“I was never told you could catch a thing from yourself”: using theories of practice to understand harm reduction needs among people hospitalised with an injecting-related invasive infection

Background: In Australia, people who inject drugs are increasingly presenting to hospital with injecting-related bacterial and fungal infections, while HIV and hepatitis C incidences have stabilised. This study explored injecting as practiced by people previously hospitalised with an injecting-related infection in Melbourne, Australia, to identify modifiable elements that introduce ‘risk’ to their practice.

Methods: In-depth qualitative interviews were conducted with participants from the SuperMIX prospective cohort in Melbourne, between April and November 2023. Eligible participants had living expertise of drug-injecting and had experienced a hospitalisation for an invasive infection. Informed by Social Practice Theory, transcripts were coded deductive-inductively to delineate the constituent (temporal, material, competency, meaning) elements of their injecting practices. We developed themes encompassing the dynamic relationship between practice elements and wellbeing aspects.

Results: Of 20 interviewees (aged 39-50), 11 were male. Ten reported endocarditis as cause of hospital admission. Participants commonly attributed their infection to the combined use of heroin and Unisom® (a viscous antihistamine) thought to accelerate venous collapse and thus necessitating multiple injecting attempts. In focusing their harm reduction efforts on preventing blood-borne viruses, many had considered it ‘safe enough’ to re-use their own needles/syringes. For participants whose care teams were skilled in harm reduction principles, hospitalisation provided opportunities to review their injecting practices step-by-step. Efforts to implement changes to their practice were complicated by material limitations (e.g., lack of filters, unsterile water) and temporal constraints (e.g., withdrawal-related urgency, hours of service provision).

Conclusion: Findings revealed that safer injecting messages should move beyond blood-borne virus risk reduction, yet emphasising injecting competency is not enough: critical updates to harm reduction education should be accompanied by improvements to injecting equipment distribution models (e.g., adding filters, spoons, sterile water to vending machine fit packs) whilst empowering people who inject drugs to implement ‘safer’ practices that work for them.

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