Search

© 2017 Background In the West, hepatitis C is predominantly transmitted via the sharing of contaminated drug-injecting equipment. Although the majority of this sharing occurs between sexual partners, the responsibility for avoiding transmission has long been conceived as an individual responsibility, with prevention measures such as the distribution of sterile injecting equipment such as injecting packs (‘fitpacks’) aimed at individuals without regard for the social contexts of injecting. In this article we draw on the work of Bruno Latour to reconceptualise the fitpack. We argue that the fitpack is not inert or neutral in its meaning or effects, that instead it ‘affords’ particular meanings and actions, for example, that injecting is an individual practice and safety an individual responsibility. Method To challenge these affordances, we developed a new fitpack prototype aimed at couples, along with related health promotion messages. We asked 13 couples who inject drugs to examine and reflect on these new objects and messages. Results Overall, we found a high level of support for the broad idea of couples-oriented materials, as well as for our prototype and associated materials. Participants identified opportunities for improving the materials and commented on implications of the symbols and language used. Together the interviews demonstrated ways in which the new fitpacks and messages could afford couples-oriented safe injecting, and better recognition of relationships that are often dismissed by researchers and health care providers as insincere. Conclusions These findings demonstrate that first, there is a need and desire for a greater range in harm reduction resources. Second, it is essential to find ways of better acknowledging the validity and value of relationships between people who inject. Third, and more broadly, recognition must be given to the role of technological objects in materialising meanings and, as Latour might put it, ‘moralities’, and in turn

© 2017Public health research treats intimate partnerships as sites of risk management, including in the management of HIV and hepatitis C transmission. This risk-infused biomedical approach tends to undermine appreciation of the emotional and socially situated meanings of care in intimate partnerships. In this article we explore qualitative interview accounts of the care enacted in partnerships between people who inject drugs, drawing on a 2014 study of 34 couples and 12 individuals living in two locations of Australia. A thematic analysis highlights ‘best friend relationships’, ‘doing everything together’, ‘co-dependency’, and ‘doing normalcy’ as core to narratives of care. As we will argue, the accounts position the care undertaken by couples as at once shaped by day-to-day practices of drug use and by social situation, with the partnership enacting care as a form of social protection, including protection from stigma and other environmental hostilities. The intimacy of doing everything together offers insulation against stigma, yet also reproduces its isolating effects. While the care produced in drug-using partnerships is presented as double-edged, we note how interview accounts are used to deflect the charge that these relationships represent harmful co-dependency. Taken together, the interview accounts negotiate a ‘counter-care’ in relation to normalcy, presenting the intimate partnership between people who use drugs as a legitimate embodiment of care.

Background: While the health-related benefits of intimate partnership are well documented, little attention has been paid to couples exposed to high levels of social stigma and exclusion. In this project we investigated an important site of stigma for partnerships by collecting accounts of changing hepatitis C (HCV) status (“sero-change”) among couples that inject drugs. We explored what these accounts reveal about the meaning of HCV for these couples, and how this understanding contributes to our collective efforts at prevention and care. Methods: Drawing from a large dataset of qualitative interviews with couples, we focussed on those containing reports of sero-change. By adopting a methodology that positioned partnerships rather than individuals as the primary unit of analysis, we addressed the commonplace tendency to either overlook or discount as dysfunctional, the sexual relationships of people who inject drugs. Results: While some couples sought greater biomedical understanding as a means of coming to terms with sero-change, others drew on alternative logics or “rationalities” that sat firmly outside conventional biomedical discourse (privileging notions of kinship, for example). Regardless of which explanatory framework they drew on, participants ultimately prioritised the security of their relationship over the dangers of viral infection. Conclusions: Effectively engaging couples in HCV prevention and care requires acknowledging and working with the competing priorities and complex realities of such partnerships beyond simply the identification of viral risk. The “new era” of direct acting antiviral treatments will provide ongoing opportunities to learn to integrate biomedical information within more socially sophisticated, relationally aware approaches.

AIMS: Despite injecting-equipment sharing between sexual partners leaving them at increased risk of hepatitis C (HCV), there is scant literature available to guide harm reduction workers in their encounters with couples who inject drugs. This article explored workers' understandings of such couples and their accounts of working with them in relation to HCV prevention. METHOD: Semi-structured interviews were conducted with 22 staff of harm reduction services located in Sydney and Melbourne, Australia. RESULTS: Overall, staff represented couples as either absent from the service or as presenting with needs indiscernible from those of individual clients. Responses to questions about HCV and couples were framed primarily in terms of risk. Staff participants questioned 'genuineness' of clients' intimate relationships, instead characterising them as inauthentic and drug-driven. Working with couples was seen to present a number of organisational and clinical challenges. The benefits of recognising and working with such partnerships received scant acknowledgement. Rather, staff tended to perceive couples as being 'impenetrable' to health promotion messaging. DISCUSSION: The framing and delivery of harm reduction in Australia remains an individualising enterprise with little capacity to recognise the intimate partnerships, including addressing the HCV risks specific to them. More effective harm reduction strategies may be achieved by transitioning to a practice framework that addresses the social context of injecting, including the experience of couples. This would require direct involvement of couples who inject drugs.

Despite the majority of needle-syringe sharing occurring between sexual partners, the intimate partnerships of people who inject drugs have been largely overlooked as key sites of both hepatitis C virus prevention and transmission, and risk management more generally. Drawing on interviews with 34 couples living in inner-city Australia, this article focuses on participants' accounts of 'sharing'. While health promotion discourses and conventional epidemiology have tended to interpret the practice of sharing (like the absence of condom use) in terms of 'noncompliance', we are interested in participants' socially and relationally situated 'rationalities'. Focussing on participants' lived experiences of partnership, we endeavour to make sense of risk and safety as the participants themselves do.How did these couples engage with biomedical knowledge around hepatitis C virus and incorporate it into their everyday lives and practices? Revisiting and refashioning the concept of 'negotiated safety' from its origins in gay men's HIV prevention practice, we explore participants' risk and safety practices in relation to multiple and alternative framings, including those which resist or challenge mainstream epidemiological or health promotion positions. Participant accounts revealed the extent to which negotiating safety was a complex and at times contradictory process, involving the balancing or prioritising of multifarious, often competing, risks. We argue that our positioning of participants' partnerships as the primary unit of analysis represents a novel and instructive way of thinking about not only hepatitis C virus transmission and prevention, but the complexities and contradictions of risk production and its negotiation more broadly.

Aim: Peer support services have been shown to be beneficial in increasing uptake and adherence to treatment in other areas but few examples of these services exist in hepatitis C (HCV) care. This study examined the performance of two community-controlled peer support services operating within a larger study aimed at increasing access to HCV care and treatment for opiate substitution treatment (OST) clients, ETHOS. Methods: Semi-structured interviews were conducted in two clinics with three groups of participants: clients (n = 31), staff (n = 8) and peer workers (n = 3) and examined the operation of the service in relation to process, outputs and impacts. Results: There was a very strong positive response to the peer worker services reported by staff and clients who had and had not interacted with a peer worker. A number of changes were reported that were not explicit goals of the service including providing access to additional services for clients and staff, peer workers acting as mediators between clients and staff and a less tangible notion of a changing "feel" of the clinic to a more positive and client-friendly social and physical space. Explicit goals of the service were also reported in peer workers supporting clients to consider and prepare for treatment (via blood tests and other assessments) as well as provide information and support about treatment. Conclusions: The peer support service was acceptable to clients and clinic staff. All groups of participants noted that the service met its goals of engaging clients, building trusting relationships and providing instrumental support for clients to access HCV treatment. Peer workers may also contribute to more effective deployment of health resources by preparing clients for clinical engagement with HCV health workers.

Efforts to increase the number of people having hepatitis C virus (HCV) treatment require understanding how to best deliver services to meet consumers' needs. The general health literature has examined the role that partners can play in supporting health outcomes. This study examines the experiences of couples who inject drugs in relation to knowledge of, decisions about and management of HCV treatment. This is a qualitative interview study of people who inject drugs in couples. Participants were recruited from harm reduction services in two major Australian cities. Couples were interviewed separately. Data were examined using the couple as the unit of analysis and to identify patterns of experience related to the HCV serostatus of couples. Knowledge of HCV and HCV treatment was low and variable but showed some relationship to serostatus. Decisions about HCV treatment were deeply informed by concerns regarding treatment side effects. Positive concordant couples considered 'staging' treatment to ensure that each partner could (in turn) care for the other. People with HCV in serodiscordant relationships may need specific support regarding HCV treatment information. Within positive concordant partnerships, our data indicated the need to support the HCV-positive 'carer' during their partner's treatment. Changing treatment regimens, and their anticipated lower side effect profiles, will need to be actively promoted to ensure that couples understand how these changes affect their treatment options.

Rates of hepatitis C virus transmission among people who inject drugs in Australia remain high despite decades of prevention education. A key site of transmission is the sharing of injecting equipment within sexual partnerships. Responsibility for avoiding transmission has long been understood individually, as have the measures designed to help individuals fulfil this responsibility, such as the distribution of sterile injecting equipment. This individualising tendency has been criticised for placing an unfair level of responsibility on poorly resourced, marginalised people and ignoring the social nature of injecting drug use and related health care. Likewise, although research has demonstrated that injecting drug use is gendered, gender and sexual partnerships remain marginal to health promotion efforts. In this article, we address these weaknesses, drawing on a qualitative, interview-based project that explored equipment sharing within (hetero)sexual partnerships. In conducting our analysis, we explore a key theme that emerged in discussions about accessing and sharing injecting equipment, that of convenience, using critical marketing theory to understand this theme. In particular, we investigate the issues of convenience that affect the use of sterile injecting equipment, the many factors that shape convenience itself, and the aspects of equipment use that go beyond convenience and into the realm of intimacy and meaning. We conclude that injecting equipment needs to be both meaningful and convenient if sharing within partnerships is to be reduced further.

Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experie

Background: Internationally, there are ongoing efforts to increase access to hepatitis C (HCV) assessment and treatment to counter a generally low uptake of treatment among people with a history of injecting drug use. The aim of this qualitative study was to examine client and staff attitudes towards and experience of co-location of HCV and opioid substitution treatment (OST) services. Methods: In-depth interviews were conducted with 57 clients and 19 staff from four NSW clinics participating in the Australian ETHOS study. Results: Client and staff participants typically welcomed integrated treatment, citing issues of convenience, reduced travel time and costs, persistent cues to engagement and immediacy of access to care. Positive attitudes towards the initiative were expressed even by clients who had not engaged with HCV care. Providing co-located care largely avoided the negative, stigmatising or discriminatory experiences that participants reported encountering in settings less familiar with people who use drugs. A minority of client participants expressed concerns about the lack of privacy and/or confidentiality available in the co-located model, preferring to seek HCV care elsewhere. Conclusions: The co-location of HCV care in OST clinics was welcomed by the large majority of participants in this study. Besides issues of convenience, the appeal of the co-located service centred on the familiarity of existing relationships between clients and staff in the OST setting. While some clients remained distrustful of OST and chose not to take up HCV care in this setting, the co-located treatment model was overwhelmingly successful amongst both client and staff participants. © 2013 Elsevier Ireland Ltd.

This article widens the debate surrounding supervised injecting facilities (SIFs) by exploring an aspect of SIFs yet to be examined in the scholarly literature: the relationships created between staff and clients within these settings. By analyzing entries made in the Sydney Medically Supervised Injecting Centre’s (MSIC) client comment books we explore the centrality of emotional connection to clients’ experiences of the service. We argue that the everyday contact between staff and clients—including the “accidental intimacy” that develops when clients inject in the presence of staff —counters the sensations of shame identified by many in the comment books, creating new relations, and new performative possibilities for the production of self, belonging and citizenship for clients of the service. In exploring the role of emotions in the operation of the MSIC we also aim to highlight the political, policy, and clinical value of qualitative forms of inquiry for the harm reduction field.

A protection profile for high-robustness separation kernels has recently been validated and several implementations are under development. However, medium-robustness separation kernel development efforts have no protection profile, although the US Government has published guidance for authoring such a profile. As a step toward a protection profile, a set of security requirements for medium-robustness separation kernels is proposed. These requirements result from an informal, yet principled, approach. By bracketing the problem with appropriate reference points and elaborating a method for interpolating the requirements both a measure of uniformity and a basis for further discussion are achieved. Our reference points include the high robustness protection profile, the existing medium robustness consistency instruction, and our familiarity with the nuances of separation kernels. This practitioner-oriented study is intended to advance the prevailing practices for commercial software development, which presently falls far short of the rigor needed for either high-robustness or medium-robustness systems. These requirements represent an incremental improvement in the pursuit of secure software -- and is intended to be a step forward on the road to higher assurance., Presented at the Annual Computer Security Applications Conference (ACSAC), held in Miami Beach, FL, on 10-14 December 2007. Prepared in collaboration with Santa Clara University, Santa Clara, CA.

Contains fulltext : 57137.pdf (publisher's version ) (Closed access), BACKGROUND: Primary prevention of type 2 diabetes is now possible with lifestyle or pharmacological interventions in people who are at risk. Primary care would seem to be the legitimate setting for this to take place. AIM: To explore the views of general practitioners and practice nurses about the detection and management of people at risk of developing type 2 diabetes. DESIGN OF STUDY: Qualitative study. SETTING: One local health board area in Wales. METHOD: General practitioners and practice nurses participated in multi-professional focus groups, and opinions of participants were analysed into themes and sub-themes according to focus group content analysis methodology to search for 'markers of text'. RESULTS: Participants from 21 practices were involved. Participants' opinions on the detection and management of individuals at risk of developing type 2 diabetes were polarised into those who considered these activities inappropriate for primary care and those who were already engaged in the detection, management and follow-up of these individuals. For the former, existing workload, the questionable role of primary care as a 'screening service', lack of resources, and conflict and concern about increasing specialisation were given as justification. Those already engaged in these activities emphasised their importance but were also concerned with the lack of available resources. Other concerns were the perceived low motivation of patients to modify their lifestyle and the unnecessary medicalisation of the precursor conditions of impaired glucose tolerance and impaired fasting glycaemia. The prevention of type 2 diabetes was seen as largely the responsibility of other agencies such as health promotion and education. CONCLUSION: The often strongly held views about this topic are at least partly influenced by current pressures on primary care. To make the primary prevention of type 2 diabetes a reality, either practitioners need to be motivated and resourced to carry out