“Something Is Going To Get Us”

A Consultation and Development Project for a National Campaign Addressing Injecting Drug Use in Indigenous Communities

Final Report November 2005

This report presents the results of a consultation process with Indigenous IDUs conducted by the Australian Federation of AIDS Organisations (AFAO) and the Australian Injecting and Illicit Drug Users League (AIVL). In response to evidence of an increase in HIV diagnoses attributed to injecting drug use in Indigenous communities, the project aimed to explore Indigenous experiences of injecting drug use and related issues, to inform the development of a national campaign to address injecting drug use in Indigenous communities.

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Executive Summary

Consultations were conducted through a series of semi-structured, individual and group interviews in six urban and non-urban sites around Australia. Participants were eligible for recruitment if they were aged 18 years and over, identified as Indigenous, and had injected drugs in the past twelve months. A total of seventy participants were recruited through AFAO and AIVL member organisations and their associated networks. It is worth noting that this approach to recruitment did not target "hidden" Indigenous IDU populations that do not access services. It is therefore possible that the findings presented in this report do not reflect the issues affecting more marginalised Indigenous IDUs.

Overall, the results challenge assumptions that injecting drug use in Indigenous communities is limited to particular age groups or geographical areas and highlights that Indigenous IDUs are not a homogenous population. In particular, Indigenous IDUs differ in terms of their responses to drug-related problems and their willingness to seek assistance from services. While results suggested there were differences between the needs of urban and non-urban participants, there were just as many differences within these groups. In order to target broad groups of Indigenous IDUs, education campaigns and other initiatives need to target all age groups in both urban and non-urban areas.

Recognition of some Indigenous IDUs’ reluctance to disclose their injecting drug use necessitates a range of innovative strategies for providing information and assistance. Results also highlighted the need to raise awareness of safer injection practices, bloodborne viral infection (BBVI) prevention and the need for regular testing among Indigenous IDUs. In particular, information that targets misconceptions regarding routes of BBVI transmission and provides accurate information on the health consequences of particular infections, is necessary. Written information in the form of pamphlets, distributed via fitpacks (sterile injecting equipment) and widely available in services and community settings, were suggested by many participants as discrete ways to provide information regarding drug-related issues. This was particularly important for those who were reluctant to be identified as IDUs by health professionals, family and/or community members. Presentation of educational material in culturally-appropriate formats was also recommended, incorporating local Indigenous speech forms and "a black face".

Although limited in scope to Indigenous IDUs who were comfortable disclosing their drug use, peer education was another option suggested by many participants. The legitimacy of the experience-based expertise of peers, as well as their informal approach, made many participants more comfortable discussing drug-related issues in this context. Services were also highlighted as potential sources of information, although this wasdependent on IDUs’ willingness to engage with health professionals.

While education was identified as an important starting point, participants indicated other strategies were also required to reduce BBVI transmission. According to some participants, greater acknowledgment by Indigenous leaders that injecting drug use was a problem, was a necessary prerequisite to "action". In addition, involvement of all community members in addressing injecting drug use would facilitate ownership and responsibility for drug problems in Indigenous communities.

Improved access to sterile injecting equipment was perceived as critical in addressing needle and syringe sharing among Indigenous IDUs. Low threshold approaches were suggested, as well as increased availability of sterile injecting equipment through services, particularly outreach Needle and Syringe Programs (NSPs) and Aboriginal Community-Controlled Health Services (ACCHSs).

Results also indicated a need to improve access to BBVI testing for Indigenous IDUs. Participants were varied in terms of their willingness to present to services for testing, particularly to ACCHSs, because of the "shame" associated with injecting drug use. While in principle, engagement with Indigenous health professionals regarding a range of injecting drug use issues was often preferred by participants, concerns regarding a perceived lack of confidentiality and judgmental attitudes of staff towards IDUs were identified as barriers. ACCHSs were clearly perceived by many participants as a potentially valuable source of assistance and support in relation to general health problems. However, participants indicated a need for changes in the way some ACCHSs deliver services to Indigenous IDUs, to increase accessibility and uptake of these services for drug-related problems. While ACCHSs have made a policy commitment to providing services that cater for Indigenous IDUs, further qualitative and quantitative research is needed to explore Indigenous IDUs’ perceptions of the way these and other services are provided, with a view to informing future policy.

The high levels of stigma and discrimination experienced by a number of participants highlight the importance of raising awareness of the risks of BBVI transmission in Indigenous communities. Reports of IDUs being ostracised by family and other social groups after becoming infected with hepatitis C and HIV, reinforce the need to challenge misconceptions regarding the risk of transmission of BBVIs, particularly through kissing, sharing eating utensils and toilets.

Participants also raised a number of other issues that exacerbate the harms associated with injecting drug use and perpetuate structural disadvantage in Indigenous communities. Boredom, poverty, low levels of literacy and/or education, racism, high levels of crime and incarceration, and limited access to public housing were implicated in increasing the vulnerability of Indigenous communities to drug-related problems. In the face of enduring health inequalities between Indigenous and non-Indigenous Australians, BBVIs were considered by participants to be just one of many potential threats to their health. The participant’s comment used as the title of this report - "something’s going to get us" - provides a striking reminder of the appalling state of Indigenous health and a warning that drug-related issues cannot be considered in isolation of the broader health context.

This consultation has identified broad principles for education and service provision but how these are implemented is up to Indigenous communities who are best placed to develop responses that incorporate the unique features and distinctive aspects of local traditions, environments, and communities. Further research will also afford greater insights to guide future policy in relation to injecting drug use in Indigenous communities. The use of ethnographic techniques and participatory approaches would allow in-depth exploration of the beliefs and practices of Indigenous IDUs, as well as the social, cultural, structural and environmental contexts within which injecting occurs (Maher 2002). Training of Indigenous researchers in these research techniques would build capacity for "culturally competent" research that involves Indigenous people in all phases of the research process and results in culturally-appropriate and acceptable harm minimisation initiatives.