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Social structural factors that shape assisted injecting practices among injection drug users in Vancouver,… Fairbairn, Nadia; Small, Will; Borek, Natasha V; Wood, Evan; Kerr, Thomas Aug 31, 2010

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RESEARCH Open AccessSocial structural factors that shape assistedinjecting practices among injection drug usersin Vancouver, Canada: a qualitative studyNadia Fairbairn1, Will Small1, Natasha Van Borek1, Evan Wood1,2, Thomas Kerr1,2*AbstractBackground: Injection drug users (IDU) commonly seek manual assistance with illicit drug injections, a practiceknown to be associated with various health-related harms. We investigated the social structural factors that shaperisks related to assisted injection and the harms that may result.Methods: Twenty semi-structured qualitative interviews were conducted with IDU enrolled in the ACCESS orVancouver Injection Drug Users Study (VIDUS) who reported requiring assistance injecting in the past six months.Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted.Results: Barriers to self-injecting included a lack of knowledge of proper injecting technique, a loss of accessibleveins, and drug withdrawal. The exchange of money or drugs for assistance with injecting was common. Harmsexperienced by IDU requiring assistance injecting included theft of the drug, missed injections, overdose, and riskof blood-borne disease transmission. Increased vulnerability to HIV/HCV infection within the context of intimaterelationships was represented in participant narratives. IDU identified a lack of services available for those whorequire assistance injecting, with notable mention of restricted use of Vancouver’s supervised injection facility.Conclusions: This study documents numerous severe harms that arise from assisted injecting. Social structuralfactors that shape the risks related to assisted injection in the Vancouver context included intimate partnerrelations and social conventions requiring an exchange of goods for provision of injecting assistance. Healthservices for IDU who need help injecting should include targeted interventions, and supervised injection facilitiesshould attempt to accommodate individuals who require assistance with injecting.IntroductionThe injection of illicit drugs is a growing public healthconcern internationally, and human immunodeficiencyvirus (HIV) transmission among injection drug users(IDU) represents a significant factor driving the globalHIV epidemic. There are an estimated 16 million indivi-duals who inject illicit drugs worldwide and 3 millioninjectors living with HIV [1]. Even in settings where acomprehensive public health response to injection druguse has been implemented, including needle exchangeand health outreach programs, IDU continue to beexposed to a range of drug-related harms [2,3].Recent studies have demonstrated that, even when ster-ile needles are accessible, individual characteristics andsocial structural factors may make IDU vulnerable to syr-inge sharing and subsequent HIV infection [2,4]. Rhodes’risk environment framework has identified a host of fac-tors beyond the individual level that shape drug injectingpractices and has illustrated how social context influ-ences the production of injection-related HIV risks [5].Social structural factors that may compromise individualability to employ HIV prevention strategies among IDUinclude the influence of extended peer networks [6], aswell as prevailing social norms among local populationsof IDU [7]. Situated cultural norms have been shown tobe particularly significant in shaping local and context-specific drug use risk practices, including routes ofadministration and"rituals” of use including drug pro-curement, exchange, and sharing [8]. Ethnographic* Correspondence: uhri@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,University of British Columbia, 608-1081 Burrard Street, Vancouver, B.C., V6Z1Y6, CanadaFull list of author information is available at the end of the articleFairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20© 2010 Fairbairn et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.research has highlighted the importance of the “culturallogics” of the street economy [9,10], as well as the gen-dered dynamics that often surround the injection process[11,12], as contextual factors that compromise individualability to enact risk reduction strategies.Previous work has indicated that a substantial propor-tion of IDU in various settings internationally receivemanual assistance with injections [13,14]. The role of‘hit doctor’ (i.e., someone who provides assistance withinjections) was first described by Murphy (1991) whoobserved that experienced injectors working in shootinggalleries in the San Francisco Bay area often providedassistance with injecting in exchange for money [15]. InVancouver, Canada, a city with high rates of injectiondrug use and HIV among IDU, nearly half of local IDUhave reported receiving assistance with injecting in theprevious six month period [16]. In this setting, receivingassistance with injecting has been identified as a strongindependent predictor of syringe sharing and HIV sero-conversion, with IDU who report this behaviour beingtwice as likely to acquire HIV in comparison to IDUwho do not require assistance injecting [16,17]. Assistedinjection has also been associated with non-fatal over-dose among IDU in Vancouver [18].Given that assisted injection is a highly prevalent prac-tice known to be associated with severe health complica-tions in our setting, including HIV infection and overdose,we conducted a qualitative study to explore the circum-stances and social conventions surrounding assisted injec-tion. We sought to pay particular attention to individualfactors as well as the broader contextual forces that shapethe experience and harms of assisted injection.MethodsThis article presents analyses of data from qualitativeinterviews with Vancouver IDU who require assistanceinjecting. One-to-one in-depth interviews were con-ducted to explore the following topics: 1) injection-related knowledge and practices; 2) experiences ofassisted injection; 3) the broader context of assistedinjection, and 4) harmful experiences resulting fromassisted injection.We draw upon data from 20 in-depth qualitativeinterviews conducted during June and July, 2007. Inter-viewees were recruited from two cohort studies in Van-couver: the Vancouver Injection Drug Users Study(VIDUS), which is composed of over 1000 HIV negativeIDU; and ACCESS, which is composed of over 500HIV-positive IDU. Database markers were used to iden-tify participants from these cohorts who reported receiv-ing assistance with injecting. Given the largerepresentation of female IDU requiring assistance inject-ing in our setting [13,17], attempts were made to recruitfemale IDU for the present study.Interviews were undertaken by three different trainedinterviewers (Fairbairn, Van Borek, and Small) andfacilitated through the use of a topic guide encouragingdiscussion of assisted injection. Interviews lastedbetween 30 and 60 minutes, were tape-recorded, andwere later transcribed verbatim. The research team dis-cussed the content of the interview data throughout thedata collection process, thus informing the focus anddirection of subsequent interviews as well as developinga coding scheme for partitioning the data categorically.The content of transcribed interviews was cataloguedusing a coding framework specific to assisted injectionand our analysis explores themes that emerged through-out the interviews. Two members of the research team(Fairbairn and Borek) separately catalogued the tran-scribed interview data using a coding framework, thusallowing for discussion of areas of agreement andinstances of divergence.All participants in the qualitative study providedinformed consent to participate, and the study wasundertaken with appropriate ethical approval granted bythe Providence Health Care/University of British Colum-bia Research Ethics Board. There were no refusals of theoffer to participate in the interview and no dropoutsduring the interview process. All interviewees receivedCDN$20 for their participation.ResultsThe study sample consisted of 20 participants, (7 maleand 13 female) who ranged in age from 24 years to51 years (median age = 40). Participant accountsdescribed the potential barriers to self-injection, namelylack of knowledge of injection techniques or difficultyaccessing veins due to long-term injecting. Social andstructural factors that shape risk among IDU whorequire assistance with injecting were described by parti-cipants, including intimate partner relationships as wellas the drug scene role of ‘hit doctors’ that require anexchange of goods for the provision of assistance inject-ing. Numerous harmful experiences that can result fromassisted injection, namely increased risk for overdoseand infectious disease transmission, were represented inparticipant narratives. One significant barrier to acces-sing care and support described by participants whorequire assistance with injecting was the rule prohibitingassisted injection at Vancouver’s supervised injectionfacility (SIF).1. Injection-Related Knowledge and Practicesa. Reasons for Requiring Assistance with InjectingThe accounts of interview participants indicate that sev-eral barriers prohibit individuals from being able to self-inject. Several participants described requiring assistancewith injections because they lacked the injection-relatedFairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20Page 2 of 7knowledge necessary to self-inject, particularly at thetime of their first injection.I was thirteen years old and I was running awayfrom a group home. And my best friend, we werewatching her cousin,... and taking license plates, forwhen she was working on the street. So at the end ofthe night, we go back to her hotel room and shewould shoot us some coke, for taking license platesand that... So she would fix herself and then shewould fix me. (Female Participant #19)Individuals described a loss of accessible veins, due tolong-term injecting, as another key barrier to self-injection.Well, it’s veins, I have no veins. It’s all collapsed, orcalloused.... So there are times I can, every once inawhile a vein will pop up, and then I can use it for afew times, and then it will go back down.... If I can’tget it in two or three times, there’s somebody I know,you know he can get me in the arm or in my neck.(Male Participant #6)Several participants described requiring assistanceinjecting due to collapsed veins and choosing to “jug”(inject in the jugular vein) in these instances.I: You do mostly your own injections?R: Ah, actually my boyfriend does it now, becausesometimes I’m having a hard time with my armsnow, because of all the injecting I did. Having to finda vein, he jugs me now {.....} Yeah, I can’t find, likeyou know just can’t find any veins sometimes, so he’llgo in the neck for me, or I go myself in the neck.(Female Participant #2)Some participants required assistance with injectingon occasion while experiencing symptoms of shakinessor feelings of anxiety, such as during instances of drugwithdrawal.Well I’m just being, I’m just being really anxiouslately. I don’t always need help, but I just want tohave that hit. I want to have it... I don’t want to fuckaround anymore, my veins are pissing me off.(Female Participant #9)One participant described his inability to self-injectdue to a physical disability that prohibited him fromusing one of his arms.My brother, my best friend, usually ties me off anddoes it because I have a disability... I can’t because ofthe handicap. (Male Participant #14)Within the context of intimate partner relationships,several female participants described assisted injectionas a way to demonstrate trust and intimacy in additionto a form of needed assistance owing to a lack of injec-tion-related knowledge or technique.Yeah my partners have all you know... they fixedright. And usually they... it’s a trust thing again.Kind of the more you know a person, then theyknow your body, how your veins are and stuff right.So it just works better that way it seems right, youknow. Yeah, yeah and having that bond is also spe-cial too, which is cool. You know like you care,right, you don’t want to hurt them, you don’t wantthem to get hurt you know?{.....} Yeah, but usually,it’s, my boyfriend will do both of us or whatever,yeah.{....}If he’s a little sick, he might do himself firstor whatever. But usually, I go first. (Female Partici-pant #16)I: The only person you ever had jug you was yourhusband?R: Yeah, and then I’d do it for him.I: He also had trouble with his veins?R: Ah no, it was just that it was easier for me to do itfor him, because I was already high, and he wantedto be high at the same time as me, so he’d fill it out,and I’d get high, and do him right away. (FemaleParticipant #10);b. Exchange for Assisted Injection ServicesParticipants described the provision of assisted injectionservices as a well-established role within the street econ-omy that typically involves an exchange of money ordrugs.R: If they’re going to fix me with a ten paper ofpowder, I’d shoot them five bucks.I: Okay and always you give something?R: Always... It’s kind of like a cardinal rule downhere. (Female Participant #19)The amount of money or drugs exchanged for helpwith an injection varied and was negotiated betweenindividuals. One participant described a willingness topay more money when feeling a greater sense ofurgency to use drugs.He likes his rock. I’ll give him the money to go buy it,or I’ll just give it to him. I mean, he doesn’t ask forit... If I want to get high real bad, it’s worth a lot {....}once I get it in me, and I get the rush, it’s worth amillion dollars. (Male Participant #6)Participants described the harms that can arise when‘hit doctors’ have material incentive to help someoneFairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20Page 3 of 7inject and may lack concern for preserving the safety ofthe individual they are injecting.It’s [assisted injection] pretty risky, because you reallydon’t know, they could be bullshitting you right?Because just to make that extra dollar or whatever....(Female Participant #4)Because of this risk, participants emphasized theimportance of having a trusting interpersonal relation-ship with a ‘hit doctor’.I’ve had people that like, ok, like, last night, I said"MI need your help.” He goes"What’s in it for me?” Isaid” Absolutely nothing” until today and then I gethim back. But a lot of times, they see if they’re beingpaid for it {....} But anyways last night... I wassaying,"I need you, and I know you can do this, buthow are you feeling"? He’s got bad eyesight, and hecan’t buy glasses but I trust him, the trust factor isfirst. And then it’s the physical, could he do it andsee it? (Female Participant #9)2. Harmful Experiences Due to Assisted InjectionParticipants identified several potential harmful out-comes that can arise from relinquishing control over theinjection process. These included missed injections andconsequent health problems, robbery, infectious diseasetransmission, and overdose.a. Missing the InjectionA variety of health complications including abscess for-mation and other forms of infection can result frommissed injections. The most harmful complications ofmissed injections described by participants involvedjugular injection, where the carotid artery, jugular vein,trachea, and recurrent laryngeal nerve are in close proxi-mity to the point of the syringe [19].Yeah, missing my shot in the neck. That was thescariest part, it was like a sharp pain right up to myhead, and I was numb on this side for the longesttime. {....} He just missed me, and I don’t know, musthave hit a, I don’t know, he hit something.... I gotscared, like I thought I was going to be gone or some-thing, you know. (Female Participant #4)The worst experience I had was before I got the abscessat the back of my throat, when somebody was juggingme, and somebody kicked the fucking, kicked me whileI was getting jugged.{....} And then so two days later,an abscess formed in the back of my throat, right here.{....} and I almost died... because it formed so fast, andso quickly. {...} and it was starting to block my swal-lowing, and my breathing. (Female Participant #9)b. HIV/HCV TransmissionHaving one’s syringe unknowingly exchanged (by theperson providing assistance with injecting) for anothercontaining only water was reported by numerous parti-cipants. In addition to theft of the drug, concern wasexpressed about receiving an injection with a syringe ofunknown origin.Actually it was my boyfriend too. When he was aheroin addict he was really bad. [...] Yeah he, I askedhim to fix me, like I had heroin for sale, and he washolding my dope for me, and I asked him to fix meup one, {....} and there I could see him shaking some-thing, he was putting water in it {....} I busted himright, he was going to switch me. Yeah. And he gotreally mad and threw my rig, and threw my dopeacross the street because I busted him. He was goingto gypsy switch [swap rigs for one filled with water]me. (Female Participant #4)Many IDU described relying on a ‘hit doctor’ to pro-vide injection equipment in addition to administeringthe injection, resulting in vulnerability to HIV and otherinfectious diseases.I: Is there anything else that you worry about whenyou’re going to have someone else fix you?R: Well not just about them switching rigs, but youdon’t know if the rig that they’re giving you has HIVin it or not. {....} Well, yeah, like two weeks ago Ifixed with a rig that had blood in it just because Iwas that dopesick. (Female Participant #19)Syringe sharing between intimate partners who pro-vide assistance injecting one another was a potentialroute of infectious disease transmission described byseveral participants.R: When I first started fixing heroin. Yeah my boy-friend would jug me and that...., we had this big can-ister. We’d just throw our used rigs in there andusually when we’d wake up, if we were dopesick, wewould just grab any rig out of the container.I: Okay and so, would you usually get injected first?R: No, he would do himself first and then me.(Female Participant #19)When I had a boyfriend he used to inject me, but heused to do bad things though, change the needlesand stuff... especially in my neck, he’d just push it in,in my neck went like this, you know, but he’dswitched the rig... I got Hepatitis C from him, ‘causehe gave me his bloody fix one time, that’s how I gotHep C. (Female Participant #5)Fairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20Page 4 of 7c. OverdoseAccidental overdose was commonly reported. Severalparticipants described incidents that involved miscom-munication over the amount of drug to be injectedwhich lead to overdose.I used to throw the whole half a gram in the spoonright, but I mixed up rigs, different rigs for eachamount, like 20 units in each one. I threw a half inthere, and I turned my back, this other guy threw a¼ gram in there and I didn’t know about it... Boom,he fixed me, I got half way and I told him to stop,stop. I said,"No, no, don’t do that”. He was going onand on and he said,"It’s okay, I’m almost there”. Isaid,"No, no wait a minute”. And boom, he pushed itin. I started vibrating, I was feeling like, Holy Shit.And I’m going"Oooh”. Like I’m really starting to spinand everything. He’s going,"are you okay”. I said,"I’mokay, just don’t touch me”. He said,"No, no you needto get up and walk”. And he grabbed me by the armand pulled me up. I took two steps, and everythingwent white. (Male Participant #3)This one girl she didn’t tell me not to push it all in..... So I smashed it all in and right after, before Ipulled the needle out, she goes"You weren’t supposedto put it all in” and then just, she just turned intolike a robot. She was like, she started running,blindly, running into telephone poles, running intowalls, into everything and just, holy smokes, Icouldn’t believe what was going on. (Female Partici-pant #19)3. Barriers to Injecting at the SIFA number of participants described the rule prohibitingassisted injection at Vancouver’s SIF as a barrier toengaging in safe injecting practices. The SIF is a placewhere IDU can inject pre-obtained illegal drugs underthe supervision of nurses trained to provide an emer-gency response in the event of overdose. Presently, onlyverbal direction and limited manual assistance (exclud-ing the act of injecting) is permissible from staff. Someparticipants noted that this assistance enabled them toadminister their own injection, while others were stillunable to self-administer their injection. Many of theseindividuals reported that they had to then leave thefacility to find another IDU in the nearby alleys to assistwith the injection.I: Have there ever been times when you’ve needed toget some help with an injection, and you couldn’tfind somebody to help you out?R: Yeah. I had to really take my time to, I had to getInsite to help me, to direct me, because I couldn’tfind nobody else that was safe. {....} Yeah, I had to doit myself and eventually, I got it. {....} They just direc-ted me, like you know, like telling me... which way togo. {...} Yeah, they talked me through it.I: Have you ever gone in there to fix, and then notbeen able to get it done yourself?R: Yeah, I have. Go outside and see somebody thereto jug me, yeah, that has happened. (Male Partici-pant #2)R: Like actually last night, it was so weird, I go,‘Well, I’m going to go inject, and then come back inhere [InSite]’. It’s because I hadn’t been able to injectmyself properly, and so I needed somebody to jug meand you can’t get any assistance at all and some-times I just can’t take the time out with myself,I can’t be with myself enough to actually inject myselfproperly and fast. Like ‘cause I want to get it in metoo fast, I get too anxious, ‘get in’. And now, that’swhy I end up with shit like this [injection-relatedinfection] on my arm, right? (Female Participant #4)Some individuals reported that they would not use theSIF because of the rule prohibiting assisted injection.I: What about that rule at INSITE where you can’tget help with an injection?R: That’s the reason why I won’t go there. I think thatsucks. That, it’s not good, it’s, they should do some-thing about something like that. ‘Cause what hap-pens if I want to go in there, and need help andnobody will help me? Well what’s this place here forthen? (Male Participant #5)DiscussionWe identified a range of individual, social, and structuralfactors that shape the context of risk associated withassisted injection. The perspectives of participants in thepresent study highlight several barriers to self-injection,including lack of injection-related knowledge and tech-nique, inability to access veins due to long-term inject-ing and physical disability. We documented a variety ofharms that can result from relinquishing control overthe injection process and identified various social factorsthat shape these harms, including intimate partner rela-tions and social conventions requiring an exchange ofgoods for provision of injecting assistance. The rule pro-hibiting assisted injection at Vancouver’s SIF was identi-fied as a structural barrier to receiving injection-relatedinstruction and support.Participant accounts detailing assisted injections high-light the difficulty in ensuring that a syringe is sterilewhen obtaining assistance with injecting, and may helpshed light on previous work that has found the charac-teristic of requiring assistance with injecting to be anFairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20Page 5 of 7independent predictor of HIV seroconversion [17]. Sev-eral participants in the present analysis described bor-rowing syringes and injection equipment from the ‘hitdoctor’ when receiving assistance with injecting. Thesedescriptions may help explain findings from previousresearch indicating that requiring help injecting is inde-pendently associated with reporting borrowing a usedsyringe and providing assistance injecting (e.g., being a‘hit doctor’) is independently associated with lendingone’s own syringe [13,19]. Switching of syringes by the‘hit doctor’ in order to steal drugs was commonlyreported, and represents one important route by whichHIV transmission may occur for individuals who receiveassistance with injecting. Additionally, the finding thatmiscommunication and confusion surrounding thequantity of drugs administered may occur duringassisted injections helps shed light on the previous epi-demiological findings indicating that this practice is alsoassociated with non-fatal overdose.Narratives from several female participants portrayedassisted injection as an opportunity to share in theinjecting process and drug high, thereby fostering anincreased sense of trust and intimacy. Assisted injectionas a symbolic act in the context of intimate relationshipsmay therefore represent an important point of intersec-tion of sexual and injecting dynamics, comprising a"dualrisk” for HIV acquisition [20]. Previous qualitative workhas investigated the gendered dynamics surroundingassisted injection by documenting women’s experiencesof theft and violence, including experiences of abusefrom intimate partners when being injected with illicitdrugs [12,21]. Though no such accounts were documen-ted in our study, the gendered dynamics of assistedinjection begs further exploration given that women aretwice as likely as men to report requiring assistancewith injecting in our setting [13,17].IDU who require assistance with injecting unani-mously reported an exchange of money or drugs inreturn for the provision of injecting assistance. Thisexchange of resources situates assisted injection serviceswithin the street economy and introduces the possibilityof harm in instances where ‘hit doctors’ provide assis-tance with injecting purely for lucrative benefit [14,15].This exchange-for-service dynamic may further exacer-bate harms for IDU who require assistance with inject-ing by increasing the likelihood of violence resultingfrom disputes over compensation given the lack of anauthority to resolve such disputes.Vancouver’s drug policy response to the ongoing HIVepidemic has involved the implementation of numerousharm reduction strategies including needle exchangeprograms, a heroin maintenance trial, and a SIF [22].A current limitation of many SIFs, including the one inVancouver, is that operational guidelines prohibitassisted injections on the premises due to concerns overcivil liability should assisted injections be permittedwithin SIFs [23,24]. However, given the significant bar-riers to accessing care and the increased risk of HIVinfection for individuals who require assistance withinjecting, we recommend reconsideration of this policy.Indeed, a previous study of an unsanctioned drug-user-run SIF documented the successful implementation ofan assisted injection policy, which resulted in many indi-viduals developing the competency to self-inject [25].The present study has several limitations that warrantacknowledgement. Firstly, our findings are based uponinterviews with local IDU participating in the currentstudy. While an effort was made to ensure that thestudy sample reflects the demographics of the localdrug-using population who require assistance injecting,some perspectives may nonetheless be underrepresented.Secondly, as injection drug use is a highly stigmatizedbehaviour, it is possible that social desirability biasaffected the responses of some participants. Thirdly, thedata collected and analyzed here presents only the view-points of IDU; the results of this analysis should becompared with the findings of ethnographic researchutilizing participant-observation within the SIF.In summary, we found that barriers to self-injectingincluded a lack of knowledge of injection practices,symptoms of anxiety or withdrawal, or a loss of accessi-ble veins. Our qualitative data indicate that numerousharms can result from the practice of assisted injection,notably increased risk for infectious disease transmissionand overdose. Some women reported a preference tohave a partner inject in order to develop trust and inti-macy, underscoring the importance of considering socialand contextual factors when examining infectious dis-ease transmission among IDU. Participants identifiedthe rule against assisted injection at the SIF to be a sig-nificant barrier to accessing health care, and thereforethis policy should be re-evaluated.AcknowledgementsWe would particularly like to thank the VIDUS and ACCESS participants fortheir willingness to be included in the study, as well as current and pastVIDUS and ACCESS investigators and staff. We would specifically like tothank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Kain, andCalvin Lai for their research and administrative assistance. The authors alsowish to thank the staff of Insite, the Portland Hotel Society, VancouverCoastal Health (Chris Buchner, David Marsh, and Heather Hay). This studywas supported by Canadian Institutes of Health Research (CIHR) grants MOP-81171 and RAA-79918. Will Small is supported a Michael Smith Foundationfor Health Research (MSFHR) Senior Graduate Studentship and a CIHRDoctoral Research Award. Thomas Kerr is supported by the Michael SmithFoundation for Health Research and the Canadian Institutes of HealthResearch.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,University of British Columbia, 608-1081 Burrard Street, Vancouver, B.C., V6ZFairbairn et al. Harm Reduction Journal 2010, 7:20http://www.harmreductionjournal.com/content/7/1/20Page 6 of 71Y6, Canada. 2Department of Medicine, University of British Columbia, 10203-2775 Laurel Street, Vancouver, B.C., V5Z 1M3, Canada.Authors’ contributionsNF and TK were responsible for the study design and prepared the first draftof the analysis. NVB, WS, and EW assisted with the main content andprovided critical comments on the final draft. All of the authors approvedthe final version submitted for publication.Competing interestsThe authors declare that they have no competing interests.Received: 20 August 2009 Accepted: 31 August 2010Published: 31 August 2010References1. 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