Injecting-related injuries experienced by people who inject drugs in New Zealand: impact, healthcare access and stigma

The most recent data from the Ministry of Health – Manatū Hauora (2007/2008) reported that 1.3% of people aged 16–64 had ever injected drugs in Aotearoa New Zealand (hereafter Aotearoa) for recreational purposes, with 0.3% reporting injecting in the previous 12 months.¹ With 2024’s population, these figures equate to approximately 44,600 and 10,300 people respectively. Injecting drug use is a highly stigmatised behaviour² and most people who inject drugs (PWID) in Aotearoa will be injecting drugs that are illegal. The most commonly injected drug in Aotearoa is reported to be methamphetamine.³ Injecting drug use is associated with multiple negative health outcomes, and results in 2.35 deaths per 100 person-years from all-cause mortality, primarily from HIV infection and drug overdose.⁴ Specifically among those who inject methamphetamine, overdose and cardiovascular disorders are a significant cause of death.⁵ PWID are potentially exposed to a large range of vascular injury, soft tissue injury and infection exposure as a result of injecting-related injuries and diseases (IRIDs).^6,7 Some IRIDs can be life-threatening, which is particularly pertinent, given that PWID are a vulnerable population facing barriers to accessing both preventive and secondary healthcare.^8,9

Abscesses and cellulitis are two of the most prevalent complications of injecting drug use, with lifetime prevalence estimated between 6 and 69% based on systematic review.⁷ A previous study by Tsao et al. reported that 55.4% of hospital visits with injecting drug-related complications were diagnosed as abscesses or cellulitis.¹⁰ IRIDs can be prevented, or their risk reduced. For example, abscesses and cellulitis can be prevented with correct equipment and aseptic technique with alcohol sterilisation,¹¹ and risk may be reduced by avoiding high-risk sites such as the groin.¹² IRIDs can have severe negative impacts on the health and wellbeing of PWID, as well as being a source of healthcare costs.¹³ Qualitative work in Scotland has also exposed the high morbidity that IRIDs can have on PWID, as well as the complicating factors of stigma and discrimination leading to untimely and inadequate healthcare provision.¹⁴ While international research has reported on the high prevalence and frequency of such outcomes,⁷ data in Aotearoa are sparse. Unpublished technical data in Aotearoa suggest a similarly high prevalence of IRIDs;^15,16 however, no formal investigation of IRID prevalence or impacts has occurred. While methamphetamine is most commonly injected in Aotearoa, the lack of heroin and other illicitly manufactured injectables means diverted pharmaceuticals are also more common than elsewhere,³ which may make extrapolations from other countries less relevant, and thus highlights the need for local data.

The use of a peer-based approach within needle exchanges has been advantageous in earning the trust of PWID, attributed to the shared understanding of lived and living experience of injecting between staff and clientele, as well as the ability to support clients, avoid stigma and maintain anonymity.^17,18 PWID may avoid other healthcare services for fear of discrimination or consequences of being discovered as a PWID,¹⁹ and for many, the needle exchange is trusted and may facilitate connections to other services;²⁰ though, stigma may still create a barrier to accessing the needle exchange, particularly for women.²¹ Therefore, PWID are likely to be under-represented in healthcare statistics and population-level surveys, and reaching PWID who utilise the needle exchange may give insight into the needs of this population.

This exploratory research will provide preliminary data on IRIDs in Aotearoa, which can contribute to future estimation of national prevalence and frequency, as well as economic impact on the public health system. We currently have a large deficiency of knowledge on this topic in Aotearoa, with limited data on the burden or impact of IRIDs, or how mainstream healthcare systems such as hospitals and general practitioners may treat these injuries. This research will aim to provide clarity for healthcare providers and also ensure PWID are provided with the best possible evidence-based care pathways to enable healthcare access, while breaking down barriers to care. We employed mixed methods to answer our exploratory research questions: 1) what are the characteristics and experiences of IRIDs in a sample of PWID, 2) how do PWID access healthcare in response to IRIDs, and 3) are there any barriers to healthcare access, including stigma?

Methods

Drug Injecting Services in Canterbury (DISC) Trust is a peer-run organisation providing care, sterile injecting equipment and harm reduction advice to the PWID community in the South Island of Aotearoa as part of the New Zealand Needle Exchange Programme (NZNEP). The services provided by the NZNEP are anonymous and, as such, data are not collected at the level of individual clients (i.e., the services do not have a robust means of knowing how many clients they have). This project was co-designed with DISC Trust staff, considering client preferences for data collection. The study was framed within a pragmatic research paradigm, which embraces an experiential view of knowledge where people’s experiences inform their understanding of the world in which they exist, using methods that best suited the research questions.²²

Ethics

Ethical approval was granted by the University of Otago Human Ethics Committee (Ref 23/112). Information about the survey and the interview was provided to clients, and written informed consent was obtained prior to beginning each survey or interview. Where a participant had challenges reading written material, the student researcher (SP) assisted by reading the information and consent sheet. No identifying information was collected, to ensure participants felt safe to disclose their experiences. Survey participants received a $20 supermarket voucher, and interview participants a $40 supermarket voucher.

Participants and recruitment

The primary participants were clients of DISC Trust who attended the two sites: the Rodger Wright Centre in Ōtautahi Christchurch and Dunedin Intravenous Organisation (DIVO) in Ōtepoti Dunedin between 31 October 2023 and 10 February 2024. These are the two largest needle exchange sites (by service provision) in the South Island. Both the Rodger Wright Centre and DIVO have some access to healthcare professionals onsite, via a part-time nurse practitioner and part-time (1 day per week) GP, respectively, which is not consistent across all NZNEP sites. Additionally, three staff members from the two sites participated in the qualitative phase. All study participants were at least 18 years old and were able to speak English.

The study was advertised with a flyer at the two sites. Client/participant recruitment was purposive and occurred primarily in conjunction with DISC Trust staff, who suggested clients who may have been willing to participate and assisted with introducing the clients to the student researcher (SP). Recruitment was also opportunistic, with SP spending time at the sites and asking clients if they were willing to participate, after clients had collected their equipment.

Survey methods

The survey was designed in consultation with DISC Trust staff and covered a range of issues relevant to determining the incidence and severity of IRIDs within DISC Trust clients. The questionnaire also aimed to elicit information regarding risk factors for IRIDs, as well as protective factors. Additionally, the questionnaire aimed to gather IRID treatment data to determine whether PWID sought professional healthcare or advice and identify any barriers to care. All data were self-reported (e.g., hepatitis C serostatus was not confirmed via testing) and based upon symptomatic experience rather than formal diagnoses. The survey was completed with the researcher (SP) present to assist with question clarification or for participants with reading challenges. Clarification and explanation were provided for medical terminology, and understanding was confirmed with the client before the response was written down. Where an “other” box was provided, there was also a free-text field for clients to elaborate on the issue.

De-identified data were collated in Microsoft Excel for cleaning. Data were verified by one researcher (RC) who was not involved in data entry validating 10% of the sample. The verifier found one transcription error, and a further 20% of the sample was then validated with no further errors identified. Data were then imported to Stata (version 16.1 for Windows)²³ for analysis. All analyses were descriptive and did not account for potential confounds or include multivariate analyses. Ninety-five percent confidence intervals are reported for type of IRID, using a binomial exact test.

Interview methods

Semi-structured interviews were conducted to develop an understanding of PWIDs’ experiences of IRIDs and associated healthcare experiences. Interviews with staff focussed on understanding their response to IRIDs. Consent was sought to record the interviews, for ease for transcription, and transcripts were then analysed thematically using NVivo software.²⁴ Interviews were transcribed verbatim by SP. Transcripts were then reviewed, and key quotes were coded in NVivo software highlighting salient features relevant to questions relating to the impact of IRIDs, how PWID access healthcare, PWID experiences of healthcare and barriers to this healthcare. The resulting analysis generated codes that were closely aligned with participant experiences or had close meaning, with these grouped to produce initial themes. Themes were then reviewed and combined as appropriate. Themes were then defined and named. Where a theme had a unique experience that fewer participants had reported, but still related to a larger theme, a sub-theme was described. This resulted in findings of themes, sub-themes and relevant supporting quotes.²⁵

Mixed methods

Mixed methods were selected as the most appropriate method to address the exploratory nature of our research questions, given the significant knowledge gaps about IRIDs that exist in Aotearoa. We aimed to provide preliminary data that would fill some knowledge gaps while also highlighting future research priorities. We used a convergent parallel design to identify areas of convergence between quantitative (survey) and qualitative (interview) results, with the aim of identifying shared outcomes and findings across the two discrete datasets. Mixed methods have been extensively used in public health research, as they offer methodological innovation for complex topics, e.g., through comparison, validation and triangulation of multiple datasets.²⁶ Not only does this methodology account for biomedical factors related to IRIDs at the individual level, but it also enables an understanding of the social and structural facets in health outcomes for this key population. This approach grounds the findings in both sets of rigorous data to offer a holistic understanding of IRIDs among the sample that may not have been possible using a single method.

Results

Major qualitative themes

Key themes, identified through the thematic analysis of interviews, included discrimination and stigma, concern of repercussion from seeking healthcare, lack of social supports or financial stability and a reliance on support from other injecting peers. Quotes are presented alongside the relevant survey results to illustrate the convergent findings. There were no obvious points of divergence between the survey and interview data.

Interview participants’ characteristics

There were 10 participants, eight of whom were recruited from the Rodger Wright Centre (80%) and two from DIVO (20%). Seven interviewees (70%) identified as male and three interviewees (30%) as female. Six interviewees (60%) were clients of NZNEP, one interviewee (10%) was both staff and client of NZNEP and three interviewees (30%) were staff of NZNEP. Of the four staff, three worked as peer workers and one worked as a nurse practitioner. Of the seven client interviewees, the median age was 43 and mean age was 47. Staff age was not recorded.

Survey participant characteristics

The survey data included 57 participants (all clients). The majority were men (63.16%) and of NZ European ethnicity (71.93%). Māori made up 22.47% of the sample. The average age of participants was 47 years, with a median length of injecting being 20 years (range 1–46 years). Forty participants (70%) were recruited from Christchurch and 17 (30%) were recruited from Dunedin.

Forty-seven percent of the sample were injecting at least daily; 7% reported injecting more than 3-times per day, 19% 2–3 times per day and 21% once per day.

The drug most recently injected was predominantly methamphetamine (24.56%) or methadone (22.81%). Other drugs injected included methylphenidate, morphine, steroids, heroin, cocaine, codeine, ketamine, oxycodone and fentanyl. Five participants (8.77%) most recently injected two drugs simultaneously last time they injected. In all of these cases, the combination was a type of opioid and a stimulant class drug.

Potential risk factors for IRIDs

Seventy percent of the sample had always used a new needle and syringe in the last month, with 17 people (30%) reporting that they had not. Of those 17, all reported that they had reused their own needle, and nobody reported reusing a needle that somebody else had used.

We categorised injecting in either the neck or groin as high risk; 11 people (19%) had injected into a high-risk site in the last month.

Protective factors against IRIDs

We asked clients about their use of eight protective factors that they “usually used”, which were pre-specified by the project team (listed below in Table 1). These are behaviours or practices that are associated with reduced risk of IRIDs (see Appendix 1).

The median number of protective factors that clients identified using was six of the possible eight asked about in the survey.

Considering the proportion reporting the types of protective factors being “usually used”, the most common were self-administration, swabbing the injection site and using a sterile needle and syringe (Table 1).

In interviews, clients described their experience of IRIDs and the ways in which they took action to try and prevent IRIDs.

“And I believe what really saved my life the most is the water filters. I used them from the day they came out. Three times I didn’t use them. Three times I got dirties.” – P2

View Table 1–5.

Types and frequency of IRIDs

We surveyed clients about their experience of nine different types of IRIDs. The median number of IRID types that clients had experienced was three (noting that they may have experienced the same type of IRID multiple times). Over 40% of clients had experienced an IRID (of any type) more than 10 times.

The most common types of IRIDs were prominent scarring or bruising and collapsed veins (Table 2). The most common “other” type of IRID reported was nerve or artery strike, which was reported as free-text in the questionnaire.

We further classified IRIDs by severity and considered abscess, septicaemia, thrombosis and endocarditis as “severe”, due to their potential to be life-threatening, and where delays to medical care have the potential to alter patient outcomes. Sensitivity testing with different definitions of IRID severity were trialled (see Appendix 2). Twenty-five clients (44%) had experienced at least one severe IRID. These 25 clients had also experienced at least one type of non-severe IRID, i.e., no clients had experienced a severe IRID without having also experienced non-severe IRIDs. Client experiences of severe IRIDs were also described in the interviews.

“I had an abscess in my groin … I woke up and I had bruises all from my knees down and then I thought that was weird and then the next day I woke up with them all blistered when I went to hospital. I had used my saliva to wipe old blood off my groin that had caused it, and I ended up in intensive care.” – P5

“The situation became severe where I needed to ring an ambulance [in reference to abscess].” – P1

“I had about 10 minutes and a spider web or something must’ve been in it, I don’t know but whatever the hell was in it, um, let’s just say I thought I was on death’s door [in context of 16 days of extreme lethargy and fever, self-managed].” – P2

“I had an abscess in my neck. I shot into the neck and that and it was a f****** pus-y thing.” – P3

Seeking of medical attention for IRIDs

The majority of clients surveyed (n=36, 63%) had never sought medical attention for any IRID. Only three clients reported having always sought medical attention.

When considering differences between those who had or had not experienced a severe IRID, there was a greater proportion of clients seeking medical attention if they had experienced a severe IRID (Table 3). However, eight of the 25 clients who had experienced a severe IRID (32%) had never sought medical attention.

When medical attention had been sought, the most common places to seek help were from the emergency department (n=13, 23%) or needle exchange (n=9, 16%). Seven (12%) clients reported seeking care from a general practice, five (9%) from a 24-hour clinic and one (2%) from a pharmacy.

Clients often talked about their desire to use needle exchange services to gather advice about health concerns prior to seeking higher care.

“I’d ring [nurse practitioner at Rodger Wright Centre] [if there were further health problems from injecting].” – P5

“… My best friend, [name removed], she is not using now. She been there, done everything. She’s a wee bit older than me and she is the first one I went to about this [abscess]. She was the one who drew the line around it and, and she sort of forced me to come in here [Rodger Wright Centre].” – P8

Clients talked about their reluctance to seek medical care in the interviews, and how bad things would have to be before they sought medical care.

“Yeah, I, I would probably only go to hospital now if I knew I was dying.” – P5

“Yeah, I mean, yeah, it’s got to come to probably losing a limb potentially or more worse implications before I am going to go [to hospital].” – P8

“I think she did wait a while [to seek healthcare for a large abscess]. I can’t remember if she used a DIVO doctor at the time or kind of had her own GP, but I think it did get pretty bad before she actually kind of went to a GP.” – P9 (staff)

A reluctance to seek medical attention due to potential repercussions was also reflected in the interview quotes.

“So yeah, absolutely would do everything in my power to avoid seeking healthcare because I believe that the methadone clinic would, ‘Ohh well, hello, hello. What’s going on here? We’ve been injecting our methadone here. Have we? Well, we got to take your takeaways off you!’ which for me would have massive impact on my ability to, you know, do my job without interruption.” – P4

“I do not want this on my notes because I’ll lose my dose [methadone] and then I’ll lose my job and I’ll lose my house and, you know the implications are huge.” – P8

“You know, avoid hospital, you avoid doctors, you avoid all of this because the Kaupapa, because of the whole programme. It’s illegal.” – P1

Barriers to accessing healthcare

The most common barriers to accessing healthcare that were reported in the survey were shame and previous negative experiences with healthcare, with cost also being reported as a barrier by almost one-third of survey participants (Table 4).

Barriers to accessing healthcare were strongly reflected in the interview findings, where participants described their previous experiences of seeking medical care, and the discrimination they had experienced.

“And I think as soon as they [healthcare workers] hear methadone, bang, you’re a junkie. You’re useless. You’re, we can’t trust you. Um, and you’re doing it to yourself.” – P8

“I had big holes in my groins, when the nurses were looking at, at it, like when they first seen it, one goes, ew, like that and it’s like, ohh god makes you feel even more ew … the lady that was from the disease clinic or whatever, she wanted me to go to the ombudsman and lay a complaint but it was just too much hassle for me and ’cos I’d already felt ashamed and that and you know, and they make me feel even more ashamed so, yeah, that puts me off hospitals.” – P5

“I ended up discharging myself from there because a doctor came in and it was the first time I’d met him and he goes, ‘I come to work every day to help people and then I’ve got to risk getting hep C from someone like you’.” – P5

“Many friends, well associates … they won’t go back [to seek medical attention].” (“They won’t ever go back?” – Interviewer) “No, the way they were treated, especially if they land in hospital or things like that, you know treat, treated pretty brutally if you’re actively using.” – P2

“I would say, you know, she would give the impression, the first impression of so underweight, bad teeth, hyperactive, probably seemed like a junkie. She meets the stereotype, and she was eventually refused care by the dentist and she’s like ‘it’s all paid for blah, blah, blah’ and they’re like ‘We’ve refused the care on the basis that she had self-disclosed that she had hep C’ and she came back here [DIVO] extremely upset.” – P10 (staff)

Clients also described how costs had impacted their ability to receive appropriate medical care or adequate standard of living.

“And, so, they’ve only got a certain amount of money so, yes, it’s all, all very well offering them accommodation. But then by the time they pay for that, pay for electricity, pay for a few groceries, they’ve got nothing left. They’d rather live on the street and have more options to them.” – P6 (staff)

“I shoplift a bit because I’ve got no money but, you know, I have to shoplift for food.” – P3

“Always [having difficulties with costs]. The other thing too is Canterbury, New Zealand is probably one of the most expensive places in the world to have a drug, opiate habit … To pay for the same or similar drugs even somewhere as close as Sydney, Melbourne, Perth, Australia, you’re looking at what you’d pay 100 dollars for here, you could pay 25 dollars in Australia.” – P1

Others also described a reliance on social support systems such as Work and Income New Zealand (WINZ) to access care.

“I had cirrhosis of the liver by 46. I had genotype 3B [hepatitis B, contracted through IV drug use], which is a real mongrel one as you may know. B is the hardest one to treat [pre-pangenotypic]. I was very lucky because I got the drugs into the country through the clinic here [Rodger Wright Centre]. They got me a grant, you know. There was a window open with WINZ. I thank every taxpayer for it.” – P2

“So, [GP at DIVO site] was working with her over that and he had arranged for WINZ to pay for her to have her teeth done. This is not the only time I’ve heard of this kind of thing happening with clients who get WINZ payments for dental issues.” – P10 (staff)

Sources of knowledge on IRIDs

Survey responses demonstrate that clients are gaining their knowledge on IRID prevention primarily from peers and needle exchange staff. The “other” sources reported in the survey included websites, YouTube and learning through experience over time (Table 5). This reliance on peer support was reflected in the interviews.

“[I]t has to be a real concerted effort of self-preservation … learning … getting connected with the different organisations like the hep C clinic, the Rodger Wright [Centre], peers, we’re so fortunate in Christchurch, in Canterbury here that all the people that work here … they’re all peers and they’re all of the older generation and they all know, we all know one another. Information sharing is just one of those things that takes place, and it’s really valued.” – P1

Discussion

IRIDs are a substantial source of health harm for PWID and represent both harm to individuals and associated healthcare costs. Knowledge of how PWID experience IRIDs in Aotearoa is vital to informing preventive and harm reduction efforts. To the best of our knowledge, this study represents the first characterisation of IRIDs in an Aotearoa sample of PWID.

We found that PWID are using a diverse range of protective methods, and are educating themselves about IRID prevention, but nevertheless are experiencing a high number and wide range of IRIDs, many of which have the potential to cause serious harm and/or be life threatening. We found that the rates of IRIDs in the South Island are broadly consistent with those from international data relating to PWID. An international systematic review of injecting-related injury and diseases among PWID found the lifetime prevalence of abscesses ranged from 6.2% to 68.6%, consistent with our finding of 32%.⁷ Our results were also consistent with international findings in relation to thrombosis and endocarditis. Thrombosis’s lifetime prevalence was estimated at 3–27% (compared with our 11%) and endocarditis lifetime prevalence was estimated as 0.5–11.8% (compared with our 4%).⁷ One contrasting difference between the international estimates and our findings was the notably higher rate of lifetime sepsis in our study. Larney et al. (2017) reviewed six studies that analysed the lifetime prevalence of sepsis and found the prevalence to be 2.0% (1.7–2.3%) in an Australian sample and 9.8% (3.3–21.4%) in a United States of America (USA) sample, both of which are significantly lower than the 23% (13–37%) we found in our Aotearoa sample. This suggests that PWID in Aotearoa are at greater risk of developing sepsis compared with PWID in other countries⁷ and are at greater risk of sepsis than the general population.²⁷ The reason for this is unknown and may be an artefact of a low power study. However, a possible hypothesis for this may be that PWID in Aotearoa may have delayed recognition and treatment of otherwise less-serious infections, which may lead to development into a more serious bacteraemia. This may indicate a need for further research into the ability of PWID and peers to recognise a bacterial infection that requires treatment so that this progression does not occur. An alternate hypothesis is that the higher prevalence of methamphetamine injecting may increase sepsis risk, possibly due to contamination within the local drug supply. Regardless, this requires additional research to validate the finding and explore potential mechanisms.

Our data also indicated that PWID in Aotearoa reported high levels of knowledge and harm reduction awareness, as shown by finding that the median number of harm reduction (protective) factors used was six out of a possible eight. We also acknowledge that this survey was conducted at a time where the NZNEP was undergoing severe supply issues and struggling to source wheel filters and sterile water overseen by Te Whatu Ora – Health New Zealand. This is reflected in our data as wheel filters were the lowest utilised protective measure at just 39%. This emphasises the responsibility our public health system has to maintain its obligations to vital harm reduction services working with vulnerable communities. While acknowledging both the skew of the sample being taken from a harm reduction site and the potential for recall bias, it is reassuring that clients report using harm reduction measures. However, the high prevalence of injury despite these harm reduction measures indicates the significance of access to healthcare remains, and the importance of reducing the barriers this population experiences to seeking care.

Almost all participants reported an unwillingness to seek healthcare and described multiple barriers to healthcare access, particularly stigma and discrimination. This is of particular concern for the almost half of our sample who had experienced at least one severe IRID, which could be acutely life-threatening, and for whom delays to medical care therefore could have significant implications for patient outcome. This stigma experience is well documented in international research as drug use has been labelled as a “social evil”.^9,28 Qualitative research from the West Coast of Aotearoa’s South Island found stigma to be a significant barrier to distributing care through healthcare services.¹⁸ Likewise, qualitative work from the USA described very similar themes of stigma and discrimination to those our interviews revealed, finding that 59.4% of participants in one study felt fear of stigmatisation or discrimination.²⁹ These authors also identified that this fear of stigmatisation led to avoidance of healthcare providers.

There is also a considerable degree of socio-economic deprivation within the PWID community, thereby exacerbating barriers to accessing healthcare. We found that cost and transport concerns acted as a barrier for 30% and 26% of our survey sample, respectively. This was reflected in interviews, with some participants lacking access to motor vehicles and financial stability. It is well documented that PWID tend to have lower incomes and have greater exposure to incarceration, poverty and violence than the general population.^30–32 It is also important to note that our study found that Māori were over-represented compared with the general population, and this is reflected in needle exchange data more generally in Aotearoa.³ Being Māori per se is not a risk factor for drug use or drug-related harm, but is likely to compound harms through processes of colonisation, marginalisation and racism.³³ Though there are limited empirical data available on social and structural determinants of health among PWID in Aotearoa, it is reasonable to hypothesise that many within this community will be structurally marginalised and experiencing multiple morbidities. This highlights the need to take a public health approach to reducing harm in this community.

These data demonstrate the importance of health practitioners being aware of the risks of IRIDs in PWID and the barriers to PWID seeking care. Stigma is a well-documented barrier to health-seeking behaviour and thus clinicians are well-placed to halt stigmatisation of taboo topics or acknowledge and mitigate the harmful effects of stigmatisation where identified.^34,35 In the context of IRIDs, the most common barrier to adequate care we identified was stigma and past negative experiences with health professionals. Evidence shows that educational interventions are effective in reducing stigma and fostering positive attitudes in healthcare students.³⁶ Therefore, one avenue to approach de-stigmatisation is for students in healthcare to be educated about injecting drug use and harm reduction services in the community. Based on our survey and interview findings, many PWID feel stigmatised, discriminated and shamed, which means that they are less likely to seek healthcare. Consideration should be given to how healthcare services can be better oriented to provide care for PWID, which could include models that better integrate already trusted services, like the needle exchange.

The study’s small size and recruitment of a convenience sample only from the South Island are limitations. However, sample demographics (both survey and interview) are broadly consistent with NZNEP data, suggesting that they were representative of PWID in Aotearoa.³ Similarly, we acknowledge the limitations of self-reported data and associated recall bias, and the risk that some clients may not have understood the medical nomenclature and thus under-reported their experience of IRIDs in the survey. We quantified IRIDs based on symptomatic experience, not on formal diagnosis, given that medical attention may not have been sought and, therefore, there was no diagnosis. However, these concerns are balanced by a key strength of the study, where mixed methods were used to add richness to the quantitative data and to support the survey findings. This methodology leveraged trusted relationships (including introductions from peer workers) to build rapport with clients and gain key insights directly from participants, amplifying the voices and perspectives of a population group that is stigmatised and “hidden”. Our study design also did not look at healthcare access for each incidence of IRID that clients experienced; we asked about their overall healthcare access behaviour in response to IRIDs. This means we cannot separate out whether clients accessed healthcare for some types of IRID and not others, or if clients sought different types of healthcare for different types of IRID. This study, albeit small, has the potential to be upscaled and conducted nationally, thereby enabling national prevalence of IRIDs to be determined. It may also be possible to elucidate clients’ responses to different IRID types with a longer and more complex survey design. Future research focussed on client outcomes (including admission and treatment) following severe IRIDs would be of particular benefit.

In conclusion, IRIDs present a significant health risk to a vulnerable population of PWID in Aotearoa who have a range of other compounding negative health predictors. We found that PWID appear to be using a wide range of harm-reducing measures, but, regardless, appear to experience a range of injecting injuries at rates comparable to international data, and in some cases exceeding these. The NZNEP, including DISC Trust, has provided PWID with a safe environment where they are able to access judgement-free harm-reduction equipment and information since 1988, and is highly trusted by PWID. At the present time, however, the NZNEP’s limited resourcing means that the health burden posed by clients’ untreated injuries exceeds the programme’s capacity in many regions. Clients are seeking support from peer staff on IRID prevention and treatment, which reinforces the need for training to support staff in this role, and to recognise when clients may need to seek healthcare. This study highlights the importance of expanding harm reduction in Aotearoa and further destigmatisation of healthcare to ensure access to vulnerable and marginalised communities.

View Appendices.