observation was discontinued after the residents were arrested and charged with delivery of heroin. The other si te was an apartment where a group of non-Hispanic White amphetamine users congregated. Involvement in these settings ranged from passive observation of injection episodes to active participation in barbecues and other social activities. Observational periods usually ranged from one to four hours. Several attempts were made to record observations as events occurred, but this strategy seemed to inhibit actors so it was abandoned. A condensed account of observations was prepared in the investigator's car shortly after he left the site. These accounts included key phrases, major events, and incidental material. The investigator prepared an expanded account of the observations as soon afterward as possible.
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METHODS T his study differs from most published ethnographic reports in that it was designed, conducted, and written by a person with an 18-year personal history of illicit drug injection. The author, in his role as project ethnographer, accompanied indigenous outreach workers into the field, where he was introduced into social networks of active IDUs . Outreach workers briefly described the nature of the research and role of the ethnographer to prospective interview participants. Interested IDUs were referred to the ethnographer, who provided a more detailed description of the study that contained all of the elements for informed consent. After verbal consent was obtained, an anonymous interview was conducted. Following each interview, the participant was paid $10 for his or her time. As the ethnographer developed rapport with some of the IDUs at each s ite , the y assisted him in recruiting and screening additional interview participants. Eligibility was restricted to persons who reported injecting a drug within the two month s preceding the interview. The ethnographer made the final determination regarding a participant's eligibility following each interview based on observations during the interview. The number of subjects interviewed at most sites ranged from five to 15. Referrals from participants at these sites led to interviews with IDUs at other sites. Two of these were selected for intensive investigation . Approximately 30 to 40 interviews were conducted at each of these sites. The strategy for selecting interview participants combined snowball sampling (Biernacki & Waldorf 1981),elements of targeted sampling (Watters & Biernacki 1989), and theoretical sampling (Glaser & Strauss 1967). Data collection and analysis proceeded concurrently. The present study employed semistructured field interviews that contained a series of open-ended questions. The interview outline was revised periodically as data analysis suggested new topics of theoretical interest. The final outline obtained information regarding demographics, illicit drug use, alcohol use, needle use, drug abuse treatment, criminal history, AIDS, and sexual behavior. Pencil and paper were used to record responses and note observations in the first 100 interviews. Some responses Journal of Psychoactive Drugs
FINDINGS Two hundred thirty-four (234) field interviews were conducted and 15 injection episodes were observed between July 1989 and September 1991. The mean age of the interview participants was 35 years. Seventy-six percent were male. The racial-ethnic composition of the sample was 48% Hispanic, 32% non-Hispanic White, 19% African-American, and 1% other. Only 15% claimed fulltime employment, while 68% were unemployed . Sixtyfour percent were high-school dropouts. Sixty-six percent were primary heroin users, 19% were primary methamphetamine users, 10% were primary cocaine users, and 4% were primary speedball (cocaine and heroin in combination) users. Seventy-five percent reported sharing needles. Seventy-four percent reported using potentially contam inated syringes to add water to powdered drugs or measure and divide the solution between two people after it was dissolved. Data were sufficient to classify the needle use of 222 interview participants as safe or unsafe. Of these, 244
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66% (146 subjects) reported unsafe needle use- sharing needles without disinfecting them. However, of the 34% (76 subjects) who reported safe needle use- either never sharing needles or always disinfecting when they did49% (37 subjects) reported using potentially contaminated syringes to prepare and divide drug solutions. Thus only 18% (39 subjects) practiced safe needle use. illicit drug users may utilize a wide variety of methods to acquire drugs, many of which are beyond the scope of this article. This analysis focuses on situations where IDUs obtain drugs by pooling their resources (money or essential prerequisite), providing a service or receiving a gift, either solicited or unsolicited.
solution is observed. The division is made by squirting a portion back into the cooker or into the barrel of another syringe from which the plunger has been removed. A syringe is almost always used to add water to the heroin. If the syringe contains HIV, the cooker, cotton, and heroin-water solution may be contaminated as soon as the water is added. If the syringe used to pick up the solution and measure its volume contains HIV, the solution may be contaminated. Because the pick up is usually performed with the same syringe used to add the water, this step is not the initial source of risk. The step is necessary because it is virtually impossible to estimate the volume of the heroin-water solution before dissolving the heroin. The liquid increases in volume when the heroin is dissolved, and the solution's volume is decreased through heating and absorption in the cotton. After the solution is picked up, a drop of water may be added to the cooker by sticking a finger, needle guard, or other convenient object in some water and flicking it over the cooker to recover residual solution. This additional solution is then picked up with the syringe, which contains the bulk of the solution, and then the division is made. One heroin user described the process as follows :
The Exchange When drug users buy drugs, they may contribute all of the money, most of the money, half of the money, or less than half. Alternatively, they may obtain drugs in exchange for an essential prerequisite or service. The prerequisites of drug injection include the drug, injection equipment, the skill to inject, and a place to inject. Criminal penalties for illegal possession of drugs and injection paraphernalia deter many users from carrying these items. Therefore it is not uncommon for an IDU to find himself or herself with some, but not all, of the essential prerequisites. Under these circumstances, each prerequisite assumes some value. Many of the injection episodes in which IDUs participate involve exchanges of one or more prerequisites. Services observed or reported in San Antonio include scoring (purchasing drugs) for another person, transporting others to and from the connection (drug dealer), and injecting a person who was unable to inject himself or herself. When IDUs pool their resources, the division of the drug almost always takes place after the drug has been dissolved in water. This practice, as described later, may increase the IDU's risk for exposure to HIV. The following descriptions of how and why the drug is divided after it has been dissolved are specific to heroin, but most of the steps in the process also apply to injectable cocaine and methamphetamine. Illicit drugs are expensive and highly valued by IDUs, so equitable division is extremely important. But it is often impractical to divide a small quantity of powder accurately. The drug may not be evenly distributed in the powder, or the drug and cut (adulterant) may be inadequately mixed or separated slightly if particles of drug and adulterant are of different size or density. Therefore, when IDUs divide a quantity of drug among themselves, according to the resources each has contributed, the division occurs after the drug has been dissolved. The process typically goes as follows: heroin is placed in a cooker ( usually a metal bottle cap), water is added with a syringe, and the mixture is heated and stirred. A small piece of cotton is placed in the solution, the liquid is "picked up" (sucked through the cotton into a syringe), and the volume of the Journal of Psychoactive Drugs
Ethnographer: Tell me about the last time you shared a needle. How did you do it? Respondent: Threw the dope in a cooker. I bought the dope myself but didn't have a syringe, so I borrowed a friend's and gave him about ten Wlits for lending me his syringe.
The following scene, from field notes recorded in an informal shooting gallery, depicts the ethnographer's perception of the process: A tecata (Hispanic female junkie) entered the house and asked the resident (R) if he had a rig (needle/syringe combination) she could use. He retrieved one from his stash (hiding place) and handed it to her along with a cooker (bottle cap). She tore a dime ($10 worth of heroin packaged in a balloon) open with her teeth and dumped the contents into the cooker. By this time, R had filled an aluminum salt shaker with water from a five gallon bucket. She drew water from the salt shaker and squirted it into the cooker. R handed her a disposable lighter, which she used to heat the solution and dissolve the heroin . She needed some couon for a filter, so R tore a thread from a cotton dish toweL She balled up the thread, dropped it in the cooker, and drew up the solution. When this was completed, the syringe contained about 40 units (.40 ml) of liquid. She squirted I 0 Wliu back into the cooker and injected the other 30 units . Then she rinsed the syringe twice with water from the salt shaker and picked up (drew into the syringe) the 10 Wliu in the cooker and handed the syringe toR. He stuck his finger into the salt shaker and flicked a drop of water into the cooker. He drew this up too and injected the contents of the syringe, which now contained almost 15 units.
The preceding observation describes an episode where the use of a syringe and a place to inject were exchanged for a small amount of heroin. The ethnographer had been 245
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HIV Risk and Reciprocity
acquainted with the resident for almost three months when this episode occurred. During that time, the resident had been educated in the use of bleach for cleaning needles. He had even begun to assist the ethnographer by distributing bleach to IDUs who dropped by the house. But in this instance he never had an opportunity to disinfect the syringe because the teeata drew his dose into the syringe before she handed it to him. In both of these instances, the preparation and division of the drug were controlled by the person who had purchased the drug, not by the person who provided the syringe. This procedure is standard; it is described again in the following interview excerpt:
with permanently affixed needles, once the needle is broken it cannot be repaired. As the syringe can never be used to inject, it is used exclusively as a "draw fit." A draw fit is any syringe that is used to add water to powdered drugs, measure the volume of the solution produced, and then divide the solution. Most IDUs use the injection syringe as a draw fit. From the IDU's perspective, designating a single syringe as a draw fit provides a secondary benefit by eliminating the possibility of dulling or barbing the point of the needle by accidentally jamming it into the bottom of the cooker. Thus the practice serves to reduce the pain caused by injecting with a dull needle and prolongs the usefulli ves of the other syringes.
Ethnographer: When you go halves (pool resources) with scmebody, do you draw yours up and they draw theirs up or do you draw it all up into one rig and see how many units there are or what do you do? Respondent: Yeah, we piclc it all up at once and see how many units we get and then we go halves on it. Whoever buys it goes first. Or whoever pays more goes first and the other has to wait.
Tbe Gift Although true giving of drugs is probably a rare occurrence, scenes similar to the one described in the following observation are relatively common. In this episode, there were no formal negotiations regarding a specific form and time of repayment Still, if the situation were reversed in the future and the recipient failed to reciprocate, he would be violating a cultural norm.
In more technical language, unequal contributions produce asymmetrical interactions. Control in asymmetrical interactions is determined by the relative value of the contributions. As a general rule, the person who contributes all or most of the money controls the preparation and division of the drug. Whether to disinfect injection equipment first is his or her prerogative. He or she may choose to forego disinfecting for a variety of reasons, which are discussed below. Exceptions to this rule may occur when other factors override the monetary contribution. An asymmetrical relationship also exists when one person offers to lend his or her rig (needle and syringe) in exchange for some heroin. Although the person with the heroin still controls the exchange, the person providing the equipment usually has the option of disinfecting the rig before it is used. In contrast to unequal contributions, equal contributions produce symmetrical interactions. When people contribute equally to the purchase of a drug, they prepare and divide the drug in the manner described previously, but the relationship approaches symmetry. In this situation, it becomes easier for either party to insist on the use of bleach or other disinfectant, such as rubbing alcohol or hydrogen peroxide. An interesting solution to the problem of how to eliminate the risk of HIV transmission while still dividing the drug accurately was reported by three IDUs. Each one, independently, adopted the same strategy for eliminating the risks that arise from dividing drug solutions. Each reported buying at least ten syringes at a time, and then breaking the needle of one syringe before any are used. Because IDUs in San Antonio use lee insulin syringes Journal of Psychoactive Drugs
Jim and the ethnographer dropped by Harry's house to visit him about one o'cloclc on a Sunday afternoon . When they arrived,
they found Harry and his brother Jody watching a football game and drinking beer. Jody, who appeared highly intoxicated , and Jim were old friends who had not seen each other in several years . When they saw each other, they exchanged greetings and immediately started to fill each other in on events in their lives since they had last seen each other. About an hour later, Jody asked Jim if he wanted to "do aD" (inject a Dilaudid). Jim indicated he would and Jody went into the bathroom. Several minutes later, Jody returned and handed Jim a syringe containing approximately .5 ml of liquid. When Jim asked Jody if the syringe had been cleaned, Jody replied, "with water." Jim shrugged his shoulders, took the syringe, and injected the contents.
In a subsequent discussion, Jim indicated that he was aware of how HIV is transmitted and that he usually tried to avoid sharing needles. He explained that when he accepted the offer, he assumed that either a new syringe would be available or he would have an opportunity to disinfect a used one. When Jody brought him the prepared injection, Jim was faced with the unanticipated choice of either turning it down or using a potentially contaminated syringe. According to Jim, by this time he was so eager to do the D that his anticipation of the rush and subsequent euphoria momentarily overrode his fear of HIV infection. In this episode, the unsolicited gift of an injection precipitated high-risk behavior. In discussions with IDUs during participant observation, no one reported turning down a free injection because the syringe had not been disinfected. An important factor here may be the low HIV seroprevalence rates (Hill Hill
