Contents lists available at ScienceDirect Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep Full length article Who goes first? Understanding hepatitis C risk among injecting networks in the prison setting Lise Lafferty ⁎ , Jake Rance, Carla Treloar Centre for Social Research in Health, University of New South Wales, Sydney NSW 2052, Australia ARTICLE INFO Keywords: Hepatitis C People who inject drugs Prisoners Risk environment framework ABSTRACT Background: Hepatitis C (HCV) is a blood-borne virus that is most commonly transmitted through shared in- jecting equipment. Due to the criminalisation of injecting drug use, HCV is highly prevalent among those in- carcerated. Using a risk environment framework, this qualitative study sought to understand the role of HCV risk within injecting networks in the prison setting. Methods: Thirty-two adult prisoners (n = 24 men; n = 8 women) with a history of injecting drug use partici- pated in this qualitative sub-study. Participants were recruited across four correctional centres. Results: Social, economic, and environmental risk factors contributed to injecting practices within prison. Commonly, the person supplying the drugs injected first, with the person who owns the injecting equipment going next. HCV did not regularly factor into determining order of injection within networks (i.e., first, second, third), although it was reported that some prisoners claimed not to have HCV in efforts to “jump the queue”. Conclusion: Social, economic, and environmental risk factors contribute to negotiation of injecting order among people who inject drugs in prison. Risk of HCV exposure rarely influenced the injecting order. Harm reduction strategies should consider the social factors influencing injecting drug use in the prison setting especially to optimise the population benefits of the roll-out of highly effective HCV treatments. 1. Introduction Hepatitis C (HCV) is a blood-borne virus and is most commonly transmitted through shared injecting equipment (Hajarizadeh et al., 2013; Shepard et al., 2005). Injecting drug use is illegal in most countries, contributing to the high incarceration rates of people who inject drugs (WHO, 2014; Wolfe et al., 2010). Once incarcerated, prison is a high-risk setting for HCV due to increased risk of exposure and greater prevalence (Larney et al., 2013; UNODC, 2014). The prisoner population is significantly more likely to have HCV than the general population (Larney et al., 2013). The majority of those imprisoned in Australia have a lifetime history of injecting drug use (Reekie et al., 2014). It is well known that people in prison may continue to inject drugs while incarcerated, although injecting occurs less often than within the community (Wright et al., 2015). Despite availability of illicit substances, equipment for drug consumption is limited, resulting in a high frequency of equipment sharing (Kinner et al., 2012; Snow et al., 2014), and is bought or hired at premium market rates (up to five or six times the equivalent of one injection of heroin) (Treloar et al., 2016). Fincol (a quaternary amine disinfectant (JASOL, North Ryde, Australia)), a bleach alternative, is available to those incarcerated in Australia; however, it is not equally available in all states and territories (AIHW, 2015). Despite availability of Fincol, there is limited data to show the product’sefficacy in redu- cing transmission in the real-world (e.g., prison) setting (Doerrbecker et al., 2011; Luciani et al., 2014). Limited access to prevention mea- sures such as bleach, in combination with frequency of equipment sharing, has been shown to be associated with increased risk of HCV transmission within the prison population (Cunningham et al., 2017). There has been little research to understand how HCV and other blood-borne viruses (BBVs) risks are navigated among injecting net- works within the prison setting where prevention strategies are limited. It has been conceptualised that relations between individuals and en- vironments jointly influence drug-related harms (Rhodes, 2009), such as transmission associated risks. Social, economic, environmental, and policy factors combine to construct perceptions of risk and shape the available responses to these perceptions (Rhodes, 2002). Furthermore, injecting drug use is a social process; prevention education for risks associated with injecting drug use should consider the social practices of injecting drug use (Fraser et al., 2014). Understanding the injecting networks of people who inject drugs (a social factor) in the prison setting (an environmental factor) in which equipment must be bought https://doi.org/10.1016/j.drugalcdep.2017.10.030 Received 29 August 2017; Received in revised form 6 October 2017; Accepted 29 October 2017 ⁎ Corresponding author. E-mail addresses: l.lafferty@unsw.edu.au (L. Lafferty), jake.rance@unsw.edu.au (J. Rance), c.treloar@unsw.edu.au (C. Treloar). Drug and Alcohol Dependence 183 (2018) 96–101 Available online 08 December 2017 0376-8716/ © 2017 Elsevier B.V. All rights reserved. T