**16. Conclusion**

290 Immunodeficiency

consequences of injecting drug use. Although some respondents were aware of the dangers of using another's injecting equipment, their judgement was impaired due to: being 'strung out' (suffering withdrawal symptoms), to administering the injection in a rushed unsterile environment, and to the distractions and confusion that can occur when injecting in the company of friends/drug buddies and allowing friends to administer the injection to them.

In a systematic review and meta-analysis of interventions to prevent Hepatitis C virus infection in injecting drug users, it was found that a complex of interventions worked best to reduce the incidence. For example combining counselling with strategies such as -- enabling the injector to maintain control over the injection process by not injecting in chaotic and rushed settings; maintenance in opiate substitution treatment of ≥ than 60 mg a day; and using sterile syringes obtained from a syringe exchange program [27]. In our study, most of the participants were accessing some of the elements in such a treatment complex. However, their attempts to reduce their risks were exacerbated by the fact that many were homeless and spent much time on the streets and were likely to inject in public places and spaces which lacked the necessary hygiene. Only three of the seven who reported being HIV positive were receiving anti retroviral treatment; two others were unsure of their HIV status. They are a high risk group in terms of passing on the virus to others. Other research has found that sex workers who are injecting drug users are associated with poorer engagement with Opioid Agonist Treatment and retention in treatment[28]. Other jurisdictions[24] in Europe have been successful in reducing the rates of new infections among people who inject drugs: for example in Switzerland and in the Netherlands, HIV infections have almost been eliminated (at most 5% of new infections in 2007 and 2008 respectively) amongst those who engage in 'social' drug use, involving several people using the same contaminated injecting equipment. Whereas in Ireland, the rate of new infections for intravenous drug users accounted for 7.9% of all newly diagnosed cases in 2009. And in this small study the

rate of HIV infection among the 35 people interviewed was 21 per cent.

For sex workers and their clients, unprotected sex increases the risk of contracting and transmitting a range of sexually transmitted infections (STIs), including HIV [29] and HCV infection [30]. In this study, sex workers were aware of the importance of protected sex and were generally proactive in the use of condoms with clients. Offers of increased money for sex without a condom weakened their resolve. This suggests that it is clients rather than sex workers who are more prepared to take the risk of contracting HIV. The power dynamics and the inequalities in physical strength between a sex worker and a customer can rob the sex worker of the opportunity to negotiate condom use [31].Gender violence against women and rape also led to the transmission of the HIV virus. Rape was a common experience for the sex working men and women. Enhanced policing practices could help to reduce the possibilities of sex workers being raped, and therefore of contracting HIV through rape. The latest Home Office Review of Effective Practice document and the new ACPO (Association of Chief Police Officers) Strategy & Operational Guidance for Policing Prostitution and Sexual Exploitation [32] mention's the partnership work in Merseyside of the UK Network of Sex Work Projects. It endorses taking a harm reduction approach to prostitution by introducing schemes such as the 'Ugly Mugs' scheme which can help to improve safety by allowing sex workers to report Despite the existence of harm reduction interventions such as opiate substitution treatment, needle exchanges for drug users who engage in sex working, this population remain a highrisk group for contracting blood borne viral infections and death. In Ireland, some injecting drug users and other young people are still taking risks as exemplified in the recent surveillance statistics[11]. The introduction of safe injecting spaces and places might enable intravenous drug users to inject in more hygienic and safer settings thereby reducing the risk of transmission. Health messages displayed in public places might inform the intravenous drug users of the harmful consequences of unhygienic injecting practices and sharing equipment and may therefore increase their awareness of the inherent risks. Marginalized, vulnerable young people such as those leaving residential care in the justice or social welfare systems need to be targeted and informed of the dangers of illicit drug use and sex work. Health messages should also target customers and potential customers of sex workers, their insistence on not wearing a condom during sexual intercourse is putting them and whoever else they are having sex with at risk.

A change in how drug use and addiction is perceived could result in a change in the risk environment in Ireland. For example, in Portugal [33], since heroin use has been decriminalised, public perceptions have changed from viewing opiate users as criminals and addicts to viewing then as sick people in need of treatment. In Switzerland and the Netherlands successful harm reduction interventions have reduced the rates of new infections among people who inject drugs

Changes to the risk environment in Ireland in terms of policy, perception and policing could lead to the creation of an enabling environment for injecting drug using sex workers so that changes in individual behaviour could be brought about by enhanced structural interventions [34]. This approach advocates all forms of social interventions (improved education, greater needle exchange coverage, enhanced condom provision) which are extraindividual – in other words interventions that change the context within which risks are produced and reproduced [12].
