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REVIEW

doi:10.1111/j.1360-0443.2007.01936.x

The importance of social networks in their association to drug equipment sharing among injection drug users: a review
Prithwish De1, Joseph Cox1,2, Jean-Franois Boivin1,2, Robert W. Platt1,3 & Ann M. Jolly4,5
Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada,1 Montreal Public Health Department, Montreal, Canada,2 Department of Pediatrics, McGill University, Montreal, Canada,3 Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Canada4 and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada5

ABSTRACT Aim To examine the scientic evidence regarding the association between characteristics of social networks of injection drug users (IDUs) and the sharing of drug injection equipment. Methods A search was performed on MEDLINE, EMBASE, BIOSIS, Current Contents, PsycINFO databases and other sources to identify published studies on social networks of IDUs. Papers were selected based on their examination of social network factors in relation to the sharing of syringes and drug preparation equipment (e.g. containers, lters, water). Additional relevant papers were found from the reference list of identied articles. Results Network correlates of drug equipment sharing are multifactorial and include structural factors (network size, density, position, turnover), compositional factors (network member characteristics, role and quality of relationships with members) and behavioural factors (injecting norms, patterns of drug use, severity of drug addiction). Factors appear to be related differentially to equipment sharing. Conclusions Social network characteristics are associated with drug injection risk behaviours and should be considered alongside personal risk behaviours in prevention programmes. Recommendations for future research into the social networks of IDUs are proposed. Keywords Hepatitis C, HIV, injection drug use, review, social network, syringe sharing.

Correspondence to: Prithwish De, Department of Epidemiology and Biostatistics, McGill University, 1020 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A2. E-mail: prithwish.de@mail.mcgill.ca Submitted 18 October 2006; initial review completed 16 January 2007; nal version accepted 13 April 2007

INTRODUCTION Ecological models of health behaviour consider health as a product of interpersonal, organizational and community determinants [1]. With regard to drug use, an ecological approach may include an examination of drug-using context (e.g. where drugs are bought and consumed, prevailing local drug use practices and neighbourhood differences in drug use patterns), prevalence of sexually transmitted and bloodborne infections [e.g. human immunodeciency virus (HIV) and hepatitis C virus (HCV)], the role of community harm reduction services (e.g. accessibility to clean injecting equipment) and of the behaviours of drug users and of their social networks [24]. With regard to HIV and HCV, the study of social networks has provided insight into the interpersonal inuences on sexual and drug-use behaviours. For

drug use, in particular, characteristics of social networks have been linked to the initiation [5,6], continuation [7,8] and cessation of drug consumption [9]. Both qualitative and quantitative epidemiological research have also shown that needle sharing among injection drug users (IDUs) is associated profoundly with the social context of drug use in which social networks play an important role [1012]. Social networks are dened by the social links between individuals that specify one or more types of relationships [13]. Such links represent pathways through which information, materials and infections can be transmitted. Social networks can be viewed from the perspective of individuals (egocentric) or as a collection of connected individuals (sociocentric). Social networks are believed to mediate the behaviour of network members through social inuence, social comparison processes, social
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engagement, fear of social sanctions and by the provision of social support [6,1416]. While network members can support healthy practices, they may also serve as negative role models by providing environmental cues that reinforce risk behaviours [1719]. For example, peer behaviours may exert an important inuence on injection risk practices such as drug equipment sharing, which is considered to be the major risk factor for the transmission of HIV and HCV among IDUs [20]. Mechanisms of peer inuence include proscriptive modes or verbalization of norms (i.e. explicit persuasion of peers to modify behaviours) and descriptive modes or social modelling (i.e. observing and imitating in order to conform to peer behaviours) [19,21]. The latter of these mechanisms appears to be most effective in inuencing drug equipment sharing [21]. In examining the evolving HIV epidemic during the mid-1980s, Klovdahl [22] proposed that the structure of sexual partner networks, together with HIV prevalence and sexual risk behaviours within those networks, contributed to the extent of HIV spread. Neaigus et al. [23] proposed similar implications for HIV transmission among IDUs by showing that the probability of HIV infection among new injectors depended on the interaction between personal risk behaviours and exposure to a highrisk injecting network. Subsequent research has supported the notion that the relationship between IDUs, rather than differences in individual risk behaviours alone, accounts for the observed disease transmission patterns in IDU populations [2426]. Thus, by understanding how social networks are associated with risk behaviours, it is hoped that interventions aimed at individuals can be better informed. In this review of the literature we investigate how the characteristics of social networks of IDUs are associated with drug equipment sharing. We also discuss briey the role of network-orientated interventions and propose future areas of research. METHODS Search strategy On 23 April 2006 a search of MEDLINE (1966 present), EMBASE (1980present), BIOSIS (1969 present), Current Contents (1993present), PsycINFO (1985present) and Web of Science was performed to identify relevant English or French language studies exploring the social networks of IDUs. The internet was also searched using Google Scholar. Various combinations of the following keywords were used in the searches: social network, drug network, social support, injection drug user, intravenous injections, intravenous substance abuse, IDU, syringe, needle sharing, drug equipment sharing and paraphernalia

sharing. Additional papers were found through the reference lists of identied articles. The social networkorientated journal Connections was also searched by hand for the years 1977 to issue 1 of 2006. Abstracts of identied publications were used initially to assess the relevance of the study, with all articles dealing with injection drug use and the social contexts of injecting retrieved for full review. Selection of articles for inclusion was performed by P. D. and A. J., with disagreement about inclusion resolved by consensus. Studies were included in the review if they described the association of egocentric or sociocentric network factors with injection equipment sharing.

Denitions For the purpose of this review, drug injecting equipment is dened as syringes, needles, drug mixing containers (i.e. cookers), lters (e.g. cotton), water or other liquid (for drug preparation or for rinsing injecting equipment) and any other material used for the purpose of drug preparation and injection. Sharing refers to borrowing and/or lending of any drug injecting equipment that has been used previously by another injector. Social network members are individuals identied by an index study subject as having a denable role in the subjects life and consist typically of people with whom there is more than casual contact and interaction. Examples include people who represent kinship (i.e. immediate family members and relatives), friendship (e.g. friends, co-workers and others providing social support), sexual partnership (regular or casual non-paying partners) and drug partnership (injecting and non-injecting drug users). Most social network studies of IDUs have assessed network characteristics for the 16-month period prior to participant enrolment. A useful framework for examining the role of social networks in drug equipment sharing is to view networks according to their structure, composition, and by the behaviours of network members. Classications of network characteristics in other study populations have used similar approaches to distinguish between structural and functional roles of networks [2729]. In the current study, network structure was dened as the physical attributes of a network including its size (i.e. number of people in a network), density (i.e. extent to which members in a network are linked), member position (i.e. location of a member in a network relative to others) and turnover (i.e. change in network membership over a dened period of time). Network composition refers to socio-demographic traits of network members, the type and quality of relationships between them, the type of drugs they use and their infection status. Finally, behaviours describe the interactions between network
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Table 1 Injecting network characteristics associated with drug equipment sharing. Network domain Structure Network characteristic Larger network size Higher density Greater centrality High network turnover Female gender Male gender Younger age Variable role of ethnicity Lower income More frequent contact with other IDUs Fewer non-drug-using people Presence of drug-using family members Longer relationships Homosexual practice Sharing behaviour is norm Characteristics of drug Degree of drug addiction Potential explanations Higher number of potential sources of contaminated equipment Greater number of available sharing partnerships Core positions associated with brokerage of equipment and drug exchange Greater change in high-risk network membership When injecting partner is a male sexual partner due to trust based on intimate relationship When male injecting partner participates in other mutual activities due to social bonding Less perceived risk among younger IDUs and bridging by older IDUs to high-risk networks Heterogeneity of norms of injection practices across ethnic groups Lack of resources in acquiring drugs or injecting equipment More cues for injecting Fewer cues for social engagement and discouragement of risk behaviours Individuals with whom there are strong or intimate ties consisting of inherent trust Greater trust and social binding, especially when several functional roles exist between members Injecting risks are rationalized in relation to existing sexual risks Social modelling of peers behaviours Pharmacokinetic and physiological effects of drug Less control over injecting behaviour

Composition

Behaviours

members as they relate to harm reduction and risk enhancing practices. Examples include the extent of mutual drug injecting, the exchange of information on injecting practices or the provision of social support to encourage safe injecting. The network dimensions discussed in this review are those that have been most studied epidemiologically in IDU populations. Interested readers are referred to social network analysis texts [13,30] for further discussion of social network measures. RESULTS The literature search yielded 104 articles on the social aspects of injection drug use, of which 58 articles discussed social networks and were included in the review. Most (54 of 58) were egocentric social network studies. The following ndings are also summarized in Table 1. Structure of networks Network size and density Large IDU networks are associated frequently with needle sharing, as network members are often motivated by strong social pressures to share [10,31]. In addition to providing greater opportunities for drug equipment

sharing, IDUs who inject within large networks are likely to have less control over injections and end up participating in unplanned injections, where sterile equipment may be unavailable or personal injecting equipment is used mistakenly by another injector [10,32]. One study found that a decrease in the size of injecting networks was associated with fewer episodes of syringe sharing, despite an increase in the total number of distinct networks over time [33]. The propensity to share equipment is increased further when injecting networks are dense, wherein there are many ties between network members that provide numerous opportunities for sharing to occur. Most research seems to suggest that size and density are not mutually exclusive properties of networks. In a longitudinal study of IDUs in Baltimore, belonging to large, dense injecting networks was associated with higher rates of needle sharing [34]. Similar results have been reported for the sharing of drug mixing containers [35]. Recent work also shows that network size and density are important for limiting the potential transmission of HIV [24,33]. Rothenberg et al. [33] found that needle sharing decreased as injecting networks became less dense over a 3-year period. A decline in the number of connected IDU networks, and hence a decrease in the size of each network, was associated with less needle sharing.
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Network position The position of an individual relative to others within a network appears to play an important role in risky behaviours and for HIV transmission [33]. The prominence of a network members position in their network is measured by the members centrality [30]. Core members have been described previously in sexual networks as individuals who occupy a central role in the acquisition and transmission of infection due to their high-risk behaviours [36,37]. In their investigation of IDUs in New York City, Friedman et al. [26] found that core members of an IDU network were more likely to engage in drug equipment sharing and had a higher probability of HIV acquisition and transmission than peripheral network members. These results are supported by a study in France in which IDUs in the densest and most central part of injecting networks had the highest likelihood of equipment sharing [38]. However, peripheral network members can also contribute to the overall risk of bloodborne infections for the networks to which they belong [25], especially if they bridge high- and low-risk networks as a result of their equipment-sharing practices. The implications for disease transmission from bridging have been examined in relation to the strength of social ties [39]. Network turnover Unstable networks are those with high member turnover in which individuals move frequently between different IDU networks. This change of network membership is often motivated by limited access to drug resources within the network and a search by IDUs for a greater resource base. In such situations, IDUs may resort to more frequent lending and borrowing of drug injecting equipment in exchange for drugs or drug paraphernalia [40]. In Chicago and Washington, DC, Hoffmann et al. [41] observed that networks characterized by frequent sexual and injection risk behaviours had high turnover over a 3-month period but were no different in network size and density compared to less risky networks. The authors posited that the elevated risk of bloodborne infections in such high-turnover networks may motivate some IDUs to withdraw from the network to avoid infection and others to readily accept new members for the resources they contribute towards the acquisition of drugs and injecting equipment. In other work, network size has been found to have an impact on turnover, whereby larger IDU networks had the highest rate of network member change [33]. Composition of networks The characteristics of individuals who comprise an IDUs social network can create or limit opportunities for

equipment sharing. Although IDUs are often fairly heterogeneous across networks but homogeneous within injecting networks, the stratication of networks along socio-demographic, drug use characteristics and infection status can help segregate IDUs and their risk behaviours [42,43]. Gender The relationship between gender and syringe sharing has been studied widely, especially with regard to network members who occupy roles as both injecting and sexual partners [42,4449]. The results suggest distinct differences among men and women. Among male IDUs, syringe sharing tends to occur more often between frequent injectors who are also kin or drinking buddies [45,48] and among close friends rather than between strangers [11,44,46,48,50]. However, some research shows that both men and women will share syringes when the sharing partner is female [46] and particularly when a female partner requires help with injecting [51,52]. Compared to their male counterparts, female injectors have smaller, more homogeneous networks of female drug injecting partners [5356]. They share syringes with a higher proportion of their network members than men [45,49,57], their IDU networks are more dense and contain members with whom they have more frequent contact [26,45] and their support networks tend to be signicantly larger than mens [45]. Among female IDUs who lived alone and whose social networks were small, Metsch et al. [58] found that subjects were more likely than highly networked women to share equipment and use shooting galleries. The authors proposed that engaging in high-risk injecting behaviours was a method to better cope with their social isolation. Age Networks of younger IDUs may be prone to a higher risk of infection with bloodborne viruses due to their higher prevalence of injection-related risk behaviours compared to older IDUs [59,60]. This is important for new injectors, especially those within 1 year of initiating injection [61]. The presence of an older IDU in ones injecting network increases the likelihood of infection in the younger needle-sharing partners [23,61]. Younger age is considered a marker of injecting inexperience and has been associated with exposure to used syringes in situations where help is required with injecting [51,52,62]. In a sample of IDUs aged less than 30 years, Thorpe et al. [47] reported that the practice of sharing containers, lters and rinse water decreased with increasing age. Potential explanations included coercion by young injecting peers to share injecting equipment and the fact that younger
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IDUs share equipment with the person that introduced them into injecting, who is often an older, more experienced injector [47]. Injecting partnerships between younger and older IDUs can also link young IDUs to high-risk injecting environments. For example, having an older IDU in ones network has been associated with earlier initiation into shooting galleries, where the renting or borrowing of syringes is often pervasive [15,44,63]. Shooting galleries also expose participants to anonymous injecting networks through the sharing of equipment with strangers. Ethnicity There are limited data comparing IDU networks according to the ethnic origins of network members. In the United States, black and white IDUs have been reported to have a greater proportion of IDUs in their social network compared to IDUs of Puerto Rican origin [64]. In their study of black IDUs in Washington, DC, Johnson et al. [65] found concordance in age, gender and risk behaviours among study subjects, showing that networks of black IDUs in this setting tended to be very homogeneous. However, research suggests that injecting networks composed of white or Latino IDUs have a higher prevalence of syringe sharing compared to those of predominantly black injectors [42,64]. Differences in sharing behaviour across ethnic groups have also been reported among IDUs in South-west China [66] and was associated with small networks among IDUs in Thailand [67]. Income The provision of instrumental or emotional support is an important element of social bonding in drug using partnerships [68]. The reciprocity of support as well as of resources is often implicit in such relationships, such that IDUs may purchase drugs jointly or provide services in exchange for drugs [69]. IDUs are more prone to sharing syringes when the injecting partner is also a source of drugs [70]. Moreover, members of IDU networks that have fewer resources to share in acquiring drugs and/or injecting equipment are often left to inject with used materials [62]. The power imbalance inherent in drugsharing relationships governs the process of preparing, dividing and consuming drugs, which ultimately inuences an individuals exposure to used injecting equipment [69,70]. In contrast, having stable resources provides the option of using ones own equipment and thereby offers more control over personal injecting practices [41]. Role of network members The likelihood of needle sharing decreases when there are fewer IDUs in ones social environment and there is

more frequent contact with non-injecting drug users [15,7173]. Having supportive friends who are non-drug users may serve as an avenue for social integration, as these individuals can discourage involvement in a drugusing life-style and change fatalistic attitudes toward risktaking [74]. Structural factors can interact with compositional characteristics of networks to increase the likelihood of needle sharing. For example, Suh et al. [75] found a higher prevalence of syringe sharing in larger drug networks despite the provision of social support from these drug-using network members. However, when injecting networks were small, they were associated with needle sharing only if they lacked social support. The authors hypothesized that the sharing of drug equipment in social networks may act as a form of close social bonding and is counteracted by social support when network sizes are small. The role of family members in risky injecting practices has been mixed. Studies suggest that kinship may both increase and decrease the likelihood of equipment sharing. In some cases, a lack of social support from family members was not found to be associated with greater risk behaviours [71,74]. Other researchers have observed that the interaction with drug-injecting kin can increase the likelihood of equipment sharing between such individuals through the strengthening of social bonds [75]. The presence of a drug-using spouse in an IDUs social network can also either motivate a decrease in drug injecting or reinforce needle sharing when injections occur together [71,75].

Quality of relationships The extent of equipment sharing also seems to be determined by the strength and duration of social relationships. Some research suggests that the selection of injecting partners occurs as a function of social distance, whereby individuals with stronger ties are chosen preferentially over those with weaker ties [7678]. Weak ties may be represented by individuals who are less well known, such as those who are new to a network. In contrast, more frequent borrowing of syringes occurs when daily contact exists between drug-sharing partners and when there exists a lower perceived risk for infection with a network member [42,79,80]. Longer social relationships help sustain sharing behaviour by strengthening social ties, as suggested by one study which found that needle sharing was associated with injecting together for more than 1 year [42]. In fact, IDUs are less likely to reduce their injecting risk behaviours with their close, supportive injecting partners compared to other drug-using partnerships [81]. Social ties that carry more than one type of functional role (also
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called multiplex relationships) appear to be a marker of closeness and are important for the adoption of risk behaviours. Sexual orientation Risk behaviours in IDU networks may also vary according to sexual orientation. One study found that women who have sex with women (WSW) were more likely than heterosexual women to borrow syringes and rinse water when their IDU network consisted of other injectors who were WSW, men who have sex with men (MSM), older IDUs and HCV-positive or HIV-positive IDUs [82]. Although WSW in that study also shared cookers and cotton lters more often than heterosexual women, the nding was not statistically signicant. Similarly, higher rates of syringe sharing have been noted among networks of IDUs who are MSM compared to heterosexual male IDUs [62]. Behaviours in networks Normative behaviours Attitudes, perceptions and behaviours related to risky injection are reinforced when they coincide with those of network members, but altered when they are discrepant [83]. Social injecting and supportive injecting environments can produce strong social ties that promote mutual injecting and create norms for risky behaviours. IDU networks in which equipment sharing is the norm have been found to sustain sharing among its members [74]. In one study, IDUs who were accustomed to injecting with others were also more likely to share syringes and three times more likely to share cookers, cotton, and water compared to those who did not typically share [47]. Using personal network exposure as a measure of social inuence on the adoption of risk practices, Gyarmathy & Neaigus [84] showed that only lters but not cookers or receptive syringe-sharing were associated positively with network exposure in a sample of Hungarian IDUs. The opposite association was found for lending syringes, which the authors attribute to the drug using context of specic injecting situations rather than to social norms, as they speculate with the sharing of lters. Patterns of drug use The drug of choice can determine the pattern of consumption, which can in turn inuence the amount of network member interaction [19,42,43]. The quantity of drug used, the frequency of injecting, as well as the frequency of contact with network members are dependent on the pharmacokinetic attributes and the physiological impact of a drug. For example, the injection of cocaine and of speedball (a mix of cocaine and heroin) is associ-

ated with a higher probability of equipment sharing as the withdrawal symptoms from these drugs often overwhelm safer injecting practices and the frequent injections that are required are sometimes poorly planned [42,44,45,79]. Severe addictive behaviour The extent of drug addiction can expose an IDU to a highrisk network and to greater opportunities for equipment sharing. A study of heroin injectors found that highly addicted users were more likely to inject in public places and to share injecting equipment with people they did not know [85]. Less dependent users injected in private settings more often, and as a result restricted their equipment sharing to selective individuals in their injecting network. DISCUSSION Our literature review found drug equipment sharing to be associated with several characteristics of social networks that could be categorized by their structural, compositional and behavioural roles. The ndings suggest that the strength of ties, whether strong or weak, can vary within a network. The result of this variability in tie strength has implications for drug equipment sharing. Perhaps most importantly, the association of each network attribute may be modied by other characteristics of the network to produce differential effects on injection risk behaviours, such as the interaction between network size and density. Some of the ndings of the review are particularly noteworthy. First, smaller networks were found to be associated with the lower rates of equipment sharing, which might be explained by the fact that they offer fewer sources of used equipment. Also, networks might be less prone to peer pressures to share used equipment or provide more encouragement to use personal injecting equipment. The result is a protective effect against drug equipment sharing, which can limit the spread of bloodborne viruses by segregating networks by their different characteristics and levels of disease risk. Secondly, it has been suggested that women borrow needles from their intimate partners more frequently than men because it is not viewed as a risky practice when the sharing partner is also a regular sexual partner [44,45,56,86,87]. In contrast, equipment sharing is viewed differently by women if it involves people outside of intimate relationships. Consequently, investigators have found that needle sharing between sexual partners is more resistant to change than other types of injecting partnerships [76,87]. Also, acquiring drugs through sex trade work can place women in an important position of risk within their social networks [42,88]. Indeed, the
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overlap of womens sexual and drug injecting networks reduces womens ability to adopt and maintain protective behaviours against bloodborne viruses [88]. Thirdly, ethnic homogeneity within social networks is probably correlated with drug equipment-sharing practices. Therefore, while disease transmission may remain stable within networks composed of individuals of similar ethnic background, the spread of infection may increase when networks are formed between ethnically discordant individuals. Finally, our review indicates that the reduction of drug using individuals in ones social network can result in fewer drug injecting risk behaviours by reducing drug availability, by decreasing the number and frequency of drug using cues and by lowering the social pressure to inject [89]. Whether high-risk networks are formed by IDUs who choose their network members accordingly or vice versa has been difcult to explain with the dearth of longitudinal studies on injecting networks [40]. This is an issue of ongoing debate relating to the causal effect of social networks on risk behaviours and a point that must considered when interpreting the associations reported in the literature. Social network studies are not without other limitations. Because no standard denitions exist about network characteristics, the comparability of network studies is difcult to assess. As with any epidemiological study, the unique nature of the sample population must be described with regard to its traits, both personal and network. Furthermore, the limited amount of data available about IDU networks from non-North American samples renders comparisons across populations difcult with regard to cultural differences. Secondly, given the often stigmatized nature of equipment sharing, selfreports of this practice may be biased. However, in some cases, self-report of drug use practices among IDUs have been shown to be sufciently valid and reliable [90,91]. Thirdly, equipment-sharing practices between network members may vary in response to changes in perceived risk of infection within a network or due to network turnover. While there is less likelihood of misclassication of network characteristics when their assessment relates to a short period of time, as in many of the cross-sectional studies we reviewed, this limitation is nevertheless noted. Finally, although egocentric networks are easier to investigate, they show only the characteristics of a network from the perspective of the index subject while sociocentric analyses consider the sum of connected egocentric networks. In both cases, however, the consideration of behaviours as the sum of interactions between two or more people provides an improvement over the traditional approaches to risk assessment of individual IDUs [92]. Moreover, one of the strengths of a network perspective is the ability to use key informants to obtain a

wider array of information on IDUs than through the elicitation of data on the study subject alone [15,92,93]. The re-conguration of social networks has been one of the guiding principles of network-based interventions. In other cases, network-orientated interventions have used existing peer connections for the delivery of sterile injecting materials and of prevention messages by enlisting peers as role models within their networks [10,94,95]. Such interventions may hold promise for behavioural changes, as shown by one study in Baltimore. Subjects who reported needle sharing despite receiving information on risk for HIV were recruited into a group-based intervention [10]. Seronegative subjects were found to inject heroin and cocaine less frequently and shared materials less often following the intervention. However, among HIV-positive subjects, a high rate of risk behaviours continued to be reported, which the authors speculate was due to increased group cohesion that may have led to members supporting drug practices. In another intervention, peer leaders were identied through nomination by other IDUs and instructed to discuss HIV prevention with their network members and model safer behaviours. The peer-lead networks were signicantly less likely than controls to report sharing uncleaned needles and report always cleaning needles before injecting [95]. Public health interventions would benet from the integration of personal dimensions such as self-efcacy with contextual and social network dimensions of drug use. Future directions There has been an inadequate consideration of geographical setting in network analyses, despite its importance in the acquisition, preparation and injection of drugs [96]. Social network analyses should also consider unconventional network inuences such as the staff of drug treatment clinics, outreach workers and providers of drug user services whose roles in inuencing injecting practices has been largely undocumented in the prevention literature. Although knowledge about a network members HIV or HCV infection status may be used to discern risk, this information can sometimes be secondary to the degree of inherent trust and emotional bonding in intimate drugsharing relationships [46]. Limited data exist on how infection status is used to decide with whom to share equipment and how status affects risk behaviours relative to other personal and network factors. Moreover, the literature is limited in its consideration of seropositioning, namely how an individual considers the direction of equipment exchange with his or her peers when prioritizing the order of injecting [97]. The formation and dissolution of social networks among IDUs is an area of research that warrants further
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work. It is unclear how networks may self-select their members and how such networks are maintained. Future research may also benet from collecting social network information that better integrates measures of intimacy between network members, frequency of contact, multiplicity of roles and intensity of mutual drug use. Studies should also strive to understand how different types of shared equipment are discriminated across drug injecting partnerships. Finally, there is a need for a better understanding of how the interplay between network structure, composition and behaviour affects risk for the individual and to identify which combination of these elements can be targeted most effectively by interventions. Understanding why and how networks operate to mediate risk behaviours will be an important endeavour in controlling the spread of HIV and other bloodborne viruses among IDUs. Network structure and composition can be used to identify potential routes for disease transmission and locate targets for prevention with the ultimate goal of modifying behaviour. Acknowledgements Prithwish De was funded by a Canadian Institutes of Health Research (CIHR) Doctoral Research Award and by the CIHR Strategic Training Program in Public and Population Health Research of Quebec. Robert Platt holds a Chercheur-boursier award from the Fonds de la recherche en sant du Qubec. References

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