Publications by authors named "Joanne Bryant"

45 Publications

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex.

Int J Drug Policy 2021 Mar 25;94:103229. Epub 2021 Mar 25.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia.

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.
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http://dx.doi.org/10.1016/j.drugpo.2021.103229DOI Listing
March 2021

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex.

Int J Drug Policy 2021 Feb 15;93:103163. Epub 2021 Feb 15.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2054, Australia.

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.
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http://dx.doi.org/10.1016/j.drugpo.2021.103163DOI Listing
February 2021

Sexual risk-taking among homeless young people in Pakistan.

Health Soc Care Community 2020 Nov 10. Epub 2020 Nov 10.

Centre for Social Research in Health, The University of New South Wales, Sydney, Australia.

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.
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http://dx.doi.org/10.1111/hsc.13220DOI Listing
November 2020

Understanding 'risk' in families living with mixed blood-borne viral infection status: The doing and undoing of 'difference'.

Health (London) 2020 Aug 1:1363459320946469. Epub 2020 Aug 1.

Centre for Social Research in Health, UNSW, Australia.

'Risk' has long been at the centre of expert and popular perceptions of transmissible and stigmatised blood-borne viral infections, such as HIV and viral hepatitis. There is a substantial body of research on transmission risk among couples with mixed viral infection status (serodiscordance). But we know very little about how families affected by HIV and viral hepatitis engage with understandings of infectiousness and how these shape family relationships in different ways. Guided by cultural theories of risk that build on Mary Douglas' work, we draw on qualitative interviews to explore the 'performativity' of risk in serodiscordant families in Australia. We show how the 'doing' of risk could be constitutive of difference, which unsettled the family connection or deepened existing fault lines. Conversely, the 'undoing' of risk enabled the preservation of the family bond by rejecting difference and reframing risk as an external threat to the family in the form of stigma. We conclude that risk in the context of serodiscordant families had relational implications far beyond viral transmission and consider what our findings might mean for service provision and health promotion campaigns related to blood-borne viruses.
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http://dx.doi.org/10.1177/1363459320946469DOI Listing
August 2020

Destabilising the 'problem' of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men's crystal methamphetamine use.

Int J Drug Policy 2020 04 14;78:102697. Epub 2020 Feb 14.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2054, Australia.

In Australia, the crystalline form of methamphetamine ("crystal") is a commonly used illicit substance associated with sexual activity among gay and bisexual men. Attention to psychoactive substance use among this population is the subject of increasing global concern regarding the intentional and simultaneous combination of sex and drugs, often referred to as "chemsex". While not all gay and bisexual men who use psychoactive substances report problematic use, those who do often become representative of chemsex practices more generally, and the harms they experience become attributable to all men who use drugs for sex. The way in which these practices have been framed over the past few decades contributes to the rise of a narrow set of understandings of chemsex defined by the circumstances and behaviours presumed of drug-enhanced sexual activity. In effect, these understandings now align recognisable combinations of sexual and drug-using practices with assumed correlates of risk. The Crystal, Pleasures and Sex between Men study conducted 88 interviews with gay and bisexual men in four Australian cities between 2017 and 2018. Findings from the project revealed that men used crystal in a variety of settings and relations, which mediated their sexual practices and patterns of use. In looking at the wider context in which practices were associated with the combination of sex and drugs, we identified experiences that the contemporary discourse of chemsex-in its rhetorical proposition of at-risk behaviours and circumstances-may leave out of consideration. Our findings indicate that researchers should remain open to the variability and contingency of settings, relations and practices in gay and bisexual men's different networks when recommending public health responses to their engagement in drug-enhanced sexual activity. Accordingly, we seek to destabilise the definition of chemsex that precludes consideration of the influence of experiences beyond pre-determined risk parameters.
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http://dx.doi.org/10.1016/j.drugpo.2020.102697DOI Listing
April 2020

The embodied relationality of blood-borne viruses: How families matter in the context of a stigmatised viral infection.

Soc Sci Med 2019 12 22;243:112620. Epub 2019 Oct 22.

Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia. Electronic address:

This paper argues that blood-borne viruses are relationally embodied, providing an alternative ontology to the individualising tendencies in medical science, and a more inclusive analysis of serodiscordance (mixed infection status) than the literature's focus on transmission risk in couples. We know little about the wider world of significant relationships in the lives of those with blood-borne viruses. People with HIV and hepatitis C are in a mixed-status relationship not just with intimate partners, but with other family members too. Drawing on qualitative interviews and phenomenological theory, we make the case that families (broadly defined) matter in the context of stigmatised, transmissible infections in ways that extend beyond individual bodies and beyond the usual preoccupation with risk. Despite recent advances in the treatment of blood-borne viruses, our study shows that these infections continue to be experienced and negotiated through embodied connections to significant others, made meaningful through culturally situated understandings and expectations regarding kinship, affinity, love, shared history and obligations. Our findings encourage broader recognition of these viral infections as intercorporeal phenomena, with families intimately entangled in co-creating the meanings and experiences of disease.
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http://dx.doi.org/10.1016/j.socscimed.2019.112620DOI Listing
December 2019

Care, agency and criminality: Making sense of authorised extended distribution in the accounts of key stakeholders.

Int J Drug Policy 2019 09 18;71:56-61. Epub 2019 Jun 18.

New South Wales Users and AIDS Association (NUAA), 345 Crown St, Surry Hills, NSW, 2010, Australia.

Introduction: One of the current harm reduction debates in Australia concerns the legalisation of the extended distribution of sterile needles and syringes, a practice that is currently unlawful in most Australian settings.

Methods: We used data from a unique pilot program of authorised extended distribution to document the opinions held by 22 key stakeholders -service staff, drug users and police - about the risks and benefits of authorisation, and to analyse the ways in which drug users were understood within these.

Results: Opinions were strongly in favour of authorising extended distribution, based on the belief that this would reduce the transmission of hepatitis C. However, stakeholders also identified that distributors risked attention from police and some noted that the consequences of this would be borne by distributors themselves and not the services that support them. These opinions rested on specific assumptions about people who inject, some of which reflect negative constructions of drug users as a source of danger to the public or as helpless 'addicts' with little control over their risk reduction. But there were other representations that positioned drug users more positively as responsible agents with a strong duty of care to themselves and others whose choices are often limited by inadequate service structures. Staff participants drew on these understandings in careful and strategic ways, arguing for the rationality and expertise of drug users, while also problematizing the individualised approach that any form of authorised extended distribution might take.

Conclusion: We argue that localised and incremental changes such as those that took place to support this pilot project, and the extensive support for extended distribution among stakeholders in this study including police, creates meaningful opportunities to think about extended distribution differently, which can in turn support conditions for future discussions about legislative change.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.008DOI Listing
September 2019

Making sense of 'side effects': Counterpublic health in the era of direct-acting antivirals.

Int J Drug Policy 2019 10 17;72:77-83. Epub 2019 Jun 17.

Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia. Electronic address:

Direct-Acting Antiviral (DAA) treatments for hepatitis C have been widely promoted by health promotion professionals and medical clinicians as being 'side-effect free'. In this paper, we draw on data that troubles this approach. We used a mixed method design to collect data from people who inject drugs, and who were DAA treatment naïve, in New South Wales, Australia. We describe knowledge about and perceptions of DAA treatment. We found that concerns about side effects were commonplace - for example, one-third (37%) of participants who had not taken up treatment worried "a lot" about 'side effects' - and that these concerns were underpinned by a general distrust and suspicion of medical institutions and their technologies, including widespread negative associations linked to interferon treatment. In trying to make sense of this, we draw on the concept of counterpublic health and its recognition that the everyday health needs, knowledges and aspirations of subordinated citizens frequently contradict the normative frameworks governing public health interventions. We suggest that failing to engage with concerns about 'side effects' could hinder elimination efforts. Our analysis suggests that addressing the issue of 'side effects' within the 'public' discourse of DAAs will not dampen or damage elimination efforts, as some might fear, but rather it will legitimate the concerns of people who inject, decrease their suspicion of medical interventions, and better support the uptake of DAA treatments.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.002DOI Listing
October 2019

Patterns of Peer Distribution of Injecting Equipment at an Authorized Distribution Site in Sydney, Australia.

Subst Use Misuse 2018 12 11;53(14):2405-2412. Epub 2018 Jun 11.

b New South Wales Users and AIDS Association (NUAA) , Surry Hills , NSW , Australia.

Background: Extended distribution refers to the practice whereby people who inject drugs pass on sterile injecting equipment to their networks and can be a means to access people who inject drugs who do not attend state-sanctioned needle and syringe programs. While it is legal, to possess a sterile syringe for the purpose of injecting drugs in New South Wales, Australia, it is a criminal offence to pass this equipment on for others to use. In 2013 a pilot project was established to trial the authorization of "extended" peer distribution. This research describes patterns of distribution among attendees participating in this trial.

Methods: A cross-sectional survey was conducted during one week in October 2014 of the trial with 200 clients. The survey focused on the extent, characteristics, and perceived risks and benefits of extended distribution practices within peer groups.

Results: Extended distribution is widespread, not in an organized or intentional manner but as a consequence of day-to-day drug using activities. The profiles of those who do and do not distribute were similar. Willingness to distribute small quantities of equipment to others was higher than willingness to distribute larger quantities, and willingness to distribute was related to perceived benefits of extended distribution. Police scrutiny was a key reason for not wanting to distribute.

Conclusion: Extended peer distribution is widespread though mostly not organized. This study supports the evidence that drug users act responsibly to prevent harm and promote the use of sterile equipment among their peers.
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http://dx.doi.org/10.1080/10826084.2018.1480039DOI Listing
December 2018

The rush to risk when interrogating the relationship between methamphetamine use and sexual practice among gay and bisexual men.

Int J Drug Policy 2018 05 24;55:242-248. Epub 2017 Dec 24.

Centre for Social Research in Health University of New South Wales, Sydney, NSW 2052, Australia. Electronic address:

Much research concerning drug use in the context of sexual activity among gay and bisexual men derives from public health scholarship. In this paper, we critically examine how the relationship between methamphetamine use and sexual risk practice is treated and understood in this body of research. While public health has made important contributions to establishing the link between methamphetamine use and sexual risk-taking, the precise nature of the relationship is not well defined. This creates space for ungrounded assumptions about methamphetamine use to take hold. We outline what appear to be two dominant interpretations of the methamphetamine/sexual practice relationship: the first proposes that methamphetamine has specific pharmacological properties which lead to sexual disinhibition, risky behaviour and poor health outcomes; the second proposes that methamphetamine attracts men who are already inclined toward highly sexualised interactions and risky practice, and that such men are likely to engage in these practices with or without drugs. We suggest that both interpretations are problematic in that they individualise and cast drug and sex practices as inherently risky and biopsychologically determined. We outline a more historically, socially and politically engaged way to understand methamphetamine use in the context of sexual activity by drawing on the concept of sex-based sociality and the ways in which gay and bisexual men may use methamphetamine and sex as social resources around which to build identities, establish relationships, participate in gay communities, and maximise pleasure while protecting themselves and others from harm.
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http://dx.doi.org/10.1016/j.drugpo.2017.12.010DOI Listing
May 2018

Families Living with Blood-Borne Viruses: The Case for Extending the Concept of "Serodiscordance".

Interdiscip Perspect Infect Dis 2017 18;2017:4352783. Epub 2017 Oct 18.

Social Policy Research Centre, Goodsell Building, Level 3, UNSW, Sydney, NSW 2052, Australia.

The concept of "serodiscordance" (mixed infection status) is primarily associated with epidemiological concerns about HIV transmission risk in couples. We make the case for extending this concept to include families with mixed HIV and viral hepatitis status. Social research on couples with mixed HIV and hepatitis C status has laid an important foundation for illuminating how experiences of serodiscordance within intimate partnerships are much broader than concerns about risk. This body of work attests to serodiscordance holding promise as a valuable concept for understanding viral infections as socially situated and intensely relational phenomena. However, serodiscordance is still limited as a concept because of its near universal focus on couples. It is rarely applied to wider relationships, including family networks beyond the couple. Despite evidence in the literature that families are affected by blood-borne viruses in multiple social, emotional, financial, and generational ways, the concept of serodiscordance does not capture these broader dynamics. Making serodiscordance more inclusive is an important step in recognising the diverse ways families' everyday lives, relationships, and futures can be entangled with HIV, hepatitis C, and hepatitis B, and for understanding how today's era of effective treatment options might shape the "family life" of viral infections.
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http://dx.doi.org/10.1155/2017/4352783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688372PMC
October 2017

Low education levels are associated with early age of sexual debut, drug use and risky sexual behaviours among young Indigenous Australians.

Sex Health 2018 02;15(1):68-75

South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia.

Background Earlier age at sexual debut is associated with drug and alcohol use, risky sexual behaviours and sexually transmissible infections (STI).

Methods: In the present study, 2320 young Indigenous Australians were surveyed.

Results: Most study participants had sex for the first time when they were 14 years or younger (79% and 67% for males and females respectively). More than 80% of participants were categorised as being in the high-risk category for the combined sexual risk factors (i.e. not using condoms, drunk or high at last sexual act, or three or more sexual partners in the past year). There was a linear decreasing trend between the proportion of males and females who had less than high school education and age at first sex (Ptrend<0.001). Compared with the highest quintile of age at first sexual debut (≥18 years), those in the bottom quintile (<15 years) were less likely to have completed high school (63% vs 32% respectively for males; 68% vs 26% respectively for females; Ptrend<0.001 for both).

Conclusions: The findings of the present study suggest that sex education and STI prevention should start early when targeting Indigenous young people, with age-appropriate messages. Sex education should be comprehensive and address individual risk behaviours, sexual agency and societal vulnerability to not only delay sexual debut, but also to emphasise the importance of STI prevention through condom use, which clearly already works to a certain extent with this group.
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http://dx.doi.org/10.1071/SH17039DOI Listing
February 2018

Development of a Risk Algorithm to Better Target STI Testing and Treatment Among Australian Aboriginal and Torres Strait Islander People.

Arch Sex Behav 2017 Oct 26;46(7):2145-2156. Epub 2017 May 26.

South Australian Health and Medical Research Institute, Adelaide, SA, Australia.

Identifying and targeting those at greatest risk will likely play a significant role in developing the most efficient and cost-effective sexually transmissible infections (STI) prevention programs. We aimed to develop a risk prediction algorithm to identify those who are at increased risk of STI. A cohort (N = 2320) of young sexually active Aboriginal and Torres Strait Islander people (hereafter referred to as Aboriginal people) were included in this study. The primary outcomes were self-reported high-risk sexual behaviors and past STI diagnosis. In developing a risk algorithm, our study population was randomly assigned to either a development (67%) or an internal validation data set (33%). Logistic regression models were used to create a risk prediction algorithm from the development data set for males and females separately. In the risk prediction models, older age, methamphetamine, ecstasy, and cannabis use, and frequent alcohol intake were all consistently associated with high-risk sexual behaviors as well as with a past STI diagnosis; identifying as gay/bisexual was one of the strongest factors among males. Those who had never tested for STIs, 52% (males) and 66% (females), had a risk score >15, and prevalence of undiagnosed STI was estimated between 30 and 40%. Since universal STI screening is not cost-effective, nor practical in many settings, targeted screening strategies remain a crucial and effective approach to managing STIs among young Aboriginal people. Risk prediction tools such as the one developed in this study may help in prioritizing screening for STIs among those most at risk.
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http://dx.doi.org/10.1007/s10508-017-0958-9DOI Listing
October 2017

"Don't think I'm going to leave you over it": Accounts of changing hepatitis C status among couples who inject drugs.

Drug Alcohol Depend 2017 Apr 31;173:78-84. Epub 2017 Jan 31.

London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Electronic address:

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.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.12.020DOI Listing
April 2017

Harm reduction workers and the challenge of engaging couples who inject drugs in hepatitis C prevention.

Drug Alcohol Depend 2016 Nov 14;168:170-175. Epub 2016 Sep 14.

National Drug Research Institute, Curtin University, Suite 6, 19-35 Gertrude Street, Fitzroy, VIC 3065, Australia.

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.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.09.010DOI Listing
November 2016

Practices of partnership: Negotiated safety among couples who inject drugs.

Health (London) 2018 01 3;22(1):3-19. Epub 2016 Aug 3.

Centre for Social Research in Health, UNSW Australia, Australia.

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.
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http://dx.doi.org/10.1177/1363459316660859DOI Listing
January 2018

Individual and population level impacts of illicit drug use, sexual risk behaviours on sexually transmitted infections among young Aboriginal and Torres Strait Islander people: results from the GOANNA survey.

BMC Public Health 2016 07 19;16:600. Epub 2016 Jul 19.

Kirby Institute, University of New South Wales, Kensington, 2052, New South Wales, Australia.

Background: Sexually transmitted infections (STIs) have been increasing among Australian Indigenous young people for over two decades. Little is known about the association between alcohol and other drug use and sexual risk behaviours and diagnosis of STIs among this population.

Methods: A cross-sectional, community based self-administered survey was conducted among young Aboriginal people aged 16-29 years of age. Questionnaires included socio-demographic characteristics, knowledge, sexual risk behaviours alcohol and other drug use and health service access including self-reported history of diagnosis with a STI. Logistic regression models and population attributable risks were used to assess individual and population level impacts of illicit drug use on high risk sexual behaviours and ever reported diagnosis of an STI.

Results: Of the 2877 participants, 2320 (81 %) identified as sexually active and were included in this study. More than 50 % of the study population reported that they had used at least one illicit drug in past year. Cannabis, ecstasy and methamphetamines were the three most commonly used illicit drugs in the past year. The prevalence of self-reported STI diagnosis was 25 %. Compared with people who did not report using illicit drugs, risky alcohol use and sexual behaviours including inconsistent condom use, multiple sexual partners in the past year and sex with casual partners were all significantly higher among illicit drug users. In adjusted analysis, participants who reported using illicit drugs were significantly more likely to engage in sexual risk behaviours and to ever have been diagnosed with an STI. Adjusted Odds Ratios ranged from 1.86 to 3.00 (males) and from 1.43 to 2.46 (females). At the population level, more than 70 % of the STI diagnoses were attributed to illicit drug-use and sexual risk behaviours for males and females.

Conclusion: Illicit drug use in this population is relatively high compared to other similar aged populations in Australia. Illicit drug use was associated with risky sexual behaviours and STI diagnoses among this study population. Developing and implementing effective STI prevention strategies should include not only safe sex messages but also include drug and alcohol harm reduction messages.
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http://dx.doi.org/10.1186/s12889-016-3195-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4950619PMC
July 2016

Examining the pathways for young people with drug and alcohol dependence: a mixed-method design to examine the role of a treatment programme.

BMJ Open 2016 05 25;6(5):e010824. Epub 2016 May 25.

Faculty of Medicine, School of Public Health and Community Medicine, UNSW Australia, Sydney, New South Wales, Australia.

Introduction: Young people with drug and alcohol problems are likely to have poorer health and other psychosocial outcomes than other young people. Residential treatment programmes have been shown to lead to improved health and related outcomes for young people in the short term. There is very little robust research showing longer term outcomes or benefits of such programmes. This paper describes an innovative protocol to examine the longer term outcomes and experiences of young people referred to a residential life management and treatment programme in Australia designed to address alcohol and drug issues in a holistic manner.

Methods And Analysis: This is a mixed-methods study that will retrospectively and prospectively examine young people's pathways into and out of a residential life management programme. The study involves 3 components: (1) retrospective data linkage of programme data to health and criminal justice administrative data sets, (2) prospective cohort (using existing programme baseline data and a follow-up survey) and (3) qualitative in-depth interviews with a subsample of the prospective cohort. The study will compare findings among young people who are referred and (a) stay 30 days or more in the programme (including those who go on to continuing care and those who do not); (b) start, but stay fewer than 30 days in the programme; (c) are assessed, but do not start the programme.

Ethics And Dissemination: Ethics approval has been sought from several ethics committees including a university ethics committee, state health departments and an Aboriginal-specific ethics committee. The results of the study will be published in peer-reviewed journals, presented at research conferences, disseminated via a report for the general public and through Facebook communications. The study will inform the field more broadly about the value of different methods in evaluating programmes and examining the pathways and trajectories of vulnerable young people.
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http://dx.doi.org/10.1136/bmjopen-2015-010824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885449PMC
May 2016

Prevalence and Correlates of a Diagnosis of Sexually Transmitted Infection Among Young Aboriginal and Torres Strait Islander People: A National Survey.

Sex Transm Dis 2016 Mar;43(3):177-84

From the *South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; †Kirby Institute and ‡Centre for Social Research in Health, University of New South Wales, Kensington, New South Wales, Australia; §Aboriginal Medical Service Western Sydney, Mount Druitt, New South Wales, Australia; ¶School of Public Health and Community Medicine, University of New South Wales, Kensington, New South Wales, Australia; ∥Australian Research Centre in Sex, Health and Society, Melbourne, Victoria, Australia; **Victorian Aboriginal Community Controlled Health Organisation, Collingwood, Victoria, Australia; ††Aboriginal Medical Services Alliance Northern Territory, Darwin, Northern Territory, Australia; ‡‡Kirby Institute, University of New South Wales, Kensington, New South Wales, Australia; and Sydney Sexual Health Centre, Sydney, New South Wales, Australia.

Background: Young Aboriginal and Torres Strait Islander (Aboriginal) people are recognized as a priority population for the control of sexually transmissible infections (STIs) in Australia. This article reports the prevalence of self-reported STI diagnoses and their correlates among Aboriginal people aged 16 to 29 years.

Methods: Results were analyzed from a survey conducted between 2011 and 2013 at regular community events. Univariate and multivariate logistic regression models were used to identify the correlates of a history of STI diagnosis among participants who reported being sexually active and ever having been tested for STIs. All analyses were stratified by sex.

Results: Of the 2877 participants in this study, 2320, comprising 60% females, self-reported ever having had vaginal or anal sex, and a further subset of 1589 (68%) reported ever being tested for any of the following STIs: chlamydia, gonorrhea, syphilis, or trichomonas. Within this latter group, the proportion who reported that they had had a positive STI diagnosis was 25%. In multivariate analysis, women who reported sexual debut before the age of 16 years (prevalence ratio [PR], 1.53; 95% confidence interval, 1.16-2.81; P < 0.05), ever having had oral sex (PR, 2.66; 1.47-4.82; P < 0.001), inconsistent condom use in the past 12 months (PR, 1.71; 1.13-2.58; P < 0.012), having had sex with someone they had just met (adjusted odds ratio, 1.74; 1.21-2.50; P < 0.003), and using ecstasy (PR, 1.81; 1.16-2.81; P < 0.009) were significantly associated with a self-reported history of an STI diagnosis. For men, being older (25-29 years; PR, 2.10; 1.10-3.96; P < 0.023), being gay or bisexual (PR, 2.22; 1.16-4.27; P < 0.016), not using a condom during last sex, (PR, 1.74; 1.10-2.76; P < 0.019), past ecstasy use (PR, 1.88; 1.11-3.20; P < 0.019), and injecting drug use (PR, 2.81; 1.35-5.88); P < 0.006) were independent predictors of ever reporting being diagnosed as having an STI.

Discussion: In the first community-based survey of this population, a self-reported history of ever being diagnosed as having prevalent STIs was common in sexually active young Aboriginal people who reported STI testing in the past. This population requires targeted education and health service interventions to address the high burden of STIs.
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http://dx.doi.org/10.1097/OLQ.0000000000000417DOI Listing
March 2016

Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia.

Drug Alcohol Rev 2016 07 15;35(4):447-55. Epub 2015 Sep 15.

Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.

Introduction And Aims: To examine patterns of illicit drug use among Australian Indigenous young people, identify correlates of frequent use separately in urban, regional and remote settings and characterise those who inject.

Design And Method: Cross-sectional design at 40 Indigenous events. Self-complete surveys were administered to Indigenous people aged 16-29 years using mobile devices.

Results: 2,877 participants completed the survey. One in five reported using cannabis at least weekly in the previous year, but the use of other drugs was less prevalent. Patterns of drug use were largely similar across regions, although more participants in urban and regional areas reported using ecstasy (12% vs 11% vs 5%) and cocaine (6% vs 3% vs 1%) and more reported weekly cannabis use (18% vs 22% vs 14%). Injecting was rare (3%) but those who did inject reported a high incidence of needle sharing (37%). Methamphetamine (37%), heroin (36%) and methadone (26%) were the most commonly injected drugs, and injecting was related to prison experience (AOR 5.3 95% CI 2.8-10.0).

Discussion And Conclusion: Attention is needed in relation to cannabis use, particularly among those Indigenous young people living in regional and urban settings. Also, although injecting is uncommon, it is associated with prison involvement. Priority must be given to reducing the numbers of Indigenous youth entering justice settings, delaying the age at first entry to justice settings, and reducing the risk of BBV acquisition while in custody through, for example, prison-based NSP, BBV education, and Indigenous-specific treatment that emphasises connection to country and culture. [Bryant J, Ward J, Wand H, Byron K, Bamblett A, Waples-Crowe P, Betts S, Coburn T, Delaney-Thiele D, Worth H, Kaldor J, Pitts M. Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia. Drug Alcohol Rev 2016;35:447-455].
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http://dx.doi.org/10.1111/dar.12320DOI Listing
July 2016

Methods of a national survey of young Aboriginal and Torres Strait Islander people regarding sexually transmissible infections and bloodborne viruses.

Aust N Z J Public Health 2016 Apr 10;40 Suppl 1:S96-101. Epub 2015 Aug 10.

Australian Research Centre in Sex, Health and Society, La Trobe University, Victoria.

Objective: To describe the methods and basic demographics of participants in a national survey of Aboriginal and Torres Strait Islander (Aboriginal) people specific to sexually transmissible infections and bloodborne viruses.

Methods: A national cross-sectional survey of Aboriginal people aged 16-29 years in all Australian jurisdictions between 2011 and 2013 conducted at Aboriginal community events. Questions comprised demographic information, knowledge, risk behaviours and health service utilisation. Questionnaires were completed on personal digital assistants (PDAs).

Results: A total of 2,877 people at 21 unique community events completed the questionnaire. A total of 59% of participants were female, median age was 21 years and more than 60% were single at the time of the survey. Just over half the participants were resident in an urban area (53%) and 38% were from a regional area. Aboriginal health organisations played an important role in implementing the research. PDAs were found to be an acceptable method for collecting health information.

Conclusion: This survey has recruited a large representative sample of Aboriginal people aged 16-29 years using a methodology that is feasible, acceptable and repeatable.

Implications: The methodology provides a model for ongoing monitoring of this population as programs and policies are implemented to address young Aboriginal people's STI and BBV risks.
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http://dx.doi.org/10.1111/1753-6405.12427DOI Listing
April 2016

Sexual identity and its relationship to injecting in a sample of disadvantaged young drug users.

Drug Alcohol Rev 2016 Mar 18;35(2):218-22. Epub 2015 Jun 18.

Centre for Social Research in Health, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia.

Introduction And Aims: People who are new to injecting are at the highest risk of acquiring blood-borne viruses, and certain other characteristics, such as sexual identity, have been known to further heighten this risk. We investigate whether disadvantaged drug-using young people who are gay, lesbian, bisexual or who identify as other sexual identity (GLBO) are more likely to have ever injected drugs compared with their heterosexual peers.

Design And Methods: Convenience sampling was employed across 15 youth services in metropolitan Sydney. Respondents were required to be 16-24 years of age, to have used an illicit drug, to have been exposed to injecting through social networks and been socially disadvantaged in the past 12 months. Participants self-completed a survey using touch screen laptops.

Results: In a sample of 250 young people, GLBO participants more commonly reported ever injecting drugs [37.1%, confidence interval (CI) 21.5-55.1% vs. 12.3%, CI 8.1-17.4%] or injecting drugs in the past 12 months [31.4%, CI 16.9-49.3% vs. 5.7%, CI 2.9-9.6%] compared with participants who identified as heterosexual.

Discussion And Conclusions: The higher rates of injecting among GLBO young people found in this sample advocates for the development of targeted prevention strategies for this group. Utilising existing networks in GLBO communities could be one strategy to limit the transition to injecting drug use and reduce the risk of drug-related harms among this group.
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http://dx.doi.org/10.1111/dar.12281DOI Listing
March 2016

Young people at risk of transitioning to injecting drug use in Sydney, Australia: social disadvantage and other correlates of higher levels of exposure to injecting.

Health Soc Care Community 2015 Mar 4;23(2):200-7. Epub 2014 Dec 4.

Centre for Social Research in Health, UNSW Australia, Sydney, New South Wales, Australia.

While numerous studies have examined characteristics of young people who have recently initiated injecting, little attention has focused on young people who may be at high risk of transitioning to injecting. This study sought to examine the extent that socially disadvantaged young people were exposed to injecting, determine their level of hepatitis C (HCV) knowledge and identify correlates of higher injecting exposure. A cross-sectional survey was administered to 210 young people in 2010-2011 who were exposed to injecting drug use, but had not transitioned to injecting. Respondents were primarily recruited from youth services in metropolitan Sydney. Exposure to injecting in the previous 12 months was assessed with four items that examined whether close friends, romantic/sexual partners or family members/acquaintances injected drugs, and whether they were offered an injection. Most respondents had at least a few close friends who injected drugs (65%) and almost half had been offered drugs to inject in the previous 12 months (48%). It was less common for respondents to report having a partner who injects (11%). Correlates of higher injecting exposure were examined with multivariate ordinal regression. In the multivariate model, higher exposure to injecting was independently associated with the experience of abuse or violent crime [adjusted odds ratio (AOR) = 1.80] and reporting more favourable attitudes towards injecting (AOR = 0.86). Higher exposure to injecting was not independently associated with patterns or history of drug use. HCV knowledge was low to moderate and was not associated with higher exposure to injecting. That drug use was not independently associated with higher injecting exposure may suggest that exposure is shaped more by social disadvantage than by drug use patterns. Additional research is required to investigate this, using an improved measure of exposure to injecting.
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http://dx.doi.org/10.1111/hsc.12145DOI Listing
March 2015

Discrimination by health care workers versus discrimination by others: countervailing forces on HCV treatment intentions.

Psychol Health Med 2015 3;20(2):148-53. Epub 2014 Jun 3.

a Centre for Social Research in Health , University of New South Wales , Sydney , Australia.

Hepatitis C virus (HCV) infection is a major public health burden. Despite recent advances in HCV treatment, uptake remains low, particularly amongst people who inject drugs. HCV-related stigma and discrimination are common, especially within the health care sector. This research examines a more nuanced approach for how HCV-related stigma and discrimination impacts treatment access and uptake. Based on a social identity framework, we explore whether perceived HCV-related discrimination is associated with attempts to remove the stigma of being HCV-positive via HCV treatment intentions. Based on the results of prior research it was also hypothesised that the source of discrimination (health care workers versus others), and whether the discrimination is perceived to be directed to oneself or to the HCV-positive group, will differentially impact treatment intentions. The sample consisted of 416 people living with HCV in New South Wales, Australia, who acquired HCV from injecting drugs. Participants were asked about their experiences of perceived discrimination directed towards themselves versus their HCV-positive group and perceived discrimination within the health care sector. Findings indicate that discrimination towards the self is a more powerful indicator of treatment intentions than discrimination aimed at the HCV-positive group. This finding is consistent with social identity theory suggesting that people from low status groups are motivated to change their stigmatised status when it is possible to do so. The source of the perceived discrimination also matters, however, as participants who report experiencing discrimination from health workers have lowered intentions to engage with HCV treatment in the future. In combination, the results indicate that while perceived discrimination is commonly understood to act as a barrier to treatment uptake, the relationship is actually more complex than previously conceptualised.
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http://dx.doi.org/10.1080/13548506.2014.923103DOI Listing
September 2015

Use of health services for sexually transmitted and blood-borne viral infections by young Aboriginal people in New South Wales.

Aust J Prim Health 2013 ;19(1):81-6

The Kirby Institute, University of New South Wales, Darlinghurst, Sydney, Australia.

The objective of the present study was to describe use of health services for sexually transmitted infections (STI), blood borne viral infections (BBV) and drug and alcohol issues by young Aboriginal people in New South Wales (NSW). A cross-sectional survey was conducted at two Aboriginal sports and cultural events in NSW, in 2007 and 2008, among Aboriginal people aged 16-30 years to ascertain their knowledge of STI, BBV, associated risk behaviours and health service access in NSW. A total of 293 young Aboriginal people completed the survey; 58% were female, the mean age was 20 years, and almost 70% were single. Just over one-third (34%) of participants had been tested for an STI in the past 12 months, and over half (58%) reported that they had ever had an STI test (including HIV). Of respondents who had had an STI test in the past 12 months, 54.0% had done so at an Aboriginal Community Controlled Health Service (ACCHS) and 29% by a GP. Just over one-third (36%) of participants had ever had a test for hepatitis C, 45% of whom had received their test at an ACCHS. Participants were also asked about the types of services they had used for advice about STI and BBV. Of the 69% who had sought STI advice, ACCHS was the most common clinical location for doing so (36% for STI and 26% for hepatitis C). This study highlights the important role that ACCHS play in the provision of STI and BBV testing care and management for a cohort of young Aboriginal people in NSW.
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http://dx.doi.org/10.1071/PY11032DOI Listing
July 2013

Risk practices among aboriginal people who inject drugs in New South Wales, Australia.

AIDS Behav 2013 Sep;17(7):2467-73

National Centre in HIV Social Research, University of New South Wales, Sydney, NSW, 2052, Australia.

This paper describes patterns of injecting drug use and blood borne virus (BBV)-related risk practices among Australian Aboriginal and non-Aboriginal people who inject drugs (PWID). A total of 588 participants, 120 of whom self-identified as Aboriginal completed a questionnaire. Aboriginal participants were more likely to have been in prison (37.6 vs. 16.5 %), to inject daily (72.7 vs. 55.0 %), to share ancillary equipment (64.9 vs. 44.8 %) and less likely to know about BBV transmission (72.0 vs. 87.7 %) and treatment (47.2 vs. 67.6 %). Aboriginal participants used services such as BBV testing and drug treatment at a comparable rate to non-Aboriginal participants. The findings suggest that Aboriginal PWID are at greater risk for acquiring BBV. The prison setting should be used to deliver health promotion information and risk reduction messages. More information is needed on Aboriginal people's access and use of services to ensure beneficial services are received in the most appropriate settings.
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http://dx.doi.org/10.1007/s10461-012-0226-xDOI Listing
September 2013

Does drug and alcohol use undermine concordance between doctors' assessments of major depression and patients' scores on a screening tool for depression among gay men attending general practice?

Aust J Prim Health 2012 ;18(2):116-22

The University of New South Wales, Sydney, Australia.

General practitioners (GPs) identify that depression can be difficult to diagnose in populations with high rates of alcohol and other drug (AOD) use. This is a particular concern with gay men who are a population known to engage in high rates of AOD use and who are vulnerable to depression. This paper uses data from 563 gay men and their GPs to describe concordance between assessments of major depression and, in particular, whether AOD use undermines concordance. Data were collected as part of a larger study of male patients and GPs at high HIV-caseload general practices in Australia. Concordance was measured by comparing patients' scores on the Patient Health Questionnaire-9 screening tool, which is based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria, and GPs' ratings of the likelihood of depression for each participant. We observed high concordance between GPs' assessments of major depression and patients' scores on the PHQ-9 (79% agreement), although our analysis also suggested that concordance was better when it related to cases in which there was no depression. The high concordance observed in our study did not appear to be undermined by gay male patients' AOD use, with the exception of frequent use of crystal methamphetamine. Here, men who reported frequent use of methamphetamine were significantly less likely to have concordant assessments (adjusted odds ratio 0.3, 95% CI 0.1-0.8). Overall, GPs appear to identify depression among many of their gay male patients. While GPs should be aware of the potential complications presented by frequent crystal methamphetamine use, other AOD use may have less impact on the diagnosis of depression.
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http://dx.doi.org/10.1071/PY11011DOI Listing
July 2012

Comparing 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression.

Health Soc Care Community 2012 Jul 28;20(4):412-9. Epub 2011 Nov 28.

The University of New South Wales, National Centre in HIV Social Research, Sydney, Australia.

High rates of both illicit drug use and depression are consistently reported among gay men. However, little is known about how beliefs about drug use shape clinical encounters between gay men and health professionals, and that in turn affect clinical communication and care, particularly in relation to depression. We compared 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression. Semi-structured interviews were conducted during August-December 2006 with 16 general medical practitioners working in seven 'gay-friendly' practices in Sydney, Adelaide and a rural-coastal city in New South Wales, and during February-May 2008 with 40 gay men with depression recruited through four Sydney and Adelaide practices. A thematic analysis of these two sets of interviews found that doctors expressed the beliefs that: illicit drug use is related to depression in gay men; illicit drug use impedes effective diagnosis and treatment of depression in gay men; and illicit drug use increases the level of complexity involved in caring for gay men with depression. Gay men expressed the beliefs that: illicit drug use is closely related to depression; illicit drug use can be helpful in dealing with difficult experiences; and illicit drug use is just what you do as a gay man living in a big city. Both groups believed drug use and depression were related, but doctors emphasised the negative outcomes of drug use and interpreted these in relation to health. Gay men believed that drugs could have both negative and positive uses and differentiated between health and social outcomes. While the doctors articulated a pragmatic position on drug use, which is consistent with harm reduction principles, communication with gay male patients could be enhanced if both groups acknowledged their divergent views of illicit drugs and their potential role in mental health.
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http://dx.doi.org/10.1111/j.1365-2524.2011.01044.xDOI Listing
July 2012

Respondent-driven sampling and the recruitment of people with small injecting networks.

AIDS Behav 2012 May;16(4):890-9

National Centre in HIV Social Research, University of New South Wales, Sydney, Australia.

Respondent-driven sampling (RDS) is a form of chain-referral sampling, similar to snowball sampling, which was developed to reach hidden populations such as people who inject drugs (PWID). RDS is said to reach members of a hidden population that may not be accessible through other sampling methods. However, less attention has been paid as to whether there are segments of the population that are more likely to be missed by RDS. This study examined the ability of RDS to capture people with small injecting networks. A study of PWID, using RDS, was conducted in 2009 in Sydney, Australia. The size of participants' injecting networks was examined by recruitment chain and wave. Participants' injecting network characteristics were compared to those of participants from a separate pharmacy-based study. A logistic regression analysis was conducted to examine the characteristics independently associated with having small injecting networks, using the combined RDS and pharmacy-based samples. In comparison with the pharmacy-recruited participants, RDS participants were almost 80% less likely to have small injecting networks, after adjusting for other variables. RDS participants were also more likely to have their injecting networks form a larger proportion of those in their social networks, and to have acquaintances as part of their injecting networks. Compared to those with larger injecting networks, individuals with small injecting networks were equally likely to engage in receptive sharing of injecting equipment, but less likely to have had contact with prevention services. These findings suggest that those with small injecting networks are an important group to recruit, and that RDS is less likely to capture these individuals.
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http://dx.doi.org/10.1007/s10461-011-0032-xDOI Listing
May 2012

Safer sex and condom use: a convenience sample of Aboriginal young people in New South Wales.

Sex Health 2011 Sep;8(3):378-83

National Centre in HIV Social Research, University of New South Wales, Sydney, NSW 2052, Australia.

Background: This paper examines condom use in a sample of Aboriginal young people in New South Wales (NSW) aged 16-30 years.

Methods: Cross-sectional data were collected using hand-held computer devices from 293 Aboriginal people attending two Aboriginal events in NSW.

Results: Almost two-thirds of respondents reported having had a casual sex partner in the previous 6 months. Of these, 39.2% reported always using a condom with casual partners. Having always used a condom with casual partners varied among respondents, and was more likely among younger respondents (adjusted odds ratio (AOR): 2.7, 95% confidence interval (CI): 1.2-6.1) and less likely among those who used illicit drugs (AOR: 0.2, 95% CI: 0.1-0.7).

Conclusions: In comparison to published studies of other Australians, casual sex appears to be more common among this sample of Aboriginal young people; however, the proportion who report having always used condoms with casual partners is very similar. This suggests that although casual sex is more common, Aboriginal young people do not engage in risky behaviour any more often than other young Australians. Further work should be conducted with those who do not always use condoms, such as those who are older and who use illicit drugs, particularly with regards to how abstinence from drug use supports protective behaviours such as condom use among this population of Aboriginal young people.
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http://dx.doi.org/10.1071/SH10138DOI Listing
September 2011